| Formulary |
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Approved for coverage if included under a member's benefit. |
| Non-Formulary |
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Specific medications that are not covered, but other medications in the same class are available. |
| Generic is Formulary, Brand is Non-Formulary |
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Symbol indicates that a generic is available. In most cases, the generic is covered and the brand is not covered. |
| Prior Authorization |
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Approved for coverage only after certain conditions are met. Click here for commonly used prior authorization forms. |
| Quantity Limit |
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Limits the amount of drug that a member may receive in a certain period of time based on published guidelines. |
| Step Therapy |
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Approved for coverage automatically if there is a record that the member has already tried the first line medication. If there is no record, clinical information will need to be supplied by the prescriber. |
| Medicare Excluded |
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The product is excluded for reimbursement under section 1927(d)(2) of the Medicare Modernization Act. |
| Determination of Part B or D |
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This medication may be covered under either Medicare Part B or Part D. Please call the Health Plan for more details. |
| Notes |
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The notes contain information on criteria or coverage limits for certain drugs. |
| Tier 1 |
|
The first tier is for generic drugs, which have the lowest copayment. Generic drugs are cost-effective alternatives that offer the same level of safety and quality as their brand-name equivalents. Before a drug can be considered a generic equivalent, it must meet multiple quality and safety standards. These drugs also have been on the market for a number of years before being released as generics and thus have been thoroughly tested for safety. |
| Tier 2 |
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The second tier is for preferred brand-name drugs. UPMC Health Plan classifies these drugs as "preferred" because of their value and effectiveness. |
| Tier 3 |
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The third tier is for brand-name drugs. |
| Tier 4 |
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The fourth tier is for Specialty medications with a cost of over $600 per month. |
| Not Covered |
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This medication is not on the UPMC for Life formulary. |
