3-Tier
Drug List
(effective 2/1/08)

About Preferred Care Tiered Prescription Drug Benefits

Preferred Care offers pharmacy programs that support your health, wellness and safety, while reducing costs for employers and members. The cost of prescription drugs varies widely, even for drugs that are used to treat the same condition. Our 3-Tier Drug List can help you and your doctor choose lower-cost drug options that work just as well, and save you money.

What is a “formulary”?
Why are prescription drugs divided into ”tiers”? 
What is the difference between tiers?
Who determines the tier a drug falls under?
Why are generic drugs less expensive?

What is the Generic Maximum Allowable Cost (MAC) Program?

How can I save money on prescriptions?

What is Medco?

What is "prior justification?

What drugs require prior justification?

What is Specialty Pharmacy?

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What is a “formulary”?

• A formulary, sometimes called a Prescription Drug List, is a list of prescription drugs generally covered by your pharmacy benefit. Both brand-name and generic drugs are included on Preferred Care’s formulary.
• Preferred Care uses an “open formulary,” which means that your pharmacy benefit covers medications that are on the prescription drug list (formulary), as well as many that are not. (Please see your plan documents for a complete description of your pharmacy benefit. Or call the Medco phone number on your ID card.)
• The formulary was developed by a national group of clinicians. Use of the Preferred Prescriptions® Formulary (Medco Formulary) helps control out-of-pocket costs for Preferred Care members, while maintaining quality care.
• Drugs on the 3-Tier Drug List have been approved by the U.S. Food and Drug Administration (FDA) as safe and effective and are considered cost effective by Preferred Care.

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Why are prescription drugs divided into ”tiers”? 

Prescription drugs come in a wide range of prices, even for those that are used to treat the same condition. Preferred Care divides prescription drugs into three tiers to make it easier for you and your doctor to choose the lower-cost option for the drugs you may need.

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What is the difference between tiers?

Each tier has a copay level for covered prescription drugs within that tier. Your employer or health plan sets the copay for the drugs covered under your pharmacy benefit.

• Tier 1 is your lowest copay choice. It includes generic drugs that meet Preferred Care’s guidelines for a Tier 1 drug. It’s important to remember that not all generic
  drugs will be Tier 1 drugs.

• Tier 2 is your mid-range copay choice and includes covered brand-name drugs that have been selected as Tier 2 drugs because of their overall value. Consider Tier 2 drugs if you and your doctor decide that no Tier 1 medication is right for you.

• Tier 3 is your highest copay choice and includes all other covered prescription drugs - generic and brand name. It also includes those that are not on the prescription drug list, and new drugs that are being reviewed.

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Who determines the tier a drug falls under?

Our Pharmacy Benefits Manager (Medco) and Pharmacy & Therapeutics (P&T) Committee, consisting of doctors and pharmacists from our community, work together to create and review the Preferred Care formulary (3-Tier Drug List). Drugs are selected based on the role they play in treating a given disease or condition. Only medications that have passed U.S. Food and Drug Administration (FDA) testing are considered for coverage.

• Medco reviews clinical information on the medications being considered for the Prescription Drug List and provides comments to the P&T Committee.

• The P&T Committee reviews information from different sources for each medication. Each medicine is put in Tier 1, Tier 2 or Tier 3 on the Prescription Drug List according to how it compares with other drugs that are used to treat the same disease or condition.

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Why are generic drugs less expensive?

There are generic versions of many brand-name drugs that can save you money. Choosing lower-cost generic drugs is like using store-brand products at your grocery store — you can get the same product at a lower price.

• Generic drugs have been approved by the FDA. They are as safe and effective as brand-name versions.
• Generics contain the same active ingredients in the same amounts as the brand-name products.

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What is the Generic Maximum Allowable Cost (MAC) Program?

The Food and Drug Administration rates generic drugs. This program promotes the use of A-rated generic drugs. The program applies when a generic substitute with a therapeutic equivalent “A” or “A/B” FDA rating is available. If the doctor does not write “DAW” (dispense as written), the pharmacist will automatically supply the generic and the member avoids the extra costs. If the doctor specifies “DAW”, the member gets the brand name drug and pays the generic copay as well as the difference in cost between the generic and the brand name drug.

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How can I save money on prescriptions?

Consider the following options to help you save money on your prescription drugs:

• Talk with your doctor or pharmacist about using generic drugs; and
• Use your mail order benefit if you have one and if it offers lower copays.

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What is Medco?

Medco is the Preferred Care pharmacy benefits manager. Medco Services can answer many of the questions you may have about your prescription coverage. Medco also makes it easy for you to order your prescriptions through the mail. For more information about Medco, call Medco Member Services at (800) 233-7063. TTY users may call
(800) 759-1089. You may also visit the Ordering Presriptions and Understanding your Pharmacy Coverage section of the Preferred Care Web site.

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What is “prior justification”?

"Prior justification" is a type of approval. Prior justification is a process in which Preferred Care works with you and your health care provider to make sure you receive medically-necessary, high-quality medical treatment at a reasonable cost. It also makes sure that you meet clinical criteria for the service or procedure that your doctor is recommending. A list of drugs that require prior justification is posted on the Preferred Care Web site.

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What drugs require prior justification?

A list of drugs that require prior justification is posted on the Preferred Care Web site. You may also contact Member Services to find out if a specific drug requires prior justification.

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What is “Specialty Pharmacy”?

Preferred Care works with Curascript, a specialty pharmacy services company. The company provides selected injectable medications to our members with chronic conditions. This helps members better manage their medication. Prescriptions are delivered by next-day service to the member’s home or office. Please visit the Specialty Pharmacy Benefits section of the Preferred Care Web site for a list of medications available through the Specialty Pharmacy program. You may also visit the Curascript Web site at www.curascript.com for additional information.

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Last updated: September 20, 2006