CurrentAmeriHealthPolicy N/A

AmeriHealth Select Drug Program Formulary and Prior Authorization Procedures

This document governs the AmeriHealth Select Drug Program formulary structure, safety edits (prior authorization, age/quantity/MME/stimulant limits), and related pharmacy benefit procedures that affect members and providers participating in AmeriHealth plans.

Policy Summary

PayerAmeriHealth

PolicyAmeriHealth Select Drug Program Formulary and Prior Authorization Procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for drugs flagged 'PA' or when opioid/stimulant dosing exceeds the listed MME or cumulative stimulant thresholds.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90opioid daily MME prior authorization threshold

60-72stimulant cumulative limit (examples)

>$10kclaim dollar threshold needing PA

75%refill-too-soon threshold

tiers listedformulary tiers

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Coverage and Safety Edits

General coverage and prior authorization

Covered when ALL of the following are met

General prior authorization criteria: Provider must request prior authorization for certain covered drugs to confirm medical necessity, clinical appropriateness, and FDA‑labeled or medically accepted use; clinical pharmacists evaluate requests using clinical data, provider‑submitted information, and the member's prescription history.

Claim dollar limits require PA for claims exceeding $10,000; PA approvals may be time‑limited and without PA the prescription will not be covered at retail or mail order.

Opioid safety edit

Prior authorization required if ANY of the following exceed thresholds

Opioid MME threshold: Prior authorization required for opioid doses that exceed 90 MME per day.>90 MME/day

MME is calculated across opioid products per day.

Cumulative stimulant limits

Prior authorization required when cumulative daily stimulant dose exceeds agent-specific limits

Stimulant cumulative dose rules: Total daily stimulant dose is calculated by active ingredient; claims exceeding the specified high cumulative daily dose for the active ingredient require prior authorization.agent-specific (see list)

Examples include amphetamine 60 mg/day; amphetamine‑dextroamphetamine 60 mg/day; dextroamphetamine 60 mg/day; lisdexamfetamine 70 mg/day; methamphetamine 60 mg/day; dexmethylphenidate 40 mg/day; methylphenidate 72 mg/day; serdexmethylphenidate 52.3 mg/day.

Stimulant cumulative dose coverage

Covered when dispensing does not exceed cumulative stimulant limits; claims exceeding limits require prior authorization

Cumulative stimulant authorization logic: All stimulant claims are subject to a cumulative dosing calculation by active ingredient; if the total daily dose for that active ingredient exceeds the listed threshold, prior authorization is required before the claim will be approved at point‑of‑sale.see thresholds in coding module

Provider must submit PA via ePA or fax; clinical pharmacists review therapy history and may discuss overrides with prescriber when appropriate.

Coverage stance by drug row

Coverage and administrative requirements vary by drug and are indicated in each row.

Drug row example - Tyvaso: Tyvaso: tier and flags shown across drug rows (examples include NPD, SP) and specific rows indicate Prior Authorization where listed.

Shows tier (NPD), specialty (SP) and PA requirement

Drug row example - Uptravi: Uptravi: drug rows indicate tier (NPD, SP) and REQUIREMENTS/LIMITS fields (PA where shown).

Uptravi marked NPD and PA

Drug row example - Dupixent: Dupixent: DRUG TIER = PB, SP and REQUIREMENTS/LIMITS = PA in the drug row, indicating it is a preferred brand specialty drug requiring prior authorization.

Dupixent is a preferred brand specialty drug requiring PA

Inclusion of a drug on this formulary does not guarantee coverage for every member. Drug coverage varies by group benefit and some cost-share tiers (including Low-Cost Generic and Specialty) may not be available on all plans. Coverage decisions are based on medical necessity and the member's specific benefit design; providers or members with questions should contact Customer Service using the number on the member ID card. (Formulary is subject to change.)

The formulary is maintained and reviewed by a Pharmacy and Therapeutics Committee of physicians and pharmacists; drugs included were selected for reported medical effectiveness, safety, and value, but inclusion alone does not override plan-specific coverage or utilization management rules.

Tier exception requests are limited by plan design: drugs on the Generic, Preferred Brand, and Specialty tiers are not eligible for tier exceptions. When allowed, requests for tier exceptions require supporting documentation and may require trials of formulary alternatives; completed formulary exception request forms should be faxed to 1-888-671-5285.

