Know what drugs are covered under your plan and how to find the best price.
Prescription drug tiers defined
You’ll notice there are nine total tiers on the Approved Drug List, also known as a formulary. Different tiers denote different costs and coverage as determined by Priority Health. The type of tiers available to you for each drug will depend on your formulary type, either Traditional or Optimized. Check the back of your member ID card to know what type of formulary your plan has.
Traditional formulary: The backside of your member ID card says Prescription: Yes.
Optimized formulary: The backside of your member ID card says Optimized Rx: Yes.
If you have the Optimized formulary:
Tier 1a: ($) The least expensive prescription drugs available to you. This tier includes lowest-cost generic drugs-proven to be as safe as brand-name drugs-and, on some formularies, select brand-name drugs.
Tier 1b: ($) This tier includes low-cost generic drugs-proven to be as safe as brand-name drugs-and, on some formularies, select brand-name drugs.
If you have the Traditional formulary:
Tier 1: ($) The least expensive prescription drugs available to you. This tier includes low-cost generic drugs—proven to be as safe as brand-name drugs—and, on some formularies, select brand-name drugs.
The following tiers apply to both formularies:
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: ($$$$) Includes very expensive brand-name and generic drugs, and preferred specialty drugs used to treat complex conditions. Specialty drugs often have high costs and may have special handling or storage requirements. They are usually dispensed by trained personnel at specialty pharmacies. If you need to take a specialty drug, you should work with your provider to choose one that is covered here. These drugs do not typically have a specific copay. Instead, you may pay a percentage of the total cost, up to a maximum amount per prescription.
Tier 5: ($$$$$) Non-preferred specialty drugs, and the most expensive brand-name and generic drugs are covered here because they offer limited clinical value. Most have a similar lower-cost option offering the same clinical value on tiers 1 through 4. Ask your provider about alternatives. These drugs typically do not have a specific copay. Instead, you may pay a percentage of the total cost, up to a maximum amount per prescription.
Tier 9: ($$$$$$$$) 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.
In your member account, select Get Help to send us a secure message. Or you can call the Customer Service phone number on the back of your member ID card.
*If you have a Telehealth PCP - Virtual First plan you must first contact your assigned virtual Doctor On Demand primary care physician (PCP) to receive non-emergency care. Please refer to your plan documents for more information.