CurrentHealth-New-EnglandPolicy N/A

Prescription drug copay tiers and mail-order rules

Defines retail and mail-order copayment structure by drug tier and coverage rules for out-of-plan and specialty prescriptions 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 ActionApply 20% coinsurance after the copay for prescriptions from out-of-plan retail pharmacies; mail-order and specialty prescriptions from out-of-plan providers are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$60/$160/$375mail-order copay levels

5copay tiers

20%out-of-plan coinsurance

Prescription Coverage Criteria

inv-01: Prescription coverage criteria

Coverage and cost-sharing by drug tier and dispensing setting.

Covered when listed below; cost-sharing varies by drug tier and dispensing site.

Drug tier definitions

Generic / Tier 1: FDA‑approved generics with same active ingredients as brand drugs; pharmacists in Massachusetts must fill generics unless prescriber writes 'no substitution'.
Brand Formulary / Tier 2: Brand drugs selected for formulary based on relative 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 ActionApply 20% coinsurance after the copay for prescriptions from out-of-plan retail pharmacies; mail-order and specialty prescriptions from out-of-plan providers are not covered.

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 Mail-Order Notes

Copay tiersmixed

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 2	Brand/Formulary drugs are marketed under a trademarked brand name and do not have less expensive generic equivalents; selected based on review of relative safety, effectiveness and cost. Copay higher than generic but lower than Brand/Non-Formulary.
Brand Non-Formulary/Tier 3	Any brand name drug not selected as Brand/Formulary; covered at a higher copay level; copays are not waived or reduced.
Formulary Specialty/Tier 4	Formulary Specialty Drugs selected based on review of relative safety, effectiveness and cost of FDA-approved drugs.
Non-Formulary Specialty/Tier 5	Any brand name drug not selected as a Formulary Specialty Drug; covered but at the highest copay level; includes brand drugs that have formulary generic and brand alternatives.

Mail-order specialty availability

Mail-order specialty availabilityMail order is not available for Specialty drugs.

Mail-order copay examplesMail order copays listed for non-specialty tiers: $60 / $160 / $375.

Out-of-plan mail orderMail Order prescriptions from Out-of-Plan providers are not covered.

Out-of-Plan and Mail Order Coverage Rules

Billing Rule

Out-of-Plan and Mail Order Coverage Rules

For prescriptions filled at an Out-of-Plan retail pharmacy, a 20% coinsurance applies in addition to the member copay. Mail order prescriptions from Out‑of‑plan providers are not covered, and specialty drugs from Out‑of‑plan providers are not covered.

20% coinsurance applies after copay for Out-of-Plan retail pharmacy fills.
Mail order prescriptions from Out-of-Plan providers are not covered.
Specialty drugs from Out-of-Plan providers are not covered.

Tier Definitions

Generic / Tier 1 — definition and substitution rules

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

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

Cost-sharing positionGenerics are assigned the lowest copay tier (Tier 1).

Brand Formulary / Tier 2 — definition and copay characterization

DefinitionBrand Formulary/Tier 2: Brand drugs marketed under a trademarked name without less expensive generic equivalents, selected based on safety, effectiveness and cost.

Copay characterizationCopay for Brand/Formulary drugs is higher than generic (Tier 1) but lower than Brand Non-Formulary (Tier 3).

Coverage selectionTier assignment reflects formulary review of relative clinical and cost attributes.

Brand Non-Formulary / Tier 3 — definition and coverage notes

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

Coverage noteThese medications are still covered but at a higher copay level; copays are not waived or reduced for Brand Non-Formulary drugs.

Relative cost positionCopay level is higher than Tier 2 and Tier 1.

Formulary Specialty / Tier 4 — specialty formulary definition

DefinitionFormulary Specialty/Tier 4: Specialty drugs selected based on review of relative safety, effectiveness and cost among FDA-approved drugs.

Site-of-service restrictionSpecialty tier drugs are subject to specialty-specific rules; mail order is not available for Specialty drugs.

Coverage stanceFormulary Specialty drugs are covered with criteria consistent with specialty tier designation.

Non-Formulary Specialty / Tier 5 — definition and copay level

DefinitionNon-Formulary Specialty/Tier 5: Brand specialty drugs not selected as Formulary Specialty (Tier 4), including those with formulary generic or brand alternatives.

Copay levelThese medications are still covered but at the highest copay level (highest specialty tier).

Coverage noteSpecialty drugs from Out-of-Plan providers are not covered; mail order is not available for Specialty drugs.