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Code	Description	NDC	Brand Name Generic Name	Brand/ Generic/ Repackager	Dose/Strength	Status	Notes & Restrictions

Definition of Status

Icon	Status	Definition
	Medical Benefit	Drugs that are covered under the medical benefit.
	Non-preferred Medical Benefit	Drugs that require a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within therapeutic class.
	Medical and Pharmacy	Drugs that may be covered under the medical benefit when administered by a health care professional or under the pharmacy benefit when self-administered.
	ACA Preventive	Preventive
	Self-Administered Rx	Self-Administered Drug Exclusion Policy: Certain medications considered to be self-administered by the patient or their caregiver are excluded from coverage under the medical benefit without prior-authorization. Self-Administered Drug Exclusion Policy
	Preferred Diabetic Medical Supply	Preferred manufacturers/products for items covered under the durable medical equipment (DME) or diabetic supply benefit.
	Non-Formulary	Non-Formulary

Definition of Restrictions

Icon	Restriction	Definition
	Biosimilar	Biosimilar
	Excluded Drug
	Home Infusion	Home Infusion is available for this medication.
	Infusion Therapy Site of Care	Infusion Therapy Site of Care requirements apply: Providence Health Plan (PHP) requires site of care prior authorization for certain medications when given in an unapproved hospital setting. A separate prior authorization may be required for the drug.
	Limited Access	This drug may only be filled at certain pharmacies per the drug manufacturer. Credena Health may not be able to provide some of these drugs since they are limited to only a few pharmacies. Contact Customer Service at 877-216-3644 (TTY: 711), Monday – Friday, 8 a.m. to 6 p.m. (Pacific Time) for more information.
	Note	This will be a message specific to that drug to outline special requirements for coverage.
	Prescriber Note	Prescriber Note
	Prior Authorization	You (or your provider) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, your drug may not be covered.
	Quantity Limit	There are limits to the amount of this drug that is covered per prescription or within a specific time frame.
	Quantity Limit (Over Time)