CurrentAnthemPolicy N/A

Anthem Four-Tier Drug Formulary (Partial) - Coverage Criteria

This document governs the prescription drug formulary (four-tier drug list) for Anthem members, describing coverage tiers, utilization management indicators (PA, ST, QL, etc.), and how members/providers can access and use the drug list. It affects Anthem plan members and their prescribing providers.

Policy Summary

PayerAnthem

PolicyAnthem Four-Tier Drug Formulary (Partial) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when the formulary Notes column lists PA before dispensing the drug.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Formulary tiers

QuarterlyUpdate frequency

PA/ST/QLUtilization flags

multipleNotes types present

ACA preventive coveragePreventive $0 coverage

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Some drugs listed on the formulary may be excluded from coverage depending on the member's specific plan design. If a drug is excluded under the member's Certificate/Evidence of Coverage or Summary Plan Description, the member may be responsible for full cost unless another coverage arrangement applies. Providers and members should consult the member’s plan documents or Anthem Member Services to confirm whether a listed drug is covered for that plan.

Anthem’s online pharmacy resources provide the most current information about network pharmacies, pricing, brands and generics, and plan-specific coverage details; these resources can help determine whether an identified drug is excluded under a given benefit design.

Within this document segment the formulary entries are presented with assigned tiers and utilization notes (for example, PA, QL, SP, LD), but the excerpt does not set out any standalone explicit exclusion rules or exclusion conditions. Coverage status for a specific product should be confirmed against the member’s benefit design and plan documents.

The Notes column shown for many therapeutic classes (e.g., anti‑obesity agents, aminoglycosides, NSAIDs) signals utilization management requirements rather than explicit exclusion language; absence of an exclusion statement in this segment does not guarantee the drug is covered for all members.

This excerpt does not contain formal medical necessity criteria or not‑medically‑necessary (NMN) statements. Content in the cited chunks is limited to drug group headings, tier assignments and utilization notes such as PA, QL, LD and SP without inclusion of clinical coverage logic or specific medical necessity decision rules.

For requests requiring a clinical determination, providers must follow Anthem’s prior authorization processes and submit the documentation specified by the plan; the detailed medical necessity criteria (if any) are maintained separately from this formulary listing.

Coding / Drug Listings

Drug listing (no billing codes provided)mixed

No codes listed

Antiretroviral agents (examples)mixed

STRIBILD	STRIBILD ORAL TABLET (Tier = 4; Notes = QL)
TRIUMEQ	TRIUMEQ ORAL TABLET (Tier = 4; Notes = QL)
maraviroc	maraviroc oral tablet (Tier = 4; Notes = QL)

Hepatitis C agentsmixed

EPCLUSA	EPCLUSA ORAL PACKET / ORAL TABLET (Tier = 4; Notes = PA; QL; SP)
HARVONI	HARVONI ORAL PACKET / ORAL TABLET (Tier = 4; Notes = PA; QL; SP)
VOSEVI	VOSEVI ORAL TABLET (Tier = 4; Notes = PA; QL; SP)
ribavirin	ribavirin oral capsule / oral tablet (Tier = 4; Notes = QL; SP)

Common antiviral and beta blocker agents (examples)mixedCovered

acyclovir	acyclovir oral capsule / oral suspension / oral tablet and IV (Tier = 1 or 1b*)
valacyclovir	valacyclovir hcl oral tablet (Tier = 1 or 1b*; Notes = QL)
carvedilol	carvedilol phosphate (oral) (examples listed; Notes = QL for some formulations)
metoprolol	metoprolol succinate ER and tartrate forms (listed; Notes vary)

Pulmonary hypertension agentsmixed

ORENITRAM	ORENITRAM (treprostinil oral tablet / UPTRAVI) Month 1/Month 2/Month 3 therapy pack entries (Tier = 4; Notes = PA; LD; QL; SP)
treprostinil	treprostinil injection solution (Tier = 4; Notes = PA; LD; SP)
ambrisentan	ambrisentan oral tablet (Tier = 4; Notes = PA; QL; SP)
bosentan	bosentan oral tablet / soluble (Tier = 4; Notes = PA; LD; QL; SP)
OPSUMIT	OPSUMIT ORAL (macitentan) (Tier = 4; Notes = PA; LD; QL)
SGC	Soluble guanylate cyclase stimulator class (SGC) agents (Tier = 4; Notes = PA; LD; QL; SP)

Listed injectables and dosesmixed

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 1000 MG, 250 MG, 500 MG	listed product with Tier = 3
methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg, 500 mg	listed product
dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml	listed product

