Drug list — Five Tier Drug Plan (Formulary)
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Defines the prescription drug list (formulary) structure, tiering, and basic member-facing rules for coverage, prior authorization, step therapy, quantity limits, and specialty distribution for Anthem members. Affects members and providers using the Anthem prescription benefit and pharmacy administrators.
No material clinical or coverage changes in this revision.
Formulary Coverage Rules & Tiering
Formulary coverage conditions
Covered when ALL of the following are met:
Tier definitions include distinctions such as Tier 1a/1b and specialty tiers
See the Notes column on the formulary row for applicable restrictions and required administrative actions
Providers must submit PA requests or documentation per payer procedures when 'PA' is listed; follow step-therapy requirements where 'ST' is noted
Drugs listed on the formulary may still be subject to your specific plan's benefit design. If a medicine is not included on a member's drug list, the member may be required to pay the full cost. Providers may request coverage review or prior authorization on a member's behalf by calling the Member Services number on the back of the member ID card or by submitting a prior authorization form; if approved, the member’s cost share will depend on their plan benefits.
Within the provided excerpt there are no explicit statements that particular drugs are categorically excluded; the listings show tier assignments and Notes (for example, quantity limits or PA) for specific formulations (e.g., vancomycin and linezolid entries). Refer to each formulary row for tier and Notes details that govern coverage requirements.
This excerpt does not contain any explicit coverage exclusions. The antineoplastic and biologic entries are presented with tiers and utilization notes (e.g., LD, PA, SP) but no blanket exclusion language is shown in the provided text.
Some drugs appearing on the formulary may nevertheless not be covered depending on the member's benefit design; the document notes members and prescribers should confirm coverage and pursue prior authorization as needed. The excerpt does not include clinical 'Not Medically Necessary' criteria for denying coverage of specific drugs.
No explicit 'Not Medically Necessary' (NMN) determinations or clinical NMN criteria are present in the excerpt. Utilization flags such as PA, LD, QL, and SP are used to document administrative requirements, but NMN language is not provided here.
Formulary Note Codes & Coding Entries
| PA | prior authorization |
| ST | step therapy |
| QL | quantity limits |
| SP | specialty drugs / specialty pharmacy |
| DO | dose optimization |
| AL | age limits |
| BE | benefit exclusion |
| $0 | preventive drugs / $0 cost share |
| LD | limited distribution |
| NDC not provided | Multiple vancomycin intravenous and oral formulations listed with tier assignments (e.g., VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1000 MG/200ML; vancomycin hcl intravenous solution reconstituted 1 gm, 2 gm, 5 gm, etc.; vancomycin hcl oral capsule; vancomycin hcl oral solution reconstituted 25 mg/ml; VANCOMYCIN HCL ORAL SOLUTION RECONSTITUTED 250 MG/5ML) — NDC values not provided in this excerpt. |
| Linezolid (IV and oral), aztreonam, EMBLAVEO, CAYSTON, polymyxins, colistimethate, SIVEXTRO, ORLYNVAH, BLUJEPA and other listed agents — presented without procedure/diagnosis or billing codes in this excerpt. |
| No codes listed |
Authorization, Documentation & Denial Risk
Prior authorization required when 'PA' listed
Prior authorization (PA) is required when the formulary Notes field lists “PA.” Review the Notes column for every drug entry — if “PA” appears the provider must obtain prior authorization before the drug will be covered.
- How to request PA: Call the Member Services number on the member ID card or submit a prior authorization form via the plan website.
- Formulary entries include drug name, strength, tier assignment and a Notes field that indicates utilization controls such as PA, QL (quantity limit), LD (limited distribution), SP (specialty), ST (step therapy), DO (dispense as written) or AL (site-of-care/administration limits).
Prior authorization required for many agents
Many agents across formulary sections require prior authorization — including commonly used classes and specific high‑cost products. Failure to obtain PA may result in claim denial or member full cost responsibility.
- Examples of products and classes requiring PA: simvastatin 80 mg; certain testosterone formulations (DEPO‑TESTOSTERONE, JATENZO, NATESTO, XYOSTED); selected specialty biologics (FASENRA, NUCALA, TEZSPIRE); PCSK9 and other specialty injectables (e.g., some ORENCIA and ENBREL presentations).
