View Chart
| Tier Classifications | |
|---|---|
|
Note: Individual plans may vary and formulary information changes. You are encouraged to contact the prescription drug benefit provider for the most current formulary information. |
|
| Tier | Description |
| 1 | This drug is available at the lowest co-pay. Most commonly, these are generic drugs. |
| 2 | This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs. |
| 3P | Preferred – This drug is available at a preferred co-pay. Most commonly used when Tiers 1 and 2 apply to preferred generic and non-preferred generic drugs, respectively. |
| 3 | This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs. |
| 4 | This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products. |
| 5 | This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products. |
| 6 | This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products. |
| 7 | This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products. |
| NC | Not Covered Drugs that are not covered by the plan. |
| N/A | Not Available Formulary data for this drug/health plan are not available. |