Retail and Mail-Order Prescription Copays and Tier Definitions
Defines copayment amounts for retail and mail-order prescriptions across formulary tiers and explains tier definitions and substitution rules; affects Health New England members receiving pharmacy benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria
Pharmacy copay and tier coverage
Copay structure and coverage stance for medication tiers and mail-order availability.
ALL of the following
- Retail copays are established by tier as follows: Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty — $10 / $50 / $150 / $200 / $250.
- Mail-order copays are established by tier as follows: Generic / Brand Formulary / Brand Non-Formulary — $20 / $100 / $450; specialty drugs are not available by mail order.
- Definitions of tiers: Generic (Tier 1); Brand Formulary (Tier 2); Brand Non-Formulary (Tier 3); Formulary Specialty (Tier 4); Non-Formulary Specialty (Tier 5).
- Massachusetts substitution requirement: pharmacists must fill generic drugs unless the prescriber indicates 'no substitution' on the prescription to require brand dispensing.
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