How to read a drug list
Each prescription drug on our drug lists is assigned to a “tier.” Each tier has a different out-of-pocket cost. The number of tiers you have depends on your plan.
What are the tiers of prescription drugs?
Our tiers of prescription drugs include:
ACA preventive drugs
Generic preventive drugs can help members prevent illnesses, diseases or other health problems.
The Affordable Care Act, or ACA, requires us to cover these drugs without charging you a copay or other out-of-pocket costs. Examples of preventive drugs include drugs for smoking cessation and contraceptives for women of childbearing age.
For commercial and QHP plans, we break generic prescription drugs down into two types: preferred generic and non-preferred generic.
- Preferred generic drugs are non-brand-name drugs that have the lowest copay, or the fixed amount you pay for the covered drug.
- Non-preferred generic drugs also are non-brand-name drugs, but may have a higher copay under some plans.
Copay differences can vary by plan. To see your plan’s tiering structure, log in.
There are two types of brand-name drugs in this class: preferred brand and non-preferred brand.
- Preferred brand drugs are brand-name prescription drugs that have the lowest brand copay. However, they will have a higher copay than generic drugs.
- Non-preferred brand drugs also are brand-name drugs, but they have a higher copay than preferred brand drugs.
Specialty drugs require specific handling, extra patient education or close monitoring for safe and effective use.
Some plans group all specialty drugs together in one class. Other plans classify specialty drugs as either preferred specialty drugs or non-preferred specialty drugs (preferred specialty drugs have a lower copay under these plans).
Copays for specialty drugs may vary by plan. To see your plan's tiering structure, log in and click “My Prescription Coverage.”
Medical drugs may be infused, or taken by needle or catheter. We only list medical drugs that need to be dispensed in the pharmacy on our drug list.
Medical drugs are covered under your medical benefits, not your prescription drug benefits. You may need to fill prescriptions for medications classified as medical drugs from our specialty pharmacy partner, Pharmacy Advantage.
Pharmacy Advantage can deliver prescription medications to your home. To get information about your medical benefits for medical drugs, log in.
Your copay for a drug is based on the type of drug and what tier it is in. Medications in lower tiers have lower copays than medications in higher tiers.
HAP plans can have up to six tiers. It depends on the specific plan. Your plan may have fewer than six copay tiers.
- Commercial plans with fewer copay tiers consolidate some of the different classes of prescription medications into one tier, as shown in the table below.
- Qualified health plans, or QHPs, follow a six-tier structure.
To see the prescription drug tier structure for your plan:
|Description of tier||Six-tier plan||Five-tier plan||Four-tier plan||Three-tier plan|
|Preferred generic||Tier 1||Tier 1||Tier 1||Tier 1|
|Non-preferred generic||Tier 1A|
|Preferred brand||Tier 2||Tier 2||Tier 2||Tier 2|
|Non-preferred brand||Tier 3||Tier 3||Tier 3||Tier 3|
|Preferred specialty||Tier 4||Tier 4||Tier 4|
|Non-preferred specialty||Tier 4A||Tier 4A|
|ACA preventive||No copay or other out-of-pocket costs||No copay or other out-of-pocket costs||No copay or other out-of-pocket costs||No copay or other out-of-pocket costs|
|Medical drugs||Covered under your plan’s medical benefit||Covered under your plan’s medical benefit||Covered under your plan’s medical benefit||Covered under your plan’s medical benefit|
|Description of tier||Tier level|
|Preferred generic||Tier 1|
|Non-preferred generic||Tier 1A|
|Preferred brand||Tier 2|
|Non-preferred brand||Tier 3|
|Preferred specialty||Tier 4|
|Non-preferred specialty||Tier 4A|
|ACA preventive||No copay or other out-of-pocket costs|
|Medical drugs||Covered under your plan's medical benefit|
Log in to find your prescription drug benefit tiering structure.