This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). Prescription drugs covered by Part D are divided into four price levels called tiers, with Tier 1 being the lowest and Tier 4 the highest. �/� �2~3�?�O�. Not all tier 3 non-preferred drugs are listed in the formulary. Tier 2 Mid-range Cost Mix of brands and generics. These drugs have the highest co-payment and are often brand-name drugs that have a generic version available. Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require special . The following is a list of plan names to which this formulary may apply. A mix of brand-name instead of Tier 4, to help reduce and generic drugs. They may be the highest-cost, brand-name drugs or generic drugs that cost more than others used to treat the same condition. • clopidogrel bisulfate 75 mg • Jantoven • warfarin sodium. Introduction The Prescription Drug List (PDL) is the list of covered medications for PHP Marketplace Members and Members who have coverage through their employer group. << /Length 295 /Filter /FlateDecode >> stream Two-Tier Covered Drug List 04HQ1442 R 09/20 HMO Louisiana, Inc. is a subsidiary of Blue Cross and Blue Shield of Louisiana. These costs are decided by your employer or health plan. endobj It's Your Choice 2015 Decision Guide – Department of Employee … etf.wi.gov. Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require special . Tier 4 — Specialty drugs. 0000617573 00000 n … 0000001502 00000 n Tier 4 Highest Cost Mostly higher-cost brand as well as select generic drugs . Ask your doctor if they could work for you. Also may include higher-priced generics that have more cost-effective options at lower tiers. Specialty drugs are used to treat complex, chronic conditions and may need special handling. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage. 4 Specialty Drugs: High‐cost brand or generic drugs that are identified as specialty drugs. Medications are listed by the condition they treat, then listed alphabetically within tiers (or cost-share levels). This formulary lists all covered Tier 1 and Tier 2 drugs but only lists representative products in Tier 3. Ask your doctor if they could work for you. This is a list of preferred drugs which includes brand drugs and a partial listing of generic drugs. Tier Number - This is the actual numerical tier level from the formulary. your out-of-pocket costs. Tier 4 …. Diuretics. Tier 4 Non-Preferred Prescription Drugs Tier 5 Preferred Specialty Prescription Drugs Tier 6 Non-Preferred Specialty Prescription Drugs. 0000616648 00000 n Specialty drugs are used to treat complex, chronic conditions and may require special handling, storage, or clinical management. Multi-Tier Basic Drug List . You can view the most up-to-date list, or the specialty drug list, at MyPrime.com. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). Use Tier 2 or Tier 3 drugs instead of Tier 4 to help reduce your out-of-pocket costs . Some plans may only have three Tiers. << /Type /XObject /Subtype /Image /BitsPerComponent 8 /Filter /DCTDecode /ColorSpace /DeviceRGB /Width 550 /Height 151 /Length 19675 >> Jan 1, 2019 … 2. Over the Counter (OTC) drugs listed on the formulary must have a prescription (written or verbal) from a participating prescriber. Examples of non-covered test strips include, but are not limited to: Ascensia, BD, FreeStyle, Precision, TrueTrack test strips esomeprazole delayed-rel QL Nexium QL Prilosec OTC, omeprazole, lansoprazole, pantoprazole; Nexium Oral Packets are covered for members 12 years of age and younger. Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require special . Tier 4 or Tier IV, also called specialty drugs: These are usually newly approved pharmaceutical drugs that your payer wants to discourage because of their expense. Tier IV is a newer designation, first used in 2009. 0000414968 00000 n 0000722067 00000 n 0000515729 00000 n Select 4 Tier Drug List Drug list — Four Tier Drug Plan Your prescription benefit comes with a drug list, which is also called a formulary. Use Tier 2 drugs, instead of Tier 3 to help reduce your out-of-pocket costs. %PDF-1.3 Ask your name drugs, as well as some generics. These drugs offer a medium co-payment and are often brand name drugs that are usually more affordable. doctor if they could work for you. Here are a few things to remember about the list: Tier 4 drugs are only available at retail pharmacies at full out-of-pocket cost to the beneficiary. 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