CurrentHealth-New-EnglandPolicy N/A

Prescription drug copay tiers and mail-order rules

Defines retail and mail-order copay tiers, deductible and out-of-network cost sharing, and specialty drug coverage rules for Health New England members.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail-order rules

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMail order and specialty prescriptions from out-of-plan providers are not covered; for out-of-plan retail, 20% coinsurance applies after copay.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$40/$100/$450example mail-order copay values listed

5 tiersdefined copay tiers

20%out-of-plan retail coinsurance

Unavailablemail-order specialty availability

Coverage and Cost-Sharing Rules

Prescription coverage criteria

Coverage and cost-sharing rules for prescription drugs:

ALL of the following

Copay tiers
- Generic / Tier 1: generic drugs; typically lower cost; pharmacists in Massachusetts must fill generic unless prescriber indicates 'no substitution'
- Brand Formulary / Tier 2: brand drugs selected for formulary based on safety, effectiveness and cost; copay higher than generic but lower than non-formulary
- Brand Non-Formulary / Tier 3: brand drugs not selected as formulary; covered at a higher copay; copays are not waived or reduced

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail-order rules

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMail order and specialty prescriptions from out-of-plan providers are not covered; for out-of-plan retail, 20% coinsurance applies after copay.

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.

Copay Tiers and Examples

Generic / Tier 1mixed

Generic / Tier 1

Approved by the FDA, generic drugs contain the same active ingredients as brand name drugs, are just as safe and effective, and usually cost less. Note: In Massachusetts, pharmacists are required to fill generic drugs unless your doctor orders the brand name by including 'no substitution' on the prescription.

Brand Formulary / Tier 2mixed

Brand Formulary / Tier 2

Brand/Formulary drugs are marketed under a trademarked brand name, by one company, and do not have less expensive generic equivalents. Selected based on review of relative safety, effectiveness and cost. Copay is higher than generic but lower than Brand Non-Formulary.

Brand Non-Formulary / Tier 3mixed

Brand Non-Formulary / Tier 3

Any brand name drug that Health New England has not selected as a Brand/Formulary drug. These medications are still covered, but at a higher copay level. Health New England does not waive or reduce copays for Brand/Non-Formulary drugs.

Formulary Specialty / Tier 4mixed

Formulary Specialty / Tier 4

Formulary Specialty Drugs are selected based on a review of the relative safety, effectiveness and cost of the many FDA-approved drugs on the market.

Non-Formulary Specialty / Tier 5mixed

Non-Formulary Specialty / Tier 5

Any brand name drug that Health New England has not selected as a Formulary Specialty Drug (Tier 4). This category includes brand drugs that have formulary generic and brand alternatives. These medications are still covered, but at the highest copay level.

Mail order copay example

Mail-order copay example (Generic / Brand Formulary / Brand Non‑Formulary)$40 / $100 / $450

Plan deductible applicationDeductible applies to Brand Formulary, Brand Non‑Formulary, Formulary Specialty and Non‑Formulary Specialty drugs

Mail order availability for specialtyMail order is not available for Specialty drugs

Provider and Billing Notices

Denial Risk

Out-of-Plan and Mail Order Coverage

Mail order prescriptions written by out-of-plan providers are not covered. In addition, specialty drugs provided by out-of-plan providers are not covered; mail order is not available for specialty drugs.

Billing Rule

Out-of-Plan Retail Cost Sharing

When a prescription is filled at an out-of-plan retail pharmacy, a 20% coinsurance applies after the member copay.

Coinsurance is assessed after the applicable copay is applied.

Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: Approved by the FDA; contain the same active ingredients as brand name drugs and are usually lower cost

Cost behaviorTypically have the lowest copay compared with higher tiers

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

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name and selected for formulary based on safety, effectiveness and cost

Placement guidanceCopay is higher than Generic (Tier 1) but lower than Brand Non‑Formulary (Tier 3)

Selection rationaleIncluded after review of relative safety, effectiveness and cost among FDA‑approved options

Brand Non-Formulary / Tier 3

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

Coverage implicationsThese medications are still covered but at a higher copay level; Health New England does not waive or reduce copays for Brand Non‑Formulary drugs

Mail order copay exampleMail order Brand Non‑Formulary copay shown as $450 in plan example

Formulary Specialty / Tier 4

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

Coverage handlingCovered as specialty drugs; plan deductible applies to Formulary Specialty drugs

Mail order restrictionMail order is not available for Specialty drugs

Non-Formulary Specialty / Tier 5

DefinitionNon‑Formulary Specialty/Tier 5: Brand specialty drugs not selected as Formulary Specialty drugs

Coverage implicationsThese medications are still covered but carry the highest copay level; plan deductible applies

Alternatives noteCategory includes brand drugs that have formulary generic and brand alternatives