CurrentHealth-New-EnglandPolicy N/A

Retail and Mail-order Prescription Copay Tiers

Defines member copayment amounts and tier descriptions for retail and mail-order prescription fills for Health New England members; applies to pharmacy benefit administration and members in the plan.

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 is not available for Specialty drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$10/$50/$150/$200/$250Retail copays (G/ BF/ BNF/ FS/ NFS)

$20/$100/$450Mail-order copays (G/ BF/ BNF)

5 tiersCopay tiers

No specialtyMail-order limitation

Pharmacy Coverage Criteria

Pharmacy copay criteria by tier

Coverage stance and member cost-sharing by drug tier:

Pharmacy copay structure by tier applies as listed below; drugs are covered with member cost-sharing according to tier.

ALL of the following

Tier: Generic / Tier 1
Retail copay: $10$10
Covered at the Generic / Tier 1 copay
Mail-order copay: $20$20

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 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.

Copay Amounts and Tiers

Retail copay tiersmixedCovered

Generic / Tier 1	$10
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 tiersmixedCovered

Generic / Tier 1	$20
Brand Formulary / Tier 2	$100
Brand Non-Formulary / Tier 3	$450

Retail copay tiers

Generic / Tier 1 (retail)$10

Brand Formulary / Tier 2 (retail)$50

Brand Non-Formulary / Tier 3 (retail)$150

Formulary Specialty / Tier 4 (retail)$200

Non-Formulary Specialty / Tier 5 (retail)$250

Mail-order copay tiers

Generic / Tier 1 (mail order)$20

Brand Formulary / Tier 2 (mail order)$100

Brand Non-Formulary / Tier 3 (mail order)$450

Provider Actions and Restrictions

Billing Rule

Mail-order specialty restriction — mail order not available for Specialty drugs

Mail order dispensing is not available for Specialty drugs; specialty medications must be filled at retail. Ensure prescriptions for Formulary Specialty (Tier 4) and Non-Formulary Specialty (Tier 5) are submitted for retail pickup rather than mail order to avoid claim denials or incorrect member cost-sharing.

Specialty drugs (Formulary Specialty / Non-Formulary Specialty) are excluded from mail-order service.
Submit specialty prescriptions as retail fills to ensure correct processing and copay application.

Tier Definitions

Generic / Tier 1

TermGeneric / Tier 1

DefinitionApproved by the FDA; contains the same active ingredients as brand-name drugs; usually lower cost; in Massachusetts pharmacists must dispense generic unless 'no substitution' is ordered.

Coverage implicationCovered at the lowest copay tier (see retail/mail-order amounts).

Brand Formulary / Tier 2

TermBrand Formulary / Tier 2

DefinitionTrademarked brand drugs selected for the formulary based on safety, effectiveness and cost; copay higher than generic but lower than non-formulary.

Coverage implicationCovered at the formulary brand copay tier (see retail/mail-order amounts).

Brand Non-Formulary / Tier 3

TermBrand Non-Formulary / Tier 3

DefinitionBrand-name drugs not selected as formulary; still covered but at a higher copay; copays are not waived or reduced.

Coverage implicationCovered at the non-formulary copay tier (see retail/mail-order amounts).

Formulary Specialty / Tier 4

TermFormulary Specialty / Tier 4

DefinitionSpecialty drugs selected for the formulary based on safety, effectiveness and cost.

Coverage implicationCovered at the formulary specialty copay (retail); specialty drugs are not available by mail order.

Non-Formulary Specialty / Tier 5

TermNon-Formulary Specialty / Tier 5

DefinitionBrand specialty drugs not selected as formulary specialty; may have formulary alternatives and carry the highest copay.

Coverage implicationCovered at the highest specialty copay (retail); not available by mail order.