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Covered Population Size

500,000 individuals—the majority of members are age 0 to 64 (only a small percentage are age 65 and older)

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Table 1 Tiers within Commercial Managed Care Formulary
Tier Drug Costs to MCO Member/Patient
Tier I Preferred generics No copay required ($0 copayment)
Tier II Nonpreferred generic $15 copayment
Tier III Preferred brand $130 copayment
Tier IV Nonpreferred brand $150 copayment
Tier V Specialty drugs 30% co-insurance payment*

*Co-insurance payment is determined based on total drug cost. Specialty medications are those that treat complex, chronic, and rare conditions; are not routinely stocked at retail pharmacies; are the highest-cost; require special handling, storage (eg, refrigeration), inventory, or distribution; require complex patient education, complex dosing, intensive monitoring, or clinical oversight.

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Table 2 Restrictions that May Be Applied to Drugs within Tiers
Restriction Check below if your assigned medication meets the following criteria Description
Unrestricted (UR)   No restrictions placed on dispensing.
Prior Authorization (PA)   The prescribing physician will need to submit a prior authorization request for coverage of these medications and the request will need to be approved, before the medication will be covered.
Step Therapy (ST)   The patient must try another proven, cost-effective medication before coverage may be available for the drug included in the program.
Quantify Limit (QL)   May pertain to either quantity of covered medication per prescription or quantity of covered medication in a given time period. Intended to encourage use as approved by FDA and summarized in evidence-based guidelines.

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