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CurrentAmeriHealthPolicy N/A

Select Drug Program formulary coverage criteria

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Governs how prescription drugs are covered under the AmeriHealth Select Program formulary, including tiering, prior authorization, safety edits (age, quantity, MME, stimulant limits), and ACA preventive medications; affects AmeriHealth members and their prescribing providers.

Policy Summary

PayerAmeriHealth

PolicySelect Drug Program formulary coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for drugs flagged 'PA' or for claims exceeding limits (e.g., opioid >90 MME/day, stimulants > specified cumulative doses, claims > $10,000).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MME/dayopioid MME PA threshold

75%refill-too-soon threshold

>10kclaim dollar threshold

60 mg/dayamphetamine cumulative limit

72 mg/daymethylphenidate cumulative limit

G → SPtiers described

Coverage criteria and formulary rules

General formulary coverage criteria

Covered when ALL of the following are met:

General coverage prerequisites: Drug is included on the plan formulary and is medically necessary per the plan and PBM clinical criteria.

Formulary inclusion does not guarantee coverage for all groups; verify member benefits and benefit riders (e.g., weight‑loss drugs may require a rider).

Authorization when indicated: Prior authorization must be obtained for drugs flagged as requiring PA on the drug line to confirm medical necessity and appropriate use.

Authorization reviews may take up to two business days after complete information is received; approvals may be time‑limited and require reauthorization.

Opioid dosing limits

Safety-based opioid coverage restriction — authorization required when dosing exceeds the MME safety threshold:

Policy Summary

PayerAmeriHealth

PolicySelect Drug Program formulary coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for drugs flagged 'PA' or for claims exceeding limits (e.g., opioid >90 MME/day, stimulants > specified cumulative doses, claims > $10,000).

SourceLink

On This Page

Opioid MME limit: Prior authorization is required for any opioid regimen when the calculated total daily Morphine Milligram Equivalent (MME) exceeds 90 MME per day.>= 90 MME/day

MME is calculated across all opioid products the member is taking; applies to the active ingredients listed in the MME section of the policy.

Stimulant cumulative limit

CNS stimulant safety measure — authorization required when cumulative daily active‑ingredient doses exceed specified limits:

Stimulant cumulative assessment: Stimulant prescriptions that cause the member's total daily cumulative dose (calculated by active ingredient) to exceed specified limits require prior authorization.

This check is intended to ensure assessment of alternatives and counseling on stimulant‑associated risks (e.g., cardiac events, psychosis).

Amphetamine-class threshold: Prior authorization required when amphetamine‑class cumulative daily dose by active ingredient exceeds 60 mg/day.>60 mg/day

Applies to listed amphetamine products and generics specified in the policy.

Methylphenidate-class threshold: Prior authorization required when cumulative methylphenidate daily dose by active ingredient exceeds 72 mg/day.>72 mg/day

Applies to listed methylphenidate products and generics specified in the policy.

Quantity limits and refill rules

Quantity and supply limits to ensure safe use:

Quantity‑over‑time and day‑supply limits: Specific drugs have quantity limits (QL) defined over time periods (e.g., Nuvaring: 1 ring per 28 days; Boniva 150 mg: 1 tablet per 30 days; Sumatriptan 50 mg: 18 tablets per 30 days) and maximum daily dose limits for some agents.examples provided in document

See formulary quantity limits for product‑specific QL values and QIT entries.

Supply limits for opioids and certain agents: Some classes (short‑acting opioids, butalbital‑containing agents, opioid cough/cold products) have day‑supply limits and maximum quantities allowed without authorization (examples: two 5‑day supplies per 60 days for adults).examples provided in document

Supply limits and maximum quantities without authorization are detailed in the policy's Quantity Limits section.

Refill‑too‑soon edit: Refills are permitted only after 75% of the current supply has been consumed (e.g., a 30‑day supply refill is available on/after day 24).75%

This edit prevents early refill/stockpiling.

Dose-based prior authorization criteria

Prior authorization required when ANY of the following dose thresholds are exceeded:

Opioid dosing threshold: Prior authorization required for any opioid regimen exceeding 90 MME per day.>90 MME/day

MME calculated across all opioid products.

Amphetamine high cumulative dose: Prior authorization required when amphetamine‑class cumulative daily dose by active ingredient exceeds 60 mg/day.>60 mg/day

Applies to amphetamine and amphetamine‑dextroamphetamine products listed in the policy.

Methylphenidate high cumulative dose: Prior authorization required when cumulative methylphenidate daily dose by active ingredient exceeds 72 mg/day.>72 mg/day

Applies to methylphenidate products listed in the policy.

