What is Tier Pricing With Prescription Medications?

Have you ever wondered why the amount that you pay at the pharmacy counter varies so much depending on the prescription that you’re filling? Generics, certain brand name prescription drugs and even some types of medications can all have wildly different coverages. In most cases, what you pay for a drug is dependent on your insurer’s tier pricing.

What Are Drug Tiers?

Your health insurance company’s formulary is a list of all the different drugs that their plans cover. Within the formulary, there are drug tiers. These tiers determine the level of coverage your prescription drug plan offers for a specific type of medication. Many prescription drug plans use a 4-tier system, while some insurers have an additional 5th or even 6th-tier system. Your insurer’s formulary and tier system are available on the company website or in the documents you received when you enrolled in your prescription drug plan.

Tier 1 Prescriptions:

This tier is usually the cheapest and generally includes generic medications.

Tier 2 Prescriptions:

This tier can include more expensive generic or less expensive brand name drugs that are preferred by your health insurance company. Just as your health insurance company provides better coverage for in-network healthcare providers, it provides better coverage for preferred drugs.

Tier 3 Prescriptions:

This tier includes brand name drugs that are not preferred by your health insurance company. These drugs are still covered, but you will likely pay more out of pocket than you would for a preferred drug.

Tier 4 Prescriptions:

This tier includes specialty drugs, such as those used for cancer treatment. These drugs have a much higher out-of-pocket cost.

Tier 5 Prescriptions:

This tier, which is not included in all prescription drug plans, includes highest cost specialty drugs.

Tier 6 Prescriptions:

With this tier many companies will use and not charge a copay at all, using a tier-6 medication for “maintenance medication”. You’ll need to check your plan details.​

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Why Is Tier Pricing Used?

The primary purpose of tier pricing is to help health insurance companies manage their costs. In most cases, the drugs listed on a plan’s formulary are both effective and the most economically priced for treating a condition. To promote the use of generics or more cost-effective brand name drugs, health insurance companies may cover a larger portion of the costs for Tier 1 and Tier 2 drugs.

Understanding Tier Pricing Can Help You Save Money

Understanding your drug plans’ formulary and tier pricing and knowing what to expect at the pharmacy counter can help you save a lot of money on your prescriptions.

After you’ve reviewed your drug plans’ tiers, talk to your doctor about what conditions you’re currently receiving treatment for and what medications you are on. Your doctor can help you find the most cost-effective prescriptions that will provide effective treatment for your conditions. Additionally, in some but not all cases, generics may be substituted for brand name drugs, helping you pay the lowest price available.​