OR
Name
Prior Auth
Special Code
Tier
Category
| NC=Not Covered | |
| INF | Infertility |
| M | Medical Benefit |
| PA | Prior Authorization |
| SF | Limited to two 15 day fills per month for first 3 month |
| ST | Step Therapy |
| generic=small letters | |
| LD | Limited Distribution |
| M | Medical Benefit |
| MSP | Mandatory Specialty Pharmacy Program |
| QL | Quantity Limit |
| SMSK | Smoking Cessation |
| VAC | Vaccine Program |
| BRANDS=CAPITAL LETTERS | |
| LMSP | Lumicera Mandatory Specialty Pharmacy Program |
| OTC | Over-the-Counter |
| RS | Restricted to Specialty |
| SP | Available through Specialty Pharmacy Program |
| RxCENTS |
| Tier NPG | Non-Preferred Generic |
| Tier PBN | Preferred Brand |
| Tier NC | Not Covered |
| Tier NPBN | Non-Preferred Brand |
| Tier SPEC | Specialty |
| Tier PG | ($0.00) Preferred Generic |