| Icon | Restriction | Definition |
 | Age Limit | Click on the more info link for additional
coverage details |
 | Benefit Exclusion | This drug may not be covered depending on your plan design. To find out if your drug is covered, log into your member portal or use the Sydney app to Price a Medication and refer to your plan documents. |
 | Clinical Criteria | Click on the more info link for additional coverage details. |
 | Contraceptive Waiver | If the contraceptive you are taking is not on the formulary, your doctor can contact us if it is medically necessary because the preferred contraceptives are inappropriate for you, and we will waive your cost share. |
 | Coverage Details | Click on the asterisk for additional coverage details |
 | Dose Optimization | Normally involves
the conversion from twice-daily dosing to a once-daily dosing schedule. Usually, this means you may have to switch from
taking a drug twice a day to taking it once a day at a higher strength. |
 | Dosing Limit | There are limits on the amount of medicine covered
within a certain amount of time. |
 | Fax Form | This form may be used to submit prior authorization requests. Prescribing providers with patients enrolled in a California Health plan must use the California Prescription Drug Prior Authorization Request form. Prescribing providers with patients enrolled in a Colorado Health plan may use the Colorado Prescription Drug Prior Authorization Request form. To obtain coverage of a contraceptive that is not on the plan’s prescription drug formulary, prescribing providers with patients enrolled in a Colorado Health Plan and Colorado Health Plan enrollees may use the Colorado Standard Exception Form for Contraceptives. Prescribing providers with Patients enrolled in a Colorado Health Plan may use the Colorado Serious Mental Illness Step Therapy Exception Form. Prescribing providers with patients enrolled in a Nevada fully insured plan must use the Nevada Prescription Drug Prior Authorization or Step Therapy Request form. Prescribing providers with patients enrolled in a New Hampshire Health plan may use the New Hampshire Prescription Drug Uniform Prior Authorization Request form.
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 | Future Drug Coverage | The future prescription drug list changes can be found here. Future drug changes are updated twice a year and typically go into effect starting on 7/1 and 1/1, respectively. |
 | Generic Drug | Generics are simply
copies of brand-name drugs. Brand-name and generic drugs have the same active
ingredients, strength and dose. And the FDA requires that generic drugs
meet the same high standards for purity, quality, safety and strength. |
 | Limited Access | These drugs are available only through certain
pharmacies or wholesalers, depending on what the manufacturer decides. |
 | Prescriber Note | Additional notes for the prescriber. |
 | Preventative Drug | For some members, this product may be covered at 100% with $0 cost share
with a prescription from your provider if specified criteria are met. |
 | Prior Authorization - New Starts | Prior authorization is the process of obtaining approval of benefits
before certain prescriptions may be filled. Drugs with this symbol
require prior authorization for patients taking the medication for the
first time. |
 | Prior Authorization Required | Prior authorization is the process of obtaining approval of benefits
before certain prescriptions may be filled. |
 | Quantity Limit | There are limits on the amount of medicine
covered within a certain amount of time. |
 | Specialty Pharmacy | Specialty drugs are used to treat difficult,
long-term conditions. You may need to get this drug through a specialty
pharmacy. |
 | Split Fill | New starts (first one or two fills) may be subject to a maximum limit of a 14 or 15 day supply for these medications. Standard supply limits will apply after the initial one or two fills. |
 | Step Therapy | You may need to use another recommended drug first before a prescribed drug is covered. Providers with patients enrolled in a Connecticut or Nevada health plan may request a step therapy exception. Providers with patients enrolled in Colorado may request a step therapy exception for a prescription medication to treat a serious mental illness, using the Colorado Serious Mental Illness Step Therapy Exception Form. Please click the link to learn more about the Step Therapy Exception Process. |