Drug-specific prior authorization

Prior authorization applies to all formulations of the following specific drugs (partial list shown):

Enumerated PA drug list: The policy enumerates a broad list of specific drugs and formulations (brand and generic) for which prior authorization applies across all formulations (tablet, capsule, suspension, injection, etc.).N/A

Refer to the full enumerated drug list in the policy (chunks 25–37) for product‑level entries and PA flags.

Drugs requiring prior authorization

Prior authorization is required for the listed drugs and applies to all formulations:

PA applies to formulations: For each drug on the PA list, prior authorization applies to all formulations (for example: tablet, capsule, oral suspension, injection, transdermal, etc.).

The policy provides an extensive, itemized listing across chunks 36–49 showing affected products and PA flags.

Additional PA conditions

Additional prior authorization triggers and requirements:

Brand prenatal vitamins: All brand prenatal vitamins require prior authorization prior to coverage.

Provider must submit PA before dispensing; see provider submission instructions.

Compound product cost threshold: Compound prescriptions with total cost equal to or greater than $75 per prescription require prior authorization.$75 per prescription

Claims meeting or exceeding this threshold will require PA and may be denied without it.

High‑cost claim review: Prescription claims exceeding the claim dollar limit threshold require prior authorization review; providers must submit authorization for claims exceeding $10,000.$10,000 per claim

See PA submission guidance for required documentation and timelines.

Coverage conditioned on listed requirements

Coverage and access are conditioned on the drug's formulary tier plus any listed requirement flags:

Tier plus requirement flags: Each formulary drug line pairs the drug name with a DRUG TIER and REQUIREMENTS/LIMITS flags (e.g., PA, QL, SDS, MME, LDD, SP); coverage is provided when the payer's requirements associated with those flags are satisfied.

Interpret individual drug lines for product‑specific controls and submit required documentation when PA/QL/SDS/LDD flags are present.

Formulary coverage entries

Formulary entries indicate coverage stance per drug with attached utilization controls:

Formulary entry interpretation: Each drug line indicates the DRUG TIER and any REQUIREMENTS/LIMITS (for example: PA = Prior Authorization; QL = Quantity Limits; SDS = Supply Limit; MME = Morphine Milligram Equivalent; LDD = Limited Distribution; SP = Specialty Drug). Coverage may be contingent on meeting those listed controls.

Providers should follow the formulary legend and submit PA requests or exception requests as indicated by the drug line.

Inclusion of a medication on the Select Drug Program formulary does not by itself guarantee coverage for a given member. Coverage is determined by the member's specific plan and benefit design and medical necessity rules administered by the PBM; benefits and available tiers or incentives may vary by group. Providers should verify member benefits prior to prescribing or dispensing.

Tier exception requests are subject to restrictions. Drugs on the Generic, Preferred Brand, and Specialty tiers are not eligible for tier exceptions, and some plans may not permit tier exceptions at all. Providers must submit a completed formulary exception request form and supporting documentation to the number specified for review.

Authorization is required for most diabetic blood glucose test strips. All diabetic test strips require authorization except for Contour, which is exempt from prior authorization. Confirm strip coverage and any quantity limits before dispensing.

Within the excerpted document there are no explicit general policy exclusions listed. The formulary primarily identifies tier placement and utilization controls (PA, QL, etc.) rather than a stand-alone exclusions section in this extract.

No explicit clinical exclusion conditions are provided in the available excerpt. The document content in this window focuses on tiering, prior authorization, and utilization controls rather than enumerating clinical exclusions.

Formulary placement alone does not supersede the medical necessity rules of the member's plan. Coverage of a listed drug is contingent on meeting the plan's medical necessity criteria and any requirements shown on the drug line (for example, PA, QL, MME, or other flags). Providers should include appropriate documentation when requesting authorization.

The excerpt does not identify any drugs or situations that are explicitly designated as "not medically necessary." Coverage determinations in this document are expressed through tiering and utilization control flags rather than explicit not-medically-necessary statements.

There are no explicit 'not medically necessary' determinations provided in the excerpted material; the policy uses prior authorization and other requirement flags to govern access instead of listing NMN rulings in this window.

