01Tier 1
Generic drugs
Generics contain the same active ingredient as the brand they copy and have to meet the same standards for strength, quality, and how the body absorbs them. They sit on the lowest cost sharing tier on nearly every plan.
Prescription benefits
Pharmacy and drug coverage, decoded.
Whether a plan is right for you often comes down to one thing: how it treats the medications you already take. Here is how drug lists, tiers, and pharmacy networks decide what you pay.
Search for a specific drug
Check before you enrollLook up every medication you take on a plan drug list before you choose it. Coverage, tier, and pharmacy rules differ from plan to plan, even between plans from the same insurer.
Drug tiers
Where a drug sits decides what you pay.
Most plans sort covered drugs into tiers, from generics at the bottom to specialty medications at the top. Tier names and counts vary by plan, but the logic is consistent.
02Tier 2
Preferred brand drugs
Brand name drugs the plan has selected for its list, usually because it has negotiated a better price. Cost sharing is higher than a generic and lower than a non-preferred brand.
03Tier 3
Non-preferred brand drugs
Covered brand name drugs that sit outside the preferred list, often because a generic or a preferred alternative exists. Cost sharing is higher, and asking your prescriber about an alternative can move you down a tier.
04Specialty
Specialty drugs
High cost medications for complex conditions, often injected or infused, sometimes requiring special handling or a designated specialty pharmacy. These usually carry the highest cost sharing and the most coverage rules.
Pharmacy networks
Where you fill it changes what it costs.
Plans contract with pharmacies the same way they contract with doctors. Many have a preferred network where your cost sharing is lowest, a broader standard network where it is higher, and a mail order option for medications you take every month. Specialty drugs often have to be filled through a designated specialty pharmacy. Two people on the same plan filling the same prescription can pay different amounts purely because of where they filled it.
Coverage rules
The requirements that sit behind a drug list.
Being on the formulary is not always the whole story. These rules decide whether a covered drug is paid for on the day you take the prescription to the counter.
- Prior authorization: your prescriber has to get approval from the plan before the drug is covered
- Step therapy: the plan asks you to try a lower cost option first unless your prescriber documents a reason not to
- Quantity limits: coverage is capped at a set amount over a set period, often matching the approved dosing
- Age or diagnosis limits: coverage applies only for the uses the plan lists
- Formulary changes: plans can add or remove drugs and move them between tiers during the year, with notice
- Exceptions and appeals: you and your prescriber can ask the plan to cover a drug it excluded, and you can appeal a denial
Practical steps
Ways to lower what you pay at the pharmacy.
None of these require changing plans. Most take one conversation with your prescriber or one look at your plan drug list.
- Ask whether a generic or a therapeutic alternative on a lower tier would work for you
- Fill at a preferred in-network pharmacy rather than any pharmacy that takes your card
- Use a 90 day supply for medications you take regularly, where the plan allows it
- Compare mail order against retail, since plans often price them differently
- Check whether the drug counts toward your deductible or has its own copay from day one
- Look up the drug list before you enroll, not after your first fill
- Ask your prescriber to note a medical reason if a step therapy requirement does not fit your history
- Keep an eye on notices about formulary changes at the start of each plan year
Good to know
Common questions about prescription coverage.
What is a formulary?
A formulary is the list of prescription drugs a health plan covers, organized into tiers that determine your share of the cost. Every plan publishes its own, and two plans from the same insurer can cover the same drug differently. Because the formulary decides both whether a drug is covered and how much you pay for it, it is the single most useful document to read if you take regular medication.
How do I know if my prescription is covered?
Search the drug list for the specific plan you are considering, using the exact drug name and strength. Our drug search is the fastest way to start, and the plan formulary document confirms the tier, any quantity limit, and whether prior authorization or step therapy applies. Do this before you enroll: it is much easier to choose a different plan than to change a formulary.
Why did my pharmacy charge more than I expected?
The common reasons are that the pharmacy is out of network or not the preferred network pharmacy for your plan, that you have not met a deductible that applies to prescriptions, that the drug moved to a different tier at the start of the plan year, or that the quantity filled exceeded what the plan covers at that price. Your plan member portal shows the tier and the coverage rules that were applied.
What is prior authorization?
Prior authorization means the plan wants your prescriber to explain why a particular drug is appropriate before it will cover it. It is common for expensive drugs, drugs with a lower cost alternative, and drugs approved only for specific diagnoses. Your prescriber submits the request; if it is denied, you have the right to appeal, and plans have to tell you how.
Are generic drugs as good as brand name drugs?
A generic has to contain the same active ingredient in the same strength and dosage form as the brand it copies, and it has to be shown to work the same way in the body. Inactive ingredients such as fillers and dyes can differ, which matters for a small number of people. If your prescriber has a reason to keep you on a specific product, that reason can support an exception request with your plan.
How is Medicare prescription coverage different?
Medicare drug coverage comes either from a stand-alone Part D plan added to Original Medicare or from a Medicare Advantage plan that includes drug coverage. Part D plans use formularies and tiers much like other plans, but they follow their own federal rules, including required coverage of certain drug classes and a yearly cap on what you pay out of pocket for covered drugs. Compare Part D plans by their drug lists and preferred pharmacies, not by premium alone.
Check your medications
See plans and drug coverage in your area.
Enter your ZIP code to compare plans, then check each drug list against your prescriptions.