4-Tier Premium Formulary
Drug Category Look-Up (2018)

The Drug Category Look-up below shows common drugs and their tiers, by category (e.g., beta blockers, antibiotics, etc.).

This is provided to help members and providers discuss drug options. We encourage you to print the table
and share it when discussing your prescriptions. Medications within the same category may not be
appropriate substitutions for one another.
All decisions to modify a drug regimen must be made between the Member and his/her health care provider.






Tier Description

$0|Zero Cost Share Eligible
$0 indicates that the drug may be covered at $0 copayment for some benefit plans.
Tier 1|$
Tier 1 is made up of lower costing generic drugs that have been selected by Harvard Pilgrim. These drugs contain the same active ingredients as their brand-name counterparts.
Tier 2|$$
Tier 2 is primarily made up of higher costing generic drugs. These drugs contain the same active ingredients as their brand-name counterparts. Tier 2 may also include brand-name drugs that Harvard Pilgrim has determined to be more effective, less costly or to have fewer side effects than similar medications.
Tier 3|$$$
Tier 3 is primarily made up of brand name drugs for which generic equivalents are not available. These drugs have been selected by Harvard Pilgrim based on review of the relative safety, effectiveness and cost of the many brand name drugs on the market. Tier 3 may also include generic drugs that Harvard Pilgrim has determined to be more costly than their brand name alternatives.
Tier 4|$$$$
Tier 4 is made up of drugs that Harvard Pilgrim has not included in Tier 1, Tier 2, or Tier 3. You pay the highest Copayment or Coinsurance Amount for Tier 4 drugs.
MD
Medical
N/C
Drug is not covered.

Certain controlled substances and other prescribed medications may be subject to dispensing limitations, exclusions or restrictions as required by state and federal law or benefit plan design. Please contact Member Services if you have any additional questions.

Some hospitals and physician practices have lists of drugs that they prefer their doctors to prescribe.(Such a list might be called a "Drug Formulary" or a "Preferred Drug List.") Hospital or physician drug lists do not effect the coverage provided by Harvard Pilgrim and its affiliated health plans. Harvard Pilgrim's prescription coverage is generally explained in the Prescription Drug Brochure for the benefit plan in which a member is enrolled.

Please Note: This list represents only the most commonly prescribed drugs. Harvard Pilgrim makes regular changes based on the FDA approval process and decisions made by the Harvard Pilgrim Pharmacy & Therapeutics Committee. Therefore, this list is subject to change at any time.