Coding, thresholds, and measure flags

No explicit CPT/HCPCS/ICD codes in this excerptmixed

No codes listed

Formulary requirement/limit codesmixed

PA	Prior Authorization (formulary requirement)
QL	Quantity Limits
SDS	Supply Limit
MME	Morphine Milligram Equivalent
PB	Preferred Brand tier
NPD	Non Preferred Drug tier
G	Generic tier
SP	Specialty Drug
LCG	Low Cost Generic
ACA	ACA preventive drug indicator

inv-21: Opioid MME threshold — numeric threshold for opioid prior authorization

Opioid MME threshold>= 90 MME per day

Applies toAll opioid products using MME conversion (e.g., hydromorphone, fentanyl, hydrocodone, morphine, tapentadol)

Authorization actionPrior authorization required when daily MME exceeds threshold

inv-22: Refill-too-soon threshold — refill allowed after 75% utilization (e.g., day 24 of 30)

Refill-too-soon thresholdRefill allowed after 75% utilization (e.g., day 24 of a 30-day supply)

PurposePrevent stockpiling and encourage appropriate utilization

Examples30-day supply filled 1/1/2025 refillable on/after 1/24/2025; 90-day supply filled 7/1/2025 refillable on/after 9/7/2025

inv-23: Opioid MME Limit — PA required for opioid dose > 90 MME/day

Opioid MME Limit (PA trigger)Prior authorization required for opioid dose > 90 MME/day

CalculationDaily limit calculated across opioid products using Morphine Milligram Equivalent conversions

ConsequenceClaims exceeding this limit require PA and may be denied without it

inv-24: Amphetamine cumulative dose — 60 mg/day threshold

Amphetamine cumulative dose threshold60 mg/day

ScopeApplies to amphetamine-class products (brands and generics) listed in formulary

Authorization actionPrior authorization required when cumulative daily amphetamine dose exceeds threshold

inv-25: Methylphenidate cumulative dose — 72 mg/day threshold

Methylphenidate cumulative dose threshold72 mg/day

ScopeApplies to methylphenidate products (brands and generics) listed in formulary

Authorization actionPrior authorization required when cumulative daily methylphenidate dose exceeds threshold

inv-26: Prescription dollar limit threshold — claims > $10,000 may require PA

Prescription dollar limit thresholdClaims exceeding $10,000 per claim may trigger prior authorization

ConsequenceProvider must submit authorization for claims > $10,000; claims may be denied without PA

ReferenceListed among additional PA triggers in formulary document

inv-27: Compound product cost threshold — compound products >= $75 require PA

Compound product cost thresholdCompound products with total cost >= $75 per prescription require prior authorization

ConsequenceClaims for compound products at or above this cost may be denied without PA

ReferenceListed as an additional PA condition in the formulary

inv-28: MME monitoring reference — MME thresholds referenced but not fully specified

MME monitoring referenceMME thresholds are referenced as a utilization control in the formulary but some MME details are not fully specified in every entry

UsageMME appears as a flag on drug entries and is used to identify when additional review or PA is required

GuidanceMME calculations aggregate potency across opioid products to determine daily total

inv-29: MME references — MME limits referenced without exact numeric values in these chunks

MME referencesMME limits are referenced across drug entries, but exact numeric thresholds are not specified in these cited chunks

Formulary useMME appears alongside other requirement flags (PA, QL, SDS) to indicate monitoring or limits apply

Action implicationClaims flagged with MME may require prior authorization or will be subject to MME-based edits

inv-30: MME flag usage — MME used as a flag; numeric thresholds not shown in these chunks

MME flag usageMME is used as a formulary flag to indicate morphine milligram equivalent checks on claims; numeric thresholds are not shown in these chunks

ContextMME flag appears in legends and alongside PA/QL indicators across the drug list

Operational effectClaims triggering MME checks may be subject to denial or require PA if thresholds exceeded

inv-31: Zolpidem ER/SL QL thresholds — specific QL entries noted

Zolpidem ER QLZolpidem tartrate ER: QL applies for 12.5 mg strength only

Zolpidem SL QLZolpidem tartrate sublingual: QL applies for 3.5 mg strength only

ReferenceSpecific QL entries shown in drug-list mapping

Actions required of providers

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Certain prescription drugs and specific situations require prior authorization (PA) before the plan will cover the medication. Prior authorization confirms medical necessity and appropriate use based on criteria approved by the Pharmacy & Therapeutics Committee. Providers must obtain PA for drugs or claims flagged with the PA indicator in the formulary. Without an approved PA, the member's prescription will not be covered at retail or mail-order.

PA is required for many listed drugs — see formulary entries flagged 'PA'.
Prior authorization may be required for select high-cost, specialty, or non-preferred agents (examples listed in formulary).
All brand prenatal vitamins require authorization prior to coverage.
Claims exceeding the dollar-threshold (e.g., $10,000 per claim) require prior authorization.
Compound prescriptions with total cost ≥ $75 may require PA and may be denied without it.

