| Formulary |
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Approved for coverage if included under a member's benefit. |
| Prior Authorization |
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Approved for coverage only after certain conditions are met. See FAQs on Prior Authorization for more information. Prior Authorization is required for this drug, however, some select benefit plans do not require prior authorization. Check your plan document for specific prior authorization requirements. |
| Non Formulary |
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Drug is not on the formulary and may not be covered or may require a higher copayment/ coinsurance depending on the member's benefit (Third tier coverage applies for selected plans). |
| Not Reimbursed |
 |
This product is not covered under the prescription drug benefit. Some injectable medications may be covered under the member's medical benefit. Please contact the Health Plan for information. |
| Generic |
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Symbol indicates that a generic is available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. There are no data published showing brand name versions are more effective or have fewer side effects compared to generics. |
| Quantity Limit |
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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 |
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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. |
| Mail Order |
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Not available through mail order as 90-day supply* |
| Notes |
  |
The notes contain information on criteria and coverage limits on certain drugs. |
| Specialty Pharmacy |
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Some plans direct distribution of specialty medications through a participating specialty pharmacy (Fourth or fifth tier coverage applied for selected plans) |