Entries flagged as NPD (Non Preferred Drug) indicate that a product is designated non-preferred on the formulary. The document does not list NPD products as categorically excluded; rather, NPD denotes a tiering and potential cost-share difference and may be paired with utilization controls (e.g., PA, QL) on the drug row.

This excerpt does not provide a list of drugs that are explicitly excluded from coverage. Instead, the drug list rows show per-drug tier assignments and utilization controls (PA, QL, AL, etc.); absence from coverage or plan-level exclusions are governed by member benefit documents and are not specified in the provided excerpt.

The document excerpt does not set out formal medical necessity decision algorithms for specific conditions. Rather, coverage decisions are managed through prior authorization and utilization controls where indicated on each drug row; prior authorization is used to confirm medical necessity and appropriateness for those drugs flagged with PA.

No clinical exclusions (for example, blanket clinical contraindications listed as exclusions) are specified in this excerpt. The policy presents per-drug administrative controls (tiering and requirement flags) rather than explicit clinical exclusion statements.

When a prescription falls outside FDA-labeled guidance (for example, an age outside the product's FDA age range), coverage may not be provided unless a Prior Authorization (PA) is obtained documenting medical necessity. Providers may request coverage for off-label or out-of-range use by submitting the PA with supporting clinical rationale.

The excerpt does not contain line-item 'not medically necessary' declarations for specific drugs. General rules indicate that use outside FDA guidance may require prior authorization; explicit not-medically-necessary statements for named products are not included in the provided sections.

Formulary Codes, Limits, and Key Thresholds

Examples of preventive drugs listedNDC | mixed

Descovy 200-25mg	HIV PrEP product listed as available at $0 for eligible members
Tamoxifen 20mg	Breast cancer chemoprevention product listed as ACA preventive

Formulary administrative codes and flagsmixed

PA	Prior Authorization
QL	Quantity Limits Apply
LDD	Limited Distribution Drug
PB	Preferred Brand
SP	Specialty Drug
AL	Day Supply/Age Limit
NPD	Non Preferred Drug
G	Generic
LCG	Low Cost Generic
R	Requires Rider

Opioid MME limit — 90 MME/day

Opioid MME limitPrior authorization required for opioid doses that exceed 90 MME per day.

MME calculationDaily MME is calculated across all opioid products using standardized potency conversions.

Applies toOpioid products containing listed active ingredients (e.g., hydromorphone, fentanyl, hydrocodone, morphine, oxycodone, tapentadol).

Cumulative stimulant limits — Agent-specific limits

Cumulative stimulant limits (overview)Prior authorization required when total daily stimulant dose by active ingredient exceeds the agent-specific thresholds below.

Calculation method

Prior Authorization, Submissions, and Denial Risk

Prior Authorization

Prior authorization requirements

Prior Authorization Required — AmeriHealth requires prior authorization (PA) for certain prescription drugs to confirm medical necessity, appropriate dosing, and use per FDA‑labeled or medically accepted indications. Clinical pharmacists review PA requests using clinical data, provider‑submitted information, and the member’s prescription history; medical director review may occur if criteria are not met. Without prior authorization, the member’s prescription will not be covered at retail or mail‑order pharmacies. PA approvals may be time‑limited (for example, 6–12 months) and must be renewed when expired. Claim dollar limits trigger PA review for claims exceeding $10,000.

PA approvals are based on Pharmacy & Therapeutics Committee‑approved criteria and may include review of drug‑drug interactions, contraindications, dosing, therapy duration, and prior therapies.
PA review may take up to two business days after receipt of complete provider information; incomplete submissions can delay decisions.
Some drugs require a benefit rider (e.g., certain weight‑loss drugs); contact the health plan for member eligibility and rider details.

Prior Authorization

Prior authorization required for listed PA drugs

Initial Therapy Requirements

Step Therapy / Prior Trials

Requirement	Interpretation / Action
Prior authorization and other utilization controls (PA, QL, AL, 5DS) may be applied	Procedures such as prior authorization, age limits, and quantity limits support safe prescribing; providers must obtain PA when a drug row indicates 'PA' prior to coverage
Step therapy implication	These procedures may require documentation of prior trials or contraindications to alternatives; however, no explicit multi-step (failed‑first) sequences are defined in the provided excerpt

