Specialty drugs are generally injectable, high-cost medications that have special handling requirements or require special training before use. These types of medications may be obtained through our specialty pharmacy, unless administered by a participating PHP network provider. Depending on the benefit plan, specialty drugs may have a different copayment and out-of-pocket expense than the three-tier pharmacy structure.
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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 equivlant 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 non- formulary brand-name drugs with a higher pharmacy copayment.
- TIER 5 Specialty Drugs: Specialty drugs are generally injectable, high-cost medications, which you may obtain through our specialty pharmacy, unless administered by a PHP network provider.
If you or your doctor want a brand name drug when there is a generic drug available, you will have to pay more than the formulary or non-formulary brand copayment.
Speciality Drugs
- Tier 1 Preferred Speciality Drugs*: These medications can be injectables or orals that are extremely expensive, must be fulled at a specialty pharmacy, and may need special instructions and handling.
- TIER 2 Specialty Drugs: These medications can be injectables or orals that are extremely expensive, must be fulled at a specialty pharmacy, and may need special instructions and handling.
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A doctor may prescribe a prescription drug that is not on the PHP formulary. The member has the option to receive the non-formulary medication at a higher pharmacy copayment or to ask the doctor for a formulary medication.
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Yes, but members are required under their contract to pay the applicable cost sharing, which includes the Deductible, Copay, or Coinsurance as shown on the Schedule of Benefits. The requirement to pay the applicable cost sharing (Deductible, Copay, or Coinsurance) cannot be waived by a provider, a pharmacy or anyone under any “fee forgiveness,” “no out-of-pocket,” “discount program,” “coupon program” or similar arrangement. If a provider, pharmacy or third party (other than family) waives, discounts, reduces, or indirectly pays the required cost sharing (Deductible, Copays, Coinsurance) for a particular claim, the applicable cost sharing met by the member on the claim will be reduced to reflect the amount of such waiver, discount, reduction, or third party payment. The total amount accumulated toward any overall deductible and/or maximum out-of-pocket amounts will also be reduced by the amount of any discount.
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By asking the doctor if a generic drug is available for the treatment of a medical condition, the member may become eligible to take advantage of savings by lowering the pharmacy copayment. To allow for generic drug substitution, ask your doctor to use the signature line located on the right side of the prescription.
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