Pharmacy Resource Guide – Section 5

How the formulary works

The medications covered are the same in both the HSA Advantage and Signature Plans but how you pay for them is different.

Signature Plan members

• Both medication type (acute, maintenance or specialty) and cost tier in the formulary will affect the amount of your copay. The prescription drug formulary classifies medications by four cost tiers, with tier 1 being the least expensive and tier 4 being the most expensive for non-specialty medications. For specialty medications there are three tiers, with tier 1 again being the least expensive.
  • For example, a 30-day supply of a tier 1 maintenance prescription would be a $5 copay while a 30-day supply of a tier 1 specialty prescription would be a $20 copay.
• Find your medication tier on the formulary using this guide.
• To help manage your prescription costs, always ask your provider for a medication in tier 1, if available, for the lowest cost.

HSA Advantage Plan members

• The percentage of coinsurance doesn’t change based on medication type (acute, maintenance or specialty) or cost tier in the formulary, but does change based on where you fill your prescription.
  • For example, an antibiotic at the health system pharmacy will be a 10% coinsurance after you have met your deductible, but that same antibiotic will be a 30% coinsurance at an in-network pharmacy such as Walgreens or Walmart. Plus, the health system deductible is lower than the in-network deductible, saving you more overall by using the health system pharmacy.
• There can be a big difference in the overall cost of the drug based on whether you choose lower-cost generics or higher-cost brand-name drugs, which will make the amount of your coinsurance higher.
• For preventive medications only, you pay the Signature Plan copay, which is typically lower than the deductible plus coinsurance.
• Copay cards or manufacturer assistance cards for specialty and high-cost brand medications cannot be used until you have met your deductible, and these amounts do not apply to your maximum out of pocket.