Documentation Required

How to Submit Prior Authorization

PA Submission and Review Process: Providers should submit clinical information and relevant medication history to support PA requests. Use the plan's electronic prior authorization (ePA) platform (e.g., SureScripts) when available, or submit the completed authorization fax form or a letter of medical necessity. The PBM's clinical pharmacists review requests against established criteria; if not approved by a pharmacist, a medical director will review. Decisions may take up to two business days after receipt of complete information.

Electronic submission (ePA) preferred — real‑time approvals may be possible at point of care.
Alternative: fax the formulary authorization form or send a letter of medical necessity.
Include the REQUIREMENTS/LIMITS field information and supporting documentation (dosing, prior therapies, interactions) with the request.
Incomplete or missing documentation may delay the decision.

Prior Authorization

Approval, Denial, and Expiration

Decision Notifications, Appeals, and Continuation: If a request is approved, the provider is notified via fax and/or telephone and the adjudication system is coded with the approval. If denied, the prescribing provider and member are notified via letter/fax/phone and denial letters include appeal rights and instructions. Many authorizations may be time‑limited (e.g., 6–12 months); if therapy should continue past the expiration, submit a new PA request.

Approved PAs are entered into the adjudication system; members can call Customer Service to confirm.
Denials include appeals instructions — providers and members receive written notification.
PA approvals that expire require a new authorization for continuation of coverage.

Note

Required Flags, Interpretation, and Triggers

Utilization Controls and Common Triggers: The formulary uses standardized flags and limits that trigger utilization management actions. Providers must be aware of PA, Quantity Limits (QL), Limited Distribution Drug (LDD), Supply Day Limit (SDS), Morphine Milligram Equivalent (MME), Quantity Over Time (QIT), Age Limits (AL), and Rider requirements (R). PA may be required alone or in combination with QL/SDS/MME edits; failure to meet these triggers may result in claim denial or limitation.

Common flags: PA = Prior Authorization; QL = Quantity Limits; LDD = Limited Distribution Drug; SDS = Supply Limit Day; MME = Morphine Milligram Equivalent; QIT = Quantity Over Time; AL = Age Limit; R = Requires Rider.
PA often pairs with QL or MME edits (e.g., high‑dose opioids carry PA + MME + QL).
Use the REQUIREMENTS/LIMITS field from the formulary when preparing documentation and requests.

Prior Authorization

Safety Limits: Opioids, Stimulants, and Refill Edits

Safety Edits — Opioids, Stimulants, and Refill‑too‑soon: Specific clinical edits apply to opioid and stimulant prescribing. Prior authorization is required for opioid doses exceeding 90 MME/day. Cumulative stimulant dose thresholds (e.g., amphetamine high cumulative dose 60 mg/day; methylphenidate 72 mg/day) require authorization when exceeded. Refill‑too‑soon edits prevent refills until 75% of the previous supply has been used to discourage stockpiling.

Opioid: PA required when total daily opioid dose > 90 MME.
Stimulants: PA required when cumulative stimulant limits are exceeded (examples: amphetamine 60 mg/day; methylphenidate 72 mg/day).
Refill‑too‑soon: refills covered only after 75% of current supply is consumed (e.g., 30‑day supply refill allowed on/after day 24).

Documentation Required

Required Documentation for Authorization Requests

Documentation and Evidence: Providers must supply clinical justification when requesting PA or when PA is paired with QL/LDD/MME edits. Required documentation may include diagnosis, prior therapies and outcomes, dosing, expected duration, drug‑drug interaction review, and any monitoring plans. Use formulary legend definitions to ensure proper interpretation of requirements.

Include detailed medical rationale and prior medication history to demonstrate medical necessity.
When submitting for QL, SDS, LDD, or MME exceptions, document the requested supply quantity and dispensing channel, if applicable.
Refer to the formulary legend for abbreviations: PA, QL, LDD, SDS, MME, QIT, AL, R.

Billing Rule

Distribution, Channel, and High‑Cost Claim Controls

Distribution, Channel, and High‑cost Claim Restrictions: Some drugs are limited to specific distribution channels (LDD or specialty pharmacy) and high‑cost claims or specialty products may require additional PA steps. Claims exceeding the plan's dollar threshold (e.g., $10,000) trigger an authorization requirement. Verify permitted dispensing channels before submission to avoid denial.

Limited distribution drugs (LDD) may be restricted to specific specialty pharmacies — confirm channel prior to dispensing.
Claims over the defined dollar threshold require PA (example threshold: $10,000).
Compound products with total cost ≥ $75 may require PA and can be denied without prior authorization.

Step Therapy

Formulary Exception and Step Therapy Process

Formulary Exceptions and Step Therapy: The PBM may manage drugs with step edits and formulary exception processes. Providers can request tier exceptions or step‑therapy exceptions using the formulary exception request form and must provide supporting clinical detail. Some tiers or drug groups may not be eligible for tier exceptions — consult the member benefit booklet for plan‑specific limitations.

