<Treatment Category 2> - [Plans should insert a plain language description of the category.] What the drug will Necessary actions, Name of drug cost you (tier level) restrictions, or limits on use [If plans use codes in the actions, restrictions, or limits on column, they should “Necessary use” include a key at the bottom of each page of the Drug List. The key below is only an example; plans do have to use the same abbreviations/codes] Plans also have the option of further dividing the therapeutic categories into classes as shown below: <Treatment Category 1> - [Plans should insert a plain language description of the category.] What the drug will Necessary actions, Name of drug cost you (tier level) restrictions, or limits on use <Therapeutic Class Name 1> - [<Plain Language Description>] <AZASAN> <$0–$3 (Tier 3)> <PA>
<Treatment Category 2> - [Plans should insert a plain language description of the category.] Name of drug What the drug will cost you (tier level) Necessary actions, restrictions, or limits on use [If plans use codes in the “Necessary actions, restrictions, or limits on use” column, they should include a key at the bottom of each page of the Drug List. The key below is only an example; plans do have to use the same abbreviations/codes] Plans also have the option of further dividing the therapeutic categories into classes as shown below: <Treatment Category 1> - [Plans should insert a plain language description of the category.] Name of drug What the drug will cost you (tier level) Necessary actions, restrictions, or limits on use <Therapeutic Class Name 1> - [<Plain Language Description>] <AZASAN> <$0–$3 (Tier 3)> <PA>