Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available Notes $Relative cost compared to others in category Specialty distribution for selected plans

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