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*Two-tier and Three-tier drug plans are distinguished on each member's Physicians Plus Membership Card.
Two-tier Plan: Generic Copay (formulary code = 1) or Brand Copay (formulary code = 2) for formulary products. Non-formulary products are excluded (formulary code = N) (e.g., $5 generic copay or $10 brand copay).
Three-tier Plan: Generic Copay (formulary code = 1) or Brand Copay (formulary code = 2) for formulary products and 50% Coinsurance for non-formulary products (formulary code = 3) (e.g., $5 generic copay, $20 brand copay, or 50% of a $70 prescription = $35).
Prior Authorization Medications (formulary code = PA). Prior authorization (PA) criteria have been included for each of the PA drugs on the Physicians Plus formulary.
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