PRESCRIPTION DRUG - Public Employees' Benefits Program (PEBP)

health plan members. Unless exceptions are noted, all forms (tablet, capsule, liquid,topical) andstrengths of a drug product are included in the Formulary and will be covered by theplan. Medicationsare listed by their brand and generic name. Generic names are listed in lower caseletters.Members that are covered by a 3-tiered pharmacy benefit will be able to obtainmedications not listed,which are non-formulary (non-preferred medication) a.k.a. 3rd tier/level, at the 3rdtier/level copayment.Members with a closed formulary benefit design will be responsible for entire cost ofthose products notlisted, unless an override is granted. See MEDICAL EXCEPTION REQUESTS belowfor the procedure torequest an override for those members.Specific drugs have dispensing quantity limits. The clinical criteria for determining thequantity level limitis based upon FDA approved dosing guidelines as stated in the manufacturer's productpackage insertas well as other medical literature.The Drug Formulary applies only to prescription medications dispensed to outpatientsby participatingpharmacies. The Formulary does not apply to inpatient medications or to medicationsobtained fromii of iv and/or administered by a physician.RELATIVE COST INDEXMost listings are preceded by a "relative cost index," represented by a series of one tofive dollar signs($) or five exclamation points (!!!!!). This is a relative indication of the cost to the healthplan formedications within selected therapeutic categories:$ product A least expensive$$ product B more expensive than "A"$$$ product C more expensive than "B"$$$$ product D more expensive than "C"$$$$$ product E more expensive than "D"!!!!! product F is substantially more expensive than "A-E"Cost ranges are applicable to the therapeutic categories listed below the cost rangelisting. Cost rangesreflect cost/day of therapy or cost/prescription based on prevalent dosing patterns asindicated. Therelative cost index does not necessarily reflect costs that may be incurred by non-healthplan members.PRIOR AUTHORIZATION/STEP THERAPY