Blood Modifiers and Electrolytes
Colony Stimulating Factor

Brand/Generic Name
(Generics in italics)		 Dosage/Strength Status Restrictions Notes Copayment
Tier
Epogen
Epoetin Alfa		   approved.gif (510 bytes)

priorauth.gif specialty.gif

NOTES.gif (377 bytes) Tier 4

Key for Product(s) Listed Above
Formulary
Non-Covered Medications that have Covered Alternatives
Prior Authorization
 Not Covered
Quantity Limit
Generic is Formulary, Brand is Non-Formulary
 Step Therapy Notes
Specialty Medications
Tier 1Generic Drugs
Tier 2Preferred Brand Name Drugs
Tier 3Non-Preferred Brand-Name Drugs
Tier 4Specialty Drugs - Tier 3 Copay
      

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