What makes one drug a tier 1 to an insurance company, and another a tier 3?

Just curious, does anyone know? We are switching in Feb to a plan that has a 3 tier list, At first, I was elated, all our meds, insulin and test equip was tier 1 (lowest co pay) on last years list, this years list wasn't available. Well, just went back and checked this year's list. Ouch, unless we switch to Humalog insulin (from Novolog), and I was considering switching to the new bayer USB meter, but since the test strips are tier 3, AND supply limited (which I think means they are going to want me to send in BG logs every 3 months to ensure I am using the quantity the Dr writes for), I think I'll just stay put with the one touch system I've been using for years.

Just Curious, is this something we're going to need to keep looking at year after year? My older daughter already deals with a lot of site issues, is there any way I can appeal Novaog's non preferred status since it does have a different formulation than humalog and I think using humalog is going to make her site issue worse, or am I just going to be stuck paying a LOT of money for her insulin since, after all, they're not saying she can't use it, it's just not the preferred brand.

Based on the letters I also received, you have United Healthcare. And all test strips, not just bayer, are now limited supply of 204 a month, which you can appeal. It basically just means they are being cheap and want you to pay out of pocket of any testing over 6-7 tests a day unless the doctor can convince them that you need more.

Anyway, the way it works usually is that insurance companies negotiate with the drug companies to get preferred rates and tier status. United Healthcare made a better deal w/ Eli Lilly, who makes Humulog than they did with Novo Nordisk, who makes Novolog. So they will charge you more in your co-pay to make up the difference.

Sometimes the tier system has to do with cost-effectiveness analysis, but not always. Insulin is a biologic drug, which is a special kind that makes it difficult to compare to each other because they are chemically different, so I don't think this is the case here (but I'm a health policy person, not a pharmacist or doctor, so I could be wrong).

If insurance companies were really looking out for our best interests, they would put all chronic disease meds as tier 1, so people would not feel like they were being punished for having an illness. However, they are not, so it all comes down to number crunching.

We've always received 250 a month, which is typically the "just right" amount.

I figured it had a lot to do with price negotiations, the HR woman at my company was trying to tell me the federal government controlled tier placement, and I found that hard to believe, at least not right now, anyway.

Yes, this is UHC we are switching to, from BC/BS New York, which was a great plan for us, but nothing stays the same.