| Formulary |
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Approved for coverage if included under a member's benefit. |
| Non-Formulary |
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Specific medications are not on the formulary and are not covered, but other medications in the same class may be available. |
| Prior Authorization |
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Approved for coverage only after certain conditions are met. See Prior Authorization FAQs. Click here for commonly used prior authorization forms. |
| Not Reimbursed |
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Specific medications that are benefit exclusions and are not covered. |
| Generic |
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Symbol indicates that a generic is available. Data has not been published to show brand name versions are more effective or have fewer side effects compared to generics. In most cases, the generic is covered and the brand is not covered. |
| Quantity Limit |
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Limits the amount of drug that a member may receive in a certain period of time based on published guidelines. |
| Step Therapy |
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Approved for coverage automatically if there is a record that the member has already tried the preferred medication. If there is no record, clinical information will need to be supplied by the prescriber. See Step Therapy FAQs. |
| Specialty |
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Specific medications must be obtained through the contracted specialty provider, CuraScript Pharmacy, Inc. See Specialty Medication FAQs. |
| Notes |
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The notes contain information on criteria or coverage limits for certain drugs. |
| Tier 1 |
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The first tier is for generic drugs, which have the lowest copayment. Generic drugs are cost-effective alternatives that offer the same level of safety and quality as their brand-name equivalents. Before a drug can be considered a generic equivalent, it must meet multiple quality and safety standards. These drugs also have been on the market for a number of years before being released as generics and thus have been thoroughly tested for safety. |
| Tier 2 |
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The second tier is for select brand-name drugs without a generic equivalent. This tier has the middle level of copayment. |
| Tier 3 |
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The third tier is for specialty drugs, which are high-cost medications and biologicals, regardless of how they are administered (injectable, oral, transdermal, or inhalant). These drugs also have the highest level of copayment. These medications are often used to treat complex clinical conditions and usually require close management by a physician because of their potential side effects and the need for frequent dosage adjustments. |
