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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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.
