How Many Formulary Tiers Is Enough?

Just this week, I’ve seen two things about creating more formulary tiers.  One was talking about splitting generics into two tiers.  The other mentioned that CMS said a sixth tier could be used in certain circumstances.  It sounds like this could get out of control.

Will we end up with something like this:

  • Low-cost generics (i.e., $4)
  • Generics
  • Formulary brands (non-specialty)
  • Non-formulary brands (non-specialty)
  • Lifestyle drugs
  • Specialty biosimilars
  • Formulary specialty drugs
  • Non-formulary specialty drugs

It seems reasonable that we could end up with 8 tiers!  That is a patient nightmare.  It’s difficult enough to understand today.  Maybe, I’ll finally become a believer in a percentage copay model with just two or three tiers of cost share with maximums.

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