Answers to questions about pharmacy benefits
Pharmacy benefits among Priority Health members can vary based on the coverage purchased.
Here are answers to some frequently asked questions:
Q: Who determines the copay the patient pays?
A: Priority Health offers employers many different options for pharmacy coverage. The employer
or purchaser then analyzes the options and makes the decision. The level of copay affects the total cost of health-care coverage for which the employer is responsible. Some purchasers elect
not to cover prescriptions in their benefit plans.
Q: What are flat, two-tier and three-tier copays? Or specialty drug copays?
A: A flat copay is when the patient pays the same fixed dollar amount for the copay, independent
of whether the prescription is for a brand-name or generic product.
The two-tier copay is when the patient pays the lower copay if the prescription is filled with a
generic medication, or a more expensive copay if it is for a branded product. Patients with twotier
coverage have access to non-preferred products if their condition warrants their use and the
products are medically necessary.
A three-tier copay is similar to a two-tier copay for the two lower copay levels. The third tier is for
non-preferred products. The non-preferred agents on the third tier will always require payment of
the third-tier copay.
Some members will pay more for specialty pharmacy drugs, including those administered in a
physician’s office or infusion center. Specialty drugs are classified as “preferred specialty” (fourth
tier) or “non-preferred specialty” (fifth tier). Preferred specialty drugs typically have a lower copay
than non-preferred specialty drugs.
Q: Why can one patient have a different copay than another patient?
A: Priority Health offers many pharmacy benefit choices: employer-sponsored (commercial),
Medicaid and Medicare. Employer-sponsored plans have many different options for coverage
and copay. Priority Health Medicaid members are covered under a formulary that is similar to
the standard, closed formulary, although the State of Michigan may require some coverage that
is not part of the standard commercial benefit. Priority Health Medicare members typically have
a four-tier copay, though some Medicare plans provided by an employer may choose to have a
two-tier copay.
Q: Do you cover birth control pills or drugs for erectile dysfunction?
A: Priority Health covers birth control for those who have contraceptive medication as part of their
benefits. The employer has to purchase this coverage, and certain conditions will apply. Some
employers have decided to cover birth control for medical diagnosis only, while others have
chosen not to cover birth control at all. Drugs to treat erectile dysfunction are only covered if the
employer has selected a rider that provides coverage for these drugs. If either of these options
is selected by the employer, the appropriate copay will apply to the prescription. Medicaid and
Medicare plans cover contraceptives but do not cover drugs for erectile dysfunction. Certain
employer-sponsored Medicare plans choose to add coverage for erectile dysfunction drugs.
Q: What other limits apply to the pharmacy benefit?
A: Priority Health limits coverage to a maximum 31-day supply per prescription. Mail-order
prescriptions may provide up to a 90-day supply of medication for either one or two copays. And
many of the pharmacies in our network participate in our “90 day at retail” program, allowing
members to fill a 90-day supply for three copays at a local, retail pharmacy. (Medicaid members
are not eligible for 90-day fills.) Some specialty drugs must be obtained from a network specialty
pharmacy for commercial members. Priority Health may also use specific prior authorization criteria
for some prescriptions, as well as quantity limits based on clinical data or cost-effectiveness. Some
drugs also require step–therapy (see previous article in this issue).
If you have questions about pharmacy benefits, please contact your PAR or the pharmacy call center
at 800 466-6642.
Topics: Priority Health updates
