YOUR HEALTH
Pharmacy Benefit Guide
With a four-level drug benefit, your prescription medications fall into one of four categories or “levels”. Each level has a different copay or coinsurance. Don’t worry, we’ll break it down.
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.
Drug benefit tiers
Tier 4
Tier four drug benefit
Definition
Tier 1
Generic
Generic
Copay
Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Tier 2
Preferred brand-name
Preferred brand-name
Copay or coinsurance
Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Tier 3
Non-preferred brand-name
Non-preferred brand-name
Copay or coinsurance
Often have Tier 1 or Tier 2 alternatives. These drugs may be more expensive than their alternatives in Tier 1 or Tier 2. Also includes new drugs not yet reviewed for their safety and effectiveness.
Often have Tier 1 or Tier 2 alternatives. These drugs may be more expensive than their alternatives in Tier 1 or Tier 2. Also includes new drugs not yet reviewed for their safety and effectiveness.
Tier 3
Non-preferred brand-name
Non-preferred brand-name
Specialty drugs are typically self-injected and are often used to treat complex medical conditions. These drugs may require more involvement with your doctor, and may require special storage and handling.
Tier 3
Tier three drug benefit
Definition
Tier 1
Generic
Generic
Copay
Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Tier 2
Preferred brand-name
Preferred brand-name
Copay or coinsurance
Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Tier 3
Non-preferred brand-name
Non-preferred brand-name
Copay or coinsurance
Often have Tier 1 or Tier 2 alternatives. These drugs may be more expensive than their alternatives in Tier 1 or Tier 2. Also includes new drugs not yet reviewed for their safety and effectiveness.
Often have Tier 1 or Tier 2 alternatives. These drugs may be more expensive than their alternatives in Tier 1 or Tier 2. Also includes new drugs not yet reviewed for their safety and effectiveness.
Tier 2
Tier two drug benefit
Definition
Tier 1
Generic
Generic
Copay
Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Tier 2
Preferred brand-name
Preferred brand-name
Copay or coinsurance
Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Tier 1
A single tier drug benefit is usually part of a major medical or HSA-qualified high deductible health plan.
If you have a plan with a single coinsurance, it usually has an up front combined medical and pharmacy deductible. Once you meet your deductible, you will pay a flat coinsurance for the remainder of the year for your medications.
Use Rx Search to see if your drug is covered or excluded.
Closed Tier 1
Closed Tier One drug benefit
Definition
Tier 1
Medical plan cost shares apply to formulary drugs. Once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out of pocket maximum limit.
Tier 2
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 isapproved, your medical plan cost shares will apply.
Metallic Tier 4
Metallic Tier Four drug benefit
Definition
Tier 1
Preferred Generics. Lowest cost share. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Tier 2
Preferred Brands. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Tier 3
Formulary non-preferred Drugs will be charged a Tier 3 copay. We recommend using preferred drugs whenever possible.
Tier 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 isapproved, Tier cost share will be charged based on whether the drug is generic, preferred brand, non-preferred brand or specialty.
Preventive drug list
Our preventive drug lists are HSA-qualified and provide full coverage to ensure that you have access to those medications that are determined to help keep your condition from getting worse. Deductibles, copays or coinsurances are waived for certain generic medications that treat cardiovascular disease and diabetes.