Covered drugs
Get information about prescription drugs, including how a drug may be covered and alternate drugs you can choose from.
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Some drugs may need to meet certain requirements before your prescription is covered. Learn more about the pharmacy prior authorization program.
Drug lists
Different plans have different lists of covered drugs. Your drug list code can be found on your member ID card. Look for Rx Plan.
Formulary exception review
A formulary exception review is required if the drug is not on formulary. For these drugs, submit a review using the Pharmacy Formulary Exception Request fax form. If we approve the exception, your cost will be charged, based on whether the drug is generic, brand, or specialty.
Requesting a HIV PrEP (human immunodeficiency virus pre-exposure prophylaxis) drug cost share exception
If you have preventive benefits and you think your HIV PrEP drug should be available at no cost under your health plan, your provider may request an exception by submitting the Pharmacy Exception Request form by fax. For these pharmacy exception reviews, we apply this benefit coverage guideline. We review most standard exception requests within 72 hours and urgent requests within 24 hours.
Pharmacy benefits & drug tiers
With a four-level drug benefit, prescription medications fall into one of four categories or “levels”. Each level has a different copay or coinsurance depending on a members’ plan. The cost to members depends on the “tier” the drug is assigned to.
Check LifeWise ID card to see copay or coinsurance for each drug tier.
Drug benefit tiers
Tier 4
Tier 4 drug benefit
Definition
Tier 1: Generic
Copay: Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Tier 2: Preferred brand-name
Copay or coinsurance: Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Tier 3: Non-preferred brand-name
Copay: 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 4: 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 4 drug benefit
Definition
Tier 1: Generic
Copay: Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Tier 2: Preferred brand-name
Copay or coinsurance: Moderate cost. Considered "preferred" when there is no generic, and because of their value and effectiveness.
Tier 3: Non-preferred brand-name
Copay: 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 4 drug benefit
Definition
Tier 1: Generic
Copay: Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
Tier 2: Preferred brand-name
Copay or coinsurance: 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.
Drugs are placed into each level 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.
Drug list changes
Effective July 1, 2024
B3, B4 drug lists (No changes for A1/A2 list)
Preferred B3 drug list
Drug name
Description of change
Cost-effective alternatives*
No changes
NA
NA
Preferred B4 drug list
Drug name
Description of change
Cost-effective alternatives*
No changes
NA
NA