Learn About Our Essentials Formulary

  • December 21, 2017

    More Premera health plans are using our value-based Essentials formulary, which has four copay tiers:

    • Tier 1: preferred generics
    • Tier 2: preferred brands
    • Tier 3: preferred specialty drugs
    • Tier 4: Nonpreferred

    Tier 4 consists of drugs that offer your patients less value for their money. These drugs also have higher co-insurance. Standard benefits include specialty drugs in the fourth tier, while this approach is different. All kinds of drugs can be in Tier 4-even generics.

    How can I find Essentials Formulary status?

    View information on formulary status of drugs.

    Select the correct formulary from the pull down menu using the two-digit code. In most cases, this code can be found after the words “RX PLAN” on the customer ID card. Essentials formulary is coded E4.

    Background

  • To determine a treatment’s value, we assess its clinical benefit against the increased total medical cost. Simply put, “How much more will the customer pay for this, and will the customer get more clinical benefit in return?”

    In setting a drug’s status in the formulary, we also consider unmet medical need, rare disease status, and ensuring equitable access to medications.

    Examples:

    • Lisinopril ($10 a month) is a preferred ACE inhibitor. Ramipril ($40 a month) is nonpreferred.
    • Cyclosporine, a generic immunosuppressant that’s used to fight rejection in transplant patients, is very costly. However, Cyclosporine is a preferred drug because of its clinical benefit.

    The Essentials Formulary Exclusion List describes drugs that aren’t covered. The Essentials formulary excludes drugs that are excessively priced, with a lower-cost alternative that can provide the same clinical benefit.

    These include drugs that have lower cost, or over-the-counter alternatives, with prices comparable to a Tier 1 or Tier 2 copay. For these reasons, the Essentials Formulary doesn’t cover most proton pump inhibitors, antihistamines, H2 antagonists, and intranasal steroids. This reduces costs to customers without reducing access to the drugs.
    A few companies have raised drug prices to very high levels, while lower-priced alternatives exist. Prescribers and patients may not notice these prices because manufacturers supply providers with samples and give copay coupons to their patients.
    Other exclusion list drugs are newly approved by the FDA. Sometimes, Premera’s review determines that these new drugs are investigational or not medically necessary. This temporary exclusion prevents your patient from getting a prescription, then having refills rejected.

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