Pharmacy benefit tiered copay structure
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, retail and mail-order copay amounts, tier definitions, and prior authorization/medical necessity rules for Health New England HMO Essential Plus 2000 LG members.
No material clinical or coverage changes in this revision.
Pharmacy Tier Coverage Criteria
Coverage criteria for pharmacy tiers
Coverage is tier-based with specified retail and mail-order copays; medical necessity/prior authorization is required for brand-name drugs with FDA‑approved generics in some situations.
ALL of the following
3‑Tier option
- Tier count: 3; Tiers: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non‑Formulary (Tier 3).
See copay examples for retail and mail‑order amounts.
5‑Tier option
- Tier count: 5; Tiers: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non‑Formulary (Tier 3), Formulary Specialty (Tier 4), Non‑Formulary Specialty (Tier 5).
Mail order is not available for Specialty drugs.
ALL of the following
3‑Tier examples
- Example retail copays (3‑tier): $20 (Generic) / $60 (Brand Formulary) / $90 (Brand Non‑Formulary). Mail order example: $40 / $120 / $270.
- Alternate 3‑tier retail example shown: $25 / $50 / $100 with mail order $50 / $100 / $300.
5‑Tier example
- Example retail copays (5‑tier): $20 (Generic) / $50 (Brand Formulary) / $100 (Brand Non‑Formulary) / $150 (Formulary Specialty) / $250 (Non‑Formulary Specialty). Mail order example: $40 / $100 / $300 (mail order not available for Specialty).
ALL of the following
- Generic / Tier 1: FDA‑approved generics contain the same active ingredients as brand drugs, are as safe and effective, and usually cost less. In Massachusetts, pharmacists are required to dispense generics unless the prescriber indicates 'no substitution'.
- Brand Formulary / Tier 2: Brand drugs chosen for the formulary based on relative safety, effectiveness and cost; copay is higher than generic but lower than non‑formulary.
- Brand Non‑Formulary / Tier 3: Brand drugs not selected as formulary; covered at the highest copay level (or higher copay in 5‑tier structure). Coverage of brand name drugs that have FDA‑approved generics requires demonstration of medical necessity.
- Formulary Specialty / Tier 4 & Non‑Formulary Specialty / Tier 5 (5‑tier only): Specialty drugs selected or not selected for formulary specialty; specialty tiers are covered at higher copays and mail order is not available for specialty drugs.
ALL of the following
- Health New England covers brand‑name drugs that have FDA‑approved generic equivalents only if medical necessity is demonstrated.
- Examples of medical necessity include inadequate response or allergic reaction to the generic(s) and failure of alternatives in the drug class.
- Provider action: the prescriber may request prior authorization by completing a drug request form and faxing it to Health New England with documentation of medical necessity for review.
Copay Examples and Coding
| Generic / Tier 1 | $20 |
| Brand Formulary / Tier 2 | $60 |
| Brand Non-Formulary / Tier 3 | $90 |
| Generic / Tier 1 | $40 |
| Brand Formulary / Tier 2 | $120 |
| Brand Non-Formulary / Tier 3 | $270 |
| Generic / Tier 1 | $25 |
| Brand Formulary / Tier 2 | $50 |
| Brand Non-Formulary / Tier 3 | $100 |
| Generic / Tier 1 | $50 |
| Brand Formulary / Tier 2 | $100 |
| Brand Non-Formulary / Tier 3 | $300 |
| Generic / Tier 1 | $20 |
| Brand Formulary / Tier 2 | $50 |
| Brand Non-Formulary / Tier 3 | $100 |
| Formulary Specialty / Tier 4 | $150 |
| Non-Formulary Specialty / Tier 5 | $250 |
| Generic / Tier 1 | $40 |
| Brand Formulary / Tier 2 | $100 |
| Brand Non-Formulary / Tier 3 | $300 |
| Formulary Specialty / Tier 4 | Mail order not available for Specialty drugs |
| Non-Formulary Specialty / Tier 5 | Mail order not available for Specialty drugs |
Provider Requirements and Prior Authorization
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.
- Submit a completed drug request form and fax it to Health New England for review.
- Include documentation demonstrating medical necessity (e.g., inadequate response to generics, allergic reaction to generics, or failure of alternatives).
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.