Understanding Drug Tiers

What is a drug tier?

Your plan lists the drugs it covers. This list is called the Drug List, or formulary. Every drug on the list is placed in a group called a tier.

Tiers are based on cost. In general, drugs in a lower tier cost you less. Drugs in a higher tier cost you more.

Think of tiers like steps. The lower the step, the less you usually pay.

Elderplan's five drug tiers

Elderplan plans that include drug coverage use five tiers:

• Tier 1: Preferred Generic Drugs. These cost you the least. Generic drugs work like brand-name drugs but usually cost less.
• Tier 2: Generic Drugs. Other generic drugs. These still cost less than most brand-name drugs.
• Tier 3: Preferred Brand Drugs. Brand-name drugs your plan prefers.
• Tier 4: Non-Preferred Drugs. Other brand-name drugs and some generics. These cost more.
• Tier 5: Specialty Tier Drugs. These are high-cost drugs, often for complex health needs. This tier costs the most.

How tiers affect what you pay

The tier of your drug helps decide your share of the cost. In general, the higher the tier, the more you pay.

Your exact cost depends on your plan. To see the amounts for your plan, read your plan’s Summary of Benefits, or look up your drug in the Drug List.

No matter the tier, you pay no more than $35 a month for covered insulin.

Your cost can also change based on the “drug payment stage” you are in during the year. You can learn more in our Medicare Part D guide.

How to find your drug's tier

You can find out which tier your drug is in:

• Look up your drug in your plan’s Drug List (formulary)
• Or call Member Services. The number is on your member ID card. We will look it up for you.

What if your drug is in a high tier?

If your drug is in a higher tier, you still have options:

• Ask about a lower-tier drug. Talk to your doctor. There may be a drug that works just as well and costs less, like a generic.
• Ask for a tiering exception. You or your doctor can ask the plan to charge you a lower amount for a drug. Your doctor must explain the medical reason. If we approve it, you pay less. (This is not allowed for Tier 5 specialty drugs.)

We are here to help you get the drugs you need.

A note about Extra Help and Medicaid

Many Elderplan members have Medicaid or get Extra Help. Extra Help is a program for people with limited income and savings. It can lower your drug costs a lot.

If you have Medicaid, you likely already get Extra Help. This can mean you pay little or nothing for your drugs, no matter the tier.

Want to learn more? See Extra Help for Medicare Part D.