Coverage Tiers (Formulary)

The Alliance Prescription Drug Coverage Tiers (Formulary) is a document that summarizes the Plan’s coverage tiers, step-therapy (ST) requirements, prior-authorization (PA) requirements, quantity limits (QL), other limits or requirements, and/or exclusions that apply for most drugs available in the marketplace. This document can be downloaded from the home page of www.CoalBenefits.com.

Periodically, all drugs are reviewed and re-assigned to the Plan’s coverage tiers based on the EnvisionRxOptions Preferred Drug List (explained in the following paragraph) and each drug’s average cost. Periodically, new drugs are added to the coverage tiers, and some drugs are re-assigned to different tiers or excluded from coverage. The Federal Drug Administration approves new prescription drugs for sale in the U.S. during the year, but these “new-to-market” drugs are not covered under the Plan until they are added to one of the Plan’s coverage tiers and listed in the Alliance Prescription Drug Coverage Tiers (Formulary).

As noted above, one basis of the Alliance Prescription Drug Coverage Tiers (Formulary) is the EnvisionRxOptions Preferred Drug List. This list of commonly prescribed drugs is maintained by the EnvisionRxOptions Pharmacy and Therapeutics Committee, which is made up of independent physicians and pharmacists. Factors that affect decisions regarding the EnvisionRxOptions Preferred Drug List include safe use, clinical efficacy, and therapeutic need. Cost factors are considered only after a review of these criteria.

How the Plan Uses the Coverage Tiers (Formulary)

The Coverage Tiers (Formulary) assigns each drug to one of these six benefit levels:

  • Tier 1: Approved Preventive, Approved Disease-Management, and Generic Preferred Drugs
  • Tier 2: Generic Non-Preferred Drugs
  • Tier 3: Brand-Name Preferred Drugs
  • Tier 4: Brand-Name Non-Preferred Drugs
  • Tier 5: Specialty Preferred Drugs
  • Tier 6: Specialty Non-Preferred Drugs

Generally, your benefit level for each drug is based on the tier identified in the Coverage Tiers (Formulary). The benefit levels are shown in "Highlights of the Plan" and "Specialty Drugs."

Step-therapy (ST) requirements, prior-authorization (PA) requirements, generic-substitution requirements, Care Coordination requirements, quantity limits (QL), other limits or requirements, and/or exclusions apply for certain medications. For details, refer to Coverage Tiers (Formulary); for additional information, call EnvisionRxOptions Customer Service at (800) 361-4542.

The prescription drug marketplace changes frequently. As a result:

  • The Coverage Tiers (Formulary) is not all-inclusive,
  • A drug’s inclusion on the Coverage Tiers (Formulary) does not guarantee Plan coverage in all cases, and
  • The Plan reserves the right to change the Coverage Tiers (Formulary) at any time and for any reason.

Minimizing Your Out-of-Pocket Costs

Often when you need a prescription drug, you can reduce your out-of-pocket costs by asking your doctor to prescribe a drug with a lower cost, such as an over-the-counter drug or a Generic Preferred drug.

By law, generic drugs must meet the same standards as brand-name drugs for safety, purity, strength, and effectiveness. If a generic drug is available, often the brand-name version of the same drug is on the higher-cost Brand-Name Non-Preferred Drug tier.

You may be able to reduce your costs by talking with your doctor. When your doctor is prescribing a drug, ask him or her to review the Covered Tiers (Formulary) and consider selecting lower-cost drugs, when available. Even if your doctor has selected a higher cost drug, you can also ask your pharmacist to review your Alliance coverage in the Envision claims system. He or she may be able to determine if there are drug options that will save you money. Your pharmacist can then contact your doctor to discuss switching to the lower-cost drug.

For instance, if last year you were taking a generic drug that was Generic Preferred ($5 copay at the 2017 benefit level), and this year the drug is classified as Generic Non-Preferred (10% coinsurance), you may want to investigate to see if you have additional options. You might look into whether another drug is now available as Generic Preferred. Otherwise, you will share in the total cost of the Generic Non-Preferred drug by paying 10% coinsurance ($10 minimum coinsurance), and the Plan paying 90%.