Brand/Generic Name (Generics in italics)

Dosage/Strength

Status

Restrictions

Notes

Copayment Tier

Key for Product(s) Listed Above

Formulary Non-Covered Medications that have Covered Alternatives Medicare Excluded Generic is Formulary, Brand is Non-Formulary Prior Authorization Quantity Limit Step Therapy Determination of  Part B or D Notes Tier 1 Generic Drugs Tier 2 Preferred Brand-Name Drugs Tier 3 Brand-Name Drugs Tier 4 Specialty medications with a cost of over $600 per month Not Covered This medication is not on the UPMC for Life formulary. Click “Show Alternative Medications” above

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