Specialty biologicsmixedCovered

COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE	COSENTYX formulations (Tier = 4; Notes = PA; LD; QL; SP)
DUPIXENT SUBCUTANEOUS SOLUTION AUTO-	DUPIXENT (Tier = 4; Notes = PA; SP)
SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR	SKYRIZI (Tier = 4; Notes = PA; QL; SP)
TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR	TALTZ (Tier = 4; Notes = PA; LD; QL; SP)

Drugs listed without codesmixed

No codes listed

inv-12: ORENITRAM titration months

ORENITRAM titration packsTherapy pack entries for Month 1, Month 2 and Month 3 are present (tadalafil-containing therapy packs listed under ORENITRAM).

ORENITRAM product tier & notesORENITRAM oral tablet extended release listed at Tier 4 with Notes = PA; LD; SP and separate entry showing Notes = PA; QL for tadalafil therapy pack.

Associated agentstreprostinil injection solution and other pulmonary hypertension agents are listed nearby with PA; LD; SP notes, indicating similar utilization controls for ORENITRAM therapy packs.

inv-13: Quantity Limits / Age Limits / Step Therapy flags

QL/AL/ST markers presentFormulary Notes include QL (quantity limit), AL (age limits) and ST (step therapy) markers indicating those controls apply but exact numeric limits are not enumerated in this segment.

Examples with QLMultiple product entries (e.g., dexamethasone packs, benzoyl peroxide–erythromycin gel) include 'Notes = QL' indicating quantity limits apply.

Examples with ST/ALSome entries (e.g., febuxostat, certain topical agents) show 'ST' or 'AL' in Notes indicating step therapy or age limits apply per product.

inv-14: None specified

PlaceholderNone specified in the brief for this item; no additional thresholds provided in this segment.

Example chunk referenceSee midazolam and related entries where $0 and QL notes appear in nearby listing, but inv-14 has no defined thresholds.

ActionNo action required — retain as placeholder pending further threshold details.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Requirement

Prior authorization (PA) is required for many drugs listed in the formulary. Providers must obtain PA before dispensing when the Notes column for a product includes "PA". Claims submitted without required PA may be denied. To request PA, providers should call the Member Services number on the back of the member's ID card or submit the Anthem prior authorization form via the plan's website or designated provider portal.

PA required when Notes include "PA"; obtain approval before dispensing
Request channels: Member Services phone number on member ID, Anthem prior authorization form, provider portal

Prior Authorization

Prior Authorization Required for Selected Products

Selected products and categories flagged in the Notes require PA — examples include stimulants, anti‑obesity agents (GLP‑1/GIP), certain injectables, and many specialty oral therapies. When a product is marked LD (limited distribution) or SP (specialty), providers must follow the manufacturer/distribution requirements and may need to route the PA to a specified specialty pharmacy.

Examples: ADHD stimulants (many entries show PA; QL; DO), anti‑obesity agents (e.g., ZEPBOUND, WEGOVY, liraglutide — Notes: PA; BE; QL), incretin mimetics (MOUNJARO, OZEMPIC, liraglutide — Notes: PA; QL)
Injectables & specialty orals flagged PA/QL/SP/LD (examples: XOLAIR, TEZSPIRE, many oncology and biologic agents)

Step Therapy

Prior Authorization and Step Therapy Requirements

Some drugs require both prior authorization and step therapy (ST). Providers should confirm ST requirements where Notes include "ST" and submit PA documentation that demonstrates trial of required preferred agents when applicable.

ST examples: select antidiabetic agents (SGLT2, DPP‑4, GLP‑1 combinations), sodium‑glucose agents (dapagliflozin entries show ST; QL), fenofibrate tablet 120/40 mg (Notes: ST; QL)
Needles/syringes and select insulin supplies: many marked ST; QL — follow step edits prior to coverage

Documentation Required

Prior Authorization Required When Notes Include PA

When the Notes column on the drug list includes PA (or related flags such as LD, QL, SP), providers must submit required documentation with the PA request. Failure to include requested clinical information may delay or result in denial.

Common flags: PA (prior authorization), QL (quantity limits), LD (limited distribution), SP (specialty pharmacy), DO (dose optimization), AL (age limits), BE (benefit exclusion)
Provide clinical rationale, prior treatment history, and any required lab or diagnostic results to support the PA

Prior Authorization

PA Required for Select Biologics and Topicals

Certain biologic and topical products specifically require PA and may be dispensed only through specialty channels. Examples include topical antipsoriatics and biologics where Notes show PA; QL; SP (or PA; SP), so providers must initiate PA and, if indicated, use the designated specialty pharmacy or distribution channel.

