- Non-formulary drugs need a formulary exception for medical necessity for coverage at Tier 3
MB
- Medical Benefit
SF
- Starter Fill
OAC
- Oral Anti-Cancer
NF-S
- Non-formulary drugs need a formulary exception for medical necessity for coverage at Tier 4
CW
- Cost Waived
BL
- Benefit Limit
† Denotes brand name drug, otherwise generic drug
Quantity Limit
There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame.
Prior Authorization
Coverage for this prescription requires prior authorization from Blue Shield. Call Blue Shield to provide the necessary information to determine coverage. Some drugs may require Part B or Part D coverage determination, based on Medicare coverage rules. These drugs are noted with “PA – Part B vs. D Determination”
Step Therapy
In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
Age Limit
This prescription drug may only be covered if you meet the minimum or maximum age limit.
Limited Access
This prescription drug is limited to certain pharmacies.
Retail Only
This prescription is only available at retail.
Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.
Affordable Care Act
This product is covered under the Affordable Care Act.
Quantity Limit (Custom)
There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame.
Non-formulary drugs need a formulary exception for medical necessity for coverage at Tier 3
Medical Benefit
Medical Benefit drug, typically administered by a health care professional and not self-administered. Refer to your Evidence of Coverage/Certificate of Insurance for coverage information and exceptions.
Starter Fill
Blue Shield’s Starter Fill Specialty Drug Program allows initial prescriptions for select specialty drugs to be filled for up to a 15-day supply. When this occurs, the copayment or coinsurance will be prorated.
Oral Anti-Cancer
There may be a limit on the copay/coinsurance for orally administered anti-cancer drugs. Please review your Summary of Benefits for more information.
Non-formulary drugs need a formulary exception for medical necessity for coverage at Tier 4
Cost Waived
This drug may be available with no out of pocket cost. Certain benefit limitations may apply. Please see your Certificate of Insurance (COI) or Evidence of Coverage (EOC) for more detailed information.
Benefit Limit
Coverage for this drug may be limited by your Plan. Please see your Evidence of Coverage (EOC) for more detailed information.