CurrentHealth-New-EnglandPolicy N/A

Prescription drug copay tiers and retail/mail-order coverage

Defines copay amounts by drug tier for retail and mail-order prescriptions, rules for out-of-plan pharmacy/provider claims, and descriptions of each copay tier; applies to Health-New-England members subject to this benefits schedule.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and retail/mail-order coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor prescriptions from an out-of-plan retail pharmacy, apply 20% coinsurance after the copay; mail-order and specialty prescriptions from out-of-plan providers are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$30/$80/$125/$150/$200Retail copays by tier

$60/$160/$375Mail-order copays

20%Out-of-plan coinsurance

Not availableMail-order specialty

Coverage Criteria

Drug tier coverage and cost-sharing

Coverage and cost-sharing rules by drug tier and pharmacy channel.

ALL of the following

ALL of the following
- Tier 1 — Generic: $30
- Tier 2 — Brand Formulary: $80
- Tier 3 — Brand Non‑Formulary: $125
- Tier 4 — Formulary Specialty: $150

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and retail/mail-order coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor prescriptions from an out-of-plan retail pharmacy, apply 20% coinsurance after the copay; mail-order and specialty prescriptions from out-of-plan providers are not covered.

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.

ALL of the following

Tier 1 — Generic: FDA‑approved generics with same active ingredients as brand name drugs; in Massachusetts pharmacists must fill generic unless the prescriber indicates 'no substitution'.
Tier 2 — Brand Formulary: Brand drugs selected for the formulary based on safety, effectiveness and cost; copay higher than generic but lower than Brand Non‑Formulary.
Tier 3 — Brand Non‑Formulary: Brand drugs not selected as Brand/Formulary; covered at a higher copay; copays are not waived or reduced.
Tier 4 — Formulary Specialty: Specialty drugs selected based on review of safety, effectiveness and cost.
Tier 5 — Non‑Formulary Specialty: Brand specialty drugs not selected as Formulary Specialty; may have formulary alternatives; covered at the highest copay level.

Copays, Mail-order, and Coding Notes

Retail copays by tiermixed

Tier 1 (Generic)	$30
Tier 2 (Brand Formulary)	$80
Tier 3 (Brand Non-Formulary)	$125
Tier 4 (Formulary Specialty)	$150
Tier 5 (Non-Formulary Specialty)	$200

Mail-order copays by tiermixed

Tier 1 (Generic)	$60
Tier 2 (Brand Formulary)	$160
Tier 3 (Brand Non-Formulary)	$375

Out-of-Plan pharmacy rulesmixed

Out-of-Plan retail	20% coinsurance applies after copay
Out-of-Plan mail order	Mail Order prescriptions from Out-of-Plan providers are not covered
Out-of-Plan specialty	Specialty drugs from Out-of-Plan providers are not covered

Mail-order specialty availability

Mail-order specialty availabilityMail order is not available for Specialty drugs.

Mail-order copays listedMail Order Copays provided for non-specialty tiers: Generic $60, Brand Formulary $160, Brand Non-Formulary $375.

Out-of-plan mail-order ruleMail Order prescriptions from Out-of-Plan providers are not covered.

Provider Actions and Out-of-Plan Rules

Billing Rule

Out-of-Plan & Specialty Provider Rules

For prescriptions obtained from providers or pharmacies outside the member's plan network, follow these rules: Out-of-Plan retail pharmacy prescriptions are subject to 20% coinsurance after the applicable copay. Mail order prescriptions obtained from Out-of-Plan providers are not covered. Specialty drugs obtained from Out-of-Plan providers are not covered.

Out-of-Plan retail pharmacy: 20% coinsurance applies after copay.
Mail order from Out-of-Plan providers: Not covered.
Specialty drugs from Out-of-Plan providers: Not covered.

Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: Approved by the FDA; contains the same active ingredients as brand-name drugs; equally safe and effective and usually cost less.

Massachusetts substitution ruleIn Massachusetts, pharmacists are required to fill generic drugs unless the prescriber writes 'no substitution' on the prescription.

Cost-sharing positionGeneric copay is lower than brand tiers (see copay table for specific amounts).

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Trademarked brand drugs without less expensive generic equivalents, selected for the formulary based on safety, effectiveness and cost.

Cost-sharing characteristicCopay for Brand/Formulary drugs is higher than generic but lower than Brand/Non-Formulary.

Selection basisTier inclusion is based on a review of relative safety, effectiveness and cost among FDA-approved drugs.

Brand Non-Formulary / Tier 3

DefinitionBrand Non-Formulary/Tier 3: Brand-name drugs Health New England has not selected as Brand/Formulary; still covered but at a higher copay level.

Copay policyThese medications are covered at a higher copay; Health New England does not waive or reduce copays for Brand/Non-Formulary drugs.

Formulary statusRepresents brand drugs excluded from the formulary Brand/Formulary list.

Formulary Specialty / Tier 4

DefinitionFormulary Specialty/Tier 4: Specialty drugs selected for the formulary based on a review of relative safety, effectiveness and cost among FDA-approved drugs.

Tier purposeIncludes selected specialty drugs evaluated for clinical and economic factors.

Coverage noteFormulary Specialty drugs are covered as Tier 4 with corresponding copay level.

Non-Formulary Specialty / Tier 5

DefinitionNon-Formulary Specialty/Tier 5: Brand-name specialty drugs Health New England has not selected as Formulary Specialty; may have formulary generic or brand alternatives.

Cost-sharing characteristicThese medications are covered but at the highest copay level.

Formulary implicationTier 5 indicates specialty drugs excluded from the formulary specialty list and typically subject to greater member cost-sharing.