Pharmacy Benefits Tier Design

Your client's plan may include a three-tier or four-tier pharmacy copay plan design. These plan designs offer your client the opportunity to save money by choosing prescription medications that are less costly but equally effective. The plan designs retain freedom of choice because benefits will still be available for nearly all branded prescription drugs.

The three-tier pharmacy copay plan design includes three tiers of medications:

  • Generic Drugs
  • Preferred Brand-name Drugs
  • Non-preferred Brand-name Drugs

The four-tier pharmacy copay plan design includes four tiers of medications:

  • Generic
  • Preferred Brand-name Drugs
  • Non-preferred Brand-name / Preferred Specialty
  • Non-preferred Specialty Drugs

Generic drugs are the most affordable drugs and offer members the lowest available copay. Generic drugs are pharmaceutically and therapeutically equivalent to brand-name drugs.

Preferred brand-name drugs are available at a slightly higher copay than generic drugs. The preferred brand-name drug tier consists of the vast majority of high-quality branded drugs.

Non-preferred brand-name drugs have the highest copay. Non-preferred brand-name drugs may not offer clinical or cost advantages over other drugs in the same therapeutic category.

Not all medications have a therapeutic equivalent on the generic or preferred list. Members can check with their pharmacist or physician to see if a substitute is available. Coverage for particular services will depend on their specific benefits program. A members Evidence of Coverage or Benefits Booklet will provide further details on their program.