Complete and fax the formulary exception request form to the designated fax number (e.g., 1-888-671-5285) with supporting clinical documentation.
Tier exceptions may not be available for all plans or for drugs on certain tiers (generic, preferred brand, specialty).
If an exception is approved, cost‑sharing will be adjusted accordingly; denials include appeal rights and written notification.

Note

Operational Note: Use REQUIREMENTS/LIMITS and Map Requirements

Programmatic Mapping and Provider Actions Checklist: Use the REQUIREMENTS/LIMITS field from the formulary as the primary operational guide when preparing PAs and claims. Map programmatic requirements (PA, QL, LDD, MME, SDS, QIT, AL, R) to supporting documentation and to the appropriate submission channel (ePA vs fax).

When a formulary line shows PA (or other flags), include corresponding evidence aligned to that flag in the submission.
Prefer ePA for faster decisions; include REQUIREMENTS/LIMITS and attach documentation for QL/MME/LDD exceptions.
If unsure about coverage or distribution channel, contact the PBM or Customer Service before dispensing.

Definitions, abbreviations, and legend

inv-92: Specialty drugs definition — drugs for rare/complex/chronic disease with special handling and monitoring

Specialty drugs definitionDrugs used to treat rare, complex, or chronic diseases that may have complex storage/shipping requirements and require comprehensive monitoring or patient education

ManagementMay be managed by the PBM's Specialty Pharmacy Program and often placed on a specialty tier with higher cost-sharing

Coverage noteBenefits and site-of-care requirements may vary by plan

inv-93: Refill-too-soon definition — refill allowed after 75% of supply used

Refill-too-soon definitionA refill is allowed after 75% of the current supply has been used (e.g., 30-day supply refill available on or after day 24)

PurposeDiscourages stockpiling and enforces safe dispensing intervals

Examples30-day fill on 1/1/2025 refillable on/after 1/24/2025; 90-day fill on 7/1/2025 refillable on/after 9/7/2025

inv-94: MME definition — standardized opioid potency measure used for PA triggers

MME definitionMorphine Milligram Equivalent (MME) is a standardized measure of opioid potency used to compare daily opioid doses

Use in policyMME is used to trigger prior authorization when daily opioid regimens exceed the program threshold

Calculation noteDaily MME is calculated based on opioid drugs dispensed, their potencies, and total daily usage

inv-95: MME — explanation of MME usage

MME explanationMME converts various opioid products to a morphine-equivalent potency and is used to identify when additional caution or authorization is needed

Policy implicationMME-based edits apply across opioid products to assess total daily exposure

Operational noteClaims exceeding the MME threshold require prior authorization and may be denied without it

inv-96: cDUR — concurrent utilization review definition

cDUR definitionConcurrent Utilization Review (cDUR): automated pharmacy claim adjudication checks for drug-drug interactions, therapy duplications, and other safety concerns

FunctionCan reject claims at point-of-sale or generate pharmacist alerts for review and possible override

ExamplesDrug-drug interaction alerts (e.g., sildenafil + nitrates); therapy duplication alerts (e.g., simvastatin + atorvastatin)

inv-97: Brand vs generic display conventions

Brand vs generic display conventionsBrand-name medications are shown with an initial uppercase letter and bold; generic medications are shown in lowercase and italic

PurposeFormatting distinguishes brand versus generic on the formulary list

ExampleAugmentin (brand) vs lisinopril (generic) shown in lowercase italic in examples

inv-98: Tier definitions — PB/NPD/G/LCG/SP explained

Tier definitions (abbreviations)PB = Preferred Brand; NPD = Non Preferred Drug; G = Generic; LCG = Low Cost Generic; SP = Specialty Drug

Other flagsAL = Age Limit; LDD = Limited Distribution Drug; QL = Quantity Limits Apply; QIT = Quantity Over Time; SDS = Supply Limit

UsageTier and flag abbreviations indicate cost-sharing and utilization controls applied to each drug entry

inv-99: PA abbreviation definition

PA abbreviationPA = Prior Authorization

MeaningAuthorization required from the health plan prior to coverage/payment

ImplicationClaims for drugs marked PA may be denied without approved authorization

inv-100: QL / QIT abbreviation definition

QL / QIT abbreviationQL = Quantity Limits Apply; QIT = Quantity Over Time

MeaningQL indicates a quantity restriction; QIT indicates a limit measured over a defined time window (rolling days)

