Drugs are categorized into tiers, typically ranging from generic options on the lower end to specialty brand-name medications on the higher end. Utilizing these tools empowers you to make informed decisions before filling a prescription, preventing unexpected denials or higher costs at the point of sale.
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Specialty Drugs and Exceptional Cases For members requiring specialized medications, often used to treat chronic conditions like multiple sclerosis or rheumatoid arthritis, the formulary may have a distinct specialty tier. Mid tiers often include preferred brand-name drugs, while higher tiers are designated for non-preferred brands and specialty medications, which may involve higher copays or coinsurance percentages.
This specific list of medications is the cornerstone of your plan, dictating which drugs are covered, at what cost, and under what specific rules. Step therapy, on the other hand, requires you to try and fail on a lower-cost, alternative medication before the plan will cover a more expensive option.
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Mobile apps and printed materials are also available to help you check coverage in real-time at the pharmacy. Reviewing this structure annually during the Open Enrollment period is crucial, as a drug’s placement can change year to year based on new negotiations and plan adjustments.
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