What specific detail should consumers check regarding Prescription Tiers in the Summary of Benefits and Coverage (SBC)?
The specific copay associated with accessing drugs in a defined tier, such as a Tier 3 brand-name drug.
When reviewing the Summary of Benefits and Coverage (SBC), understanding prescription drug costs requires looking beyond general coverage statements into the specific tier structure. Prescription tiers categorize drugs based on cost and preference (e.g., Tier 1 for generics, Tier 4 for specialty medications). The critical action for the consumer is to determine the exact out-of-pocket cost, which is usually a copayment, associated with obtaining medication from a particular tier. For example, knowing that a Tier 3 brand-name drug requires a $75 copay versus a generic Tier 1 drug requiring a $15 copay directly impacts monthly budgeting. Assuming all prescriptions cost the same across tiers can lead to significant and unexpected expenses.
