Three-Tier Drug Plan
Under our Three-Tier Drug Plan, covered prescription drugs are placed into one of three categories, or tiers:
- Tier 1: Most generic drugs, some brand-name drugs, and select over-the-counter drugs (lowest copayment)
- Tier 2: Preferred brand-name drugs and some generic drugs (midrange copayment)
- Tier 3: Includes most other drugs not in Tier 1 or Tier 2 (highest copayment)
The tier that we assign to a specific drug determines the amount of your copayment. Your Benefit Summary specifies the copayment required for each tier.
For a list of commonly prescribed drugs and their copayment level, please click here.
Cost-effectiveness requirement
The Three-Tier Drug Plan requires the use of the most cost-effective drug for maximum reimbursement. Therefore, you must purchase a Tier 1 drug for the least out-of-pocket expense. You may purchase drugs in Tiers 2 or 3; however, we limit our reimbursement to the charge for the Tier 1 equivalent unless:
- Your physician provides us with compelling medical evidence that either the Tier 1 equivalent is not effective for you or, for some medical reason, you are unable to take the Tier 1 drug.
If you buy a Tier 2 or Tier 3 drug when this exception does not apply, you'll pay more.
Dispensing limits
A prescription or a refill of a prescription dispensed at a retail pharmacy is limited to a medical appropriate dosage or a standard 30-day supply.
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 have to pay only two copayments 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. |
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To submit claims under Coordination of Benefits Rules, or if you have paid for a prescription out-of-pocket, please click here.
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