Retail and Mail Order Prescription Copay Structure
Defines copay amounts and tier descriptions for retail and mail-order prescription drugs for Health New England members; affects members and pharmacy/payment processing for prescriptions.
No material clinical or coverage changes in this revision.
Coverage Criteria
Copay-based coverage rules
Coverage is tiered by drug formulary status with specified member copays; specialty drugs are not available via mail order.
ALL of the following
Retail copay tier
- Generic / Tier 1 — Retail copay: $25. (Generic drugs contain the same active ingredients as brand name drugs and typically cost less.)$25
Pharmacists in MA are required to dispense generic unless 'no substitution' is indicated.
- Brand Formulary / Tier 2 — Retail copay: $50.$50
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