• Pharmacy Benefit Guide

    How Drug Benefits Work

    Premera members have many different drug benefit options with our plans. You pay a designated copay or coinsurance, depending on the “tier” the drug is assigned to. If you’re not sure what prescription coverage you have, or if you have a different benefit than what is shown here, log into Premera.com, check your benefits booklet for complete details or contact Customer Service.

  • Check your ID card to see your copay or coinsurance for each drug tier.

    ID Card Sample PBC 

    The sample card here may not match what appears on your card, as benefits differ by plan.

    Use Rx Search to find your medication’s drug tier.

    Tiered Drug Benefits

    With a four-tier drug benefit, your prescription medications fall into one of four categories or “tiers.” Each tier has a different copay or coinsurance.

  • Four-Tier Drug BenefitDefinition
    Tier 1 – Generic

    Copay

    Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.

    Learn more about generic drugs

    Tier 2 – Preferred brand-name

    Copay or coinsurance

    Moderate cost. Considered “preferred” when there is no generic, and because of their value and effectiveness.

    Tier 3 – Non-preferred brand-name

    Copay or coinsurance

    Often have Tier 1 or Tier 2 alternatives. These drugs may be more expensive than their alternatives in Tier 1 or Tier 2. Also includes new drugs not yet reviewed for their safety and effectiveness.

    Tier 4 – Specialty drugsSpecialty drugs are typically self-injected and are often used to treat complex medical conditions. These drugs may require more involvement with your physician, and may require special storage and handling.
    Three-Tier Drug BenefitDefinition
    Tier 1 – Generic

    Copay

    Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.

    Learn more about generic drugs

    Tier 2 – Preferred brand-name

    Copay or coinsurance

    Moderate cost. Considered “preferred” when there is no generic, and because of their value and effectiveness.

    Tier 3 – Non-preferred brand-name

    Copay or coinsurance

    Often have Tier 1 or Tier 2 alternatives. These drugs may be more expensive than their alternatives in Tier 1 or Tier 2. Also includes new drugs not yet reviewed for their safety and effectiveness.

    Two-Tier Drug BenefitDefinition
    Tier 1 – Generic

    Copay

    Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.

    Learn more about generic drugs

    Tier 2 – Brand-name

    Copay or coinsurance

    Considered “preferred” when there is no generic, and because of their value and effectiveness.

    A single-tier drug benefit is usually part of a major medical or HSA-qualified high deductible health plan.

    If you have a plan with a single coinsurance, it usually has an upfront combined medical and pharmacy deductible. Once you meet your deductible, you will pay a flat coinsurance for the remainder of the year for your medications.

    Use Rx Search to see if your drug is covered or excluded.

    Closed Single-Tier Drug BenefitDefinition
    Tier 1 Medical plan cost shares apply to formulary drugs. Once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out of pocket maximum limit.
    Non-Formulary Coverage for non-formulary drugs requires an exception for medical necessity. Your doctor needs to request the exception with an explanation of why the drug is required for your condition instead of a preferred drug. If the exception is approved, your medical plan cost shares will apply.
    Closed Three-Tier Drug BenefitDefinition
    Tier 1 Preferred Generics. Lowest cost share. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
    Tier 2 Preferred Brands. Considered “preferred” when there is no generic, and because of their value and effectiveness.
    Tier 3 Formulary Specialty Drugs will be charged a Tier 4 copay. These are biologics and other targeted drugs usually used for complex medical conditions and often requiring special handling.
    Non-Formulary Coverage for non-formulary drugs requires an exception for medical necessity. Your doctor needs to request the exception with an explanation of why the drug is required for your condition instead of a preferred drug. If the exception is approved, Tier cost share will be charged based on whether the drug is generic, brand or specialty.
  • *Drugs are placed into each tier based on decisions made by our Pharmacy and Therapeutics (P&T) Committee. This team of community doctors and pharmacists meets regularly to collaboratively review the most current medical studies and make updates to our Preferred Drug List.

    Preventive Drug Benefit

    Our preventive drug benefits are HSA-qualified and provide full coverage to ensure that you have access to those medications that are determined to help keep your condition from getting worse. Deductibles, copays or coinsurances are waived for certain generic medications that treat cardiovascular disease and diabetes.

    Consult the HSA Generic Preventive Drug List to see if your drug is included in this benefit.

    Value-Based Drug Benefit

    With a Value-Based Drug Benefit, your prescription medications fall into one of four categories or “tiers.” Each tier has a different copay or coinsurance. Under the Value-Based Drug Benefit, medications are categorized by tier based on their quality, value and effectiveness—not by their generic, brand-name or specialty drug label. So, for this benefit each tier may contain a combination of generic, brand-name and specialty drugs.

    Four-Tier Drug Benefit Description
    Tier 1  Low Cost Share 
    Tier 2  Moderate Cost Share 
    Tier 3  High Cost Share 
    Tier 4  Highest Cost Share 
       
    Preventive Drugs  Certain generic preventive drugs will have a very low or no cost share  

    Who decides a drug’s value? 

    A drug’s value is based on science. An independent set of experts made up of leading physicians, pharmacists, health economists, a bioethicist, and a member representative review new and existing drugs. The drugs are evaluated on how well they work relative to their cost and how their effectiveness compares to similar drugs used to treat the same condition.