Two Tier Copay Chart
Using Example Of $10.00 Copay Amount
Tier 1 Preferred Formulary Brand Drug

Example - $10.00 Copay
All Generic Drugs Are Considered Formulary Drugs.

 Tier 2 Non-formulary/ Non-prefered Brand Drug

Example - $25.00 Copay

 Mandatory Generic An Approved Generic Substitute To A Brand Drug

Generic = Tier 1 copay

Physician/Member request brand = Brand – generic + Tier 1 formulary copay
Member will be charged their standard group copay amount. Tier 1 is a listing of Preferred formulary drugs that have no approved generic equivalent. If an approved generic drug becomes available the drug will then follow the mandatory generic column. Member will be charged their standard group copay amount plus an additional $15.00 copay. Tier 2 is a listing of non-preferred/non-formulary drugs that have no approved generic equivalent. If an approved generic drug becomes available the drug will then follow the mandatory generic column.
Example 1 Total < cost calculation
Brand drug cost $60.00
Generic drug cost $30.00
Cost difference = $30.00
Plus Brand Formulary copay $10.00
Member Pays $40.00
Example 2 Total cost calculation
Brand drug cost $60.00
Generic drug cost $15.00
Cost difference = $45.00
Plus Brand Formulary copay $10.00
Member Pays $55.00
Example 3 Total > cost calculation
Brand drug cost $60.00
Generic drug cost $ 5.00
Cost difference = $55.00
Plus Brand Formulary copay $10.00
Total Calculation $65.00
Member Pays $60.00
Please note that certain class medications require prior authorization on all lines of business. This list may contain drugs in the 1 and/or 2 Tier columns. Please check the Drugs Requiring Prior Authorization list.
There are also drug limitations on the 2-tier program. Please check the drug limitations list.
There is a short list of brand drugs that are exempt from the mandatory generic benefit. Please see the Exempt Drug List.
Pennsylvania law requires a pharmacist to dispense an approved generic substitution when available unless the physician/member request the brand drug be dispensed. The member will then be responsible for the cost difference between the brand and generic plus their tier 1 copay.
Member/Physician requests brand when an approved generic is available the member is required to pay the cost difference between the brand and generic plus their preferred formulary brand copay.