How your prescription drug coverage works
Your prescription plan coverage
Drug tiers and approved drug lists
Generic drugs
Prescriptions by mail
Your prescription plan coverage
Q: How do I know if I have prescription drug coverage?
Not all Priority Health plans include prescription coverage. Check the back of your member ID card. Or you can look for prescription drug information (called a "prescription rider") in the packet of information you received from Priority Health. Call the Customer Service number on the back of your ID card if you have questions.
Q: How does my prescription drug coverage work?
If your plan has prescription drug coverage, you can get up to a 31-day supply of your covered prescriptions for one copay. Your prescription must be filled at a network pharmacy. Check the Medication Center for a list of participating pharmacies, or use our Find a Pharmacy directory to find a network pharmacy near you.
To maximize your savings, make sure your medication is on the approved drug list, also called the formulary, for your plan. This is the list of drugs covered by Priority Health. Also, generic drugs usually cost less than brand-name drugs, so ask your doctor if there's a generic version that might work for you.
Q: Do I have to pay a deductible or copay for my prescriptions?
Probably. When you log in to your personal Priority Health member account, you can see your deductible balance (if you have a deductible) and any prescriptions, copays, doctor visits, etc. This was included in your packet of information from Priority Health when you enrolled; look for the Schedule of Copays and Deductibles. It gives you your costs for health care services and the maximum limits of your health care benefits. You will probably have to pay higher copay for brand-name drugs than for generic drugs.
Drug tiers and approved drug lists
Q: What are drug tiers?
Tiers are simply a way of categorizing or classifying the medications. Generic drugs are the least expensive because they are not brand names. It's the difference between buying Kleenex® Tissue and other tissues; some are equivalent to brand-name products in the way they're made, and some just treat the same conditions, but they cost less, so your copay may be lower.
- "Preferred brand" drugs may cost more than a generic, but you'll often pay a lower copay than for non-preferred brand drugs.
- "Non-preferred brand" drugs are the most costly drugs, so your copay may be higher with these prescriptions. Ask your provider to prescribe a generic or preferred drug whenever possible.
- "Preferred specialty" drugs are generally self-administered medicines used for a chronic illness. They have special handling requirements or require special training before use.
- "Non-preferred specialty" drugs are more costly than the preferred specialty drugs. Ask your provider to prescribe a preferred specialty drug whenever possible.
Q: What is the approved drug list?
An approved drug list, also called a formulary, is a list of drugs approved for coverage under a specific plan. A committee of local doctors and pharmacists as well as Priority Health staff reviews research to find out which drugs are proven to work. Based on this research, they then add or remove drugs from the approved list.
Each Priority Health plan (e.g., PriorityHMOSM, Priority Health Medicare Advantage, Priority Health Medicaid) has a separate approved drug list. To see which drugs are covered by your plan (if you have prescription coverage), use the approved drug list tool.
Q: What if the medication I take is not on my plan's approved drug list?
If your drug is not on the approved drugs list for your Priority Health plan, you might have to pay the full price for that drug instead of just a copay. Some plans also have a "non-preferred" drug copay that's higher than the brand-name drug copay. Talk to your primary care physician (PCP) or other primary health care provider. He or she usually can prescribe a drug that is on the list.
Generic drugs
Q: What is the difference between generic and brand-name drugs?
The brand name is the name given to a drug by the company that invented or patented it. The generic name is usually a drug's chemical name.
There are two types of generic drugs. "Generic equivalents" have the same active ingredients and are available in the same strength and dosage as brand-name products. Generic equivalents meet FDA requirements, which are equivalent to requirements for the brand-name products.
The second type, "generic alternatives," are drugs that treat the same conditions as brand-name drugs but use different chemicals. They must meet FDA requirements for safety and effectiveness. Generic drugs cost an average of 40% to 60% less than brand-name drugs. For a list of approved generic drugs, see the approved drug list. Learn more by using the Generic Drug Savings Calculator.
Q: What are the benefits of using generic drugs?
They're safe, effective and cost less - an average of 40% to 60% less than brand-name drugs. Generic equivalent drugs have the same active ingredients and are available in the same strength and dosage form as brand-name products. Generic drugs meet FDA requirements, which are equivalent to requirements for the brand-name products.
If you have prescription drug coverage, ask your doctor or other health care provider to prescribe generic or preferred brand-name drugs. For a list of approved generic drugs, see the approved drug list.
Learn more in the Medication Center section of this website:
- About generics
- Generic Drug Savings Calculator
Prescriptions by mail
Q: How can I get my prescriptions filled by mail?
When you use the Priority Health mail service pharmacy, you'll get a 90-day supply of your prescription for less and shipping is free. You'll need to ask your doctor to write the prescription for a one-year or 90-day supply of an approved drug, and then order your prescription. Allow 14 days for delivery of your prescription.
Q: How can I save money on my prescriptions?
Besides ordering your drugs from the mail service pharmacy in 90-day quantities and asking your doctor to prescribe generic drugs whenever possible, you can call pharmacies in your area and ask what your prescription might cost. You'd be surprised at the difference from one pharmacy to another.
Read more about saving money on your prescriptions:
- Save on 90-day quantities
- Using the mail service pharmacy
- Mail service FAQ
Need more information?
If you have additional questions or need further information, call or email Customer Service.
