| 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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