Have you ever picked up a prescription and wondered why it costs more or less than other medications? In many cases, the answer comes down to drug tiers.

 

As your pharmacy benefit manager, we work with your employer to organize medications on your Drug Formulary into different coverage levels, called tiers, based on factors like cost, effectiveness, and available alternatives.

 

 We have plans that have 3 Tiers, 4 Tiers, and 5 Tiers.

 

Generally, medications in lower tiers cost less out of pocket, while medications in higher tiers may cost more. While every plan is different, a typical structure may include:

 

• Tier 1: Lower-cost generic medications
• Tier 2: Preferred brand-name traditional and specialty medications
• Tier 3: Non-preferred brand-name traditional medications
• Tier 4 or higher: Non-preferred brand specialty medications and non-preferred genetic specialty medications used to treat complex or chronic conditions

A medication tier can affect whether you pay a copay and what that out-of-pocket cost may be. In addition, tiers often dictate whether additional coverage requirements, such as prior authorization or step therapy, apply. It’s also important to know that drug tiers can change over time as new medications become available or drug pricing changes occur.

 

Understanding drug tiers can help you make more informed healthcare decisions and potentially lower your prescription costs. Generic medications, for example, are approved by the U.S. Food and Drug Administration (FDA) to work the same way as their brand-name counterparts and are typically available at a lower cost. In some cases, your doctor may also be able to recommend a preferred alternative that’s covered at a lower tier.

 

Reviewing the formulary and becoming familiar with drug tiers can help you better understand your coverage, estimate costs, and avoid surprises at the pharmacy counter.

 

You can access your plan’s covered medication list: Drug Formulary on our website and/or via your Member Portal. 

Connect

You can learn more about your pharmacy benefit and explore helpful resources anytime at pbdrx.com/members. As always, if you have specific questions about your coverage, Pharmacy Benefit Dimensions Member Services Department is available Monday through Friday from 8 a.m. to 11 p.m. ET. at (716) 635-7880 or 1-888-878-9172 (TTY/TDD users can call 711).