Which Tier Will a Drug Fall Into?

Drug tiers are determined by our PBM partner, CapitalRx, and are listed in their online formulary:

👉 CapitalRx Formulary Search

How to Check a Tier

1. Open the formulary search tool.
2. Enter the drug name (plus strength/form if needed).
3. Review the result—each medication will be assigned a tier.

What the Tiers Mean

• Tier 1 – Preferred Generic: Lowest member cost, best overall value.
• Tier 2 – Preferred Brand: Higher than Tier 1, but still favorable pricing.
• Tier 3 – Non-Preferred: Higher cost to both member and plan.
• Tier 4 – Specialty: High-cost drugs, often limited to specialty pharmacy channels.

Additional Flags

• PA (Prior Authorization) – Requires clinical approval before coverage.
• ST (Step Therapy) – Must try another drug first.
• QL (Quantity Limit) – Limited to a set amount per time period.
• SP (Specialty) – Must be filled through an approved specialty pharmacy.

Tip: If your drug shows PA, ST, QL, or SP, contact your Nurse Navigator (nurse@selffundhealth.com, 608-284-8831). They’ll coordinate approvals and help identify lower-cost alternatives when available.