Understanding Your Insurance Prescription Coverage in Ohio

Insurance coverage for prescriptions can be confusing. Understanding the basics — formularies, tiers, copays, and prior authorizations — can save you hundreds of dollars each year.

What Is a Formulary?

A formulary is a list of medications that your insurance plan covers. Most formularies are organized into tiers, with lower tiers costing you less out of pocket. Generic medications typically fall into Tier 1, while brand-name and specialty drugs are in higher tiers.

Understanding Prescription Tiers

• Tier 1 (Generic) — Lowest copay. These are generic versions of brand-name drugs.
• Tier 2 (Preferred Brand) — Moderate copay. Brand-name drugs your insurer has negotiated discounts on.
• Tier 3 (Non-Preferred Brand) — Higher copay. Brand-name drugs without preferred pricing.
• Tier 4 (Specialty) — Highest cost. Complex medications for chronic or rare conditions.

How to Maximize Your Benefits

Here are strategies to get the most from your prescription coverage:

• Ask about generics — Generic medications are FDA-approved and equally effective at a fraction of the cost.
• Use mail-order when possible — Many plans offer lower copays for 90-day supplies by mail.
• Check for manufacturer coupons — Drug manufacturers often offer savings programs for brand-name medications.
• Review your formulary annually — Coverage changes each year. What wasn't covered last year might be this year.
• Work with your pharmacist — We can help identify lower-cost alternatives and find savings programs.

What Is Prior Authorization?

Prior authorization is when your insurance requires approval before covering certain medications. Your prescriber submits clinical information to the insurance company, who decides whether to approve the medication. This process can take 2-5 business days.

At ExpressRx, we track prior authorizations proactively and contact your prescriber's office to expedite the process.