| Icon | Restriction | Definition |
 | Benefit Exclusion | This medication may not be covered under your Plan. Contact Member Services for more information. |
 | Copay Armor | Copay Armor, powered by PillarRx, helps members afford high cost medications (mostly specialty) by leveraging manufacturer coupon dollars.
|
 | Day Supply Limit | Depending
on member benefits, this medication may be limited to a 30, 31, or 34 day
supply at retail and/or mail pharmacies. Select products available as
prepackaged products that supply a day supply greater than this limit are
exempt.
|
 | Generic Indicator | Generic or Authorized Generic Medication. Authorized generic medications may take a brand cost-share. |
 | HDHP Preventative | For
select plans, drugs on this list will be covered as if the deductible has
already been met, so the member may only be responsible for a
copay/coinsurance, if applicable. |
 | Market Watch | Coverage of this drug is subject to review by the plan and is based on Pharmacy policy. Select High-Cost Low-Value medications (HCLV), Prescription Drugs with an Over-the-Counter (OTC) Equivalent (RxOTC), and New to Market (NTM) products may be included in the Market Watch Program. Click the Market Watch icon next to the drug name for more details. |
 | Member Note | Please
click next to medication for further details. |
 | Over The Counter | OTC product that may be covered and dispensed by an in-network pharmacy without a prescription if in accordance with State specific dispensing requirements. |
 | PM | Preventative
Medication: May be available with a copay exception. Medications may be
available to some members at no cost with a prescription. |
 | Prior Authorization | Coverage of this drug is subject to review by the plan and is based on Pharmacy policy. |
 | Quantity Limit | Limits the amount of drug that a beneficiary may receive in a certain period. |
 | Specialty Pharmacy | To assist in the management of select specialty medications, some pharmacy benefit designs require the use of a preferred specialty pharmacy. Please call the number on the back of your member ID card for assistance.
|
 | Step Therapy | For
a step therapy drug to be covered, the beneficiary will be first required to
try another medication(s). |