CurrentHealth-New-EnglandPolicy N/A

Prescription drug copay structure and coverage rules

Describes retail and mail-order prescription copays by formulary tier, coinsurance rules for out-of-plan pharmacies, mail-order and specialty coverage restrictions, and definitions of formulary tiers for Health New England plan members.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay structure and coverage rules

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIn Massachusetts, pharmacists must dispense the generic unless the prescriber writes 'no substitution'; follow tiered copay and deductible rules and note that out-of-plan mail-order and specialty prescriptions are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$20/$70/$180example copay tier amounts listed

5 tierscopay tiers defined

20%out-of-plan retail coinsurance after copay

Policy Snapshot

This policy describes retail and mail-order prescription copays by formulary tier, coinsurance rules that apply for prescriptions obtained from out-of-plan retail pharmacies, coverage restrictions for mail-order and specialty drugs obtained from out-of-plan providers, and the definitions of formulary tiers used for Health New England plan members.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay structure and coverage rules

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

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.

When Coverage and Cost Apply

Coverage and cost application rules

Rules determining copay/coverage depending on pharmacy type and provider network status.

ALL of the following

Prescription drugs are subject to the combined medical pharmacy deductible for this plan.
For prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after copay.20% after copay
Mail Order prescriptions from Out-of-Plan providers are not covered.
Specialty drugs from Out-of-Plan providers are not covered.

Formulary Tier Definitions

Generic / Tier 1Approved by the FDA, generic drugs contain the same active ingredients as brand name drugs, are just as safe and effective, and usually cost less.

Brand Formulary / Tier 2Brand/Formulary drugs are marketed under a trademarked brand name, do not have less expensive generic equivalents, selected based on safety, effectiveness and cost; copay higher than generic but lower than Brand Non-Formulary.

Brand Non-Formulary / Tier 3Any brand name drug not selected as Brand/Formulary by Health New England; covered at a higher copay level and copays are not waived or reduced for these drugs.

Formulary Specialty / Tier 4Formulary Specialty drugs are selected based on relative safety, effectiveness and cost among FDA-approved specialty medications.

Non-Formulary Specialty / Tier 5Brand specialty drugs not selected as Formulary Specialty (Tier 4); may have formulary generic and brand alternatives and are covered at the highest copay level.

Actions, Billing Rules and Documentation Requirements

Documentation Required

Massachusetts generic substitution requirement

In Massachusetts, pharmacists are required to fill generic drugs unless the prescribing clinician writes 'no substitution' on the prescription to request a brand product.

Billing Rule

Copay application and deductible

Prescription copays apply by tier and prescriptions are subject to the combined medical pharmacy deductible. For prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after the copay; mail-order prescriptions from Out-of-Plan providers and specialty drugs from Out-of-Plan providers are not covered.

Out-of-plan retail pharmacy claims incur 20% coinsurance after the copay.
Mail-order prescriptions from out-of-plan providers are not covered.
Specialty drugs from out-of-plan providers are not covered.

Clinical / Administrative Background

This policy explains the plan's prescription cost-sharing structure, including tiered copays for Generic (Tier 1), Brand Formulary (Tier 2), Brand Non-Formulary (Tier 3), Formulary Specialty (Tier 4), and Non-Formulary Specialty (Tier 5) medications, and notes that prescription drugs are subject to the plan's combined medical pharmacy deductible. For out-of-plan retail pharmacy claims, a 20% coinsurance after the copay applies, and mail-order prescriptions from out-of-plan providers and specialty drugs from out-of-plan providers are not covered. Example copay amounts are listed as $20/$70/$180 in the source document.

OpenPayer