Access the Approved Drug List online. When browsing the Approved Drug List, you’ll notice that drugs are listed with a tier level. Different tiers denote different costs and coverage as determined by Priority Health, and the type of tiers available to you for each drug will depend on your plan type.
Here's a breakdown of the meaning of each tier (this information can also be found in the Approved Drug List):
Tier 1: ($) The least expensive prescription drugs available to you. This tier includes lowest-cost generic drugs—proven to be as safe as brand-name drugs—and, on some formularies, select brand-name drugs. Some plans offer lower copays for preferred generics. Check your prescription drug benefit to see if you qualify for a lower copay.
Tier 2: ($$) Includes preferred and lower cost brand-name drugs, and some higher cost generic drugs. If you must take a brand-name drug, you should work with your provider to choose one that is covered here, and the most affordable.
Tier 3: ($$$) Non-preferred and expensive brand-name drugs, as well as higher-cost generic drugs. These drugs may cost you a significant amount out of pocket so you should ask your provider if a tier 1 or 2 option can be prescribed instead.
Tier 4: ($$$$) Includes very expensive brand-name and generic drugs, and preferred specialty drugs used to treat complex conditions. Specialty drugs often have high costs and may have special handling or storage requirements. They are usually dispensed by trained personnel at specialty pharmacies. If you need to take a specialty drug, you should work with your provider to choose one that is covered here. These drugs may not have a specific copay. Instead, you may pay a percentage of the total cost. Check your plan documents for specific details.
Tier 5: ($$$$$) Non-preferred specialty drugs, and the most expensive brand-name and generic drugs are covered here because they offer limited clinical value. Most have a similar lower-cost option offering the same clinical value on tiers 1 through 4. Ask your provider about alternatives. These drugs may not have a specific copay. Instead, you may pay a percentage of the total cost. Check your plan documents for specific details.
Tier 6: (Vaccine coverage) Priority Health covers a number of routine vaccines administered in the pharmacy. These vaccines are also covered under your medical benefit when given in your doctor’s office. Most plans cover vaccines at no charge to you; check your plan documents to verify what you need to pay.
Tier 9: ($$$$$$$$) A drug that your prescription plan will not pay for or that is not included on the Approved Drug List. Check your plan documents for details.
Preventive Drug: Preventive medications may be 100% covered if certain conditions (ie age or gender requirements) are met. If a health care provider lists a service or medication as “preventive,” check the Priority Health Preventive Health Care Guidelines to confirm your portion of the cost.