- Antineoplastics and many IV/injectable oncology agents are frequently labeled PA; LD; SP and require advance authorization and designated distribution channels.
PA for incretin/GLP‑1 agents
Incretin / GLP‑1 receptor agonists and related agents are subject to prior authorization and often quantity limits; providers should submit PA documentation before dispensing.
- Common examples flagged PA and QL: OZEMPIC (all strengths), RYBELSUS, TRULICITY, and liraglutide pen‑injectors.
- Some combination products and incretin combinations (e.g., TRIJARDY XR, GLYXAMBI) may also have step‑therapy (ST) and QL requirements — verify Notes for each formulation.
Prior authorization required for listed specialty / high‑tier agents
Certain listed specialty or high‑tier agents require PA and may also have limited distribution, quantity limits, or specialty pharmacy requirements. Submit supporting clinical documentation with PA requests.
- Examples: OTEZLA XR, ORENCIA (ClickJect, Prefilled), ENBREL presentations, FASENRA, NUCALA, TEZSPIRE — Notes include PA; LD; QL; SP.
- Providers should include clinical rationale, prior therapy history (for ST), and dosing plan when requesting PA for specialty agents.
Prior authorization and utilization controls for antineoplastics and LD/SP products
Prior authorization and utilization controls apply to many antineoplastic and other limited‑distribution products; follow site‑of‑care and specialty distribution instructions when present.
- Antineoplastics commonly annotated with PA; LD; QL; SP — examples: ADCETRIS, MYLOTARG, DARZALEX, POLIVY, IMJUDO, YERVOY, LYNPARZA, RUBRACA, ZEJULA.
- Authorization requests should specify intended site of care, dosing, and whether product requires limited distribution or specialty pharmacy dispensing.
Prior authorization required for specific products
Some specific products explicitly require PA — ensure the PA is obtained and documentation accompanies the request to avoid denial.
- Cardiovascular and lipid examples: JUXTAPID (PA; LD; QL), TRYVIO (PA; QL).
- Antimicrobials / others: certain oral or IV formulations may list PA (see cefazolin reconstituted examples below).
Prior authorization for select reconstituted cefazolin formulations
Certain reconstituted cefazolin/dextrose intravenous solutions have PA on specific formulations — verify the exact NDC/format before administration and submit PA when noted.
- Examples: cefazolin sodium‑dextrose IV solution reconstituted 3‑2 gm‑%(50ml) is noted with PA in the formulary excerpt.
- When reconstituted or pre‑mixed IV formulations have PA, include indication, expected dose/volume, and anticipated duration in the authorization request.
Prior authorization required for selected biologics and specialty agents
For biologic and specialty injectable agents, Notes frequently include PA and SP/LD designations. Use required specialty channels and include distribution documentation with PA submissions.
- Examples: SIMPONI ARIA, ENBREL, ORENCIA, REPATHA, FASENRA, NUCALA — many presentations are annotated PA; QL; SP; LD.
- Some biologics additionally include site‑of‑care or administration limits (AL) or require use of a specialty pharmacy — follow plan instructions to avoid denial.
Higher‑tier IV agents — PA and medical review risk
Higher‑tier IV agents and many injectables may trigger medical review, PA, and specialty distribution requirements; include infusion site and dispensing details in PA documentation.
- Examples: Many IV antineoplastics and high‑cost injectables (e.g., ADMIRAL‑class agents, select carbapenems/vancomycin IV presentations) show PA; LD; SP or QL.
- Claims for higher‑tier IV agents without the required PA or LD/SP billing information risk denial or retrospective audit.
Quantity limits and limited distribution denial risk
Quantity limits (QL) and limited distribution (LD) flags are common; exceeding QL or using non‑designated distribution channels can cause denial even when PA is present.
- If Notes show QL, ensure the requested quantity/days‑supply is within the limit or justify medical necessity in the PA.
- For LD products, only approved distributors or specialty pharmacies may supply the drug — include distributor information on the PA to prevent delays.