Drug / Class	Step therapy / Step edits noted	Notes
General drug list entries	No explicit step‑therapy sequences are listed; individual drugs are annotated with PA, QL, AL, etc.	Providers should follow the per‑drug requirement flags shown in each row (PA = prior authorization; QL = quantity limits; AL = age limit)
Selected antibiotics and other agents (example: doxycycline entries)	Annotated with requirement flags (some formulations show PA or QL); no step order specified	See the drug row for formulation‑specific flags (e.g., Doxycycline DR 80mg = PA in chunk 76)

Drug / Group	Specialty / Oncology / Transplant Flag	Action required
Multiple oncology and transplant agents (examples: dasatinib, Erivedge, Erleada)	Frequently designated SP (Specialty) and many list PA in REQUIREMENTS/LIMITS	Prior authorization is required for entries marked 'PA'; explicit step therapy sequences are not provided in this excerpt
Broad oncology/transplant list (Rezurock, many others)	Entries often show 'NPD, SP' and 'PA' or 'PA, QL' where indicated	Providers must submit PA for PA‑flagged specialty agents prior to coverage

Product / Class	Step edit / PA applied?	Reference detail
Amphetamine‑containing products (various branded and generics)	Step edits and utilization controls may apply; many amphetamine entries show PA and QL	Examples: amphetamine aspartate/.../dextro- listed with REQUIREMENTS/LIMITS = PA (chunk 121); amphetamine tablet (Evekeo) = PA, QL, 5DS, MME (chunk 123)
Cumulative stimulant dosing	Claims exceeding agent‑specific cumulative daily dose limits require prior authorization	Agent thresholds referenced in coding (e.g., amphetamine 60 mg/day) — see stimulant limit rules

Drug / Note	Step therapy indicated?	Comment
Glatiramer acetate / glatopa and other entries	No explicit step therapy sequences provided in this excerpt	Some rows indicate NPD or SP which reflect non‑preferred or specialty pathways and associated PA/QL flags (chunk 151)
General formulary rows	Managed access indicated by tier flags (NPD, SP) and PA/QL where shown; step therapy not defined here	Follow per‑drug flags for prior authorization or quantity limits

Drug / Example	Step therapy / PA flag	Implication
Pregabalin formulations (caps, ER, solution)	Several pregabalin entries are flagged PA or PA, QL depending on formulation	Providers must obtain PA for formulations listed with PA prior to coverage; no step algorithm provided
Pramipexole (and similar CNS agents)	Some entries show PA or QL as requirement flags	PA/QL indicate managed access; follow the drug row requirements

Drug	Step therapy / Requirement	Action
Eltrombopag	Requirements/Limits = PA (and appears as G, SP in list)	Prior authorization required for eltrombopag formulations listed with PA prior to coverage

Drug / Type	PA / QL indicated?	Notes
Sildenafil citrate (various strengths) and related products	Listed with REQUIREMENTS/LIMITS = PA for many formulations	Specialty or PA flags apply to some formulations; follow per‑drug PA requirements
Tadalafil (generic Adcirca / Cialis) and Tadliq Susp	Entries show PA or QL depending on formulation (chunk 235)	Some generics and specialty forms are subject to PA before coverage; no multi‑step sequences specified

Drug / Example	Step therapy / PA flag	Guidance
Topical and dermatology agents (e.g., diclofenac 3% gel, Differin formulations)	Many entries show PA and/or AL and sometimes QL (chunk 251)	Follow per‑drug flags; no explicit step therapy sequencing shown in this excerpt
Relenza and other respiratory agents	Relenza is annotated QL (chunk 90)	Quantity limits or PA apply as indicated on the drug row; step therapy not listed

Quantity Limits and Day Supply Restrictions

Etonogestrel-ethinyl estradiol (Nuvaring) — 1

Etonogestrel-ethinyl estradiol (Nuvaring)Quantity limit = 1 ring per 28 days (1).

ContextListed as a Quantity Over Time example in the formulary quantity limits section.

Action for overridesIf member requires more than the limit, provider must submit prior authorization request.

Ibandronate 150mg — 1

Ibandronate 150mg (Boniva)Quantity limit = 1 tablet per 30 days (1).

ContextListed as an example under Quantity Over Time limits.

Action for overrides

Formulary Abbreviations and Definitions

Formulary / Tiers

Formulary definitionA formulary is a list of medications chosen for safety, cost, and effectiveness and organized into cost-sharing tiers (Low-Cost Generic, Generic, Preferred Brand, Non-preferred, Specialty).

