CurrentHealth-New-EnglandPolicy N/A

2025 Pharmacy Benefit Tier Structures and Copay Rules

Defines 3-tier and 5-tier pharmacy benefit options, associated retail and mail-order copays, and related coverage rules for Health New England PPO and HDHP plans. Affects members enrolled in the listed 2025 pharmacy benefit options.

Policy Summary

PayerHealth-New-England

Policy2025 Pharmacy Benefit Tier Structures and Copay Rules

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionProviders may request prior authorization for a brand-name drug by submitting a drug request form with documentation of medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-tierpharmacy benefit option described

5-tierpharmacy benefit option described

$15/$30/$50example retail copay sequence

No mail-ordermail-order limitation for Specialty drugs

Coverage rules and copays

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.

Copays and network limitations

Retail and mail-order copays and coverage limitations for listed 3- and 5-tier plan options.

Member copay amounts vary by plan option and tier; examples include: $15/$30/$50 (3-tier) and $15/$30/$50/$100/$150 (5-tier) for Generic / Brand Formulary / Brand Non-Formulary (and Specialty tiers when applicable).

Mail-order copays are provided for non-specialty tiers and are generally higher per-dispense amounts (examples shown next to retail sequences in plan listings).

Mail-order is not available for Specialty drugs on 5-tier plan options.

Prescription drugs are subject to the combined medical/pharmacy deductible for applicable plans where stated.

For prescriptions filled at an Out-of-Plan retail pharmacy, 20% coinsurance applies after the copay for affected plan options.

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

Specialty drugs from Out-of-Plan providers are not covered (3-tier plan statement).

Out-of-Plan and Specialty coverage

Out-of-plan and specialty provider rules

Out-of-Plan retail pharmacy fills: 20% coinsurance applies after the applicable copay.

Mail-order fills from Out-of-Plan providers: not covered.

Specialty drugs obtained from Out-of-Plan providers: not covered.

Actions providers must take

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 to Health New England (fax) for review.
Include documentation demonstrating medical necessity (e.g., inadequate response or allergy to generics, failure of alternatives).

Tier definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: FDA-approved generics with the same active ingredients as brand drugs; as safe and effective and usually lower cost.

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

Cost postureTypically the lowest member copay compared with higher-brand tiers.

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 positionCopay is higher than Generic/Tier 1 but lower than Brand Non-Formulary/Tier 3.

Selection criteriaIncluded after review of the many FDA-approved drugs on the market for safety, effectiveness, and cost.

Brand Non-Formulary / Tier 3

DefinitionBrand Non-Formulary/Tier 3: Brand name drugs not selected as Brand/Formulary (3-tier) or not selected as Brand/Formulary by Health New England (5-tier); still covered but at a higher copay level.

Medical necessityHealth New England covers brand drugs that have FDA-approved generic equivalents only if medical necessity is demonstrated; providers may request prior authorization with a drug request form and documentation (e.g., inadequate response or allergic reaction to generics, failure of alternatives).

Copay policyCovered at the highest non-specialty copay (3-tier) or at a higher copay level (5-tier); Health New England does not waive or reduce copays for Brand/Non-Formulary drugs (5-tier).

Formulary Specialty / Tier 4

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

Coverage statusThese specialty medications are included on the formulary and covered under the specialty tier (Tier 4).

Selection criteriaSelection follows the same review principles as other tiers: safety, effectiveness, and cost among FDA-approved specialty drugs.

Non-Formulary Specialty / Tier 5

DefinitionNon-Formulary Specialty/Tier 5: Specialty brand drugs not selected as Formulary Specialty (Tier 4); includes brand drugs that have formulary generic and brand alternatives.

Copay positionThese medications are still covered but at the highest copay level for specialty tiers.

Relationship to alternativesCategory includes specialty brand drugs with formulary generic and brand alternatives, implying preference for formulary options when available.