What’s the deal with pharmacy tiers?

Do you wonder why your pharmacy costs are divided into tiers and what they mean? Here’s some help understanding drug tiers.

Look at the medical plan comparisons for your member type, below. Your plan’s pharmacy tiers and other pharmacy benefit details are available in these medical benefit comparisons. The pharmacy section will be on the last page. When you compare different medical plans you see that prescription drugs are divided into tiers.

Where to find your pharmacy tiers

• PEBB Employees, Continuation Coverage members, and non-Medicare retirees
• PEBB Medicare retirees
• SEBB Employees and Continuation Coverage members

What the tiers mean

Each tier shows you how prescription drugs are covered under your plan. For example, it shows whether you have a pharmacy deductible and whether it’s a set amount or a percentage of the drug price.

Each tier covers specific prescription drugs, which may be a little different from plan to plan. The drugs listed within each tier are safe and effective when used appropriately and as prescribed. Your provider will write the prescription for the drug that’s best for you, so you don’t have to worry about which tier your prescription belongs in.

The biggest difference between the tiers is typically the cost. The amount you pay for your prescription drug usually depends on the tier your prescription belongs to, as well as the price charged by your pharmacy, and how your plan covers that tier (as you saw in the comparison table).

How the tiers are organized

Here’s a general model of how drugs are grouped into different tiers, although each plan’s actual drug tier structure may differ.

• Tier 1: Generic or value – These are the least expensive and most commonly prescribed drugs. Examples include antibiotics, most antidepressants, and medications to treat high blood pressure.
• Tier 2: Preferred brand-name – Brand-name drugs are made by just one company. Preferred brand-name drugs do not have a generic alternative available but still might be an important treatment option. Examples may include some drugs for the treatment of diabetes. These cost more than Tier 1 drugs.
• Tier 3: Non-preferred – These are usually brand-name drugs that are more expensive than Tier 2 preferred drugs. This does not mean they are more effective. Using prescription drugs from Tier 3 is similar to seeing a provider who is “out of network.”
• Tier 4: Specialty – Specialty drugs sometimes require special storage or handling and are used for certain complex diseases, like rheumatoid arthritis or cancer. Many drugs you see advertised, like Rinvoq and Ozempic, are specialty drugs. This is the most expensive tier.

Different plans organize their pharmacy tiers in slightly different ways. For example, Uniform Medical Plan (UMP) has a Value Tier for specific high-value, low-cost prescription drugs that are used to treat certain chronic conditions like high blood pressure, depression, and diabetes. UMP’s Tier 1, the next highest tier, is primarily low-cost generic drugs, and Tier 2 combines preferred brand-name, high-cost generics, and preferred specialty drugs.

As another example of how they might differ, some plans do not have a named specialty tier, but they cover specialty drugs in another tier. Some plans divide specialty drugs into two tiers.

Where to find your plan’s formulary

Each plan’s “carrier,” which administers the medical plans (for example, Regence administers UMP plans), has a “formulary,” or list of drugs it covers. You can check to see if your prescriptions are covered by these carriers.

• Uniform Medical Plan (UMP) Preferred Drug List
• Kaiser Permanente Northwest, KP Washington, and KPWA Options Drug Formularies
• Premera Essential Drug List
• UnitedHealthcare – Use this drug search tool to look for your prescription, or call UnitedHealthcare Customer Service at 1-855-873-3268 to ask for a copy of the formulary.