GovernanceMaintained and reviewed by a Pharmacy & Therapeutics Committee that evaluates safety, effectiveness, and value.

Tier examplesTiers include Low-Cost Generic (LCG), Generic (G), Preferred Brand (PB), Non-Preferred Drug (NPD), Specialty (SP).

Morphine Milligram Equivalent (MME)

Morphine Milligram Equivalent (MME)A standardized measure to compare opioid potency and to calculate total daily opioid dose for safety limits (used to determine the 90 MME/day threshold).

PurposeIdentifies when additional caution or prior authorization is needed for opioid prescribing.

Specialty and Site-of-Care Notes

Note

Formulary Governance

The formulary is reviewed and maintained by a Pharmacy and Therapeutics Committee composed of physicians and pharmacists to ensure included drugs meet standards for safety, effectiveness, and value. The PBM routinely monitors drugs and applies safety edits (such as age limits, quantity limits, MME limits, and cumulative stimulant limits) to align prescribing with FDA guidance and clinical practice.

Policy Summary

PayerAmeriHealth

PolicyAmeriHealth Select Drug Program Formulary and Prior Authorization Procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for drugs flagged 'PA' or when opioid/stimulant dosing exceeds the listed MME or cumulative stimulant thresholds.

SourceLink

On This Page

Total daily stimulant dose is summed by active ingredient across all stimulant products on the claim.

PurposeSafety edit to mitigate cardiac and neuropsychiatric risks associated with high-dose stimulant use.

Refill too soon — Refill allowed after 75% utilization

Refill-too-soon thresholdRefill allowed after 75% utilization (member may refill once 75% of the previous supply is consumed).

Examples30-day supply filled 1/1/2026 refillable on/after 1/24/2026; 90-day supply filled 7/1/2026 refillable on/after 9/7/2026.

PurposePrevents stockpiling and encourages appropriate utilization; overrides require prior authorization.

Amphetamine high cumulative daily dose — 60mg/day

Amphetamine high cumulative daily doseHigh cumulative daily dose threshold = 60 mg/day.

Affected products (examples)Adzenys ER ODT, Dyanavel, Evekeo (and other amphetamine brands/generics).

Authorization actionClaims exceeding 60 mg/day for amphetamine require prior authorization.

Amphetamine-Dextroamphetamine high cumulative daily dose — 60mg/day

Amphetamine–Dextroamphetamine thresholdHigh cumulative daily dose threshold = 60 mg/day.

Affected products (examples)Adderall IR/XR, Mydayis (brands and generics).

Authorization actionClaims exceeding 60 mg/day for amphetamine–dextroamphetamine require prior authorization.

Dextroamphetamine high cumulative daily dose — 60mg/day

Dextroamphetamine thresholdHigh cumulative daily dose threshold = 60 mg/day.

Affected products (examples)Dexedrine, Zenzedi, ProCentra, Xelstrym (brands and generics).

Authorization actionClaims exceeding 60 mg/day for dextroamphetamine require prior authorization.

Lisdexamfetamine high cumulative daily dose — 70mg/day

Lisdexamfetamine thresholdHigh cumulative daily dose threshold = 70 mg/day.

Affected productVyvanse (lisdexamfetamine) — brands and generics.

Authorization actionClaims exceeding 70 mg/day for lisdexamfetamine require prior authorization.

Methamphetamine high cumulative daily dose — 60mg/day

Methamphetamine thresholdHigh cumulative daily dose threshold = 60 mg/day.

Affected productDesoxyn (methamphetamine) — brands and generics.

Authorization actionClaims exceeding 60 mg/day for methamphetamine require prior authorization.

Dexmethylphenidate high cumulative daily dose — 40mg/day

Dexmethylphenidate thresholdHigh cumulative daily dose threshold = 40 mg/day.

Affected products (examples)Focalin IR/XR (dexmethylphenidate) — brands and generics.

Authorization actionClaims exceeding 40 mg/day for dexmethylphenidate require prior authorization.

Methylphenidate high cumulative daily dose — 72mg/day

Methylphenidate thresholdHigh cumulative daily dose threshold = 72 mg/day.

Affected products (examples)Ritalin IR/LA, Daytrana, Concerta, Quillivant XR, Jornay PM, Adhansia XR, Relexxii (brands/generics).

Authorization actionClaims exceeding 72 mg/day for methylphenidate require prior authorization.

