Prescription drug tiers, explained (optimized & traditional formulary)
Key takeaways:
- Priority Health sorts covered drugs into six tiers. In general, the lower the tier, the less you pay.
- Tiers 1 – 3 cover generic and brand-name drugs, Tiers 4 – 5 cover specialty drugs, and vaccines are also covered.
- Find any drug’s tier and your exact cost in the approved drug list or by logging in to your MyPriority account.
- When you fill a prescription, you pay a copay (a flat fee) or coinsurance (a percentage of the drug cost) based on the drug’s tier.
What is a prescription drug tier?
The list of medications covered by your plan is called an approved drug list, also known as a “formulary,” and is organized by cost into leveled groups, or tiers. For Priority Health plans, drugs are sorted into six tiers.
Typically, lower-cost drugs (like generics and more affordable brand names) are in low tiers, while higher-cost brand-name and specialty drugs are in high tiers. When you fill a prescription, the pharmacy works with your plan provider to determine if the medication is on its approved drug list, and calculates the cost based on the drug’s tier on the approved drug list, and your plan’s cost (copay or coinsurance) for that tier.
How Do I Know if My Medication Is Covered?
If you’re unsure whether a medication is covered by your health plan, start by checking your plan’s approved drug list. When searching Priority Health’s approved drug list, the medication information also includes the drug ’s tier. You can also find approved drug information by logging in to your Priority Health account or calling the number on the back of your member ID card. The back of your member ID card can also help you identify if your plan has the optimized formulary (optimized = yes) or the traditional formulary (no information).
Priority Health Drug Tiers, Explained (Tiers 1–5)
When you search for a medication on your plan’s approved drug list, you may notice a tier level on each listing. The drug tiers indicate the price range of the medication. The traditional formulary and the optimized formulary have different tiers for the same medication.
Here's a breakdown of the meaning of each tier, which can also be found in the approved drug list:
Tier 1 Medications ($): Your lowest-cost drugs
Tier 1 medications are least expensive, and usually consist of generics and low-cost brand-name drugs. Some plans put preferred generics in this tier for the lowest possible copay. Check your plan documents to verify if you have preferred generic coverage.
Tier 2 Medications ($$): preferred brand-name drugs
Tier 2 includes preferred and lower cost brand-name drugs, and some higher cost generic drugs. If you opt for a brand-name drug, consider working with your provider to choose an affordable option that is covered in this tier.
Tier 3 Medications ($$$): non-preferred brand-name drugs
Tier 3 consists of non-preferred and expensive brand-name drugs, as well as higher-cost generic drugs. These drugs may have a significant out-of-pocket cost, so you should ask your prescriber if there is a similar option in tier 1 or 2 instead.
Tier 4 Medications ($$$$): high-cost and preferred specialty drugs
Tier 4 includes very expensive generic and brand-name, as well as preferred specialty drugs used to treat complex conditions. Specialty drugs often have high costs and may require special handling or storage requirements when dispensed by a specialty pharmacy. If you need to take a specialty drug, you should work with your provider to choose one that is covered by your plan. These drugs may not have a specific copay; instead, you may pay a percentage of the total cost (such as a coinsurance). Check your plan documents for details.
Tier 5 Medications ($$$$$): highest-cost, non-preferred specialty drugs
Non-preferred specialty drugs and the most expensive generic and brand-name drugs are in this tier. They are often included here because their clinical value may be limited, or they have a lower-cost alternative on a lower tier. 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.
Vaccine coverage
Vaccines are often provided under health coverage plans at no cost to you. Priority Health covers several routine vaccines administered in your pharmacy or provider’s office. Check your plan documents to verify your cost for a specific vaccine.
Non-Formulary Medications (NF): drugs your plan won’t cover
A non-formulary medication is a drug that your prescription plan will not pay for, or that is not included on the approved drug list. If your doctor prescribes a non-formulary medication, ask if there are alternative options covered by your plan. Check your plan documents for details.
Benefit Exclusion Medications (BE): drugs excluded by your plan
A Benefit Exclusion Medication is a drug that is excluded per plan documents. Check your plan documents for details.
Preventive Drugs: often 100% covered
Preventive Drug: Preventive medications may be 100% covered if you meet certain conditions (e.g. age or gender requirements). 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.