CurrentHealth-New-EnglandPolicy N/A

Prescription drug copay tiers and mail order copays

Defines retail and mail-order copay amounts by drug tier and explains tier definitions and mail-order availability; applies to Health New England members subject to this plan's pharmacy benefits.

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail order copays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMail order is not available for Specialty drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$30/$80/$125/$150/$200Retail copays (G/BF/BNF/FS/NFS)

$60/$160/$375Mail-order copays (G/BF/BNF)

Not availableMail-order specialty

Combined med-pharmDeductible

Prescription Drug Coverage Rules

Prescription drug copay and tier coverage

Copays and coverage categories by tier; includes mail-order rules and deductible applicability.

ALL of the following

Retail copays
- Generic / Tier 1 — Retail copay: $30
- Brand Formulary / Tier 2 — Retail copay: $80
- Brand Non-Formulary / Tier 3 — Retail copay: $125
- Formulary Specialty / Tier 4 — Retail copay: $150

Policy Summary

PayerHealth-New-England

PolicyPrescription drug copay tiers and mail order copays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMail order is not available for Specialty drugs.

SourceLink

On This Page

Tier definitions

Generic / Tier 1: FDA-approved generic drugs with the same active ingredients as brand drugs; typically lower cost. In Massachusetts, pharmacists must fill generics unless the prescriber writes 'no substitution'.
Brand Formulary / Tier 2: Brand drugs selected for the 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; Health New England does not waive or reduce copays for Brand Non-Formulary drugs.
Formulary Specialty / Tier 4: Specialty drugs selected for formulary based on review of safety, effectiveness and cost.
Non-Formulary Specialty / Tier 5: Brand specialty drugs not selected as formulary specialty; may have formulary alternatives and carry the highest copay.

Copay Amounts by Tier

Retail copays by tiermixed

Generic / Tier 1	$30
Brand Formulary / Tier 2	$80
Brand Non-Formulary / Tier 3	$125
Formulary Specialty / Tier 4	$150
Non-Formulary Specialty / Tier 5	$200

Mail-order copays by tiermixed

Generic / Tier 1	$60
Brand Formulary / Tier 2	$160
Brand Non-Formulary / Tier 3	$375
Formulary Specialty / Tier 4	Mail order is not available for Specialty drugs
Non-Formulary Specialty / Tier 5	Mail order is not available for Specialty drugs

Deductible applicabilitymixed

Combined medical pharmacy deductible

Prescription drugs are subject to the combined medical pharmacy deductible for this plan.

Provider & Pharmacy Notices

Note

Mail-order specialty restriction — use specialty or retail dispensing

Mail order is not available for Specialty drugs. Prescribers should arrange for specialty medications to be dispensed via appropriate specialty pharmacy or retail channels rather than mail-order, and counsel patients about alternate fulfillment options when prescribing tier 4 or tier 5 (specialty) products.

Do not submit specialty drug fills for mail-order dispensing; use specialty or retail pharmacies instead.
Inform patients that specialty medications are excluded from mail-order and discuss alternate pickup/delivery arrangements.

Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: Approved by the FDA; contains same active ingredients as brand drugs; as safe and effective and usually lower cost.

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

Cost positionTypically carries the lowest copay compared with higher tiers.

Brand Formulary / Tier 2

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

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

Coverage noteThese are covered medications chosen from among FDA‑approved options for clinical and cost considerations.

Brand Non-Formulary / Tier 3

DefinitionBrand Non‑Formulary/Tier 3: Brand name drugs not selected as Brand/Formulary by Health New England; still covered but at a higher copay level.

Cost noteThese medications carry a higher copay than Tier 1 and Tier 2; Health New England does not waive or reduce copays for Brand/Non‑Formulary drugs.

Coverage statusCovered under the plan subject to the higher copay structure.

Formulary Specialty / Tier 4

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

Specialty remarkThese are specialty medications chosen after clinical and cost evaluation among FDA‑approved drugs.

Copay positionPlaced in a higher tier reflecting specialty status and associated costs (see copay schedule).

Non-Formulary Specialty / Tier 5

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

Cost implicationThese medications are still covered but are placed at the highest copay level.

Formulary alternative guidanceThis category may include drugs with available formulary alternatives (generic or brand) that may be preferred for lower cost sharing.