Topical and biologic examples: TREMFYA, DUPIXENT, SKYRIZI, TALTZ, TREMFYA and others marked PA; QL; SP
Topical agents with PA: some acne/antineoplastic topicals (e.g., adapalene, acyclovir external cream entries show PA)

Prior Authorization

Prior Authorization Required for Listed Specialty Drugs

Listed specialty drugs require prior authorization and may also have limited distribution, quantity limits, or specialty pharmacy requirements. Providers must submit PA following Anthem procedures and coordinate dispensing through the plan‑designated specialty pharmacy when required.

Examples of specialty drugs with PA/LD/QL/SP: XOLAIR, TEZSPIRE, many oncology agents (COMETRIQ, LYNPARZA, ZEJULA), ENTYVIO, REPATHA, injectable biologics (SKYRIZI, SELARSDI)
Follow manufacturer/plan instructions for limited distribution and specialty pharmacy routing

Prior Authorization

PA for G‑CSF Products

Granulocyte colony‑stimulating factors (G‑CSF) such as Neulasta, Udenyca, Zarxio require prior authorization and often have quantity limits and specialty pharmacy handling. Submit PA with indication and dosing information to ensure coverage.

Examples: NEULASTA ONPRO, NEULASTA prefilled syringe, UDENYCA (Notes: PA; QL; SP) and ZARXIO (Notes: PA; SP)
PA should include diagnosis, chemotherapy regimen or neutropenia risk, and dosing schedule

Prior Authorization

Prior Authorization Required for Selected CGM/Pump Products

Certain continuous glucose monitoring systems and insulin pump/patch kits are subject to prior authorization and quantity limits. Providers should include clinical justification and device training/care plan where applicable.

CGM/pump examples: FREESTYLE LIBRE sensors/readers (Notes: PA; QL), Dexcom/FreeStyle sensors and Omnipod kits (Notes: PA; QL), OMNIPOD 5 and Omnipod kits (Notes: PA; QL)
Provide documentation of diabetes management needs and prior supplies usage when requesting PA

Denial Risk

Non‑Formulary Drug Cost/Coverage Risk

If a medication is not listed on the formulary (non‑formulary), the member may need to pay full cost. Providers can pursue PA or an exception request if the non‑formulary drug is medically necessary; coverage is not guaranteed and depends on plan rules and submitted clinical information.

Members may be responsible for full cost of non‑formulary drugs unless an exception/PA is approved
Providers should consider covered therapeutic alternatives, generics, or OTC options and can request review via Member Services or Anthem forms

Note

Prior Authorization May Be Required

Prior authorization may be required for many items across the formulary. Providers should always check the Notes column and plan documents to determine PA needs before prescribing or dispensing to avoid claim denials.

Claims for PA‑required products submitted without an approved PA are at risk of denial
Confirm PA and ST status in the drug list and member's pharmacy benefit summary

Billing Rule

Specialty Pharmacy Requirement

High‑cost or specialty agents often require dispensing through a specialty pharmacy (SP) as indicated in the Notes. Providers should verify the plan's preferred specialty pharmacy network and include that routing in the PA request.

SP examples: many oncology, biologic, growth hormone, and rare disease therapies (Notes: SP; LD)
Limited distribution (LD) products may only be available from manufacturer‑designated distributors

Note

PA/LD/SP/QL Triggers Utilization Management

Utilization management flags (PA, LD, SP, QL, ST, DO, AL, BE) trigger required actions by providers: submit PA, adhere to limited distribution protocols, route to specialty pharmacies, follow quantity limits, or document age/dose exceptions. These flags are enforcement points for coverage and potential denial risk.

Interpretation of flags: PA = prior authorization; QL = quantity limit; LD = limited distribution; SP = specialty pharmacy; ST = step therapy; DO = dose optimization; AL = age limits; BE = benefit exclusion
Flags may result in coverage denial or redirection to specialty channels if not followed

Step Therapy

PA/ST Trigger

Examples in the drug list illustrate PA/ST triggers that require prior treatment trials or documentation. For incretin mimetics and certain insulin‑incretin combinations, both PA and ST edits may apply — include prior therapy history in the PA submission.

