What do the different tiers mean?
Drugs on a formulary are typically grouped into tiers. The tier that your medication is in determines your portion of the drug cost. A typical drug benefit includes three or four tiers:
Tier 1 usually includes generic medications.
Tier 2 usually includes preferred brand name medications.
Tier 3 usually includes non-preferred brand name medications.
Tier 4 usually includes specialty medications (3-Tier programs do not have a unique tier for specialty medications)
A medication may be placed in tier 3 or 4 if it is new and not yet proven to be safe or effective; or there is a similar drug on a lower tier of the formulary that may provide you with the same benefit at a lower cost.
Note: If you have a federally qualified high deductible health plan, you do not have a tiered drug benefit – your pharmacy and medical expenses are subject to your deductible and coinsurance. This section does not apply to you.
Sometimes, the active ingredients in a generic drug are chemically identical to their brand name counterparts. When the FDA-approved generic is available, a health plan may limit coverage to the generic, and a pharmacist will dispense the generic medication. If an Arise Health Plan member requests the brand, he/she will be responsible for the difference in cost between the brand and the generic plus any applicable deductible, coinsurance, and/or copay.