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There are three “tiers” of drugs in the plan. What does that mean?
Every drug is classified as either a generic drug (Tier 1), a preferred brand drug (Tier 2) or a non-preferred brand drug (Tier 3).
Are the copayments different for each tier?
Yes. Here is a chart showing the copayments for each tier:
|Category||Tier #||Retail Pharmacy Copayment (30 day supply)||ESI Home Delivery Service Copayment (90 day supply)|
|Preferred Brand (Formulary)||2||$15||$30|
|Non-Preferred Brand (Not on Formulary)||3||$35||$70|
Is there an annual maximum for copayments?
Yes. There is a maximum out-of-pocket expense of $1,000.00. After a family has reached the $1,000.00 in copayments, no further copayments will be collected except for those drugs obtained in Tier 3 where you are responsible for the appropriate copayment.
Please note: if you were in the Cost Care program, you would also be responsible for the ancillary charges as explained above.
What is a preferred brand (formulary) drug?
A formulary is a list of approved medications created by a committee of doctors and other health care professionals for your pharmacy benefit plan. The Express Scripts Preferred Formulary includes all generic drugs and select brand-name medications.
There is a preferred brand drug (Tier 2) for most medical conditions. If your physician prescribes a brand-name drug for your particular condition — either because there is no generic or there is a special reason your physician wants to use the branded drug — and if it is on this list, then you will pay the Tier 2 copayment.
What is a non-preferred (non-formulary) brand drug?
Any brand-name drug not listed on the formulary is considered a non-preferred drug (Tier 3). Your copayments are higher since there are more cost-effective alternatives that are on the formulary to treat your condition. You would continue to pay copayments after you reached the $1,000.00 maximum out-of-pocket if your physician prescribes Tier 3 drugs.
If I am currently using a non-preferred brand drug, how can I switch to a preferred or a generic drug?
Speak to your doctor about your medication and discuss the options. Then your doctor can choose a brand or generic from the preferred formulary list and either call-in or write you a new prescription.