How do insurance companies determine a drugs tier level?

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gaylynn Asked August 2019

How do insurance companies determine a drugs tier level?

My prescription insurance company finally has a generic for a drug I have been paying a high price for, for years. But, they are charging the same high price for the new generic. They said it's because it is in tier 3. I asked why a generic would be in tier 3 and they said the drug manufacturer sets the tier. Everything I have read appears to say it's the insurance company that sets the tier for a drug. So, which is it? I tried writing the manufacturer, but never received a response. Where can I get the facts about this?

Health Insurance Medications Paying for Care

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score 0 · Answer 1

First, you are referring to the "formulary". They (the insurance company) can change the price or coverage at will. I've seen some meds dropped in the middle of a year, not even at renewal. Can't figure that out but it's probably in tiny print in the contract.

Next, download app Goodrx and it will find your meds the cheapest in proximity.

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score 0 · Answer 2

I’ve found that some generics are available from different drug companies & certain companies will be cheaper than others. This happened with a drug I was taking so I made sure my pharmacy ordered it from the cheaper one. I got my answer on line by emailing the drug manufacturer.

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I read the news release by the manufacturer when they came out with the generic drug I needed. It said that the generic would be only a 3rd of the price of the name brand. But, my insurance company that sends the mail order drugs to me said it is the same tier as the name brand so it will be the same cost. I am trying to find out who is telling the truth. Who do I ask? I guess I will try again to email the drug manufacturer.

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score 1 · Answer 3

I agree, that doesn't sound right. The generic should be cheaper.

My nephew is on Medicaid and every year we had to deal with one of his meds not being covered unless they received a letter from the doctor saying for him this was the only drug that worked. We found for a small charge a month, he fell into that tier level so the drug was available to him.

Does ur prescription plan allow mail order? If this isca maintenance drug you can get it cheaper.

We have nurses on the forum who may be able to answer u.

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My prescriptions are all mail order. I discussed the price being just as high with my mail order prescription company. They are the ones that told me that the manufacturer determines the drugs tier level.

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How do insurance companies determine a drugs tier level?

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