Your health plan includes a 3-tier prescription drug benefit, which is administered by Community First and our Pharmacy Benefit Manager (PBM) in accordance with the plan design specified by the Employees Retirement System of Texas (ERS).

• Non-maintenance copayments for a 30-day supply are $10 for Tier 1 drugs; $25 for Tier 2; and $40 for Tier 3 drugs.
• Maintenance-drug copayments for a 30-day supply are $15 for Tier 1 drugs; $35 for Tier 2 drugs; and $55 for Tier 3 drugs.
• Mail-order copayments for up to a 90-day supply, including oral contraceptives, are $30 for Tier 1 drugs; $75 for Tier 2 drugs; and $120 for Tier 3 drugs.

Please note that there is a $50 per enrollee plan-year deductible. If a brand-name medication is dispensed when a generic is available, you will be responsible for the generic copayment plus the cost difference between the generic and the brand-name medication.

Your specific prescription benefit plan design may not cover certain categories of drugs, regardless of their appearance in this list. Check your Evidence of Coverage or contact Community First’s Member Services Department for those conditions and medications not covered by your plan. In general, Tier 2 are mostly preferred brand name drugs; and Tier 3 are non-preferred and other preferred brand name drugs. The preferred list of covered drugs is subject to change. When new drugs become available during the year or the Pharmacy and Therapeutics Committee meets, drugs may move from one copayment tier to another.

This document lists some preferred and non-preferred drugs in alphabetical order; it does not contain a complete list of all preferred and
non-preferred drugs. If you don’t find your medication listed in this guide, you should contact Community First’s Member Services Department at (210) 358-6262, or 1-877-698-7032. Do not contact ERS for assistance with your medications.

* Maintenance drugs are coded as such if they meet the following criteria:

1. Medications that do not require frequent monitoring and dosage adjustments for side effects or therapeutic responses. Certain drugs that may have potential life-threatening toxicity when taken as an intentional overdose may be excluded.
   
2. Medications that are used to treat a chronic condition with no therapy endpoint. These drugs are taken continuously but do not provide a cure for the condition for which it is being treated.
   
3. Medications that are typically used as outpatient type of drugs.