It can be difficult to figure out which prescription drugs are covered under your plan. We’re here to help you get the answers you need.
Let’s start with how prescription drug coverage works. Your Regence health plan will help pay for the cost of certain prescription medications. To find out which ones—and to avoid paying more than you expect—you can look at your drug formulary.
A drug formulary, also called a covered-drug list, is a list of drugs that are covered by your health plan. In other words, it’s a list of pre-approved drugs that Regence helps cover, so when you fill your prescription, you don’t have to pay full price.
A drug formulary is designed to help you and your doctor choose medications that are safe, effective and cost-conscious. We regularly update our list to keep up with new drugs, safety data, information from the FDA, clinical trial results and doctors’ recommendations.
Your drug formulary is split into tiers, which are grouped according to price. Drugs in lower-numbered tiers generally cost less than drugs in higher-numbered tiers.
There are three drug categories: Generic, brand and specialty medications. Our Medicare plans have five tiers that include preferred and non-preferred drugs in each category.
Tier 1: Preferred generic
These are commonly prescribed generic drugs, and they usually have the lowest copay. The deductible is waived for Medicare Advantage members, so you’ll pay just a copay* starting with the first fill.
Tier 2: Generic
These are less commonly prescribed generic drugs, and they usually have a higher cost than the drugs in Tier 1. The deductible also is waived for Tier 2 medications, so you’ll pay just a copay.
Tier 3: Preferred brand
These are commonly prescribed brand-name drugs, and they usually have a lower cost than Tier 4 brand-name drugs. The cost of these medications applies toward your deductible. Once the deductible is met, you’ll pay a copay.
Tier 4: Non-preferred drugs
These are less commonly prescribed drugs, and they usually have a higher cost than the drugs in Tier 3. The cost of these medications applies toward your deductible. Once the deductible is met, you’ll pay coinsurance** or a copay.
Tier 5: Specialty
These are used to treat rare or complex medical conditions. They can be generic or brand name, and they usually have the highest cost. The cost of these medications applies toward your deductible. Once the deductible is met, you’ll pay coinsurance.
*A copay is a flat-dollar fee for treatment or a prescription fill.
**Coinsurance is a percentage of the medication’s total cost.
If you have an MAPD plan (Medicare Advantage plan with prescription coverage), insulins on Tiers 3 and 4 are a $35 copay per 30-day fill, and are not subject to the deductible.
An easy way to check whether a certain medication is on your covered-drug list is to go to your Pharmacy benefits and select Find a drug. Search for the medication, and the results will tell you whether the drug is covered, what tier it’s in and even approximately how much it will cost based on your benefits.
To view your formulary or covered-drug list:
- Sign in
- Select Covered services
- Click on the Pharmacy tab
- Under Resources, you’ll find a link to your formulary
You can then open or download a copy of your covered-drug list.
Some medications require prior authorization in order to be covered by your plan. We have this requirement to ensure that you’re getting an effective drug at an affordable price.
How do you know if your medication requires prior authorization? You can check your drug formulary, or sign in to your Pharmacy benefits and use Find a drug. The results will tell you if prior authorization is needed and if there are any other requirements.
If you need prior authorization for your medication, talk to your doctor or pharmacist about next steps.
Aside from prior authorization, there are a few other requirements or limitations that might apply to your medication:
Quantity limits: Sometimes we cover only a certain amount of the medication because too much is a safety concern. If your doctor prescribes more than this limit, you may request an exception.
- Specialty drugs: These drugs are limited to a 30-day supply. A specialty pharmacy can help you coordinate refills, monitor side effects and give you 24-hour access to clinical specialists.
If you have questions about prior authorization or other requirements, call Customer Service at 1-800-541-8981.
What you pay for your medications will depend on your plan. To see your pharmacy coverage and the percentage of prescriptions you’ll pay, go to your Benefits and view your Evidence of Coverage.
To find the price of a specific medication based on your benefits, sign in to access your Pharmacy benefits and use Find a drug. From here you can get an approximate cost estimate for your medication. Find a pharmacy lets you search pharmacies in your network and compare medication costs.
When you’re signed in at regence.com, you also have personalized medication insights and tools to help you research medications. You can even message with a pharmacist to get your medication questions answered. To get started, go to the Medications tab under Your care.
When you have a Medicare Advantage plan with prescription coverage, there are several ways to save on medications:
Use a preferred or mail-order pharmacy for savings and convenience.
Ask your doctor to write your prescription for a 90-day or 100-day supply (or the maximum days allowed by your plan). You’ll save on pharmacy dispensing fees and need to pick up your medications only a few times a year!
Ask your doctor about generics, which typically cost less than brand-name drugs and work just as well.
- Save on select insulins covered under our Insulin Savings Program and reduce your cost to just $35 per month.
Lastly, it’s always important to be open with your doctor about costs and using a drug on your formulary when possible.
Prescription coverage can be complicated. But by reviewing your drug formulary and getting to know your pharmacy benefits, you’ll have a better idea of how much you’ll pay for medications.
If you have questions about what’s covered, prior authorization or anything else, reach out to Customer Service at 1-800-541-8981. TTY users should call 711. Our hours are 8 a.m. to 8 p.m. Monday through Friday. From Oct. 1 through March 31, we are available 8 a.m. to 8 p.m. seven days a week.
If your plan is through an employer group, benefits and features may be different than described.
Pharmacy and pharmacist services are provided by JourniRx, Inc. (a licensed pharmacy).
JourniRx, Inc. is a separate company that provides pharmacy and pharmacist services to Regence members.
Last updated 03/11/2022