CY2021 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

2019 Tier Labels and Hierarchy
Non-Defined Standard Part D Plans

2019 Tier Label
2019 Tier Structure 2019 Option Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6
2 Tiers A Generic Brand --- --- --- ---
B Generic Preferred Brand --- --- --- ---

3 Tiers A Generic Brand Specialty Tier --- --- ---
B Generic Preferred Brand Specialty Tier --- --- ---
C Generic Preferred Brand Non-Preferred Brand --- --- ---
D Preferred Generic Preferred Brand Non-Preferred Drug --- --- ---
E Generic Preferred Brand Non-Preferred Drug --- --- ---

4 Tiers A Generic Preferred Brand Non-Preferred Brand Specialty Tier Optional * ---
B Preferred Generic Generic Preferred Brand Non-Preferred Brand Optional * ---
C Preferred Generic Generic Preferred Brand Specialty Tier Optional * ---
D Generic Preferred Brand Non-Preferred Brand Injectable Drugs Optional * ---
E Preferred Generic Preferred Brand Non-Preferred Drug Specialty Tier Optional * ---
F Preferred Generic Preferred Brand Non-Preferred Drug Injectable Drugs Optional * ---
G Preferred Generic Generic Preferred Brand Non-Preferred Drug Optional * ---
H Generic Preferred Brand Non-Preferred Drug Specialty Tier Optional * --- New for CY2019
I Generic Preferred Brand Non-Preferred Drug Injectable Drugs Optional * --- New for CY2019

5 Tiers A Preferred Generic Generic Preferred Brand Non-Preferred Brand Specialty Tier Optional *
B Preferred Generic Generic Preferred Brand Non-Preferred Brand Injectable Drugs Optional *
C Preferred Generic Generic Preferred Brand Injectable Drugs Specialty Tier Optional *
D Generic Preferred Brand Non-Preferred Brand Injectable Drugs Specialty Tier Optional *
E Preferred Generic Preferred Brand Non-Preferred Drug Injectable Drugs Specialty Tier Optional *
F Preferred Generic Generic Preferred Brand Non-Preferred Drug Specialty Tier Optional *
G Preferred Generic Generic Preferred Brand Non-Preferred Drug Injectable Drugs Optional *
H Generic Preferred Brand Non-Preferred Drug Injectable Drugs Specialty Tier Optional * New for CY2019

6 Tiers A Preferred Generic Generic Preferred Brand Non-Preferred Brand Injectable Drugs Specialty Tier
B Preferred Generic Generic Preferred Brand Non-Preferred Drug Injectable Drugs Specialty Tier Formerly 6C for CY2018
"*The optional 5th or 6th tier can be used as an excluded-drug-only tier or for other meaningful offerings such as a $0 vaccine-only tier, Select Care or Select Diabetes Drugs."