CurrentHealth-New-EnglandPolicy N/A

Prescription drug copay tiers and mail order copays

Defines retail and mail-order copay amounts and explains the three copay tiers (Generic, Brand Formulary, Brand Non-Formulary) including prior authorization for brand-name drugs with generic equivalents. Applies to Health New England members to whom these benefit rules are offered.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail order copays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete a drug request form and fax it to Health New England with documentation to request prior authorization for a brand-name drug when medical necessity is demonstrated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$10/$25/$50Retail copay (G / F / NF)

$20/$50/$150Mail-order copay (G / F / NF)

3Copay tiers

Coverage Criteria

Brand-name with generic equivalent

Covered when ALL of the following are met:

ALL of the following

Brand-name drugs that have FDA‑approved generic equivalents are covered only when medical necessity is demonstrated.
Medical necessity may be demonstrated by one of the following:
- Inadequate response to the generic(s).
- Allergic reaction to the generic(s).
- Failure of alternatives in the same drug class.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail order copays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete a drug request form and fax it to Health New England with documentation to request prior authorization for a brand-name drug when medical necessity is demonstrated.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Copays and Medical Necessity Examples

Retail copays - Generic / Brand Formulary / Brand Non-Formularymixed

Generic	$10
Brand Formulary	$25
Brand Non-Formulary	$50

Mail-order copays - Generic / Brand Formulary / Brand Non-Formularymixed

Generic	$20
Brand Formulary	$50
Brand Non-Formulary	$150

Medical necessity criteria examples

Medical necessity examplesInadequate response to the generic(s) or allergic reaction to the generic(s); failure of alternatives in the drug class.

Prior authorization triggerBrand name drugs with FDA‑approved generics are covered only when medical necessity is demonstrated.

Provider documentationProvider must complete a drug request form and fax it to Health New England with documentation of medical necessity.

Provider Actions and Requirements

Prior Authorization

Prior authorization required for brand-name drugs with FDA-approved generics

Prior authorization may be requested for a brand name drug that has an FDA‑approved generic equivalent when medical necessity is demonstrated (for example, inadequate response or allergic reaction to the generic(s), or failure of alternatives in the drug class). Providers must complete a drug request form and fax it to Health New England with documentation of medical necessity for review.

Complete and sign the drug request form.
Fax the completed form and supporting documentation of medical necessity to Health New England for review.
Document examples of medical necessity: inadequate response to generics, allergic reaction to generics, or failure of alternatives in the drug class.

Tier Definitions

Generic / Tier 1 definition

DefinitionFDA‑approved generic drugs that contain the same active ingredients as the brand name product; considered as safe and effective and usually cost less.

Massachusetts pharmacist substitutionIn Massachusetts, pharmacists are required to fill generics unless the prescriber writes 'no substitution' on the prescription.

Copay tierClassified as Generic / Tier 1 with the lowest copay relative to brand tiers.

Brand Formulary / Tier 2 definition

DefinitionBrand/Formulary drugs marketed under a trademarked brand name and selected for the formulary based on relative safety, effectiveness and cost.

Copay positionHigher copay than generics (Tier 1) but lower than Brand Non‑Formulary (Tier 3).

Generic availabilityThese drugs do not have less expensive generic equivalents.

Brand Non-Formulary / Tier 3 definition

DefinitionAny brand name drug not designated as Brand/Formulary; covered but at the highest copay level (Brand Non‑Formulary / Tier 3).

Coverage for brands with genericsBrand name drugs that have FDA‑approved generic equivalents are covered only if medical necessity is shown; prior authorization may be requested.

Prior authorization processProvider may request prior authorization by filling out a drug request form and faxing it to Health New England with documentation of medical necessity.