Serdexmethylphenidate high cumulative daily dose — 52.3mg/day

Serdexmethylphenidate thresholdHigh cumulative daily dose threshold = 52.3 mg/day.

Affected productAzstarys (serdexmethylphenidate) — brands and generics.

Authorization actionClaims exceeding 52.3 mg/day for serdexmethylphenidate require prior authorization.

Day Supply / Age Limit (AL) — AL (day supply/age limit as noted per drug)

Day Supply / Age Limit (AL)AL flags indicate a day-supply or age restriction noted per drug row; refer to each drug's REQUIREMENTS/LIMITS entry for specific AL details.

ExamplesSome entries show AL alongside QL or PA (e.g., Molnupiravir 200mg = QL, AL; topical diclofenac 3% gel = PA, AL).

Action when AL appliesPrescriptions outside the age/day-supply limit may require prior authorization to be covered.

Prior authorization is required for many specific drugs listed on the formulary when the drug’s REQUIREMENTS/LIMITS field includes the notation "PA". This PA requirement applies to all formulations of a listed drug (tablet, capsule, oral suspension, transdermal, injectable, etc.) unless otherwise specified. Claims submitted without the required PA may be denied.

The drug list shows requirement flags (e.g., PA, QL, Q/T, MME, AL, SP) next to product entries to indicate utilization management controls.
Providers should check the formulary row for the drug and formulation being prescribed to confirm whether PA applies prior to dispensing.

Denial Risk

Authorization/Denial triggers

Denial Risk & Authorization Triggers — Claims for drugs flagged with requirement codes (PA, QL, Q/T, MME) may be denied if required prior authorization or documentation is not obtained. Providers should follow the PA process and supply supporting documentation to avoid payment denials.

Examples of denial triggers: absence of PA when "PA" is indicated; exceeding Quantity Limits (QL) or Day Supply limits (5DS); exceeding Morphine Milligram Equivalent (MME) thresholds.
Claim dollar over‑limit (+) will require PA review (claims > $10,000).
Many specialty products and oncology/transplant agents are frequently marked PA and may also have QL or LDD requirements.

Prior Authorization

Prior authorization for opioid MME and cumulative stimulant limits

Safety limits that trigger prior authorization — AmeriHealth applies specific safety thresholds that require PA when exceeded, including opioid MME limits and cumulative stimulant dose limits.

Opioid MME limit: prior authorization is required for opioid dosing that exceeds 90 MME per day. The MME calculation aggregates all opioid products and potencies.
Cumulative stimulant limits: PA is required when total daily stimulant dose by active ingredient exceeds specified thresholds (examples: amphetamine 60 mg/day; methylphenidate 72 mg/day; lisdexamfetamine 70 mg/day; dexmethylphenidate 40 mg/day; serdexmethylphenidate 52.3 mg/day).
High‑dose stimulant and opioid claims may be denied without an approved PA.

Billing Rule

How to submit PA and formulary exceptions

How to submit prior authorization and formulary exception requests — Providers may submit PA requests electronically (ePA platforms such as SureScripts™) or by fax using the AmeriHealth/PBM prior authorization form. Formulary tier‑exception requests require documentation of trials or contraindications to alternatives as specified.

ePA (e.g., SureScripts™) can yield real‑time approvals in the office.
Fax prior authorization and formulary exception requests to the PBM at 1‑888‑671‑5285; forms and instructions are available at https://www.amerihealth.com/resources/for-providers/policies-and-guidelines/index.html.
Tier exceptions: when applicable, requests for preferred coverage of a non‑preferred drug generally require trial of, or contraindication to, at least three formulary alternatives. Tier exceptions are not available for some tiers/plans—refer to the member benefit booklet.

Documentation Required

Requirement abbreviations and required documentation (legend)

Requirement abbreviations and documentation legend — The formulary uses standardized abbreviations to indicate utilization management and documentation needs. Providers must supply documentation consistent with the legend when submitting PA or appeals.

Key abbreviations: PA = Prior Authorization; QL = Quantity Limits Apply; Q/T = Quantity Over Time; AL = Age Limit; 5DS = Day Supply Limit; LDD = Limited Distribution Drug; SP = Specialty Drug; MME = Morphine Milligram Equivalent; + = Claim Dollar Limit; R = Requires Rider.
When a drug entry includes PA, providers must submit the PA request with clinical rationale and supporting records (e.g., prior therapy history, contraindications).
The formulary rows may also include QL, MME, AL flags that indicate additional documentation or limits that must be met.

