Coverage

Prescription Drug Coverage

Making Sense of Prescription Coverage

Formularies and tiers

Every plan keeps a formulary, its list of covered drugs sorted into tiers. Tier 1 generics might cost $10; a tier 4 specialty drug might cost hundreds. The same medication can sit in different tiers on different plans, which is why your prescriptions should help pick your plan, not the other way around.

Ways people overpay without knowing

• Filling a brand name when an identical generic exists
• Using a retail pharmacy when the plan's mail-order option is cheaper for maintenance drugs
• Not asking about 90-day fills, which often cost less per dose

Before you switch plans

Bring us your medication list. We check each drug against the formulary of any plan you are considering, so a plan switch never turns into a pharmacy surprise.

Prescription Coverage Verification Worksheet

For every medication you or a covered family member takes regularly, confirm the following before you enroll:

• Is it on the plan's formulary at all? Some plans exclude certain drugs entirely.
• What tier is it in? The same medication can be a low-cost tier on one plan and a high-cost specialty tier on another.
• Does it require prior authorization? Some medications need insurer approval before the pharmacy can fill them at the covered rate.
• Does it require step therapy? Some plans require trying a cheaper drug first before covering a specific medication.
• Is there a quantity limit? Confirm the covered quantity matches your actual prescribed dosage and refill schedule.
• Is a generic available, and is it identical? Confirm with your prescriber whether a generic substitution is appropriate for your situation.
• Is mail-order or a 90-day fill available and cheaper? Maintenance medications are often less per-dose through these options.