PA/ST trigger examples: MOUNJARO, liraglutide, OZEMPIC and some SOLIQUA/XULTOPHY entries (Notes: PA; QL; ST where indicated)
Provide trial history of preferred agents when ST is present

Billing Rule

Quantity Limit Enforcement

Quantity limits (QL) are enforced on many products; prior authorization requests should document the medical necessity for quantities above the limit. Exceeding QL without authorization may result in non‑coverage or reduced benefit.

Examples: QL noted across inhalers, injectables, chronic dermatologics, G‑CSF, CGM sensors, and many oral therapies
When requesting overrides, include dosing rationale and expected duration of therapy

Note

Utilization Management Indicators

The formulary contains multiple utilization management indicators (PA, ST, QL, LD, SP, DO, AL, BE). Providers should review the Notes for each product and follow the plan's operational processes for PA, specialty dispensing, step therapy, and quantity limit requests.

Utilization management indicators are present across therapeutic classes — oncology, biologics, anti‑obesity agents, stimulants, pulmonary hypertension agents, dermatologics, and more
Check member's pharmacy benefit summary for plan‑specific rules and tiering that affect coverage

Denial Risk

Utilization Management Triggers

Utilization management triggers across the drug list (PA, LD, QL, SP, ST) may lead to coverage denial if requirements are not met. Providers must submit complete documentation and use specified distribution channels to reduce denial risk.

Examples where triggers may cause denial: oncology agents with PA; LD; QL; SP, ENTYVIO and SKYRIZI entries (Notes: PA; LD; QL; SP)
Include full clinical supporting documentation and follow LD/SP routing when required

Prior Authorization

PA Required for Many PA/Tier 4 Agents

Many Tier 4 and PA‑flagged agents require prior authorization. Providers should be aware that drugs placed in higher tiers or marked with PA often have additional clinical review steps before coverage is approved.

Tier 4 examples with PA: many specialty injectables, oncologics, pulmonary hypertension agents, and high‑cost biologics
PA for Tier 4 agents commonly requires detailed clinical documentation and may involve specialty pharmacy processes

Denial Risk

PA/LD/QL/SP May Trigger Denial

PA, LD, QL, and SP flags may result in claim denial if plan requirements are not satisfied. Providers should anticipate these controls and proactively submit complete PA requests to avoid interruptions in therapy.

Plan examples: EPCLUSA, HARVONI, VOSEVI (hepatitis C agents) — Notes: PA; QL; SP and may be denied without proper PA
Specialty biologics and limited distribution products are frequent denial drivers when procedures are not followed

Prior Authorization

HAE‑Related Drug PA Requirements

Hereditary angioedema (HAE) and related agents require prior authorization and often have additional utilization controls (QL, LD, SP). Providers should submit indication, genetic or specialist documentation, and dosing details for PA requests.

HAE examples: icatibant acetate, BERINERT, HAEGARDA, RUCONEST and related kallikrein or C1 esterase products (Notes: PA; LD; QL; SP)
Include attack history, prophylaxis rationale, and specialist consultation notes where applicable

Prior Authorization

Supportive Care Agent Controls

Supportive care agents (G‑CSF, IV iron, ESAs) have utilization controls — PA, QL, and specialty pharmacy requirements. Provide diagnosis, prior treatments, and clinical labs to support PA for these agents.

Supportive care examples: NEULASTA, UDENYCA, ZARXIO, ARANESP, iron sucrose, ferumoxytol (Notes: PA; QL; SP)
Documentation should include indication (e.g., chemotherapy‑induced neutropenia), lab values, and planned dosing

Documentation Required

PA; QL Items

Some items are specifically marked as PA; QL in the device and supply sections (sensors, readers, pumps, and supplies). Providers should include clinical justification for devices/supplies beyond standard QL or when requesting an exemption.

Device examples: FREESTYLE LIBRE sensors and readers (Notes: PA; QL), OMNIPOD kits and pods (Notes: PA; QL), Dexcom sensors (Notes: PA; QL)
For durable device coverage, attach diabetes management plan and prior usage documentation

Documentation Required

Required Documentation Types

Required documentation types include prior authorization forms, clinical notes, lab results, prior treatment history, and any specialty pharmacy or limited distribution routing instructions. Use the plan's PA form and include all requested supporting information to expedite review.

Documentation types: completed PA form, diagnosis codes, progress notes, prior medication trials, lab/diagnostic results, specialist consult notes
If LD or SP is indicated, include pharmacy routing instructions and manufacturer distribution details

Documentation Required

Notes Indicate Required Documentation

Notes throughout the drug list indicate the specific documentation and operational requirements tied to flags (PA, QL, LD, SP, DO, AL, BE). Providers should consult the Notes for each product and include the corresponding documentation elements with PA submissions.

