We offer several pharmacy benefit designs. Each design determines drug coverage and members’ copay amounts. Each pharmacy benefit plan is subject to regulations, state and federal laws, clinical guidelines, a prior approval process, and quantity limitations, unless otherwise specified. Covered pharmacy services must be listed on the Commercial, or Medicare formularies, unless the member's benefit includes nonformulary/nonpreferred drugs (the drug formularies may describe drugs as either "formulary" or "preferred," or "nonformulary" or "nonpreferred").
Generic Versus Brand
Our prescription benefit designs are formatted into three categories of prescription medications. Due to the number of drugs on the market, the continuous introduction of new drugs, new applications of existing drugs, and new information regarding safety, the designs are continually revised.
Tier 1 - Preferred Generic Drugs
Generic drugs (Tier 1) are chemically identical to brand drugs but are priced at a fraction of the cost and offer an excellent value to the member. To gain FDA approval, generic drugs must:
- Contain the same active ingredients as the branded drug (inactive ingredients may vary).
- Be identical to the brand drug in strength, dosage form, safety, and route of administration.
- Be of the same quality, performance characteristics, and use indications.
- Be manufactured under the same strict standards of the FDA's good manufacturing practice regulations required for branded products.
When writing for generic drugs, remember to leave the “DAW” field blank to ensure the generic version of the drugs are dispensed.
Tier 2 - Preferred Brand Drugs
Our preferred brand drugs are on Tier 2 and offer our members brand drugs at a lower copay or cost-share than nonpreferred drugs. These preferred drugs are typically multi-source brand drugs produced by various manufacturers.
Tier 3 - Nonpreferred Brand and Generic Drugs
Drugs placed in Tier 3 generally have a similar, more cost-effective option available in either the preferred generic drug category (Tier 1) or the preferred brand drug category (Tier 2).
Most new FDA-approved drugs are initially placed in Tier 3 and excluded from coverage for up to six (6) months until the P&T Committee reviews them for safety, efficacy, and clinical comparisons.
The Copay Designs Table outlines the more common benefit structures with regards to copayment.
Members must pay a copay and/or deductible for each supply of medication received at a participating retail or mail order pharmacy, as required by their benefit plan.