Provider actionClaims exceeding QL/QIT require justification or prior authorization per formulary rules

inv-101: LDD abbreviation definition

LDD abbreviationLDD = Limited Distribution Drug

MeaningMay be subject to distribution/channel restrictions and require specific supply sources

ConsequenceNoncompliance with distribution requirements could lead to coverage denial

inv-102: Tier abbreviations (PB/NPD/G/LCG)

Tier abbreviations (PB/NPD/G/LCG)PB = Preferred Brand; NPD = Non Preferred Drug; G = Generic; LCG = Low Cost Generic

InterpretationThese tiers indicate cost-sharing levels and placement on the formulary

Relation to controlsTier placement is shown alongside REQUIREMENTS/LIMITS flags (e.g., PA, QL)

inv-103: Specialty Drug (SP) definition

Specialty Drug (SP) definitionSP = Specialty Drug: drugs for rare/complex/chronic conditions requiring special handling or monitoring

Benefit noteOften placed on a specialty tier with higher cost-sharing and managed via specialty pharmacy programs

DistributionMay also carry LDD or other distribution restrictions

inv-104: Formulary flags legend — PA, QL, SP, NPD, PB, G, L...

Formulary flags legendPA = Prior Authorization; QL = Quantity Limits Apply; SP = Specialty Drug; NPD = Non Preferred Drug; PB = Preferred Brand; G = Generic; LCG = Low Cost Generic; LDD = Limited Distribution; QIT = Quantity Over Time; AL = Age Limit; SDS = Supply Limit

Claim dollar flag+= Claim Dollar Limit indicates prescription claim dollar threshold

MME flagMME = Morphine Milligram Equivalent (used as a utilization control)

inv-105: PA definition (repeated legend entry)

PA definition (legend repeat)PA = Prior Authorization (authorization required before coverage)

ActionProviders must follow the payer's PA process for drugs marked PA

Denial riskClaims may be denied if required PA is not obtained

inv-106: QL definition (repeated legend entry)

QL definition (legend repeat)QL = Quantity Limits Apply

MeaningSpecifies permitted quantities or refill timing; exceeding limits may require PA or justification

RelationOften shown with QIT or SDS for time-based or supply limits

inv-107: SP definition (repeated legend entry)

SP definition (legend repeat)SP = Specialty Drug (drugs requiring special handling/monitoring)

Program noteSpecialty drugs may be managed by the PBM's Specialty Pharmacy Program and placed on a specialty tier

Utilization controlsOften paired with PA, QL, LDD flags

inv-108: LDD definition (repeated legend entry)

LDD definition (legend repeat)LDD = Limited Distribution Drug

ImplicationMay require specific distribution channels; entries flagged LDD may have special documentation requirements

Coverage impactNoncompliance with distribution requirements could result in denial or non-coverage

inv-109: SDS definition — Supply Limit

SDS definitionSDS = Supply Limit (day supply limit)

UseIndicates maximum day supply allowed for certain drug classes or products

Relation to QLMay operate alongside Quantity Limits and refill-too-soon edits

inv-110: MME (legend repeat)

MME (legend repeat)MME = Morphine Milligram Equivalent

RoleUsed as a utilization control and flag on drug entries to monitor opioid potency and daily exposure

Policy actionExceeding MME thresholds triggers PA or claim edits

inv-111: PA (another repeat)

PA (legend repeat)PA = Prior Authorization

InterpretationAuthorization required before coverage; providers should submit supporting clinical documentation

TimingPA review may take up to two business days after complete information is received

inv-112: QL (another repeat)

QL (legend repeat)QL = Quantity Limits Apply

EffectLimits quantity dispensed or refills; exceeding may require PA or denial

ExamplesTest strips QL = 200/30 days; sildenafil/tadalafil selected strengths = 8/30 days

inv-113: NPD definition (legend)

NPD definitionNPD = Non Preferred Drug (formulary tier)

ImplicationTypically higher member cost-sharing and may have PA/QL flags

DisplayShown in formulary drug lines with associated REQUIREMENTS/LIMITS

inv-114: SP (another legend repeat)

SP (legend repeat)SP = Specialty Drug

NoteSpecialty designation often accompanied by PA and QL requirements

ManagementMay require specialty pharmacy handling

inv-115: LDD (legend repeat)

LDD (legend repeat)LDD = Limited Distribution

MeaningIndicates limited distribution channel for specified product(s)

Provider implicationSpecial paperwork or supplier may be required for coverage

inv-116: MME (legend repeat)

MME (legend repeat)MME = Morphine Milligram Equivalent — used as utilization control

ContextAppears across legend entries to remind providers that opioid potency checks apply

