CurrentHealth-New-EnglandPolicy N/A

Retail and Mail Order Prescription Copay Tiers

Defines copayment amounts and tier definitions for retail and mail-order prescription drugs under Health New England plans; applies to members receiving prescriptions in-plan and describes limited out-of-plan coverage rules.

Policy Summary

PayerHealth-New-England

PolicyRetail and Mail Order Prescription Copay Tiers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMail order and specialty prescriptions from out-of-plan providers are not covered; out-of-plan retail prescriptions require 20% coinsurance after the copay.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$30/$80/$125/$150/$200Retail copays (T1/T2/T3/T4/T5)

$60/$160/$375Mail order copays (T1/T2/T3)

20% coinsuranceOut-of-Plan retail

Not coveredOut-of-Plan mail order

Not coveredOut-of-Plan specialty

Policy Summary

PayerHealth-New-England

PolicyRetail and Mail Order Prescription Copay Tiers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMail order and specialty prescriptions from out-of-plan providers are not covered; out-of-plan retail prescriptions require 20% coinsurance after the copay.

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.

Prescription coverage by tier and network

Copay amounts apply based on drug tier and dispensing channel; out-of-plan exceptions noted.

ALL of the following

ALL of the following
- Tier 1 — Generic: Retail copay $30
- Tier 2 — Brand/Formulary: Retail copay $80
- Tier 3 — Brand Non-Formulary: Retail copay $125
- Tier 4 — Formulary Specialty: Retail copay $150
- Tier 5 — Non-Formulary Specialty: Retail copay $200
ALL of the following
- Tier 1 — Generic: Mail order copay $60
- Tier 2 — Brand/Formulary: Mail order copay $160
- Tier 3 — Brand Non-Formulary: Mail order copay $375
- Note: Mail order is not available for Specialty drugs (Tiers 4 and 5).

ALL of the following

Out-of-Plan retail pharmacy prescriptions: 20% coinsurance applies after copay.
Mail order prescriptions from Out-of-Plan providers are not covered.
Specialty drugs from Out-of-Plan providers are not covered.

Copay Tiers and Coding

Retail copay tiersmixedCovered

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

Mail order copay tiersmixedCovered

Tier 1 Generic	$60
Tier 2 Brand/Formulary	$160
Tier 3 Brand Non-Formulary	$375

Out-of-Plan pharmacy rulesmixedNot Covered

Out-of-Plan mail order	Mail Order prescriptions from Out-of-Plan providers are not covered.
Out-of-Plan specialty drugs	Specialty drugs from Out-of-Plan providers are not covered.

Out-of-Plan retail pharmacy cost sharemixedCovered

Out-of-Plan retail pharmacy

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

Copay tiers

Tier 1 — Generic (Retail)$30

Tier 2 — Brand Formulary (Retail)$80

Tier 3 — Brand Non-Formulary (Retail)$125

Tier 4 — Formulary Specialty (Retail)$150

Tier 5 — Non-Formulary Specialty (Retail)$200

Tier 1 — Generic (Mail Order)$60

Tier 2 — Brand Formulary (Mail Order)$160

Tier 3 — Brand Non-Formulary (Mail Order)$375

Out-of-Plan and Provider Rules

Denial Risk

Out-of-Plan prescription coverage limits and cost sharing

Mail order prescriptions provided by Out‑of‑Plan providers are not covered; specialty drugs dispensed by Out‑of‑Plan providers are not covered. For prescriptions filled at an Out‑of‑Plan retail pharmacy, 20% coinsurance applies after the applicable copay.

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

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.

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

Coverage stanceCovered with the lowest copay of the tiered schedule (retail $30; mail order $60).

Brand Formulary / Tier 2

DefinitionBrand Formulary/Tier 2: Trademarked brand drugs marketed by one company without less expensive generic equivalents, selected based on safety, effectiveness and cost.

Cost/coverage characteristicCopay is higher than generic but lower than Brand Non-Formulary (retail $80; mail order $160).

Selection basisIncluded on the formulary after review of relative safety, effectiveness and cost among FDA-approved drugs.

Brand Non-Formulary / Tier 3

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

Coverage characterizationThese medications are still covered but at a higher copay level; Health New England does not waive or reduce copays for Brand Non-Formulary drugs (retail $125; mail order $375).

ImplicationTypically used when no formulary alternative is selected; higher member cost-sharing applies.

Formulary Specialty / Tier 4

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

Copay (retail)$150

Mail order availabilityMail order is not available for Specialty drugs.

Non-Formulary Specialty / Tier 5

DefinitionNon-Formulary Specialty/Tier 5: Brand specialty drugs not selected as Formulary Specialty (Tier 4), often with formulary alternatives.

Coverage and cost implicationThese medications are still covered but at the highest copay level (retail $200); mail order is not available for specialty drugs.

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

OpenPayer

Retail and Mail Order Prescription Copay Tiers

Prescription Coverage Rules

Copay Tiers and Coding

Out-of-Plan and Provider Rules

Tier Definitions