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Prescription Drug Tiers

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A number of factors are considered when classifying drugs into tiers, including, but not limited to:  
the absolute cost of the drug
the cost of the drug relative to other drugs in the same therapeutic class
the availability of over-the-counter alternatives
certain clinical and economic factors
 

Tier Definitions

Tier 1

Lowest copayment — Drugs offering the greatest value within a therapeutic class. Some of these are the generic equivalents of brand name drugs.

Tier 2

Moderate copayment — Moderate cost drugs. These can be multi-source brand name drugs which are drugs which have a generic equivalent. Other drugs on this tier are the preferred drugs within a therapeutic class based on clinical efficacy and cost as determined by the Pharmacy and Therapeutics Committee.

Tier 3

Highest copayment — Higher cost drugs. These are typically single source brand name drugs which are brand name drugs that do not have a generic equivalent. These also may include single source brand name drugs that have no other therapeutic equivalent, but are determined to be a third tier drug solely on the basis of cost. In addition, drugs on this tier may be a higher cost than equivalent drugs on lower tiers or drugs determined to be less efficient than equivalent drugs on lower tiers by the Pharmacy and Therapeutics Committee.

 
The sole discretion in assigning drugs to certain tiers and in moving drugs from tier to tier is ours. Certain exclusions, limitations and prior authorization requirements may apply to some drugs covered by the three-tier prescription drug benefit plan as outlined in the member booklet or Evidence of Coverage.  
 
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When is Prior Authorization necessary?

Some medications, and certain amounts of some medications, require an approval from Anthem before they are eligible to be covered by your benefits. This approval process is called prior authorization.

 
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use