Note

Provider‑impact procedures and coverage risk

Provider impact summary — Many drugs throughout the formulary are designated PA (Prior Authorization) and/or QL (Quantity Limits) — providers should review the drug‑specific formulary row for requirements before prescribing to avoid claim denials and to ensure timely access.

PA, QL, Q/T and MME flags appear across specialty, oncology, cardiovascular, CNS, and other therapeutic classes.
PA applies to all formulations of a listed product unless otherwise noted; specialty or limited distribution drugs may have additional handling and documentation requirements (SP, LDD).
If prior authorization is denied, the prescribing provider and member will be notified with instructions for appeals; appeals processes are described in denial communications.

Providers must submit prior authorization if member requires >1 per 30 days.

Sumatriptan 50mg — 18

Sumatriptan 50mg (Imitrex)Quantity limit = 18 tablets per 30 days (18).

ContextExample of Quantity Over Time limit in formulary.

Action for overridesPrior authorization required if member needs more than the quantity limit.

Zolpidem — 1

Zolpidem (Ambien)Quantity limit = 1 tablet per day; specific formulary entries note PA and QL for certain strengths (e.g., 10 mg only).

ContextListed under maximum daily dose examples and detailed drug rows note PA/QL for strengths/forms.

Action for overridesPrior authorization required where PA is indicated on the drug row.

Oxycodone/acetaminophen 5/325mg — 12

Oxycodone/acetaminophen 5/325mg (Percocet)Quantity limit = 12 tablets per day (12).

ContextListed as a maximum daily dose example in the Quantity Limits section.

Day-supply implicationsShort-acting opioid day supply limits also apply (5DS) per other drug-row entries where noted.

Descovy — QL

Descovy 200-25mgQuantity Limits Apply (QL) as noted on formulary entries.

ContextDescovy lines in the drug list show QL and other tiering details per row.

Action for overridesProviders must submit PA when QL is exceeded per standard prior authorization process.

Molnupiravir 200mg — QL, AL

Molnupiravir 200mgQuantity Limits Apply (QL) and Age Limit (AL) — see drug row for specifics.

ContextMolnupiravir entry lists QL and AL in the REQUIREMENTS/LIMITS field.

Action for overridesPrior authorization or exception may be required when AL or QL applies.

Relenza — QL

RelenzaQuantity Limits Apply (QL) as indicated on the drug row.

ContextRelenza is listed with QL in the drug list section.

Action for overridesProvider must submit prior authorization if QL exceeded.

Sovaldi — QL, Q/T

SovaldiQuantity Limits Apply (QL) and Quantity Over Time (Q/T) as indicated on formulary rows.

ContextSovaldi entries show QL and Q/T flags in the REQUIREMENTS/LIMITS column.

Action for overridesRequests exceeding QL/Q/T require prior authorization/documentation.

Xifaxan 550mg — QL, Q/T

Xifaxan 550mgQuantity Limits Apply (QL) and Quantity Over Time (Q/T) as noted on the drug row.

ContextXifaxan 550mg entry lists PA, QL, and Q/T in the formulary.

Action for overridesPrior authorization required when QL/Q/T limits are exceeded.

Ninlaro — QL

NinlaroQuantity Limits Apply (QL) as indicated on formulary row.

ContextNinlaro listed with QL in the drug list requirements/limits section.

Action for overridesProviders should submit PA if coverage beyond QL needed.

Targretin cap — QL, LDD

Targretin capQuantity Limits Apply (QL) and Limited Distribution Drug (LDD) — see drug row for details.

ContextTargretin cap entries include PA, QL, and LDD flags in the formulary.

Action for overridesFollow PA/LDD processes for distribution and exceptions.

Tretinoin caps — QL

Tretinoin capsQuantity Limits Apply (QL) as indicated on formulary rows.

ContextTretinoin caps appear with PA and/or QL depending on formulation in the drug list.

Action for overridesProviders must submit PA if QL is exceeded where PA is also flagged.

Xatmep — PA, QL, 5DS

XatmepRequires Prior Authorization (PA), Quantity Limits Apply (QL), and Day Supply Limit (5DS) as listed.

ContextXatmep drug row includes PA, QL, and 5DS flags in the REQUIREMENTS/LIMITS field.

Action for overridesPA and distribution processes must be followed; limited distribution may apply.

