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Three-Tier Rx Benefits

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Three Tiers = Choice

Your three-tier prescription benefit gives you choice over which medications you use while also balancing costs. To do this, the benefit breaks prescription medications into three categories, or tiers:

  • Generic
  • Formulary brand-name
  • Non-formulary

You have coverage for all three categories. What you pay - your copay - depends on which medication (or tier) you and your doctor choose. Generics cost the least, and non-formulary medications cost the most with a three-tier prescription benefit design.

Let's look at two examples of what a three-tier benefit could look like (this is an example only and may not reflect a specific benefit design):

Example 1 Retail Pharmacy (30 to 34-day supply):
$10 retail pharmacy copay for generic medications
$20 retail pharmacy copay for brand-name formulary medications
$40 retail pharmacy copay for non-formulary medications

Example 2 Mail-Order (90-day supply):
$20 mail-order pharmacy copay for generic medications
$40 mail-order pharmacy copay for brand-name formulary medications
$80 mail-order pharmacy copay for non-formulary medications

How Do You Know Which Tier Your Medication Belongs To?
Our Preferred Medication List/Formulary (PML) is a guide to which medications are covered and at what copay/coinsurance level. Generic medications are in the first tier (lowest copay), brand name medications in the second and nonformulary products in the third tier (highest copay).

For a complete list of covered generic and brand-name medications, take a look at our Preferred Medication List/Formulary.

Any drug not on the PML is considered non-formulary. If you've been prescribed a medication that's not on the PML, you may be able to offer your doctor this list of alternatives to nonformulary medications. If your doctor prescribed a brand-name or nonformulary medication, you can ask the pharmacist for the generic equivalent. Unless your doctor specifically prescribed only the brand-name medication, you can receive a generic equivalent and pay the lower copay.

Also, a small number of medications on the PML require that your doctor obtain prior authorization before we can cover them.

Filling Prescriptions
First of all, make sure you visit a participating pharmacy or use one of the participating mail-order pharmacies. At the pharmacy, simply present your member card with your prescription - your pharmacist will know which tier your medication is on and charge the applicable copay.