Pharmacy benefits & coverage

This designation reference preventive medications on all plans that have no cost-share when ACA conditions are met and when the medication is filled as prescription at a participating pharmacy.

This designation is only applicable for plans that include the Chronic Illness Support Program (CISP) benefit. Enhanced coverage is limited to $0 cost-share for Tier 1 medications, and reduced cost shares on select Tier 2 and Tier 3 medications according to your plan design without having to meet deductibles first. Reduced cost-share is only available through Express Scripts Home Delivery (mail). For non-CISP eligible plans, please refer to the numeric listing in the Drug Tier column.

This designation is only applicable for plans that include the Chronic Illness Support Program (CISP) benefit. The CISP-1 designation indicates the cost-share for the medication/item is $0 through Express Scripts Home Delivery (mail).

Certain generic medications will be substituted with the brand name equivalent at the generic cost-share. The inclusion of the brand name product in this program is subject to change without notice.

This designation is only applicable for HSA Plus plans, which are Health Savings Account compatible and have Plus in the name (HSA Plus). For drugs with this designation, the deductible is waived and the Member pays the applicable drug Tier cost-share.

This designation indicates the cost-share for this medication will be no more than $35 for up to a 30-day supply.

These drugs must be obtained directly through our exclusive mandatory pharmacy, Accredo (mail order), or the drug is not covered. We may require that you try certain drugs to treat your medical condition before you are provided coverage. These drugs are limited to a 30-day supply.

This drug is an over-the-counter product that is covered with a prescription from the prescriber and when filled at an in-network pharmacy.

The Plan requires you or your Provider to get Prior Approval for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you do not get approval, we may not cover the drug. We may require that you try certain drugs to treat your medical condition before you are provided coverage.

A quantity limit (QL) defines how much of a particular drug you may get during a specific time period (days supply limit) or the maximum days supply you may get at once (quantity per days supply limit).

This means the out-of-pocket cost is at the ‘specialty’ cost-share. The Plan offers one courtesy fill at a retail pharmacy as a covered benefit. Then, this drug must be obtained directly through the exclusive specialty pharmacy, Accredo (mail), or you pay 100% of the retail cost. We may require that you try certain drugs to treat your medical condition before you are provided coverage.

In some cases, the Plan requires you to first try certain drugs to treat your medical condition within a certain look-back period before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the Plan may cover Drug B. *Note: The Prior Approval process may be used to facilitate this process.

Moderately priced generic drugs and some lower-cost brand-name drugs. These are slightly more expensive than Tier 1 medications but still affordable.

 The lowest-cost drugs, typically generic medications that are safe, effective, and widely used. These have the lowest copayments or out-of-pocket costs.

Brand-name drugs that are included on the insurer’s preferred drug list. These medications cost more than Tiers 1 and 2 but are generally covered at a lower cost than non-preferred options.

Higher-cost brand-name drugs and some non-preferred generics. These may also include certain specialty drugs not classified as high-tier. Costs are higher, and coverage may be limited.

The most expensive drugs, often used to treat complex or rare conditions. These are typically specialty medications requiring special handling or administration. Copayments or coinsurance rates for Tier 5 are the highest.

The lowest-cost drugs, typically generic medications that are safe, effective, and widely used. These have the lowest copayments or out-of-pocket costs.

Moderately priced generic drugs and some lower-cost brand-name drugs. These are slightly more expensive than Tier 1 medications but still affordable.

Brand-name drugs that are included on the insurer’s preferred drug list. These medications cost more than Tiers 1 and 2 but are generally covered at a lower cost than non-preferred options.

Higher-cost brand-name drugs and some non-preferred generics. These may also include certain specialty drugs not classified as high-tier. Costs are higher, and coverage may be limited.

The most expensive drugs, often used to treat complex or rare conditions. These are typically specialty medications requiring special handling or administration. Copayments or coinsurance rates for Tier 5 are the highest.