CurrentHealth-New-EnglandPolicy N/A

PPO Essential 2000 National SG — Pharmacy benefit copay tiers and out-of-plan rules

Defines retail and mail-order prescription copays, coinsurance rules for out-of-plan pharmacies, and tier definitions for members covered under the referenced PPO pharmacy benefit.

Policy Summary

PayerHealth-New-England

PolicyPPO Essential 2000 National SG — Pharmacy benefit copay tiers and out-of-plan rules

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, collect 20% coinsurance after the member copay; out‑of‑plan mail order and specialty drugs are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$30/$80/$125/$150/$200Retail copays (T1/T2/T3/T4/T5)

$60/$160/$375Mail order copays (T1/T2/T3)

20%Out-of-plan retail coinsurance

Not coveredOut-of-plan mail order

Not coveredOut-of-plan specialty

Policy Summary

PayerHealth-New-England

PolicyPPO Essential 2000 National SG — Pharmacy benefit copay tiers and out-of-plan rules

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, collect 20% coinsurance after the member copay; out‑of‑plan mail order and specialty drugs are not covered.

SourceLink

On This Page

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Drug coverage and cost-sharing

Covered with the following cost-sharing rules under the PPO Essential 2000 National SG pharmacy benefit:

ALL of the following

Tier cost-sharing
- Tier 1 (Generic): $30 retail; $60 mail order; covered
- Tier 2 (Brand Formulary): $80 retail; $160 mail order; covered
- Tier 3 (Brand Non-Formulary): $125 retail; $375 mail order; covered
- Tier 4 (Formulary Specialty): $150 retail; mail order not available; covered
- Tier 5 (Non-Formulary Specialty): $200 retail; mail order not available; covered
Out-of-Plan rules
- Out-of-Plan retail pharmacies: 20% coinsurance applies after copay
- Out-of-Plan mail order prescriptions: not covered
- Specialty drugs from Out-of-Plan providers: not covered

Definitions: Tier descriptions as provided (Generic/Tier 1; Brand Formulary/Tier 2; Brand Non-Formulary/Tier 3; Formulary Specialty/Tier 4; Non-Formulary Specialty/Tier 5).

Copays, mail order rules, and code references

Retail copay - Tier 1 (Generic)mixedCovered

Tier 1

$30 retail

Retail copay - Tier 2 (Brand Formulary)mixedCovered

Tier 2

$80 retail

Retail copay - Tier 3 (Brand Non-Formulary)mixedCovered

Tier 3

$125 retail

Retail copay - Tier 4 (Formulary Specialty)mixedCovered

Tier 4

$150 retail; mail order not available

Retail copay - Tier 5 (Non-Formulary Specialty)mixedCovered

Tier 5

$200 retail; mail order not available

Mail order copay - Tier 1 (Generic)mixedCovered

Tier 1

$60 mail order

Mail order copay - Tier 2 (Brand Formulary)mixedCovered

Tier 2

$160 mail order

Mail order copay - Tier 3 (Brand Non-Formulary)mixedCovered

Tier 3

$375 mail order

Out-of-Plan retail pharmacymixed

Out-of-Plan retail

20% coinsurance applies after copay

Out-of-Plan mail ordermixedNot Covered

Out-of-Plan mail order

Mail order prescriptions from Out-of-Plan providers are not covered

Out-of-Plan specialty drugsmixedNot 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 (applicable tiers)Mail order copays provided for Generic ($60), Brand Formulary ($160), and Brand Non-Formulary ($375).

Retail vs. mail orderSpecialty tiers (Tier 4 and Tier 5) are covered at retail copays but mail order is explicitly unavailable for specialty drugs.

Out-of-Plan coverage and provider-facing rules

Billing Rule

Out-of‑Plan pharmacy coverage and cost-sharing rules

For prescriptions filled at an Out-of-Plan retail pharmacy, a 20% coinsurance applies after the member copay. Mail order prescriptions provided by 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.
Out-of-Plan mail order: not covered.
Out-of-Plan specialty drugs: not covered.

Tier definitions

Generic / Tier 1

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

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

Cost-sharing positionLowest copay tier: Retail copay $30; Mail order copay $60.

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Trademarked brand drugs selected based on safety, effectiveness and cost; do not have less expensive generic equivalents.

Copay positioningHigher copay than generic but lower than Brand Non-Formulary: Retail copay $80; Mail order copay $160.

Coverage noteCovered when selected as formulary; placement reflects comparative cost and clinical review.

Brand Non-Formulary / Tier 3

DefinitionBrand Non-Formulary/Tier 3: Brand-name drugs not selected as Brand/Formulary by Health New England.

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

Cost-sharingRetail copay $125; Mail order copay $375.

Formulary Specialty / Tier 4

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

Coverage characteristicsCovered specialty drugs placed in Tier 4 carry a retail copay; mail order is not available for specialty drugs.

Cost-sharingRetail copay $150; mail order not available for Tier 4.

Non-Formulary Specialty / Tier 5

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

Coverage characteristicsThese medications are covered but at the highest copay level; mail order is not available for specialty drugs.

Cost-sharingRetail copay $200; mail order not available for Tier 5.