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| Restrictions | |
|---|---|
|
Note: Individual plans may vary and formulary information changes. You are encouraged to contact the prescription drug benefit provider for the most current formulary information. |
|
| Code | Definition |
| PA | Prior Authorization Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription. |
| QL | Quantity Limits Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of drug that will be covered. |
| ST | Step Therapy Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription. |
| OR | Other Restrictions Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription. |