CurrentHealth-New-EnglandPolicy N/A

Retail and Mail Order Drug Copays and Tier Definitions

Defines copayment amounts for retail and mail-order pharmacy fills by drug tier and explains tier definitions; applies to Health New England members (state-specific notes included for Massachusetts).

Policy Summary

PayerHealth-New-England

PolicyRetail and Mail Order Drug Copays and Tier Definitions

Policy CodePolicy N/A

Change TypeNo material change

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.

$25/$50/$150/$200/$250Retail copay schedule

$50/$100/$450Mail order copay schedule

Not availableMail-order specialty

Generic substitutionState requirement (MA)

Retail and Mail-Order Coverage Criteria

Retail copay criteria

Coverage is provided across all listed tiers; retail copay amounts vary by tier. Tier definitions are shown for reference, including a Massachusetts substitution note.

Covered when member pays the applicable retail copay for the drug tier.

ALL of the following

Retail copay schedule
- Generic / Tier 1: $25
- Brand Formulary / Tier 2: $50
- Brand Non-Formulary / Tier 3: $150

Policy Summary

PayerHealth-New-England

PolicyRetail and Mail Order Drug Copays and Tier Definitions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMail order is not available for Specialty drugs

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 same active ingredients as brand; generally lower cost. (Massachusetts: pharmacists required to fill generic unless prescriber writes 'no substitution'.)
Brand Formulary/Tier 2 — Brand drugs selected for formulary; copay higher than generic but lower than non-formulary brand.
Brand Non-Formulary/Tier 3 — Brand drugs not on formulary; covered at a higher copay; copays are not waived or reduced.
Formulary Specialty/Tier 4 — Selected specialty drugs reviewed for safety, effectiveness and cost.
Non-Formulary Specialty/Tier 5 — Specialty brand drugs not selected as formulary specialty; covered at the highest copay.

Mail-order copay criteria

Mail-order fills follow a separate copay schedule; specialty drugs are not available via mail order.

Covered when member pays the applicable mail-order copay for the drug tier.

ALL of the following

Mail-order copay schedule
- Generic / Tier 1: $50
- Brand Formulary / Tier 2: $100
- Brand Non-Formulary / Tier 3: $450

ALL of the following

Mail-order limitation: Mail order is not available for Formulary Specialty (Tier 4) or Non-Formulary Specialty (Tier 5) drugs.

Copay Schedules and Tiered Pricing

Retail copay schedulemixed

Generic / Tier 1	$25
Brand Formulary / Tier 2	$50
Brand Non-Formulary / Tier 3	$150
Formulary Specialty / Tier 4	$200
Non-Formulary Specialty / Tier 5	$250

Mail-order copay schedulemixed

Generic / Tier 1	$50
Brand Formulary / Tier 2	$100
Brand Non-Formulary / Tier 3	$450

Retail copay tiers

Generic / Tier 1$25 retail copay

Brand Formulary / Tier 2$50 retail copay

Brand Non-Formulary / Tier 3$150 retail copay

Formulary Specialty / Tier 4$200 retail copay

Non-Formulary Specialty / Tier 5$250 retail copay

Mail order copay tiers

Generic / Tier 1$50 mail-order copay

Brand Formulary / Tier 2$100 mail-order copay

Brand Non-Formulary / Tier 3$450 mail-order copay

Tier Definitions

Generic / Tier 1

DefinitionFDA‑approved drugs with the same active ingredients as brand-name drugs; generally lower cost and as safe and effective as brand-name products.

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

Tier designationReferred to as Generic / Tier 1 in the copay schedule.

Brand Formulary / Tier 2

DefinitionBrand/Formulary drugs marketed under a trademarked brand name without less expensive generic equivalents; selected based on relative safety, effectiveness and cost.

Copay implicationCopay is higher than generic (Tier 1) but lower than Brand Non‑Formulary (Tier 3).

Tier designationReferred to as Brand Formulary / Tier 2 in the copay schedule.

Brand Non-Formulary / Tier 3

DefinitionAny brand-name drug not selected as a Brand/Formulary drug by Health New England; covered but at a higher copay level.

Copay detailsThese medications remain covered, but Health New England does not waive or reduce copays for Brand Non‑Formulary drugs.

Tier designationReferred to as Brand Non-Formulary / Tier 3 in the copay schedule.

Formulary Specialty / Tier 4

DefinitionSpecialty drugs selected for the formulary based on review of relative safety, effectiveness and cost among FDA‑approved drugs.

Selection criteriaIncluded after evaluation of safety, effectiveness and cost compared to other FDA‑approved options.

Tier designationReferred to as Formulary Specialty / Tier 4 in the copay schedule.

Non-Formulary Specialty / Tier 5

DefinitionBrand specialty drugs not selected as Formulary Specialty (Tier 4); may have formulary generic and brand alternatives and are covered at the highest copay level.

Coverage noteThese medications are still covered but subject to the highest copay (Non‑Formulary Specialty / Tier 5).

Tier designationReferred to as Non‑Formulary Specialty / Tier 5 in the copay schedule (retail copay $250).

OpenPayer

Retail and Mail Order Drug Copays and Tier Definitions

Retail and Mail-Order Coverage Criteria

Copay Schedules and Tiered Pricing

Provider Notes and Operational Limits

Tier Definitions