Three Tier Copay Chart
Using Examples Of $8.00, $15.00 And $30.00 Copay Amounts.
Tier 1
Approved Generic Drugs

Example - $8.00 copay

   Tier 2
Preferred Formulary Brand Drug

Example - $15.00 Copay

 Tier 3
Non-formulary/
Non-prefered Brand Drug

Example - $30.00 Copay

 Mandatory Generic
An Approved Generic
Substitute To A Brand Drug

Generic = Tier 1copay

Member/Physician request Brand
over an approved generic equivalent =
Brand - generic + Tier 2 formulary copay
Member will be charged their group’s 1st tier generic drug copay amount. Member will be charged their groups 2nd tier preferred formulary copay amount.

Tier 2 is a listing of Preferred formulary drugs that have no approved generic equivalent.

If an approved generic equivalent becomes available to a 2-tier drug, then the payment falls under the mandatory generic column.

Member will be charged their group’s 3rd tier non-preferred group copay amount.

Tier 3 is a listing of non-preferred/non-formulary drugs that have no approved generic equivalent.

If an approved generic equivalent becomes available to a 3-tier drug, then the payment falls under 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 $15.00
Member Pays $45.00
Example 2
Total cost calculation
Brand drug cost $60.00
Generic drug cost $15.00
Cost difference = $45.00
Plus Brand Formulary copay $15.00
Member Pays $60.00
Example 3
Total > cost calculation
Brand drug cost $60.00
Generic drug cost $ 5.00
Cost difference = $55.00
Plus Brand Formulary copay $15.00
Total Calculation $70.00
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, 2, and/or 3 Tier columns. Please check the drugs Requiring Prior Authorization list.
There are also drug limitations on the 3-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.
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 formulary brand copay.