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.
If you need to use a drug list to see if your health benefit plan covers your prescription medication, you might find they're a little hard to decode. We'll help you figure out the difference between Tier 1 and Tier 2, formulary versus nonformulary, closed and open plans and more.
What's a drug list, or formulary? It's a list of drugs approved by the U.S. Food and Drug Administration and covered by Blue Cross Blue Shield of Michigan and Blue Care Network.
- Where can you find drug lists? We have them assembled here.
Tiers are important when it comes to understanding prescription drug coverage and drug lists. Medications are grouped by tiers:
- Tier 1 (also called Formulary Preferred). Drugs listed as Tier 1 are preferred because they offer the best combination of effectiveness, safety and value. They usually have the lowest copays of the three tiers.
- Tier 2 (also called Formulary Options). These are usually brand name versions of generic drugs, and cost more.
- Tier 3 (or Nonformulary). Drugs not on the approved list. They typically have the highest copays, and may not be covered at all.
Know your plan
Your prescription drug coverage (also called a drug rider) has tiers, too. Before looking at a drug list, make sure you know whether your coverage is:
Flat, 2-Tier or 3-Tier (Triple-tier). These terms tell you your copay amounts for prescription medications. A copay is the amount of money you pay towards the cost of the drug.
- Flat: your copay is the same for all drug tiers.
- 2-Tier: your plan has two fixed copays, such as $10 for Tier 1 drugs and $25 for Tier 2.
- 3-Tier or Triple-tier: your plan has three fixed copays, one for each tier of drugs, such as $5, $10 and $30.
- Some plans combine a fixed copay amount with a percentage. For example, your 2-Tier plan may have a $15 copay for Tier 1 drugs, and a 40 percent copay for Tier 2. This means you pay 40 percent of the total cost of the medication. Some plans are completely percentage-based. See below.
Open, closed or percentage-based. These terms tell you what prescription medications your plan covers.
- Open: your plan covers Tier 1, Tier 2 and Tier 3 drugs
- Closed (or managed): your plan only covers Tier 1 and Tier 2 drugs
- Percentage: you pay a fixed percentage of the cost of a medication for all tiers.
Reading a drug list
Drug lists typically group medications according to what they are used for, or the condition they treat. For example, you’ll find Prilosec under “Gastrointestinal agents.”
Let’s look at a scenario to see how a drug list works.
Your doctor prescribes Imitrex for your migraine headaches. You have a 2-Tier Closed plan through Blue Care Network with a $5 copay for Tier 1 drugs, $25 for Tier 2.
- You look for Imitrex in the Custom Drug List Quick Guide for Members (PDF), Blue Care Network’s list of the most commonly prescribed drugs.
- Under “Migraine,” Imitrex is listed as Tier 1, so it’s a $5 copay.
- It also has the word (all), a (g) and a (QL) after it.
- “All” means all forms of the drug, since Imitrex comes in both tablets and a nasal spray.
- You check the footnotes at the bottom of the page. They tell you (g) means there’s a generic form of Imitrex available. That’s what will be used to fill your prescription.
- (QL) means that there is a quantity limit for this drug. Your doctor can only prescribe so many for you.