Examples: DO indicates dose optimization steps; AL indicates age limits that may trigger PA if patient age falls outside recommended range
BE indicates potential benefit exclusion — check plan design before submitting PA

Documentation Required

Documentation Tied to Flags

Documentation requirements are tied directly to utilization flags. When submitting PA for products marked PA/QL/LD/SP, include the clinical evidence, prior therapy history, dosing regimen, and any special routing instructions to satisfy plan review criteria.

Documentation tied to flags: QL overrides need dosing/justification; LD/SP require specialty pharmacy routing; DO requires evidence of dose optimization
Incomplete documentation is a common cause of delayed approvals or denials

Documentation Required

PA/ST Documentation

When both PA and ST are present, include step‑therapy documentation showing trials of required preferred agents and the clinical rationale for escalation to the requested product. Anthem may require evidence that step requirements were met prior to approval.

PA/ST documentation: prior medication names/dates, reasons for discontinuation or intolerance, and any relevant lab or outcome data
Examples: ST noted for certain methylphenidate formulations, modafinil, and antidiabetic combinations

Billing Rule

Plan‑Specific Dispensing Notes

Some plan‑specific dispensing notes affect cost‑sharing and dispensing requirements (for example, $0 preventive coverage or dose optimization may change formular y placement). Providers should review the member's pharmacy benefit summary and plan documents for these details.

Plan note examples: $0 designation for select preventive products; DO may change preferred dosing and dispensing
Verify member's plan tiering and benefit design before prescribing

Documentation Required

Documentation of Utilization Notes

Utilization notes across the formulary should be documented in the PA submission. Providers must follow procedures for PA, QL, LD, and SP items and include the requested clinical detail to support approval.

Documentation of utilization notes: attach clinical rationale, prior treatment history, and any required lab testing
For LD/SP products, include pharmacy routing and dispense location details

Documentation Required

Required Utilization Notes

Required utilization notes (PA, QL, LD, SP) appear throughout the drug list and must be addressed when submitting prior authorization requests. Ensure each flagged requirement is satisfied in the documentation package.

Required utilization notes examples: oncology regimens (PA; LD; QL; SP), biologic therapies (PA; QL; SP), and device/sensor products (PA; QL)
Incomplete responses to required utilization notes may delay review

Documentation Required

Documentation Notes

Documentation notes in the drug list indicate specific expectations for PA submissions. Specialty biologics frequently require comprehensive clinical records, and oncology or rare disease therapies often require LD/SP coordination.

Specialty biologic documentation: diagnosis, prior therapies, objective clinical measures, and specialist notes
Oncology/rare disease examples often add LD and SP requirements

Documentation Required

Specialty Biologic Documentation

Specialty biologic products carry documentation expectations beyond routine PA. For agents like TREMFYA, SKYRIZI, and other high‑cost biologics, include comprehensive clinical notes, dosing history, and any required specialty pharmacy routing instructions.

TREMFYA, SKYRIZI, TALTZ, DUPIXENT, and similar entries show Notes: PA; QL; SP — submit full clinical rationale and follow SP processes
Failure to include complete specialty biologic documentation can result in delays or denials

Documentation Required

Prior Authorization Documentation

Prior authorization documentation should follow Anthem's PA form and include all clinical supporting materials. Use the member's pharmacy benefit summary to identify plan‑specific criteria and ensure submissions address those criteria directly.

Prior authorization documentation: completed PA form + clinical notes + prior therapy documentation + lab/diagnostic results
Use plan documents and the drug Notes to identify any additional requirements (LD, SP, QL, ST)

Documentation Required

Utilization Management Documentation

Anthem requires specific utilization management documentation for many entries. When products are marked with PA/ST or other flags, include the requested clinical evidence to expedite review and minimize denial risk.

Utilization management documentation may include rationale for medical necessity, prior treatment attempts, and measurable clinical outcomes
Attach specialist consult notes or prior authorization approvals from external programs when relevant

Documentation Required

Eltrombopag Documentation Needs

Eltrombopag (TPO receptor agonist) entries have specific documentation needs including PA, dose optimization, limited distribution, quantity limits, and specialty pharmacy handling. Include platelet counts, treatment history, and dosing justification for PA.

Eltrombopag examples: oral packet and tablets (Notes: PA; DO; SP; LD; QL as indicated)
Provide baseline platelet data, prior therapies, and treatment goal to support PA

Documentation Required

Documentation for PA/ST Items

For items that combine PA and ST edits, providers must include documentation of prior failed or intolerant therapies as part of the PA request. This applies across classes where ST is flagged in the Notes column.

