Butalbital-Acetaminophen-Caffeine W/ Codeine Caps 50-300-40-30 Mg (Generic)

STEP THERAPY
Requires the documented prior use of safe, clinically and cost-effective alternative medications prior to coverage.

QUANTITY LIMITS
The specified, limited amount of the drug that will be covered by the benefit plan.

PRIOR AUTHORIZATION
Requires a review and authorization from your Primary Care Physician (PCP) prior to coverage.

AGE RESTRICTION
Coverage based on a designated age.

FORMULARY CATEGORY
A 3-tier system is used to determine your cost share. Generics drugs are those covered at the lowest cost share defined as Cateogry 1. Formulary brand drugs will be covered at the Cateogry 2 coverage amount. Non-formulary brands drugs are covered at the Cateogry 3 coverage amount.

GENERIC
Generic drugs are determined by The Federal Food and Drug Administration (FDA) which requires that generic drugs contain the same active ingredients in the same amount as the brand name drug. The quality and effectiveness of generic drugs is the same as brand name drugs.

If prescribed a brand-name drug, you’ll get a generic substitute unless there isn’t a generic substitute or Kaiser Permanente approves use of the brand-name drug.

FORMULARY BRAND
Formulary Brand drugs are drugs that are included on the benefit plan’s list of preferred prescription drugs. These drugs are produced and sold under the original manufacturer’s name.

NON-FORMULARY BRAND
Non-Formulary Brand drugs are drugs that are not included on the plan’s list of preferred prescription drugs.

MEDICALLY ADMINISTERED (MA)
Medically administered drugs are prescription medications and vaccines that are typically administered by a health care provider in the medical office.