Understanding drug tiers

Under your insurance plan, the prescription medicines available to you are split into tiers, which then determine your cost. Medicines are typically placed into 1 of 5 tiers—from Tier 1 (generics) to Tier 5 (highest-cost medicines)—depending on their strength, type or purpose.

Your medicines may be split up into 3-tier, 4-tier or 5-tier groupings according to your insurance plan. Below you will find how your medicines could be divided depending on how many tiers your prescription drug plan has.

3-tier plan:
Covered prescription drugs are assigned to 1 of 3 different levels with corresponding copayment or coinsurance amounts. The levels are organized as follows:

• Level or Tier 1: Generic drugs, which could be low-cost preferred generics or general preferred generics
• Level or Tier 2: Brand-name drugs, including preferred and nonpreferred options
• Level or Tier 3: Highest-cost drugs

4-tier plan:
Covered prescription drugs are assigned to 1 of 4 different levels with corresponding copayment or coinsurance amounts. The levels are organized as follows:

• Level or Tier 1: Low-cost generic and brand-name drugs
• Level or Tier 2: Higher-cost generic and brand-name drugs
• Level or Tier 3: High-cost, mostly brand-name drugs that may have generic or brand-name alternatives in Levels 1 or 2
• Level or Tier 4: Highest-cost, mostly brand-name drugs

5-tier plan:
Covered prescription drugs are assigned to 1 of 5 different levels with corresponding copayment or coinsurance amounts. The levels are organized as follows:

• Level or Tier 1: Preferred, low-cost generic drugs
• Level or Tier 2: Nonpreferred and low-cost generic drugs
• Level or Tier 3: Preferred brand-name and some higher-cost generic drugs
• Level or Tier 4: Nonpreferred brand-name drugs and some nonpreferred, highest-cost generic drugs
• Level or Tier 5: Highest-cost drugs including most specialty medications

Drug tiers are a way for insurance providers to determine medicine costs. The higher the tier, the higher the cost of the medicine for the member in general.

If you look at your insurance card, you’ll see the copay values for all the tiers under your insurance plan. Copay values could be as little as $0 for generic medicines in Tier 1, while the percentage you pay will rise as you move toward Tier 5. Specialty drugs are high-cost/high-technology drugs that often require special dispensing conditions and may be listed in the highest tier or not listed within any tier. Please refer to your Evidence of Coverage for information on how much you will pay for specialty drugs.

If your drug isn’t listed within any tier, it may mean that it’s not covered under your insurance plan. In this case, it may qualify for a discount with our drug discount program, or you will have to pay the full price for the medicine. If you are prescribed a medicine not covered under your plan, you can ask your prescriber if there are options available. Or you can have your prescriber contact the Humana Clinical Pharmacy Review for approval. Your prescriber can call 1-800-555-CLIN (2546), Monday – Friday, 8 a.m. – 8 p.m., Eastern time.