Coverage Requirements and Limitations

To ensure that prescription drugs are used safely and cost-effectively, some drugs are included in our Responsible RX programs. These program requirements include:

• Prior Authorization: Your doctor may need to submit a Prior Authorization request before the drug will be covered. Without a Prior Authorization approval, your drug may not be covered and you may pay the full cost.
• Step Therapy: There may be another drug that is clinically effective that must be tried first. If you’ve already tried the other drug(s), your doctor can submit medical records for consideration.
• Quantity Limits: There may be a quantity limit on the amount filled each time. If you require more than the allowed limit, your doctor can submit a request for consideration.

Login for quick answers about your specific drug coverage. View your Medication Guide or use the Drug Comparison Tool.

Drug Tiers and Your Cost Share

In general, choosing Tier 1- generic drugs, using PrimeMail (if available) and going to an in-network pharmacy saves you the most money.

Your cost share is based on a tier level and drug category. The lower the tier, the lower your cost share will be. Some plans include 2 tiers while others include 3 to 7 tiers. Below you’ll find an example of a 4-Tier plan and how it works. For the drug tiers and cost shares that apply to your plan, login to your member account.

• Tier 1 — Generic Drugs
• Tier 2 — Preferred Brand Drugs
• Tier 3 — Non-Preferred Brand Drugs; these drugs may have generic or brand alternatives in Tier 1 or Tier 2 that can save you money.
• Tier 4 — Specialty drugs, including self-administered, injectable medications, and high-technology drugs.

These examples assume the drug is covered by your plan and you use a pharmacy in your plan’s network.

Let's say you take cholesterol medication and your cost share amounts are:

• Tier 1 — Generic = $10 copay
• Tier 2 — Preferred Brand = $25 copay
• Tier 3 — Non-Preferred Brand = $50 copay after deductible of $500
• Tier 4 — $150 copay after deductible

Your cost share is based on the tier level and drug category:

Tier 1 — Niacin Extended Release (500 MG)
Niacin Extended Release is a generic medication. Because it's a Tier 1 drug, you would pay a $25 copay.

Tier 2 — Crestor (40 MG)
Crestor is a Preferred Brand drug. You may be required to try a generic drug before your plan will cover the brand alternative. Because it's a Tier 2 drug, you would pay a $25 copay.

Tier 3 — Advicor Extended Release (500 MG)
Niaspan Extended Release is a Non-Preferred Brand drug. You may be required to try a generic drug and get a prior approval before your plan will cover a Non-Preferred Brand. Because this tier includes a deductible, you would pay full cost of your medication until you reach your deductible, then you would pay a $150 copay for each prescription.

PrimeMail Home Delivery

If your plan includes mail order services, you may be able to get a 90-day supply of medication at a lower cost. Some plans include generic medication to manage chronic conditions at no cost when you order by mail. Check your plan benefits and don’t forget to use the Drug Comparison tool.