Tiered Networks
Manage provider tier assignments, eligibility criteria, and member cost-sharing structure
Tier 1 — Preferred
47 Providers
Highest quality and cost efficiency. Members receive lowest cost-sharing.
$20
PCP Copay
$40
Specialist Copay
Criteria: Quality Score ≥8.0 AND Cost Index ≤95% of benchmark
Tier 2 — Standard
134 Providers
In-network providers meeting credentialing requirements. Standard cost-sharing.
$40
PCP Copay
$70
Specialist Copay
Criteria: Quality Score 6.5–7.9 AND Cost Index 95–120% of benchmark
Tier 3 — Non-Preferred
23 Providers
Limited network participation. Higher cost-sharing to encourage preferred tier use.
$60
PCP Copay
$100
Specialist Copay
Criteria: Quality Score <6.5 OR Cost Index >120% of benchmark
Provider Tier Assignments
| Provider Name | Specialty | Current Tier | Quality Score | Cost Score | Eligibility | Reassign To |
|---|---|---|---|---|---|---|
| Dr. Amelia Chen, MD | Internal Medicine | Tier 1 | 8.4 / 10 | 88% | Eligible T1 | |
| Dr. Robert Patel, MD | Cardiology | Tier 1 | 9.1 / 10 | 82% | Eligible T1 | |
| Dr. Sandra Kim, DO | Family Medicine | Tier 2 | 7.2 / 10 | 98% | Eligible T2 | |
| Dr. Marcus Williams, MD | Orthopedics | Tier 2 | 7.8 / 10 | 102% | Eligible T2 | |
| Dr. Carlos Rivera, MD | Gastroenterology | Tier 1 | 8.0 / 10 | 91% | Eligible T1 | |
| Dr. Helen Foster, NP | Primary Care | Tier 3 | 5.9 / 10 | 128% | Eligible T3 | |
| Dr. Laura Nguyen, MD | Endocrinology | Tier 2 | 7.5 / 10 | 96% | Eligible T2 | |
| Riverside Medical Group | Multi-Specialty | Tier 1 | 8.7 / 10 | 85% | Eligible T1 |
Tier Eligibility Criteria Configuration
Changes take effect at next quarterly reassessment (Jul 1, 2025). Providers will be notified 60 days before tier changes.
Tier 1 — Preferred Thresholds
Minimum Quality Score
Maximum Cost Index (%)
Tier 2 — Standard Thresholds
Minimum Quality Score
Maximum Cost Index (%)
Tier 3 — Non-Preferred (remainder)
Auto-assign providers below Tier 2
Member Impact — Enrollment by Tier
Tier 1 — Preferred
21,510 (45%)
Tier 2 — Standard
20,554 (43%)
Tier 3 — Non-Preferred
5,736 (12%)
Projected savings: Moving 10% of Tier 3 members to Tier 1 providers would reduce average PMPM by ~$12.40