Yale Health Pharmacy Benefit for Students with Hospitalization/Specialty Care Coverage

(Effective January 1, 2023)

Overview

No deductibles
No annual limit to coverage
When using a non-Yale Health (out-of-network) pharmacy, members pay the greater of 20% of the price of the drug or the co-pay for the Tier of the drug (Yale Health reimburses the difference)
No annual out-of-pocket maximum

Pricing

$10 co-pay for Tier 1 prescriptions up to a 30-day supply at the Yale Health Pharmacy
$30 co-pay for Tier 2 prescriptions up to a 30-day supply at the Yale Health Pharmacy
$45 co-pay for Tier 3* prescriptions up to a 30-day supply at the Yale Health Pharmacy

Tiers

Our prescription tiers reflect Yale Health’s Pharmacy and Therapeutics Committee’s assessment of the medication based on the following criteria:

FDA approval and intended use
Guidelines from medical experts and reliable sources
Published research and studies
Cost-effectiveness
How our decisions align with similar health plans

Tier 1 drugs are generics and other preferred drugs.
Tier 2 drugs are preferred drugs.
Tier 3 drugs are non-preferred drugs, often with clinical alternatives in Tier 1 and/or Tier 2.

How do I know if my drug is covered and what Tier it is in?

Review the Yale Health Drug List, it:

Provides access to quality medications Promotes appropriate and cost-effective therapy Provides clinicians with information relating to alternative therapies Gives members information to help them discuss medications with their clinician

The Yale Health Drug List is subject to change.

What are the differences between brand-name and generic drugs and why should I use generic drugs?

The Food and Drug Administration (FDA) has deemed that generic drugs are therapeutically equivalent to brand-name drugs. Generic drugs must contain the same active ingredients in the same amounts as their brand-name counterparts. Additionally, the same rigorous FDA quality and safety reviews apply to generic drugs and brand-name drugs. Under our plan the use of generic drugs will substantially lower your costs. If a drug becomes available as a generic, the generic drug would be available as a Tier 1 drug and the brand-name drug, if continued to be available and covered, will be moved to Tier 3.

How does Yale Health decide what drugs are on the Yale Health Drug List?

Our goal is to provide a drug list that gives members access to quality, cost-effective medications. Yale Health’s Pharmacy and Therapeutics (P&T) Committee meets regularly to review drugs that have been approved by the FDA. The P&T Committee is comprised of Yale Health clinicians and pharmacists from a variety of specialties. After evaluating information from multiple sources, the P&T Committee decides whether a drug is an appropriate clinical addition to our drug list and whether it will be covered. If the drug is covered the committee then decides which Tier it will be placed in and what limitations may apply. The Yale Health Drug List is subject to change.

How much will my prescription cost at the Yale Health Pharmacy?

Look up your prescription name (use the name that is on the label of your container) on the Yale Health Drug List and find the Tier and corresponding co-pay amount.

What if the price of my prescription is less than the co-pay?

If the price of your prescription is less than the co-pay you will pay the price of the prescription.

What if my prescription is for less than 30 days?

You will pay 1 co-pay.

What if my prescription is for more than 30 days but less than 60?

You will pay the applicable co-pay X 2 (e.g., prescription for 60 days of a Tier 2 drug = $30 X 2 = $60).

What if my prescription is for more than 60 days but less than 90?

You will pay the applicable co-pay X 2 (e.g., prescription for 90 days of a Tier 1 drug = $10 X 2 = $20).

Can my clinician prescribe any medication he or she chooses?

Yes, your clinician is responsible for determining the most appropriate treatment for your care; however coverage of a prescribed medication is determined according to your prescription drug benefit plan.