Program‑based denial triggers and non‑formulary risk
Program‑based denial triggers include unmet PA, missing step‑therapy (ST) requirements, surpassing QL, incorrect dispensing channel for LD/SP products, or absence of required documentation.
- Common UM flags: PA, ST, QL, LD, SP, DO, AL — include these codes with claims or PA submissions.
- If a drug is not on the formulary (non‑formulary), the member may be responsible for full cost unless PA/exception is approved; providers should advise members and consider therapeutic alternatives covered by the plan.
Step therapy requirements present
Step therapy (ST) indicators are present for numerous combination products and classes. When ST is indicated in Notes, prior trials of preferred medications must be documented in the PA.
- Examples: TRIJARDY XR, GLYXAMBI and several metformin combinations show ST; many stimulant/transdermal methylphenidate products include ST annotations for select formulations.
- Document prior therapies, reasons for failure or intolerance, and dates when submitting ST‑related PA requests.
Documentation for PA submissions
Documentation is required to support PA requests. Include clinical rationale, prior medication trials (for ST), dosing plan, expected duration, site of care, and distributor/specialty pharmacy details where applicable.
- Use the plan’s PA form or the Member Services contact to submit requests.
- Attach clinical notes, prior lab/imaging if relevant, and any specialty pharmacy acceptance or limited distribution agreements to the PA submission.
Policy Background & Scope
The formulary is a managed list of FDA‑approved brand and generic prescription drugs maintained through a Pharmacy & Therapeutics (P&T) committee. The committee evaluates safety, effectiveness, and value when assigning drugs to tiers and when applying utilization management controls such as prior authorization, step therapy, quantity limits, and specialty distribution.
Key Terms & Abbreviations
Initial Therapy — ADHD/Stimulant Notes
ADHD / stimulant initial therapy notes
Formulary notes and utilization controls for ADHD and stimulant agents:
Specific strengths and the exact Notes (PA; QL; DO) are shown on each formulary line and must be referenced when requesting authorization
Where 'ST' appears in Notes the prescriber must document trials of preferred agents per plan rules before coverage
Failure to meet PA, ST, or QL requirements may result in claim denial or member liability
Step Therapy Requirements & Examples
| Coverage item | Notes / implication |
|---|---|
| Formulary entries annotated 'ST' (step therapy) | |
| Indicates member must try specified preferred or lower‑cost agent(s) before the listed drug will be approved (ST flag shown in Notes column) |
| Product / formulation | Notes (ST presence) / implication |
|---|---|
| Methylphenidate HCl oral tablet chewable (2.5 mg) | |
| Notes = ST; DO (chewable 2.5 mg shows ST indicating step therapy applies for this formulation) | |
| Methylphenidate transdermal patch (10 mg/9hr, 15 mg/9hr; 20 mg/9hr, 30 mg/9hr) | |
| Notes = ST on several transdermal strengths (patch entries list ST and/or QL), indicating step therapy requirements for transdermal formulations |
| Biologic / specialty agent examples | Notes (ST / SP / tiering implications) |
|---|---|
| OTEZLA XR (oral extended‑release) | |
| Notes = PA; QL; SP — annotated SP and PA; some biologics/specialty agents are also annotated ST in formulary indicating step/specialty sequencing may apply | |
| FASENRA / NUCALA (subcutaneous biologics) | |
| Notes = PA; LD; QL; SP — specialty distribution and utilization controls; '1 or 1b*' tier notations used elsewhere to indicate subgroup placement which may affect sequencing |
| Biologic agent | UM flags / step therapy examples |
|---|---|
| FASENRA subcutaneous solution (prefilled) | |
| Notes = PA; LD; QL; SP — prior authorization and specialty/limited distribution; step therapy specifics not provided in excerpt but SP/LD flags imply additional controls | |
| HERZUMA / KANJINTI / MARGENZA (IV oncology/biologic agents) | |
| Notes include PA; LD; SP and in some entries ST — product lines show PA/LD/SP with occasional ST annotations indicating step/specialty sequencing may apply |
| Diabetes combination product | Notes (ST presence) / implication |
|---|---|
| Metformin HCl ER tablets and metformin-containing combinations | |
| Multiple metformin entries list Notes = ST; QL indicating step therapy and quantity limits apply for select formulations | |
