| Your health plan includes a 3-tier
prescription drug benefit, which is administered
by Community First and our Pharmacy Benefit Manager
(PBM) in accordance with the plan design specified
by the Employees Retirement System of Texas (ERS).
- Non-maintenance copayments for a 30-day supply are $10 for Tier 1 drugs; $25 for Tier 2; and $40 for Tier 3 drugs.
- Maintenance-drug copayments for a 30-day supply are $15 for Tier 1 drugs; $35 for Tier 2 drugs; and $55 for Tier 3 drugs.
- Mail-order copayments for up to a 90-day supply, including oral contraceptives, are $30 for Tier 1 drugs; $75 for Tier 2 drugs;
and $120 for Tier 3 drugs.
Please note that there is a $50 per enrollee plan-year deductible. If a brand-name medication is dispensed when a generic is available,
you will be responsible for the generic copayment plus the cost difference between the generic and the brand-name medication.
Your specific prescription benefit plan design
may not cover certain categories of drugs, regardless
of their appearance in this list. Check your
Evidence of Coverage or contact Community First’s
Member Services Department for those conditions
and medications not covered by your plan. In general, Tier 2 are mostly preferred brand name drugs;
and Tier 3 are non-preferred and other preferred
brand name drugs. The preferred list of covered
drugs is subject to change. When new drugs become
available during the year or the Pharmacy and
Therapeutics Committee meets, drugs may move from
one copayment tier to another.
This document lists some preferred and non-preferred
drugs in alphabetical order; it does not contain
a complete list of all preferred and
non-preferred drugs. If you don’t find your
medication listed in this guide, you should contact
Community First’s Member Services Department
at (210) 358-6262, or 1-877-698-7032. Do not contact
ERS for assistance with your medications.
| PA Indicates Prior Authorization |
| QL Indicates quantity limit |
Lowercase Names = Tier 1, Primarily generic
drugs |
| ST Indicates step therapy |
Uppercase Names = Tier 2, Mostly preferred
brand name drugs |
| * Indicates maintenance medication |
|
* Maintenance drugs are coded as
such if they meet the following criteria:
- Medications that do not require frequent
monitoring and dosage adjustments for side effects
or therapeutic responses. Certain drugs that
may have potential life-threatening toxicity
when taken as an intentional overdose may be
excluded.
- Medications that are used to treat a chronic
condition with no therapy endpoint. These drugs
are taken continuously but do not provide a
cure for the condition for which it is being
treated.
- Medications that are typically used as outpatient
type of drugs.
|
Deductible
Tier Schedules
