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 exceptions for Health New England members. Affects members whose plans use these copay tiers and pharmacy benefit administrators.

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; prescription drugs are subject to the combined medical pharmacy deductible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$10/$35/$60/$100/$125Retail copays by tier (Gen→Non-Formulary Specialty)

$20/$70/$180Mail-order copays (Gen / Brand Formulary / Brand Non-Formulary)

Not availableMail-order specialty restriction

AppliesCombined medical pharmacy deductible

5Copay tiers

Coverage and Delivery Rules

Copay coverage and delivery rules

Covered with tiered copays and delivery-specific rules. Retail and mail-order copays differ by tier; specialty drugs are covered but mail-order is not available for specialty tiers. Prescription drugs are subject to the combined medical pharmacy deductible.

ALL of the following

Retail copay amount
- Tier 1 (Generic) retail copay: $10
- Tier 2 (Brand/Formulary) retail copay: $35
- Tier 3 (Brand/Non‑Formulary) retail copay: $60
- Tier 4 (Formulary Specialty) retail copay: $100

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; prescription drugs are subject to the combined medical pharmacy deductible.

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.

ALL of the following

Tier definitions
- Generic / Tier 1: FDA‑approved generics with the same active ingredients as brand drugs; generally lower cost. (In Massachusetts pharmacists must fill generic unless 'no substitution' is specified.)
- Brand Formulary / Tier 2: Trademarked brand drugs selected for formulary after review of safety, effectiveness, and cost; copay higher than generic.
- Brand Non‑Formulary / Tier 3: Brand drugs not selected as formulary; covered at a higher copay and Health New England does not waive or reduce copays for these drugs.
- Formulary Specialty / Tier 4: Specialty drugs selected for formulary following review of safety, effectiveness, and cost.
- Non‑Formulary Specialty / Tier 5: Brand specialty drugs not selected as formulary specialty; covered at the highest copay and may include drugs with formulary alternatives.

Copay Tiers and Mail-order Notes

Retail copays by tiermixed

Tier 1 (Generic)	$10
Tier 2 (Brand Formulary)	$35
Tier 3 (Brand Non-Formulary)	$60
Tier 4 (Formulary Specialty)	$100
Tier 5 (Non-Formulary Specialty)	$125

Mail-order copaysmixed

Tier 1 (Generic)	$20
Tier 2 (Brand Formulary)	$70
Tier 3 (Brand Non-Formulary)	$180

Mail-order specialty restrictionmixedNot Covered

Formulary Specialty / Non-Formulary Specialty

Mail order is not available for Specialty drugs

Deductible notemixed

Prescription drugs

Subject to the combined medical pharmacy deductible for this plan

Mail-order specialty availability

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

Tier Definitions

Generic / Tier 1

DefinitionApproved by the FDA; contain the same active ingredients as brand name drugs and are as safe and effective.

Cost characteristicUsually cost less than brand-name drugs; retail copay: $10; mail-order copay: $20.

Massachusetts noteIn Massachusetts, pharmacists must fill generic drugs unless the prescriber writes 'no substitution' on the prescription.

Brand Formulary / Tier 2

DefinitionBrand/Formulary drugs marketed under a trademarked brand name and selected for formulary based on review of safety, effectiveness, and cost.

Formulary rationaleSelected following comparative review of relative safety, effectiveness and cost among FDA‑approved drugs.

Cost characteristicHigher copay than generics; retail copay: $35; mail-order copay: $70.

Brand Non-Formulary / Tier 3

DefinitionBrand name drugs not selected as Brand/Formulary (Tier 3); still covered but at a higher copay.

Coverage noteHealth New England does not waive or reduce copays for Brand/Non‑Formulary drugs.

Cost characteristicRetail copay: $60; mail-order copay: $180.

Formulary Specialty / Tier 4

DefinitionFormulary Specialty drugs (Tier 4) are specialty medications selected based on review of relative safety, effectiveness and cost.

Coverage noteThese specialty drugs are included on the formulary and covered under Tier 4.

Cost characteristicRetail copay: $100.

Non-Formulary Specialty / Tier 5

DefinitionNon‑Formulary Specialty drugs (Tier 5) are brand specialty drugs not selected as Formulary Specialty; may include brand drugs that have formulary generic and brand alternatives.

Coverage noteThese medications are covered but at the highest copay level.

Cost characteristicRetail copay: $125; mail-order is not available for specialty drugs.

OpenPayer

Prescription drug copay tiers and mail order copays

Coverage and Delivery Rules

Copay Tiers and Mail-order Notes

Provider Billing and Mail-order Alert

Tier Definitions