| TRIJARDY XR (oral extended‑release) | |
| Notes = ST; QL — TRIJARDY XR is explicitly listed with ST | |
| GLYXAMBI (oral tablet) | |
| Notes = ST; QL — Glyxambi listed with ST indicating step therapy requirement |
| Coverage item | Notes / provider implication |
|---|---|
| Step therapy applies to multiple combination diabetes products (e.g., Trijardy XR, Glyxambi, dapagliflozin combinations) | |
| Notes include ST; QL — documentation of prior trials or prior therapy may be required when ST is indicated |
| Product / group | Notes (ST presence) / implication |
|---|---|
| Ezetimibe‑simvastatin and select statin formulations (examples in statin/PCSK9 sections) | |
| Formulary notes include ST or QL for some statin entries (e.g., certain strengths or formulations flagged ST), indicating step therapy requirements for products marked ST |
| Product | Notes (ST presence) |
|---|---|
| TREXALL (methotrexate) entry | |
| Notes include ST for this entry indicating step therapy may apply |
| Product / entry | Notes (ST presence) / implication |
|---|---|
| Selected IV biologics and specialty agents (HERZUMA, KANJINTI, OGIVRI etc.) | |
| Notes include ST on some entries and PA/LD/SP on many — when ST is present step therapy rules apply; PA/LD/SP indicate additional site/distribution controls |
| Product / group | Notes / implication |
|---|---|
| Cefazolin sodium intravenous solutions and cephalosporin subgroup entries | |
| Some rows include equivalency annotations (e.g., '1 or 1b*') and other Notes but explicit step‑therapy algorithms are not provided in excerpt |
| Product / example | Notes (ST presence) / implication |
|---|---|
| Various psychiatric agents and therapy packs (e.g., FANAPT titration packs, paliperidone, aripiprazole kits) | |
| Multiple therapy packs and some oral/IM products are noted with ST — trial of preferred agents per step therapy must be followed when ST is present |
| Product / example | Notes (ST presence) / implication |
|---|---|
| ABILIFY MYCITE maintenance and starter kits; thiothixene and related antipsychotics | |
| Notes = ST on listed Abilify MyCite therapy packs and other antipsychotic entries — coverage requires adherence to step therapy protocols where ST is indicated |
| Product / entry | Notes (ST presence) / implication |
|---|---|
| Various cardiovascular and antihypertensive entries (selected formulations) | |
| Some rows include Notes = ST; where ST appears the formulary requires following the step therapy sequence before coverage will be approved |
| Formulary subgroup label | Meaning / implication for step/coverage sequencing |
|---|---|
| '1 or 1b*' and equivalent subgroup annotations (seen in cephalosporin and other groupings) | |
| Indicates preferred subgroup placement or equivalency among agents; these subgroup labels inform tiering and may affect step/coverage sequencing though explicit step algorithms are not shown in this excerpt |
Quantity Limits & Examples
Specialty Pharmacy, Infusion & Distribution Requirements
Specialty pharmacy required when Notes = SP
Agents marked 'SP' indicate specialty pharmacy dispensing may be required; providers must arrange specialty pharmacy enrollment and use the designated specialty channel when SP is noted.
Follow site‑of‑care notes for IV biologics (infusion center / hospital outpatient / office)
Some IV biologics and infusion products list site‑of‑care designations (infusion center, hospital outpatient, office); providers must follow the plan‑directed site‑of‑care instructions for administration.
SP flag summary — comply with specialty pharmacy/site‑of‑care restrictions
Multiple agents are flagged SP across the formulary indicating specialty pharmacy or site‑of‑care restrictions; providers must comply with specialty dispensing requirements for SP‑flagged drugs.
Infusion center/hospital outpatient administration expected for many IV agents
Many IV/infusion formulations are typically administered in infusion centers or hospital outpatient settings; providers should arrange administration in the appropriate site‑of‑care as indicated.
LD/SP notes imply restricted dispensing or site requirements (e.g., PREVYMIS, TROGARZO)
Some specialty or infused agents include LD or SP notes implying restricted dispensing or site requirements (examples include IV PREVYMIS and TROGARZO); providers must use designated distribution channels and sites for these agents.
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