CurrentHealth-New-EnglandPolicy N/A

Retail and Mail-Order Prescription Copays and Tier Definitions

Policy Summary

PayerHealth-New-England

PolicyRetail and Mail-Order Prescription Copays and Tier Definitions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionApply the specified copay and coverage rules for retail and mail-order prescriptions, including 20% coinsurance for out-of-plan retail prescriptions after the member copay and exclusion of mail-order and specialty claims from out-of-plan coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$40/$100/$225Mail-order copays listed (tiers: Generic/Brand Formulary/Brand Non-Formulary)

Tier 1–Tier 5Number of copay tiers defined

20%Coinsurance for out-of-plan retail pharmacy prescriptions after copay

Policy Snapshot

Defines copay amounts and rules for retail and mail-order prescription drugs, tier definitions for formulary placement, and coverage rules for out-of-plan and specialty drugs. Intended for billing/claims and clinical operations staff responsible for processing Health New England pharmacy benefits, this policy documents the copay structure for five tiers and the conditions under which mail-order and out-of-plan services are covered or excluded.

Policy Summary

PayerHealth-New-England

PolicyRetail and Mail-Order Prescription Copays and Tier Definitions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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.

Formulary Tiers and Definitions

This policy defines the copay amounts, tier structure, and coverage rules for both retail and mail-order prescription drugs. It specifies the five copay tiers—Generic (Tier 1) through Non-Formulary Specialty (Tier 5)—and explains differences in copays and formulary placement. The guidance is intended to inform claims and billing operations on how to apply copays, coinsurance for out-of-plan retail prescriptions, and restrictions that affect mail-order and specialty drug coverage.

Definitions

Generic / Tier 1Approved by the FDA, contain the same active ingredients as brand name drugs, considered safe, effective, and usually less costly. Pharmacists in Massachusetts must substitute generics unless 'no substitution' is specified by the prescriber.

Brand Formulary / Tier 2Brand drugs selected for the formulary based on safety, effectiveness and cost. Copay higher than generic but lower than Brand Non-Formulary.

Brand Non-Formulary / Tier 3Brand name drugs not selected for the formulary; covered but at a higher copay. Health New England does not waive or reduce copays for these drugs.

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

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

Billing Rules and Provider Impact

Billing Rule

Out-of-Plan Retail Pharmacy Billing

For prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after the member copay.

Billing Rule

Mail Order Coverage and Billing

Mail order copays are $40 (Generic), $100 (Brand Formulary), $225 (Brand Non-Formulary). Mail order is not available for Specialty drugs. Mail order prescriptions from Out-of-Plan providers are not covered.

Billing Rule

Specialty Drug Coverage from Out-of-Plan Providers

Specialty drugs obtained from Out-of-Plan providers are not covered.

Documentation Required

Massachusetts Generic Substitution Rule

In Massachusetts, pharmacists must fill a generic unless the prescriber writes 'no substitution' on the prescription to request brand.

Mail-Order and Specialty Exceptions

Mail-order prescriptions are covered at specified copays of $40 (Generic), $100 (Brand Formulary), and $225 (Brand Non-Formulary). Mail order is not available for Specialty drugs. Additionally, mail-order prescriptions from Out-of-Plan providers are not covered, and Out-of-Plan retail prescriptions are instead subject to the out-of-plan coinsurance rules.

Copays & Coinsurance

Mail-order copays$40 (Generic) / $100 (Brand Formulary) / $225 (Brand Non-Formulary)

Coinsurance for out-of-plan retail pharmacy20% after the member copay

Mail-order specialty availabilityNot available for Specialty

Administrative Context

The tier structure groups medications by formulary status and expected cost and utilization. Generic (Tier 1) drugs are FDA-approved equivalents and typically cost less; Massachusetts regulations require pharmacists to substitute generics unless the prescriber indicates 'no substitution.' Brand Formulary (Tier 2) and Brand Non-Formulary (Tier 3) reflect formulary selection and higher copays for non-formulary brands. Formulary Specialty (Tier 4) and Non-Formulary Specialty (Tier 5) identify specialty products with higher cost and coverage distinctions, including that specialty drugs obtained from Out-of-Plan providers are not covered.

OpenPayer

Retail and Mail-Order Prescription Copays and Tier Definitions

Policy Snapshot

Formulary Tiers and Definitions

Billing Rules and Provider Impact

Mail-Order and Specialty Exceptions

Administrative Context

Policy Update Changes