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How Drug Benefits Work | Prescription Drug Search | Copay Tier | Prior Review and Limitations | Self-Administered Medications | Over-the-Counter Medications | Medication Safety | Preventive Rx | Specialty Pharmacy

Medications are assigned to one of four or five categories known as copayment or coinsurance tiers, based on drug usage, cost and clinical effectiveness. Our prescription drug search can show you which tier applies to a specific medication based on your benefits plan.

Copayment Definitions for the Four-Tier Formulary (Enhanced)

Tier 1 (Generic Drugs)

• Generic drugs
• Features the lowest copayment

Tier 2 (Preferred Brand-Name Drugs)

• Preferred brand-name products based on safety, efficacy and cost
• Second lowest copayment

Tier 3 (Non-Preferred Brand-Name Drugs/Preferred Specialty Drugs)

• Brand-name drugs for which alternatives are available in Tier 1 or Tier 2; or
• Not used typically as a first line of treatment; or
• Preferred specialty brand-name drugs
• Higher copayment

Tier 4 (Non-Preferred Specialty Drugs)

• Medications classified by BCBSNC as those which require special dosing or administration, are typically prescribed by a specialist and are more expensive than most medications
• Highest copayment or coinsurance amount

Copayment Definitions for Five-Tier Formulary (Basic)

Tier 1 (Preferred Generic Drugs)

• Generic drugs
• Features the lowest generic copayment

Tier 2 (Non-Preferred Generic Drugs)

• Generic drugs
• Second lowest generic copayment

Tier 3 (Preferred Brand-Name Drugs)

• Preferred select brand-name drugs classified by BCBSNC based on safety, efficacy and cost
• Features the lowest brand-name copayment

Tier 4 (Non-Preferred Brand-Name Drugs)

• Non-preferred brand-name drugs for which alternatives are available at lower tiers; or
• Some brand-name drugs with a generic equivalent; or
• A limited number of preferred specialty or biosimilar specialty drugs
• Second lowest brand-name copayment

Tier 5 (Specialty Brand-Name Drugs)

• Medications classified by BCBSNC as those which require special dosing or administration, are typically prescribed by a specialist and are more expensive than most medications; or
• May include biosimilar specialty drugs
• Highest copayment or coinsurance amount