How to read a drug list
Who is this for?
If you want to use a drug list to find out if we cover your medication, this information will help you understand how to read one.
Most of the medications on our drug lists are grouped by tiers so that you can find out if your health plan covers your prescription. The least expensive drugs are in the lower tiers. Let’s take a look at a brief overview of each.
- Tier 1 - Generic: All drugs in Tier 1 are generic and have the lowest possible copayment. A copayment is a fixed amount you pay when you get a prescription filled or receive other health care services. Drugs listed as Tier 1 are preferred because they offer the best combination of value and effectiveness.
For members who have individual or family HMO plans, generics are split into two tiers:
- Tier 1A - Preferred Generic: Tier 1A are commonly prescribed, generic versions of brand-name medications, which include drugs to treat chronic diseases like high blood pressure and heart disease. Tier 1A has the lowest generic copayment.
- Tier 1B - Generic: Tier 1B are all other covered generic drugs. Tier 1B has the highest generic copayment.
- Tier 2 - Preferred Brand: Tier 2 includes brand-name drugs that don’t yet have a generic option. These brand-name drugs are more expensive than generics, so you’ll pay a higher copayment for them.
- Tier 3 - Nonpreferred Brand: Tier 3 is made up of nonpreferred, brand-name drugs that do have a generic option. Since there are more cost-effective alternatives available for these drugs, you’ll have the highest copayment or these drugs may not be covered.
- Tier 4 - Preferred Specialty: This tier consists of specialty drugs, both generic and brand-name, that are used to treat difficult health conditions. These drugs are generally more effective and less expensive than other specialty drugs.
- Tier 5 - Nonpreferred Specialty: In Tier 5 are nonpreferred specialty drugs that likely have a more cost-effective generic or preferred alternative available. Tier 5 has the highest copayment for specialty drugs. In some cases, they may not be covered.
What to look for on your plan's drug list
Not every insurance plan has the same drug list, but there are a few things you should look for no matter which drug list applies to your plan.
- Drug lists typically group medications according to the condition they treat or what they are used for. For example, you’ll find Prilosec under “Gastrointestinal agents.”
- Prior authorization (PA): We need to review certain drugs before your plan will cover them in order to make sure they are the right drug for your situation. Look for an indicator that your medication needs prior approval, such as (PA) after the name or a checkmark in the “Approval needed” box. For more information, take a look at our prior authorization FAQs.
- Quantity limits (QL): Many types of drugs are limited to a certain amount within a given timeframe. If your medication has a quantity limit, it will have (QA) after the name or a checkmark in the “Quantity limit” box. For a list of drugs that have quantity limits, visit our Quantity Limits & Dose Optimization (PDF).
- Specialty drugs: When you have a chronic or difficult health condition, you may need a specialty drug that requires special handling, monitoring or approval to order. Look for a checkmark in the “Specialty drug” box or take a look at the Specialty Drug Program Member Guide (PDF).