| STATUS | EXPLANATION |
| Approved | This drug is approved for coverage by the plan. |
| Non Formulary | The plan lists this drug as not on the formulary. Some plans may reimburse for non formulary drugs and some may not. Please check your plan's non formulary policy. |
| Non-Preferred / Non-PDL | Not on preferred drug list but class has been reviewed |
| Non-Preferred / PDL | On preferred drug list and listed as non-preferred |
| Not Listed | No formulary status information is available for this drug on this plan. |
| Not Reimbursed | Member is responsible for full payment of this drug. |
| Preferred | Lowest copay. Generics are often placed in this tier. |
| Preferred / Non-PDL | Not on preferred drug list, not in a reviewed class |
| Preferred / PDL | On preferred drug list and listed as preferred |
| Prior Authorization | This drug may be covered after the physician contacts the plan to obtain approval for coverage. |
| Tier 1 | Lowest copay. Generics are often placed in this tier. |
| Tier 2 | Middle copay. Preferred brands are often placed in this tier. |
| Tier 3 | Third tier copay. Non-preferred brands are often placed in this tier. |
| Tier 4 | Fourth tier copay. Non-preferred brands or drugs considered "specialty" are often placed in this tier and are generally more expensive than T3 drugs. |
| Tier 5 | Fifth tier copay. Non-preferred brands or drugs considered "specialty" are often placed in this tier and are generally more expensive than T4 drugs. |
| Tier 6 | Sixth tier copay. Non-preferred brands or drugs considered "specialty" are often placed in this tier and are generally more expensive than T5 drugs. |
| Tier 7 | Seventh tier copay. Non-preferred brands or drugs considered "specialty" are often placed in this tier and are generally more expensive than T6 drugs. |
| Tier 8 | Eighth tier copay. Non-preferred brands or drugs considered "specialty" are often placed in this tier and are generally more expensive than T7 drugs. |
| Tier 9 | Ninth tier copay. Non-preferred brands or drugs considered "specialty" are often placed in this tier and are generally more expensive than T8 drugs. |
