Coverage Tiers

The Covered Medication Search tool provided by Elixir (formerly known as EnvisionRx) gives you immediate access to information about prescription drugs covered by the Alliance Coal Health Plan. Use it to help your doctor or nurse practitioner prescribe covered medications. This online tool allows you and your health care provider to:

  • Search covered medications.
  • See a medication’s tier level and any restrictions.
  • Find alternative medications in the same therapeutic class that may be available at a lower cost to you; for example, Tier 1 drugs rather than excluded drugs (identified in the tool as EX) or Tier 3 drugs.

Periodically, all drugs are reviewed and re-assigned to the Plan’s coverage tiers based on the Elixir 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 included in the Elixir Covered Medication Search.

As noted above, one basis of the medications included in the Covered Medication Search is the Elixir Preferred Drug List. This list of commonly prescribed drugs is maintained by the Elixir Pharmacy and Therapeutics Committee, which is made up of independent physicians and pharmacists. Factors that affect decisions regarding the Elixir 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 Coverage Tiers

Coverage Tiers assigns each drug to one of these benefit levels:

  • OTC: Approved Over-the-Counter
  • ACA PV: Approved Preventive
  • Tier 1: Generic Preferred
  • Tier 2: Generic Non-Preferred
  • Tier 3: Brand-Name Preferred
  • Tier 4: Brand-Name Non-Preferred
  • Tier 5: Specialty Preferred
  • Tier 6: Specialty Non-Preferred

Generally, your benefit level for each drug is based on the tier identified in the Covered Medication Search tool. The benefit levels are shown in “Highlights of the Plan” and “Specialty Drugs.”

For certain medications, 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 details, refer to the Covered Medication Search; for additional information, call Elixir Customer Service at (800) 361-4542.

The prescription drug marketplace changes frequently. As a result:

  • The Covered Medication Search is not all-inclusive,
  • A drug’s inclusion in the Covered Medication Search does not guarantee Plan coverage in all cases, and
  • The Plan reserves the right to change the Covered Medication Search 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 Medication Search 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 Elixir 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 (10% coinsurance with $5 minimum), and this year the drug is classified as Generic Non-Preferred (10% coinsurance with $10 minimum), 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), and the Plan paying 90%.