 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. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. |
  Notes |
$ Relative cost compared to others in category |
 Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans) |
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