Pharmacy Benefit Guide

  • Express Scripts Personalized Pharmacy Services

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  • Understanding Your Coverage

    3-Tier Prescription Drug Benefit

    With a three-tier drug benefit, your prescription medications fall into one of three categories or “tiers.” Each tier has a different copay or out-of-pocket cost, with the first tier being the lowest-cost option.

    If your pharmacy plan has a minimum or maximum cost associated with it, the amount you pay for your prescription may vary. For example, let’s say your pharmacy cost share for preferred brand-name drugs (tier 2) is 20 percent with a $30 minimum and $65 maximum. You’ll pay 20 percent of the cost of the drug, or a minimum of $30 or maximum of $65.

    For information specific to your particular health plan, check your pharmacy benefits.

    Search the Preferred Drug List to see what tier a drug falls into.

    Tier 1: Plan Preferred - Generic

    • Are FDA-approved and are as safe and effective as brand name drugs
    • Usually are the lowest cost option

    Tier 2: Plan Preferred – Brand

    • Are clinically safe and effective as shown by data from medical journals
    • Usually are cost-effective, providing the best results at the most affordable price
    • Have a moderate cost

    Select a Tier 2 drug when there is no generic alternative or if your doctor decides a brand-name drug is the best for your condition.

    Tier 3: Non Preferred – Brands

    • Include new drugs that have not been reviewed for safety and efficacy by Express Scripts' Pharmacy and Therapeutics (P&T) Committee
    • Often have Tier 1 or Tier 2 alternatives (equally safe and effective but more cost-effective)
    • Can be drugs with potential safety concerns or lack of evidence of efficacy
    • Have the highest cost