Tier 3 medications

Tier 3 medications represent non-preferred brand-name drugs within a health insurance plan’s formulary, ranking below Tier 1 (generic) and Tier 2 (preferred brand) options. Insurance plans assign higher copays or coinsurance rates to Tier 3 medications; for example, Aetna charges $47 per prescription in its SilverScript Choice PDP as of 2024.

Formularies update annually, so insurers may move specific drugs–such as Xarelto or Eliquis–into or out of Tier 3 based on cost negotiations and clinical guidelines. Patients can request exceptions for Tier 3 medications if lower-tier alternatives cause adverse reactions or prove ineffective, but approval requires supporting documentation from healthcare providers.

Insurers often require prior authorization before covering Tier 3 drugs like Humira or Trulicity due to their high costs and potential alternatives. Medicare Part D plans typically place specialty drugs such as Enbrel in even higher tiers than Tier 3, resulting in greater out-of-pocket expenses for those products.

Some employer-sponsored insurance plans exclude certain expensive biologics from coverage altogether rather than placing them in any tier. Pharmacies process claims according to the tier listed by the insurer’s electronic formulary system at the point of sale, determining patient payment amounts instantly.

Appeals processes exist for denied claims involving Tier 3 medications; patients must submit formal requests with clinical evidence to overturn initial decisions, Your Insurance Info states.