CY2023 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs) (CMS-R-262)

Appendix_C_FormularyProposed2019 Tier Model.txt

CY2023 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

OMB: 0938-0763

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	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."																				
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