Documentation for PA/ST items: trial dates, dosing, reason for discontinuation, and outcome measures
Common PA/ST examples: stimulants (methylphenidate, modafinil), certain topical agents and antidiabetics

Step Therapy

Step Therapy Requirement

Step therapy (ST) is required for many products; where ST is present, providers must document trials of first‑line agents before higher‑tier or non‑preferred products will be approved.

Step therapy present for stimulants (some methylphenidate entries show ST), certain antidiabetics (SGLT2/DPP‑4/GLP‑1 combinations), topical agents, and needles/syringes
When ST is not explicitly specified in an entry, check the plan's ST rules or contact Member Services

Step Therapy

Step Therapy Present

Step therapy edits appear throughout the list. Some entries show explicit ST flags while others (particularly specialty products) rely on plan rules; providers should verify the presence and details of ST for each drug before prescribing.

ST present examples: methylphenidate formulations, modafinil, select dermatologic topicals and antidiabetics
Some specialty/LD products may have implicit step requirements even if ST is not shown — verify with plan

Billing Rule

Specialty/Limited Distribution Handling

Some specialty or limited distribution (LD) products must be dispensed by designated pharmacies. Providers should coordinate with those pharmacies and include LD routing information in the PA.

Specialty/LD handling examples: XOLAIR, TEZSPIRE, many oncology agents, and certain biologics (Notes: LD; SP)
If LD is indicated, the product may only be available through manufacturer‑specified channels

Note

Tier‑Based Utilization

Tier placement affects coverage, step therapy, and prior authorization expectations. Providers should consult the member's benefit design to understand cost‑sharing and PA/ST requirements tied to drug tiers.

Tier examples: many specialty biologics are Tier 4 and commonly require PA/QL/SP; some preventive products are $0 with criteria
Tiering may vary by member plan (1a/1b distinctions) — verify plan summary

Step Therapy

Step Therapy Indicators

Step therapy indicators (ST) require providers to document prior treatment trials. Where ST is present without explicit rules in the drug list, contact Member Services or review plan ST criteria for required first‑line agents.

ST indicators appear on stimulants, antidiabetics, certain topicals, and other classes
If step therapy rules are not fully specified in the drug list, use the plan's ST policy to determine required agents

Step Therapy

Step Therapy Not Specified in This Section

Some entries show ST flags but the explicit step rules are not specified in this section. In those cases, providers must consult the plan's step therapy policy or contact Anthem for the specific step requirements.

Examples where ST rules may be missing: select specialty topicals and some psychiatric agents
Contact Member Services or review the full plan ST policy for guidance

Note

Possible Step/Other Edits

Certain antipsychotics and other classes may have additional edits (dose, age, or other clinical checks). Providers should be prepared to supply supporting clinical data for these possible step or other edits.

Possible step/other edits examples: antipsychotics with DO/AL notes, dose optimization requirements
Include prescribing rationale and monitoring plans with PA submissions when edits are present

Step Therapy

Step Therapy / Specialty Marker

When products carry both step therapy and specialty markers (ST; SP), providers must meet step requirements and use the specialty pharmacy channel. This dual requirement is common for complex therapies and injectables.

Step therapy / specialty marker examples: many oncology, HAE, and biologic therapies show ST or have SP flags
Ensure both ST documentation and SP routing are included in the PA

Step Therapy

Step Therapy for Selected Topicals

Some topicals require step therapy in addition to PA or QL. Providers should check Notes for topical products and include prior topical therapy history when submitting PA.

Step therapy for selected topicals: ZORYVE, EUCRISA, certain acne/antipsoriatic products (Notes: PA; QL; ST where listed)
Document prior topical trials and response to support PA

Step Therapy

Step Therapy Present for Select Agents

Step therapy is present for a number of agents (including some systemic and topical products). Providers should verify required first‑line agents and document trials before requesting higher‑tier or non‑preferred therapies.

Step therapy present examples: febuxostat (Notes: ST; QL), many dermatologic and psychiatric agents
Provide clear documentation of trials and outcomes when requesting exceptions

Step Therapy

Step Therapy for Needles/Syringes

Needles and syringes used for insulin administration frequently carry ST and QL edits. Providers prescribing supplies should confirm allowable quantities and step requirements and include justification for quantities beyond the listed limits.

