Tier Changes

Brand Name Strength Common Use Tier Change Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
Truvada 200/300mg HIV Negative NC T3 T3 T3 T3 T3
Tecfidera 120mg & 240mg Multiple Sclerosis Negative NC T3 T3 T3 T3 T3

PA: Prior authorization
QL: Quantity limit
ST: Step therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.

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