Xpovio Pak — (quantity limits not summarized)

Xpovio PakListed in formulary; quantity limits not summarized on the document excerpt.

ContextXpovio Pak appears in the drug list but the summary notes quantity limits are not summarized.

Action for providersRefer to full formulary row or submit PA if exception/clarification needed.

Ambien CR — PA, QL

Ambien CRRequires Prior Authorization (PA) and Quantity Limits Apply (QL) as indicated on the drug row.

ContextAmbien CR entry in the drug list shows PA and QL flags.

Action for overridesProviders must submit PA when PA is indicated on the drug line.

Amphetamine aspartate/.../dextro- — PA, QL

Amphetamine-containing products (general)Many amphetamine products are subject to Prior Authorization (PA) and Quantity Limits (QL) per the formulary.

ExamplesAmphetamine aspartate/.../dextro- entries and amphetamine tablets (Evekeo) show PA, QL; some also show 5DS and MME flags.

Action for providersSubmit PA for amphetamine products when PA/QL/5DS/MME flags apply or limits are exceeded.

Amphetamine tablet (generic Evekeo) — PA, QL, 5DS, MME

Amphetamine tablet (generic Evekeo)Flags: Prior Authorization (PA), Quantity Limits Apply (QL), Day Supply Limit (5DS), and MME where indicated.

ContextEvekeo line explicitly lists PA, QL, 5DS, and MME in REQUIREMENTS/LIMITS.

Action for providersPA required when flagged; documentation should support requests per formulary processes.

Apomorphine inj 30mg/3ml — QL

Apomorphine injection 30mg/3mlQuantity Limits Apply (QL) as indicated on the drug row.

ContextApomorphine 30mg/3ml appears with QL in the formulary drug list.

Action for overridesSubmit PA if additional quantity beyond QL is clinically necessary.

Butal/Apap Tab 25-325mg — PA, QL, 5DS

Butalbital/acetaminophen 25/325mgFlags: Prior Authorization (PA), Quantity Limits Apply (QL), Day Supply Limit (5DS).

ContextButal/Apap 25-325mg line shows PA, QL, 5DS in REQUIREMENTS/LIMITS.

Action for overridesPA required when flagged; day-supply limits control acute use.

Various butalbital-containing products and multiple others — QL, 5DS, and in some cases MME

Various butalbital-containing productsMany entries show Quantity Limits (QL), Day Supply Limits (5DS), and in some cases MME flags.

ContextFormulary rows for butalbital combinations list QL/5DS and sometimes MME depending on formulation.

Action for providersFollow PA/QL/5DS/MME processes on the drug row; submit PA when limits are exceeded.

Escitalopram (some entries) — QL (Weekly Only or QL as indicated)

Escitalopram (selected entries)Quantity Limits Apply (QL) — some entries specify Weekly Only QL or other QL details.

ContextEscitalopram entries appear with QL or weekly-only QL flags in the drug list.

Action for providersSubmit PA if QL prevents required therapy; consult drug-row notes for weekly limits.

Opioid products (e.g., hydrocodone ER, fentanyl citrate, morphine solutions) — QL, 5DS, MME where indicated

Opioid products (examples)Many opioid entries (hydrocodone ER, fentanyl citrate, morphine solutions, oxycodone products) include QL, 5DS, and MME flags where indicated.

ContextOpioid lines in the formulary specify QL, day-supply limits, and MME monitoring as appropriate.

Action for providersPrior authorization is required when MME or day-supply limits are exceeded; follow PA submission process.

Multiple examples listing QL and/or 5DS and/or MME where specified per drug line

Multiple example entriesMany drug lines include QL and/or 5DS and/or MME flags; see each drug row for specific requirements.

ContextExamples in this section include Nucynta, Namenda XR, Neurontin, Ritalin, and others with varying QL/5DS/MME flags.

Action for providersCheck the individual drug REQUIREMENTS/LIMITS entry for exact flags and submit PA if required.

Risperidone — QL

RisperidoneQuantity Limits Apply (QL) as indicated on the formulary row.

ContextRisperidone appears with QL in the drug list requirements/limits section.

Action for providersSubmit PA if QL prevents needed therapy per formulary rules.

Roxicodone — QL, 5DS, PA, MME

RoxicodoneFlags: Quantity Limits (QL), Day Supply Limit (5DS), Prior Authorization (PA), and MME monitoring as indicated.