Needles/syringes examples: many insulin pen needles and syringes marked ST; QL across supply listings
When requesting higher quantities, include clinical rationale and anticipated usage

Background

The formulary organizes medications into therapeutic classes and assigns them to a four‑tier cost‑sharing structure to reflect preferred status and member cost. Tier placement and utilization management flags (for example, PA = prior authorization, ST = step therapy, QL = quantity limits, LD = limited distribution, SP = specialty) guide prescribing, dispensing and benefit administration.

Drug placement and tier assignments are reviewed and maintained by the plan’s Pharmacy & Therapeutics (P&T) committee; the drug list is updated regularly and members/providers should consult Anthem’s online pharmacy resources for the most current formulary and tier information.

Definitions and Abbreviations

inv-84: Formulary / Drug list definition

DefinitionFormulary / Drug list: A list of prescription medicines the plan covers, reviewed by the Pharmacy & Therapeutics (P&T) committee and used to guide prescribing and member cost sharing.

MaintenanceThe P&T committee reviews new and existing drugs regularly to recommend inclusion based on safety, efficacy and value.

Member actionsMembers/providers should consult the drug list or member portal to confirm coverage and tier placement for a specific drug.

inv-85: Utilization Management Flags overview (PA, ST, QL, LD, DO, SP)

Flags includedUtilization management flags shown on the formulary Notes include PA (Prior Authorization), ST (Step Therapy), QL (Quantity Limit), LD (Limited Distribution), DO (Dose Optimization), and SP (Specialty).

PurposeThese flags indicate administrative or clinical controls that may require documentation, prior approval, limited channels, or specialty dispensing.

Where shownFlags appear in the Notes column beside specific product entries across tiers (examples: TEZSPIRE, ORENITRAM, many specialty biologics).

inv-86: PA definition — Prior authorization required

PA meaningPrior Authorization — plan requires approval before coverage; providers must obtain PA when 'PA' appears in the Notes.

When appliedPA is noted for many specialty, high‑cost, or specific‑strength products (examples: ORENITRAM, hepatitis agents, biologics).

Provider actionProviders should submit PA requests per Anthem procedures (call Member Services or use the PA form) when Notes include 'PA'.

inv-87: QL definition — Quantity Limit

QL meaningQuantity Limit — the plan limits the amount of medicine covered within a specified time period; indicated by 'QL' in the Notes.

EnforcementRequests exceeding the specified quantity may be denied or limited; exact numeric limits are provided on the full formulary per product.

Common productsMany classes and products include 'QL' in Notes (e.g., stimulants, insulins, topical agents, specialty injectables).

inv-88: SP definition — Specialty Pharmacy

SP meaningSpecialty Pharmacy — designation indicating a drug may need to be obtained through a specialty pharmacy or channel; noted as 'SP' in the Notes.

ImplicationSP often applies to high‑cost, complex therapies (biologics, certain injectables) and may affect dispensing site and support services.

ExamplesProducts such as GENOTROPIN, ENTYVIO, TREMFYA, and many G‑CSF and specialty injectables are noted with 'SP'.

inv-89: BE definition — Bioequivalent/generic note

BE meaningBE = benefit exclusion; indicates the drug may not be covered depending on the plan design and members should consult their plan documents or member portal.

Action for membersIf a drug is marked BE, the member may be responsible for full cost unless the plan provides coverage under specific conditions.

Examples in NotesBE appears in Notes for some anorexiants and other products where manufacturer/FDA or plan rules limit coverage.

inv-90: utilization management flags list (PA, QL, LD, SP)

Common flags listUtilization management flags appearing on the formulary include: PA (Prior Authorization), QL (Quantity Limit), LD (Limited Distribution), SP (Specialty Pharmacy).

NotationThese flags are shown in the Notes column adjacent to product/tier entries to indicate applicable controls.

OverlapFlags often appear combined (e.g., PA; LD; QL; SP) for many specialty and infusion products.

inv-91: QL — Quantity Limit definition (repeat)

Quantity Limit (QL)Quantity Limit — product is subject to a limit on dispensed quantity as indicated by 'QL' in Notes for many items.

EffectQL entries require adherence to plan-specified quantity rules; exceeding limits may result in claim denial or edit at point of service.

ExamplesQL appears widely across therapeutic classes including stimulants, statins, topical agents and specialty products.

inv-92: PA definition (repeat)

Prior Authorization (PA)Prior Authorization — coverage requires prior approval documentation for the specified product/strength when 'PA' appears in Notes.

Provider requirementProviders must submit PA requests per Anthem procedures before dispensing when PA is noted.

