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 Single-Tier Drug Benefit Definition
    Tier 1 Medical plan cost shares apply to drug list drugs. Once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out-of-pocket maximum limit.
    Non-Drug List Coverage for non-drug list 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 Tier-Three Drug Benefit Definition
    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 Drug list 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-Drug list Coverage for non-drug list 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 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.

    Value-based drug benefit

    With a value-based drug benefit, 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

    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.