ContextRoxicodone entries show multiple utilization flags including PA and MME on the drug row.

Action for providersPA required when flagged; claims exceeding MME/day may be denied without PA.

Trudhesa AER — PA, QL, MME

Trudhesa AERRequires Prior Authorization (PA), Quantity Limits Apply (QL), and MME monitoring where indicated.

ContextTrudhesa AER drug row includes PA, QL, and MME flags.

Action for providersFollow PA process and document clinical need when requesting coverage.

Zolpidem tartrate — PA, QL (10mg only or other strengths specified)

Zolpidem tartratePrior Authorization (PA) and Quantity Limits Apply (QL) for specified strengths (e.g., 10 mg only) as noted on the formulary.

ContextZolpidem tartrate lines list PA and QL flags and call out strength-specific limits.

Action for providersSubmit PA when PA is indicated on the drug row or when QL is exceeded.

Entresto — QL

EntrestoQuantity Limits Apply (QL) as indicated on the formulary row.

ContextEntresto entry shows QL in the REQUIREMENTS/LIMITS field.

Action for providersSubmit PA if clinical need exceeds quantity limits.

Camzyos — QL

CamzyosQuantity Limits Apply (QL) as indicated on the formulary row.

ContextCamzyos appears with QL (and PA in some rows) in the drug list.

Action for providersFollow PA/QL processes when requesting coverage beyond limits.

Elyxyb Sol — QL

Elyxyb SolQuantity Limits Apply (QL) as indicated on the formulary row.

ContextElyxyb Sol entry lists PA and QL flags in the REQUIREMENTS/LIMITS field.

Action for providersSubmit PA if required per the drug row.

Sacub/valsar — QL

sacubitril/valsartan (sacub/valsar)Quantity Limits Apply (QL) as indicated on the drug row.

Contextsacub/valsar listed with QL in the formulary section.

Action for providersCheck the drug row for QL specifics and submit PA if needed.

Tadalafil (generic Cialis) — QL

Tadalafil (generic Cialis)Quantity Limits Apply (QL) as indicated on the formulary for some generic tadalafil entries.

ContextFormulary lists generic tadalafil with QL and some PA flags for Adcirca/generic Adcirca formulations.

Action for providersRefer to the specific drug row to determine QL or PA requirements before dispensing.

Tadalafil (generic Cialis) — QL

Tadalafil (generic Cialis) — duplicate listingQuantity Limits Apply (QL) appears across multiple generic tadalafil rows in the formulary.

ContextThe formulary shows repeated entries for tadalafil with QL in different rows/indications.

Action for providersFollow the REQUIREMENTS/LIMITS on the exact drug row submitted for the claim.

Verquvo — QL

VerquvoQuantity Limits Apply (QL) as indicated on the formulary row.

ContextVerquvo appears with QL in the drug list.

Action for providersSubmit PA if QL prevents necessary therapy per drug-row requirements.

Calculation noteMME is calculated across opioid products based on potency conversions for each active ingredient.

Cumulative stimulant limit

Cumulative stimulant limit (definition)A safety measure that sums total daily stimulant dose by active ingredient; claims exceeding predefined per-ingredient daily dose thresholds require prior authorization.

Calculation methodTotal daily dose is aggregated by active ingredient across all stimulant products on the claim.

Action when exceededClaims exceeding the agent-specific limits (see per-agent thresholds) will require prior authorization and may be denied without approval.

Brand vs Generic formatting

Brand vs Generic formattingBrand-name medications start with an uppercase letter and are written in bold; generic medications are shown in lowercase and in italic.

PurposeFormatting helps distinguish brand vs generic choices on the formulary.

ExampleBrand: Augmentin (bold uppercase). Generic: lisinopril (lowercase italic).

Formulary abbreviations

Common formulary abbreviationsPA = Prior Authorization; QL = Quantity Limits Apply; SP = Specialty Drug; LCG = Low Cost Generic; NPD = Non Preferred Drug; PB = Preferred Brand; G = Generic; LDD = Limited Distribution Drug; 5DS = Day Supply Limit; AL = Age Limit; Q/T = Quantity Over Time; MME = Morphine Milligram Equivalent.

UsageAbbreviations appear in REQUIREMENTS/LIMITS fields to denote utilization management controls on each drug row.

Provider actionProviders must follow PA/QL/AL/LDD/5DS/MME rules as indicated on the specific drug row; documentation may be required for PA requests.