CurrentHealth-New-EnglandPolicy N/A

Prescription Drug Copay Tiers and Provider Source Rules

Defines retail and mail-order copay tiers and rules for prescription drugs under the Health New England plan, including specialty drug coverage and out-of-plan provider rules. Affects plan members obtaining medications through retail or mail-order pharmacies.

Policy Summary

PayerHealth-New-England

PolicyPrescription Drug Copay Tiers and Provider Source Rules

Policy CodePolicy N/A

Change TypeNo material change — informational update

Effective DateN/A

Next Review DateN/A

Key ActionDo not use mail-order for specialty drugs; verify provider is in‑plan to avoid out‑of‑plan coinsurance.

SourceLink

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

5copay tiers

20%out-of-plan coinsurance

not availablemail-order specialty

Coverage Criteria & Copay Tiers

Copay tiers and provider source rules

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Copay tiers: Generic (Tier 1), Brand Formulary (Tier 2), Brand Non-Formulary (Tier 3), Formulary Specialty (Tier 4), Non-Formulary Specialty (Tier 5).

Generic / Tier 1: Generic drugs are covered; approved by the FDA and contain the same active ingredients as brand-name drugs; pharmacists in Massachusetts must fill generics unless prescriber indicates 'no substitution'.

Brand Formulary / Tier 2: Brand formulary drugs are covered; selected based on safety, effectiveness, and cost; copay is higher than generic but lower than non-formulary.

Brand Non-Formulary / Tier 3: Brand non-formulary drugs are covered at a higher copay; Health New England does not waive or reduce copays for Brand Non-Formulary drugs.

Formulary Specialty / Tier 4: Formulary specialty drugs are covered; mail-order is not available for specialty drugs.

Non-Formulary Specialty / Tier 5: Non-formulary specialty drugs are covered at the highest copay level; mail-order is not available for specialty drugs.

Out-of-Plan retail pharmacy: Prescriptions filled at out-of-plan retail pharmacies are subject to 20% coinsurance after the applicable copay.

Out-of-Plan mail-order: Mail-order prescriptions from out-of-plan providers are not covered.

Out-of-Plan specialty drugs: Specialty drugs obtained from out-of-plan providers are not covered.

Copay Tiers and Out-of-Plan Coinsurance

Copay tiers (informational)mixed

Generic / Brand Formulary / Brand Non-Formulary / Formulary Specialty / Non-Formulary Specialty	Retail Copays: Generic, Brand Formulary, Brand Non-Formulary, Formulary Specialty, Non-Formulary Specialty
Generic / Brand Formulary / Brand Non-Formulary	Mail Order Copays (mail order is not available for Specialty drugs); example amounts: $60/$160/$375

Out-of-Plan retail coinsurance

Out-of-Plan retail coinsurance20% coinsurance applies after copay for prescriptions from an Out-of-Plan retail pharmacy.

Out-of-Plan mail-order coverageMail Order prescriptions from Out-of-Plan providers are not covered.

Out-of-Plan specialty drugsSpecialty drugs from Out-of-Plan providers are not covered.

Provider Requirements and Restrictions

Billing Rule

Out-of‑Plan pharmacy coverage restrictions

Mail Order prescriptions and specialty drugs obtained from providers outside the Health-New-England network are not covered; prescriptions dispensed at an out-of-plan retail pharmacy are subject to 20% coinsurance after the member copay.

Mail Order prescriptions from Out-of-Plan providers are not covered.
Specialty drugs from Out-of-Plan providers are not covered.
For prescriptions from an Out-of-Plan retail pharmacy, 20% coinsurance applies after copay.

Note

Mail‑order restriction for specialty drugs

Specialty drugs are not available through the mail-order benefit; members and prescribers must obtain specialty medications through covered specialty channels per the plan.

Mail order is not available for Specialty drugs.

Tier Definitions

Generic / Tier 1

DefinitionGeneric/Tier 1: Approved by the FDA; contain the same active ingredients as brand-name drugs, are as safe and effective, and usually cost less.

Pharmacist substitution noteIn Massachusetts, pharmacists are required to fill generics unless the prescriber writes 'no substitution' on the prescription.

Coverage positionCovered (subject to applicable copay and combined medical pharmacy deductible).

Brand Formulary / Tier 2

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

Cost relation to genericCopay for Brand/Formulary drugs is higher than for generics but lower than Brand/Non-Formulary drugs.

Coverage positionCovered with applicable copay; subject to plan deductible where noted.

Brand Non-Formulary / Tier 3

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

Copay levelCovered at a higher copay level than Brand/Formulary and Generic; copays are not waived or reduced.

Coverage positionCovered with applicable copay; members may face higher out-of-pocket cost compared to Tier 1 and Tier 2.

Formulary Specialty / Tier 4

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

Mail-order restrictionMail order is not available for Specialty drugs.

Coverage positionCovered as specialty formulary medications subject to specialty dispensing rules and copays.

Non-Formulary Specialty / Tier 5

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

Copay levelThese medications are covered but at the highest copay level.

Mail-order and out-of-plan rulesMail order is not available for specialty; specialty drugs from Out-of-Plan providers are not covered.