ActionMME-flagged claims may require PA or be subject to denial

inv-117: Formulary flags legend — comprehensive

Formulary abbreviations (comprehensive)PA, QL, SP, NPD, G, PB, LCG, LDD, QIT, SDS, AL, += Claim Dollar Limit, MME

InterpretationUse these flags on drug lines to determine coverage requirements and limits

Provider actionFollow the REQUIREMENTS/LIMITS field when submitting claims or PA requests

inv-118: PA (legend repeat)

PA (legend repeat)PA = Prior Authorization

Required documentationProviders should include clinical justification and medication history when requesting PA

Denial riskClaims may be denied without PA

inv-119: QL (legend repeat)

QL (legend repeat)QL = Quantity Limits Apply

Operational noteQLs may be time-based (QIT) or single-fill limits and require documentation if exceeded

ExamplesBlood glucose test strips = 200/30 days; zolpidem ER 12.5 mg limited

inv-120: SDS (legend repeat)

SDS (legend repeat)SDS = Supply Limit (day supply)

MeaningSpecifies allowable day supply for product classes or specific drugs

RelationWorks with QL and refill-too-soon edits to control dispensing

inv-121: MME (legend repeat)

MME (legend repeat)MME = Morphine Milligram Equivalent

NoteUsed as a utilization control flag on opioid-related entries

ActionMME exceedances trigger PA or claim edits

inv-122: NPD (tier legend)

NPD (tier legend)NPD = Non Preferred Drug

ImplicationTypically subject to higher cost-sharing and may have PA/QL requirements

DisplayShown alongside REQUIREMENTS/LIMITS in drug lines

inv-123: PB (tier legend)

PB definitionPB = Preferred Brand (formulary tier)

ImplicationPreferred placement with defined cost-sharing; may still carry PA/QL flags

UsageDisplayed in drug-list entries with REQUIREMENTS/LIMITS

inv-124: G (tier legend)

G definitionG = Generic (formulary tier)

ImplicationGeneric-tier drugs typically have lower cost-sharing; some generics still carry QL/PA flags

DisplayShown in lowercase italic on the formulary

inv-125: SP (tier legend)

SP definition (tier)SP = Specialty Drug (tier designation)

ImplicationHigher cost-sharing and specialty pharmacy management often apply

Associated flagsOften co-listed with PA, QL, or LDD

inv-126: Combined legend entry (PA/QL/SP/NPD/G/PB/LCG)

Combined legend entryPA / QL / SP / NPD / G / PB / LCG — these flags and tiers indicate prior authorization, quantity limits, specialty designation, non-preferred, generic, preferred brand, low-cost generic respectively

InterpretationUse combined legend to interpret drug line REQUIREMENTS/LIMITS and tier placement

Provider actionFollow indicated requirements when submitting claims or PA requests

inv-127: PA definition (another repeat)

PA definition (another repeat)PA = Prior Authorization (authorization required before coverage)

EffectDrugs listed with PA require prior authorization or claims may be denied

DocumentationProviders should submit clinical rationale and medication history with PA requests

inv-128: QL definition (another repeat)

QL definition (another repeat)QL = Quantity Limits Apply

MeaningSpecifies allowable quantities over time or per fill; exceeding may require PA

ExamplesSildenafil/tadalafil = 8 per 30 days; blood glucose test strips = 200 per 30 days

inv-129: SP definition (another repeat)

SP definition (another repeat)SP = Specialty Drug — drugs with special handling/monitoring and often higher cost-sharing

ManagementMay be managed via specialty pharmacy program and have LDD or PA

DisplayMarked 'SP' on formulary lines

inv-130: NPD definition (another repeat)

NPD definition (another repeat)NPD = Non Preferred Drug (tier) — typically higher cost-sharing

ImplicationMay require PA/QL and appear with other requirement flags

ActionProviders may pursue tier exception/formulary exception per process described in the formulary

inv-131: PB definition (another repeat)

PB definition (another repeat)PB = Preferred Brand

ImplicationPreferred placement with set cost-sharing; still subject to utilization controls if flagged

DisplayShown on drug lines with REQUIREMENTS/LIMITS

inv-132: G definition (another repeat)

G definition (another repeat)G = Generic

ImplicationLower cost-sharing generally, formatting shows lowercase italic

NoteSome generics still carry PA/QL/SDS flags

inv-133: AL definition — Age Limit

AL definition — Age LimitAL = Age Limit

MeaningSpecifies age-based restrictions on dispensing or prior authorization

Provider actionCheck age limits on drug lines when prescribing for pediatric or geriatric patients

inv-134: Formulary flags and abbreviations (repeat)

Formulary flags and abbreviations (repeat)PA, QL, PB, NPD, SP, LDD, G, LCG, QIT, SDS, AL, MME

