Pharmacy benefit tiered copay structure and coverage rules
Customize your policy alerts
Sign up for all Health-New-England policy alerts
Know when Health-New-England releases new policies or updates existing guidance.
Monitor payer policy activity
Defines 3-tier and 5-tier pharmacy benefit options, copays (including mail order), deductible and out-of-plan coverage rules for Health New England PPO Wise Max 2000 National HDHP plans; applies to members of these plans.
No material clinical or coverage changes in this revision.
Pharmacy Copays, Access, and Coverage Rules
Copays and access rules
Multiple plan options list retail and mail order copays by tier and note limitations on out-of-plan and specialty mail order coverage.
One of the listed plan options
- 3‑Tier plan examples (retail copay Generic / Brand Formulary / Brand Non‑Formulary): $10/$50/$100; $10/$45/$75; $15/$30/$50; $15/$50/$100; $20/$50/$100.
- Corresponding mail order copays for the 3‑tier examples: $20/$100/$300; $20/$90/$225; $30/$60/$150; $30/$100/$300; $40/$100/$300.
- 5‑Tier plan examples (retail copay Generic / Brand Formulary / Brand Non‑Formulary / Specialty tiers): $15/$30/$50/$100/$150; $20/$50/$100/$150/$250; $30/$80/$125/$250/20%.
- Corresponding mail order copays for the 5‑tier examples (mail order is not available for Specialty drugs): $30/$60/$150; $40/$100/$300; $60/$160/$375.
ALL of the following
- For prescriptions from an Out‑of‑Plan retail pharmacy: 20% coinsurance applies after the applicable copay.
- Mail order prescriptions from Out‑of‑Plan providers are not covered.
- Specialty drugs from Out‑of‑Plan providers are not covered.
Mail order specialty limitation applies only where mail order specialty is indicated as unavailable; see specific 5‑tier examples stating 'Mail order is not available for Specialty drugs' and the 3‑tier statements that 'Specialty drugs from Out‑of‑Plan providers are not covered.'
Codes and Coinsurance
| No specific procedure or drug codes provided in document |
| 3-tier examples | $10/$50/$100; Mail Order: $20/$100/$300 |
| 3-tier examples | $10/$45/$75; Mail Order: $20/$90/$225 |
| 3-tier examples | $15/$30/$50; Mail Order: $30/$60/$150 |
| 3-tier examples | $15/$50/$100; Mail Order: $30/$100/$300 |
| 3-tier examples | $20/$50/$100; Mail Order: $40/$100/$300 |
Prior Authorization and Provider Requirements
Prior authorization required for brand (non‑formulary) drugs
Your doctor may request prior authorization for a brand name drug by filling out a drug request form and faxing it to Health New England for review with documentation of medical necessity. Medical necessity includes, but is not limited to, inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class.
- Complete and fax the drug request form to Health New England.
- Include documentation demonstrating medical necessity (e.g., inadequate response or allergic reaction to generics, or failure of alternatives in the drug class).
Pharmacy Tier Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.