Two-Tier Drug Plan
Under our Two-Tier Drug Plan, covered prescription drugs are placed into one of two categories, or tiers:
- Tier 1: Generic drugs (lowest copayment)
- Tier 2: Brand-name drugs (higher copayment)
Your Benefit Summary specifies the copayment amount required for each tier.
Generic substitution
The Two-Tier Drug Plan requires the use of generic drugs for maximum reimbursement. You may purchase a brand-name drug or its generic equivalent. However, we limit our reimbursement to the charge for the generic equivalent unless:
- Your physician provides us with compelling medical evidence that either the generic is not effective for you, or for some medical reason you are unable to take the generic drug.
If you obtain a brand-name drug when the above exception does not apply, you’ll pay more out-of-pocket.
Dispensing limits
A prescription or a refill of a prescription is limited to a medically appropriate dosage or a standard 30-day supply except for maintenance drugs.
A 90-day supply for maintenance drugs is available through our Home Delivery Service. When obtaining a 90-day supply through the Home Delivery Service, you'll pay only one copayment and will reduce your out-of-pocket costs.
Participating pharmacies
Participating pharmacies belong to our prescription drug administrator's nationwide network. The network includes most Wisconsin independent pharmacies and all of the major retail chains. Click here to learn about our find-a-pharmacy feature.
If you obtain a prescription from a nonparticipating pharmacy, you’ll have to pay the entire cost of the prescription and submit a claim form. We will then reimburse you for the amount that a participating pharmacy would have received, less any applicable copayment.
|
| To submit claims under Coordination of Benefits Rules, or if you have paid for a prescription out-of-pocket, please click here.
|
|