UseApply these abbreviations when interpreting REQUIREMENTS/LIMITS on each drug line

Provider implicationFollow indicated processes (PA, QL documentation, LDD paperwork) to avoid claim denials

inv-135: Formulary abbreviations (repeat across document)

Formulary abbreviations (repeat across document)PA, QL, LDD, PB, NPD, SP, G, LCG, QIT, SDS, AL, MME

InterpretationLegend is repeated through the formulary to guide providers and pharmacists

ActionConsult legend when submitting PA or addressing QL/SDS/MME edits

Step therapy and substitution notes

Abbreviation	Meaning / implication
PA	Prior Authorization — provider must obtain approval before coverage; drugs listed with PA may be denied without authorization
QL	Quantity Limits Apply — dispensing limited to the specified quantity or frequency; exceeding requires authorization
AL	Age Limit — coverage restricted to specified age ranges; claims outside age limits may require prior authorization or be denied
LDD	Limited Distribution Drug — distribution or channel restrictions may apply; may require specific specialty pharmacy
SDS	Supply Limit Day — limits on day supply (e.g., short-course opioid limits); exceeding the limit may prevent coverage
R	Requires Rider — coverage may depend on benefit rider or supplemental coverage
QIT	Quantity Over Time — quantity limits expressed over a time period (rolling or fixed interval)
MME	Morphine Milligram Equivalent — opioid dose monitoring; exceeding numeric MME thresholds triggers authorization requirements

Drug / example	Requirement(s) indicated	Notes
Harvoni	PA, QL / QIT	Specialty antiviral with course-based quantity controls; prior authorization required
Epclusa	PA, QL / QIT	Hepatitis C antiviral designated with quantity-over-time/course limits and PA
Mavyret	PA, QL / QIT	Hepatitis C antiviral requiring prior authorization and quantity/course limits
Arikayce	PA	Specialty antibiotic listed with prior authorization requirement
Cresemba	PA	Specialty antifungal noted as requiring prior authorization
Rivfloza Inj	PA, QL	Injectable anti-infective with quantity limits and PA
Xofluza Tab	QL	Antiviral with an indicated quantity limit

Observation	Implication for step therapy / coverage	Source evidence
No explicit step sequences present	Formulary uses flags (PA, QL, AL, etc.) rather than defined step-therapy steps; prior authorization and quantity limits act as utilization controls	Document lists requirement flags but not step order
Flags appear on many drug lines	Coverage decisions rely on the REQUIREMENTS/LIMITS field per drug line rather than a separate step algorithm	Multiple entries show PA/QL/M M E/QIT flags
Programmatic mapping exists (multi-field drug lines)	Encoded fields (DRUG NAME +, positions 1..5) suggest tier and requirement mapping are used for automated adjudication instead of step edits	DRUG NAME + positional mapping described

Implicit relationship noted	What it implies	Example from document
Formulary 'DRUG NAME +' columns link related agents	Suggests substitution or equivalence relationships (possible preferred alternatives) though not formal step rules	Example: eszopiclone, 3 = fluvoxamine (positional mapping)
Entries pair drugs and alternate names/ties	May be used to suggest an alternate agent on claim adjudication or to display related alternatives to prescriber/pharmacist	Minocycline entries show DRUG NAME + references to Oracea, Paxlovid, etc.
No explicit 'try X then Y' sequence	Implied substitution relationships are informational; prior authorization criteria and QLs control access rather than step-failure rules	Step-therapy mechanics are not defined in excerpt

Programmatic field	Meaning (per mapping)	Policy use
DRUG NAME +, 1 = DRUG TIER	Field position 1 encodes the formulary tier (e.g., G, NPD, PB, SP)	Used to present member cost-sharing and tier in automated adjudication
DRUG NAME +, 2 = REQUIREMENTS/ LIMITS	Field position 2 encodes requirement flags (e.g., PA, QL, MME, LDD, SDS)	Adjudication and prior authorization triggers reference these flags to enforce controls
DRUG NAME +, 5 = REQUIREMENTS/ LIMITS (alternate) or blank	Additional positions can carry supplemental requirement flags or be unused depending on product	Supports complex product lines where multiple formulations/tier-flag combos apply

Quantity limits and supply controls

Specialty and site-of-care requirements

Note

Background and context

Specialty drugs treat rare, complex, or chronic conditions and frequently require additional management. The PBM administers specialty drug controls through the pharmacy benefit, using tools such as the Specialty Pharmacy Program, prior authorization, limited distribution, and quantity/supply limits. These products may require special handling, monitoring, or patient education, and coverage can be subject to channel or site-of-care requirements and program-specific conditions.