Specialty tier
The plan's highest-cost drug tier, typically reserved for biologics, oncology drugs, and complex specialty medications.
Specialty tier (often Tier 4 or 5) is the formulary tier for the highest-cost prescription drugs — biologics, oncology infusions, hepatitis C antivirals, hemophilia clotting factors, etc. Cost-sharing is typically high (25-33% coinsurance, sometimes with cap). Many specialty drugs require prior authorization, must be filled at a specialty pharmacy, and may have step-therapy requirements.
Frequently asked questions
What is specialty tier?
Specialty tier (often Tier 4 or 5) is the formulary tier for the highest-cost prescription drugs — biologics, oncology infusions, hepatitis C antivirals, hemophilia clotting factors, etc. Cost-sharing is typically high (25-33% coinsurance, sometimes with cap). Many specialty drugs require prior authorization, must be filled at a specialty pharmacy, and may have step-therapy requirements.
Related terms
- FormularyThe list of prescription drugs your plan covers, organized into tiers with different cost-sharing.
- Prior authorization (PA)Plan approval required BEFORE a service is rendered, otherwise the plan won't pay.
- Step therapyA plan requirement to try and fail a cheaper drug before the plan covers the requested drug.
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