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Individual Medicare plan coverage level
The drug coverage level, or tier, is a classification for drugs listed in our approved drug list (or formulary). The tier determines your cost for a particular drug.
- Tier 0 – Over-the-counter (OTC): A non-prescription drug that is not normally covered by a Medicare prescription drug plan (PDP). Priority Health Medicare plans do cover certain OTC drugs at no cost to you if you have a prescription. Covered OTC drugs include loratadine, loratadine-d, cetirizine, cetirizine-d, Prilosec OTC, omeprazole and ketotifen fumarate. The cost to Priority Health Medicare for these drugs will not count toward your total drug cost.
- Tier 1 - Generic: Drug that will cost you the least amount. They are prescription drugs approved by the Food and Drug Administration (FDA) that is produced and distributed without patent protection and contains the same active ingredient as the brand drug.
- Tier 2 - Preferred brand-name: Brand-name drug that costs more than Tier 1, but less than Tier 3. A drug that has been on the market for a while or is commonly prescribed and has been selected based on their clinical effectiveness and safety.
- Tier 3 - Non-preferred brand-name: Brand-name drug that costs more than Tier 1 and Tier 2. Usually the highest cost drug in a given category that has lower-cost alternatives with equal or better clinical effectiveness.
- Tier 4 - Specialty: Drugs or drug classes whose cost on a per-month or per-dose basis exceeds the threshold established by the Centers for Medicare and Medicaid Services. Specialty drugs are limited to a maximum or a 31-day supply per prescription or refill.
- Not covered: Drug that your prescription plan will not pay for or that is not included on the approved drug list. Contact Customer Service for more information.
