To assist with receiving the highest quality of care at the most affordable price, our pharmacy benefit program has been designed to include five levels of prescription drug coverage. These five levels are described below.
Why is it important to understand pharmacy benefits?
Getting the most out of an individual's healthcare insurance coverage is important. Understanding a pharmacy benefit and how it works can save money on the cost of prescriptions and thus maximize the benefit.
It is important for patients to work with their doctor on how best to maintain good health and how to successfully manage any existing health conditions.
When medicines are needed to treat a health condition, patients should understand how to get the most effective drug treatment while controlling the cost of prescriptions.
What is a tiered copayment pharmacy benefit and how does it work?
A tiered copayment benefit means there are several possible copayment levels. A member’s copayment is based on the prescription drug being purchased. For example, the first tier represents a preferred generic drug that has the lowest copayment.
Traditional Drugs
TIER 1 Preferred Generic
Covered drugs that are no longer protected by a drug company patent allowing other drug companies to manufacture equivalent versions of the same drug at a reduced cost.
TIER 2 Non-Preferred Generic
Similar to Tier 1 covered drugs, but available with a higher copayment.
TIER 3 Brand Formulary
A list of brand-name drugs that PHP participating network doctors are encouraged to prescribe, when appropriate, for treatment of a medical condition.
TIER 4 Brand Non-Formulary
Covered drugs that are not included in the formulary listing. You may obtain nonformulary brand-name drugs with a higher pharmacy copayment.
Speciality Drugs
TIER 1 Preferred Speciality Drugs*
These medications can be injectables or orals that are extremely expensive, must be filled at a speciality pharmacy, and may need special instructions and handling.
TIER 2 Speciality Drugs
These medications can be injectables or orals that are extremely expensive, must be filled at a speciality pharmacy, and may need special instructions and handling.
*This tier is newly added, and reserved for future use. There are currently no drugs in this tier. We anticipate adding drugs to this tier in July 2023.
Maximize the Pharmacy Benefit
Sometimes it’s possible to swap a prescription for an over-the-counter drug, a great way to save dollars. Staying on top of need-to-know prescription information can also save money. But it can also save a life by preventing medical mix-ups. Tips for avoiding serious side effects and overdosing are included with prescription drugs.