| Formulary |
 |
Approved for coverage if included under a member's benefit. |
| Non-Formulary |
 |
Drug is not on the formulary and would only be covered through the exception process if the plan's alternative drug(s) would not be as effective in treating your condition and/or would cause you to have adverse medical effects. |
| Prior Authorization |
 |
Approved for coverage only after certain conditions are met. See FAQs on Prior Authorization for more information. |
| Not Reimbursed |
 |
This product is not covered under the prescription drug benefit. |
Generic
(Most Generics
Available at
Tier 1) |
 |
Symbol indicates that a generic is available. There are no data published showing brand name versions are more effective or have fewer side effects compared to generics.
|
| Quantity Limit |
 |
Certain drugs may have a limit on the amount of the drug that will be covered per prescription or for a defined period of time. |
| Step Therapy |
 |
For a step therapy drug to be covered, the beneficiary will be first required to try a therapeutically equivalent medication. If the prerequisite drug trial has occurred, the authorization will process systematically and no action will be required by the patient or prescriber. |
| Notes |
 |
The notes contain information on criteria and coverage limits on certain drugs. |
