How Your Drug Benefits Work
You’ll find many different drug benefit options with our plans. When purchasing a prescription drug, you pay either a designated copay or coinsurance. The cost to you depends on the “tier” the drug is assigned to.
Check your ID card to see your copay or coinsurance for each drug tier. Use
Rx Search to find your medication’s drug tier.
Not sure which prescription coverage you have? Log in and check your benefits booklet for complete details or call us at 800-971-1491 so we can personally help you.
Tiered Drug Benefits
With a four-tier drug benefit, your prescription medications fall into one of four categories or “tiers.” Each tier has a different copay or coinsurance.
Metallic Four-Tier Drug Benefit
Level 1
Preferred Generics. Lowest cost share. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Level 2
Preferred Brands. Considered “preferred” when there is no generic, and because of their value and effectiveness.
Level 3
Formulary non-preferred Drugs will be charged a Tier 3 copay. We recommend using preferred drugs whenever possible.
Level 4
Formulary Specialty Drugs will be charged a Tier 4 copay. These are biologics and other targeted drugs usually used for complex medical conditions and often requiring special handling.
Non-Formulary
Coverage for non-formulary drugs requires an exception for medical necessity. Your doctor needs to request the exception with an explanation of why the drug is required for your condition instead of a preferred drug. If the exception is approved, Tier cost share will be charged based on whether the drug is generic, preferred brand, nonpreferred brand or specialty.
Drugs are placed into each tier based on decisions made by our Pharmacy and Therapeutics (P&T) Committee. This team of community doctors and pharmacists meets regularly to collaboratively review the most current medical studies and make updates.