Three ways to get the most out of your pharmacy benefit and protect your wallet.

1. Prescription Cost Savings

Generics, mail order, and smart shopping tips

Ask for Generics

Always ask your doctor: “Is there a generic available?” Generic drugs have the same active ingredient, dosage, and effectiveness at a fraction of the cost.

Check Tier Before Filling

Your plan has a drug formulary with tiers. Tier 1 equals lowest cost. Ask your pharmacist or check the plan portal before filling a new prescription.

Use Mail Order

For maintenance medications (blood pressure, diabetes, cholesterol), mail order delivers a 90-day supply, often at a lower copay than monthly retail fills.

Use In-Network/Preferred Pharmacies

Using a preferred network pharmacy can significantly reduce your copay. Check your plan’s pharmacy directory via the member portal or your insurance card.

2. Specialty & High-Cost Drug Management

Biologics, injectables, and complex therapies

What are Specialty Drugs?

Specialty drugs treat complex conditions (MS, rheumatoid arthritis, cancer, crohn’s). They are often injected or infused and can cost thousands per month.

Prior Authorization

Specialty drugs typically require prior authorization (PA) before the plan will cover them. Work with your doctor’s office to submit the PA early to avoid delays.

Use the Specialty Pharmacy

Many plans require specialty drugs to be filled through a designated specialty pharmacy. Using the right pharmacy ensures coverage and access to clinical support.

Manufacturer Copay Assistance

Many manufacturers offer copay cards that can dramatically lower your out-of-pocket cost. Ask your specialty pharmacist or contact the manufacturer directly. Not available with Medicare/Medicaid.

3. Understanding Your Pharmacy Benefit

Formulary, deductibles, and how to navigate your plan

The Formulary

Your plan’s approved drug list, organized by tier. Tier 1 (generics) cost least; Tier 4-5 (specialty/brand) costs most. Search it on your member portal.

Out-of-Pocket Maximum

Once your out-of-pocket maximum is reached, your plan pays 100% of covered drugs for the rest of the plan year, including prescriptions.

Quantity Limits

Plans may limit how much of a medication is covered per fill. If your dosage exceeds the limit, your doctor can submit a prior authorization with clinical justification.

Deductibles & Copays

Some plans have a separate drug deductible. Once met, you pay a flat copay or coinsurance. Track your year-to-date spending in the member portal.

Step Therapy

Some plans require you to try a lower-cost drug before approving a more expensive one. If you believe this is medically inappropriate, your doctor can request exception.

Appeals Process

If a drug is denied, you have the right to appeal. Your HR team or benefits administrator can help guide you through the internal and external appeals process.