Pharmacy Plan Design
| Tier | Type | Copay |
|---|---|---|
| Tier 1 | Generics |
Member pays a $15 copay or the full cost of the medication, whichever is less. |
|
Tier 2 & 3 |
Preferred & non-preferred brands | Member pays 100% of the cost of the drug at the point of sale and files for 80% reimbursement subject to the $200 deductible.* |
| Tier 4 | Certain high-cost specialty drugs and brand-name diabetic drugs | Members are responsible for 20% coinsurance at the point of sale. The plan covers medications at 80%. All insulin and insulin combination products have a maximum $100 member cost share per 30-day supply filled. |
| Specialty Medications | Found in Tiers 1-4 | Filled through designated specialty pharmacies, specialty medications can be found in multiple tiers and follow the benefit structure of that tier. |
*Direct Member Reimbursement (DMR) claims: Members requesting claim reimbursement for preferred and non-preferred brand drugs can submit a DMR request by filling out the Reimbursement Claim Form.
