This information is not a complete description of benefits. Contact the plan for more information. Limitations,
copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or
copayments/coinsurance may change on January 1 of each year. Magellan Rx does not display Compound Claims in
Rejected:The claim was not processed due to a pharmacy submission error. Please contact your pharmacy.
Denied:The claim was not processed due to plan coverage restrictions, or the drug is not currently covered by the plan.