Pharmacy Benefit Guide

  • How your drug benefits work

    You'll find many different drug benefit options with our plans. When purchasing a prescription drug, you pay either a designated copay or coinsurance. The cost to you depends on the “level” the drug is assigned to.

    You can check your ID card to see your copay or coinsurance for each drug level. Use Rx Search to find your medication's drug level.

    Not sure which prescription coverage you have? Log in and check your benefits booklet for complete details.

    Or call us at 800-596-3440 so we can help you.

    Drug benefit levels

    With a four-level drug benefit, your prescription medications fall into one of four categories or “levels.” Each level has a different copay or coinsurance.

  • Four-level drug benefit Definition
    Level 1 - Generic Copay
    Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
    Learn more about generic drugs
    Level 2 - Preferred brand-name Copay or coinsurance
    Moderate cost. Considered “preferred” when there is no generic, and because of their value and effectiveness.
    Level 3 - Non-preferred brand-name Copay or coinsurance
    Often have Level 1 or Level 2 alternatives. These drugs may be more expensive than their alternatives in Level 1 or Level 2. Also includes new drugs not yet reviewed for their safety and effectiveness.
    Level 4 - Specialty drugs Specialty drugs are typically self-injected and are often used to treat complex medical conditions. These drugs may require more involvement with your doctor, and may require special storage and handling.
    Level Three
     drug benefit Definition
    Level 1 - Generic Copay
    Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
    Learn more about generic drugs  
    Level 2 - Preferred brand-name Copay or coinsurance
    Moderate cost. Considered “preferred” when there is no generic, and because of their value and effectiveness.
    Level 3 - Non-preferred brand-name Copay or coinsurance
    Often have level 1 or level 2 alternatives. These drugs may be more expensive than their alternatives in level 1 or level 2. Also includes new drugs not yet reviewed for their safety and effectiveness.
    Level Two drug benefit Definition
    Level 1 - Generic Copay
    Lowest cost. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
    Learn more about generic drugs
    Level 2 - Preferred brand-name Copay or coinsurance
    Moderate cost. Considered “preferred” when there is no generic, and because of their value and effectiveness.

    A single level drug benefit is usually part of a major medical or HSA-qualified high deductible health plan.

    If you have a plan with a single coinsurance, it usually has an upfront combined medical and pharmacy deductible. Once you meet your deductible, you will pay a flat coinsurance for the remainder of the year for your medications.

    Use Rx Search to see if your drug is covered or excluded.

    Closed Level One drug benefit Definition
    Level 1 Medical plan cost shares apply to formulary drugs. Once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out of pocket maximum limit.
    Non-Formulary Coverage for non-formulary drugs requires an exception for medical necessity. Your doctor needs to request the exception with an explanation of why the drug is required for your condition instead of a preferred drug. If the exception is approved, your medical plan cost shares will apply.
    Metallic Level Four drug benefit Definition
    Level 1 Preferred Generics. Lowest cost share. Generic drugs are as effective, safe and high quality as their brand-name counterparts, yet less expensive.
    Level 2 Preferred Brands. Considered “preferred” when there is no generic, and because of their value and effectiveness.
    Level 3 Formulary non-preferred Drugs will be charged a Level 3 copay. We recommend using preferred drugs whenever possible.
    Level 4 Formulary Specialty Drugs will be charged a Level 4 copay. These are biologics and other targeted drugs usually used for complex medical conditions and often requiring special handling.
    Non-Formulary Coverage for non-formulary drugs requires an exception for medical necessity. Your doctor needs to request the exception with an explanation of why the drug is required for your condition instead of a preferred drug. If the exception is approved, Level cost share will be charged based on whether the drug is generic, preferred brand, non-preferred brand or specialty.
  • * Drugs are placed into each level based on decisions made by our Pharmacy and Therapeutics (P&T) Committee. This team of community doctors and pharmacists meets regularly to collaboratively review the most current medical studies and make updates.

    The Select Drug List is a four level benefit that provides access to essential drugs, but does not cover medications that are available over-the-counter or brand-name drugs that have generic alternatives. Examples of excluded drug classes would be cough and cold, antihistamine and heartburn/acid reflux medicines.

  • Preventive drug list

    Our preventive drug lists are HSA-qualified and provide full coverage to ensure that you have access to those medications that are determined to help keep your condition from getting worse. Deductibles, copays or coinsurances are waived for certain generic medications that treat cardiovascular disease and diabetes.

    Consult the HSA Generic Preventive Drug List to see if your drug is included in this benefit.