CY2017 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

2017 Tier Labels and Hierarchy

Non-Defined Standard Part D Plans

2017 Tier Label
2017 Tier
Structure
2 Tiers

3 Tiers

4 Tiers

2017 Option

Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

Tier 6

A

Generic

--­

--­

--­

--­

B

Generic

Brand
Preferred
Brand

--­

--­

--­

--­

A

Generic

Brand

Specialty Tier

--­

--­

--­

B

Generic

Preferred
Brand

Specialty Tier

--­

--­

--­

C

Generic

Preferred
Brand

--­

--­

--­

D

Preferred
Generic

Preferred
Brand

--­

--­

--­

A

Generic

Preferred
Brand

NonPreferred
Brand

Specialty Tier

Optional *

--­

B

Preferred
Generic

Generic

Preferred
Brand

NonPreferred
Brand

Optional *

--­

C

Preferred
Generic

Generic

Specialty Tier

Optional *

--­

D

Generic

Preferred
Brand

Injectable
Drugs

Optional *

--­

E

Preferred
Generic

Preferred
Brand

Specialty Tier

Optional *

--­

F

Preferred
Generic

Preferred
Brand

Injectable
Drugs

Optional *

--­

G

Preferred
Generic

Generic

Preferred
Brand

NonPreferred
Drug

Optional *

--­

A

Preferred
Generic

Generic

Preferred
Brand

Specialty Tier

Optional *

B

Preferred
Generic

Generic

Preferred
Brand

Injectable
Drugs

Optional *

C

Preferred
Generic

Generic

Preferred
Brand

Specialty Tier

Optional *

NonPreferred
Brand
NonPreferred
Drug

Preferred
Brand
NonPreferred
Brand
NonPreferred
Drug
NonPreferred
Drug

NonPreferred
Brand
NonPreferred
Brand
Injectable
Drugs

5 Tiers

NonPreferred
Brand
NonPreferred
Drug

D

Generic

Preferred
Brand

E

Preferred
Generic

Preferred
Brand

F

Preferred
Generic

Generic

Preferred
Brand

G

Preferred
Generic

Generic

Preferred
Brand

Injectable
Drugs

Specialty Tier

Optional *

Injectable
Drugs

Specialty Tier

Optional *

Specialty Tier

Optional *

Injectable
Drugs

Optional *

NonPreferred
Drug
NonPreferred
Drug

NonInjectable
Specialty Tier
Preferred
Drugs
Brand
*The optional 5th or 6th tier can be used as an excluded-drug-only tier or for other meaningful offerings such as a $0
6 Tiers

A

Preferred
Generic

Generic

Preferred
Brand