CurrentHealth-New-EnglandPolicy N/A

Pharmacy benefit copay tiers and retail/mail order coverage

Defines copay and coinsurance levels, mail-order rules, and specialty drug coverage for the PPO Essential 2000 National SG plan; affects members using retail and mail-order pharmacies, including out-of-plan pharmacies.

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit copay tiers and retail/mail order coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMail order is not available for specialty drugs and out-of-plan mail order and specialty prescriptions are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$30/$80/$125/$150/$200Retail copays G/Brand F/Brand NF/Formulary Spec/Non-Formulary Spec

$60/$160/$375Mail order copays (specialty not available)

20%Out-of-plan retail coinsurance

Not coveredOut-of-plan mail order

Not coveredOut-of-plan specialty

Pharmacy Coverage Criteria

Pharmacy coverage criteria

Coverage and payment rules for outpatient prescription drugs including retail and mail order, and tier definitions. Covered when the applicable copay or coinsurance is paid and subject to out-of-plan restrictions below.

ALL of the following

Tier copays
- Generic / Tier 1: retail copay $30; mail-order copay $60; covered.
- Brand Formulary / Tier 2: retail copay $80; mail-order copay $160; covered.
- Brand Non-Formulary / Tier 3: retail copay $125; mail-order copay $375; covered.
- Formulary Specialty / Tier 4: retail copay $150; mail-order: not available for specialty; covered.

Policy Summary

PayerHealth-New-England

PolicyPharmacy benefit copay tiers and retail/mail order coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMail order is not available for specialty drugs and out-of-plan mail order and specialty prescriptions 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

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

Copays, Coinsurance, and Cost Share

Retail copaysmixed

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

Mail order copaysmixed

Generic / Tier 1	$60
Brand Formulary / Tier 2	$160
Brand Non-Formulary / Tier 3	$375
Formulary Specialty / Tier 4	not available for specialty
Non-Formulary Specialty / Tier 5	not available for specialty

Out-of-Plan retail pharmacymixed

Out-of-Plan retail pharmacy cost share

20% coinsurance after copay

Out-of-Plan mail order and specialtymixedNot Covered

Out-of-Plan mail order prescriptions	not covered
Specialty drugs from Out-of-Plan providers	not covered

Out-of-Plan Retail Cost Share

Out-of-Plan retail pharmacy cost share20% coinsurance applies after the member copay at out-of-plan retail pharmacies.

Out-of-Plan mail orderMail Order prescriptions from Out-of-Plan providers are not covered.

Out-of-Plan specialty drugsSpecialty drugs from Out-of-Plan providers are not covered.

Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: Approved by the FDA; contain the same active ingredients as brand-name drugs, are as safe and effective, and are usually lower cost.

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

Coverage/copay contextGeneric copay (retail) is $30 and mail-order copay is $60 per the plan's tier copays.

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name, selected for the formulary based on relative safety, effectiveness and cost.

Copay relationshipCopay for Brand/Formulary drugs is higher than generic copays but lower than Brand/Non-Formulary; retail copay is $80 (mail order $160).

Coverage statusThese drugs are covered under the plan as formulary brand medications.

Brand Non-Formulary / Tier 3

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

Copay & waiver rulesRetail copay is $125 (mail order $375); Health New England does not waive or reduce copays for Brand/Non-Formulary drugs.

Coverage implicationThese medications remain covered but subject to the higher Tier 3 copay.

Formulary Specialty / Tier 4

DefinitionFormulary Specialty/Tier 4: Specialty drugs selected for the formulary based on relative safety, effectiveness, and cost.

CopayRetail copay for Formulary Specialty drugs is $150; mail order is not available for specialty drugs.

Mail-order restrictionSpecialty drugs are not available through mail order under the plan.

Non-Formulary Specialty / Tier 5

DefinitionNon-Formulary Specialty/Tier 5: Brand specialty drugs not selected as Formulary Specialty; includes brand drugs with formulary alternatives.

Copay & coverageRetail copay for Non-Formulary Specialty drugs is $200; mail order is not available for specialty drugs.

Coverage implicationThese medications are covered but at the highest copay level and may have formulary alternatives.

OpenPayer

Pharmacy benefit copay tiers and retail/mail order coverage

Pharmacy Coverage Criteria

Copays, Coinsurance, and Cost Share

Mail-order and Out-of-Plan Restrictions

Tier Definitions