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 nonpreferred brand drug (Tier 3).
Drug plan design
Are the copayments different for each tier?
Yes. Here is a chart showing the copayments for each tier:
| Category | Tier | Retail pharmacy (30-day supply) | ESI home delivery service (90-day supply) | Smart 90 Walgreens/Duane Reade retail network (90-day supply) |
|---|---|---|---|---|
| Generic | 1 | $5 | $10 | $10 |
| Preferred brand (formulary) | 2 | $15 | $30 | $30 |
| Nonpreferred brand (not on formulary) | 3 | $35 | $70 | $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 brand-name drug — and if it is on this list, then you will pay the Tier 2 copayment.
What is a nonpreferred (non-formulary) brand drug?
Any brand-name drug not listed on the formulary is considered a nonpreferred 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 nonpreferred 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.