Pharmacy Benefit Guide

  • How drug benefits work

    Premera members have many different drug benefit options with our plans. They pay a designated copay or coinsurance, depending on the “tier” the drug is assigned to.

    Drug benefit tiers

    Prescription medications fall into one of four categories or “tiers.” Each tier has a different copay or coinsurance.

  • Tier-Four Drug Benefit Definition
    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 drugs Specialty drugs are typically self-injected and are often used to treat complex medical conditions. These drugs may require more involvement with your doctor, and may require special storage and handling.
    Tier-Three Drug Benefit Definition
    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-Two Drug Benefit Definition
    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 drug benefit tiers

    A closed tier plan covers only certain drugs on a set list. Covered drugs are placed into cost tiers. Drugs not on the list are not covered unless approved through a formulary exception request.

  • Tier 1 – Value generic
    Value generic drugs provide the best value as they are effective, safe, and the lowest out of pocket cost compared to other options.

    Tier 2 – Preferred generic
    Generic drugs are effective, safe and high-quality options and less expensive than their brand-name counterparts.

    Tier 3 – Preferred brand
    Considered “preferred” when there is no generic, and because of their value and effectiveness.

    Tier 4 – Non-preferred generic/brand
    Non-preferred drugs can be generic, brand, or specialty drugs. These drugs cost more and may not work as well as other options in Tier 1, 2 or Tier 3.

    Tier 5 – Preferred specialty
    Preferred specialty drugs are drugs typically used to treat chronic, complex, or rare conditions and may require enhanced clinical support. Specialty Drugs are generally limited to a month supply on dispense. Please check your member booklet for more details.

    Tier 6 – Non-preferred specialty
    These drugs provide a lower value than other options in tier 5 because they may cost more or may not work as well.

    NF – Non-formulary drugs
    These drugs are not on your list and are not covered. For consideration of coverage, non-formulary drugs require the submission of a formulary exception request.

    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 – Preferred specialty
    Preferred specialty drugs are drugs typically used to treat chronic, complex, or rare conditions and may require enhanced clinical support. Specialty Drugs are generally limited to a month supply on dispense. Please check your member booklet for more details.

    Tier 4 – Non-preferred drugs
    Non-preferred drugs can be generic, brand, or specialty drugs. These drugs cost more and may not work as well or be as safe as other options in Tier 1, Tier 2, or Tier 3.

    NF – Non-formulary drugs
    These drugs are not on your list and are not covered. For consideration of coverage, non-formulary drugs require the submission of a formulary exception request.

    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 – Non-preferred
    Non-preferred drugs can be generic, brand, or specialty drugs. These drugs cost more and may not work as well or be as safe as other options in Tier 1 or Tier 2.

    NF – Non-formulary drugs
    These drugs are not on your list and are not covered. For consideration of coverage, non-formulary drugs require the submission of a formulary exception request.

    Tier 1

    Formulary drugs include preferred generic, preferred brand, and non-preferred drugs. For these drugs, your medical plan costs apply. After you meet your deductible, you will pay coinsurance until you reach your out-of-pocket maximum.

    Tier 2

    Includes specialty drugs. These drugs are often used to treat serious or complex health conditions. They may need special care, storage, or handling.

    NF

    Non-Formulary Drugs. These drugs are not on your list and are not covered. For consideration of coverage, non-formulary drugs require the submission of a formulary exception request.

    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.

    NF

    Non-Formulary Drugs. These drugs are not on your list and are not covered. For consideration of coverage, non-formulary drugs require the submission of a formulary exception request.

  • *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 members have access to medications that are determined to help keep conditions 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 which drugs are included in this benefit.

    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.