Frequent usePA is commonly applied to specialty, high‑cost, or limited distribution therapies listed in Tier 4.

inv-93: ST definition — Step Therapy

ST meaningStep Therapy — the product requires trial and documented failure or intolerance of specified alternatives before coverage; indicated by 'ST' in Notes.

ApplicationST applies to multiple classes including some GLP‑1, SGLT2 and other agents where 'ST' is shown in Notes.

DocumentationProviders must document prior trials per plan rules when ST is required; specific sequencing not detailed in this excerpt.

inv-94: Tier definition — formulary cost-sharing categories

Tier definitionTier: formulary cost‑sharing category; some plans include subtiers (1a/1b) and tier assignment affects member cost share.

ReferenceRefer to the member's pharmacy benefit summary to determine exact copay/coinsurance associated with each tier and subtiers.

ObservationThe document shows Tier assignments across products (Tiers 1–4) with specialty/high‑cost products commonly in Tier 4.

inv-95: LD definition — Limited Distribution

LD meaningLimited Distribution — drug is available only through certain pharmacies or wholesalers as indicated by 'LD' in Notes.

ImpactLD can restrict where the drug may be dispensed and can require coordination with manufacturer-designated distribution channels.

ExamplesLD is noted for several specialty injectables and infused products (e.g., TEZSPIRE, some oncology and biologic agents).

inv-96: Abbreviations used in Notes (PA, QL, LD, SP)

Abbreviations in NotesCommon abbreviations used in the Notes column: PA = Prior Authorization; QL = Quantity Limit; LD = Limited Distribution; SP = Specialty Pharmacy.

User guidanceProviders and pharmacists should interpret these abbreviations as triggers for corresponding utilization management workflows.

Where foundAbbreviations appear throughout product listings and are the primary signals for required administrative actions.

inv-97: PA (definition)

PA — prior approval requiredPrior authorization — prior approval required as indicated in Notes; providers must obtain authorization when PA is present.

Common contextPA is used for many oncology, specialty and infusion products in this section.

ActionSubmit PA per Anthem processes (phone or PA form) to avoid claim denial.

inv-98: QL (definition)

QL — quantity limits appliedQuantity limit — limits on amount dispensed/covered; noted as 'QL' and enforced per product rules.

EffectExceeding QL may result in denial or edit at point of sale; see product-specific QL details on the full formulary.

ExamplesQL appears across many classes including statins, stimulants, topical agents, and specialty products.

inv-99: LD (definition)

LD — restricted channelsLimited distribution — product distributed through select channels as noted by 'LD', often for specialty therapies.

Operational effectLD may require ordering through manufacturer‑designated pharmacies or specialty distributors.

ExamplesLD appears with pulmonary hypertension agents and many biologics in the formulary sample.

inv-100: SP (definition)

SP — specialty pharmacy requirementSP indicates specialty pharmacy requirement or specialty distribution channel for the drug; often applied to high‑cost or complex therapies.

Implication for dispensingDrugs marked SP may only be dispensed via contracted specialty pharmacies and may require additional care coordination.

ExamplesSP is shown for biologics, growth hormone products, and many infusion agents (e.g., GENOTROPIN, ENTYVIO, TREMFYA).

inv-101: PA (definition repeat)

PA — prior authorizationPrior Authorization — approval required before coverage when 'PA' appears in Notes on product listing.

Administrative notePA triggers submission of documentation to support medical necessity per plan procedures.

Common placementsPA commonly accompanies LD/QL/SP on oncology and specialty products.

inv-102: LD (definition repeat)

LD — limited distributionLimited Distribution — denotes restricted supply pathways for select agents; see 'LD' in Notes.

ExamplesLD appears for pulmonary hypertension agents and C1 esterase inhibitors among others.

Operational impactLD may necessitate coordination with specified pharmacies or manufacturers for supply and billing.

inv-103: QL (definition repeat)

QL — quantity limitsQuantity limits are noted as 'QL' and restrict the maximum units covered in a specified period; product listing shows where QL applies.

Provider implicationProviders should check the product-specific QL on the formulary before prescribing larger quantities.

ExamplesQL is applied across therapeutic classes including stimulants, antibiotics, and specialty injectables.

inv-104: SP (definition repeat)

SP — specialty designationSpecialty — indicates requirement for specialty pharmacy dispensing or specialty handling; noted as 'SP' in product Notes.

ExamplesMany biologics and infused products display 'SP' along with PA/QL/LD flags.

ImpactMay affect site of care and claims routing; providers should coordinate with specialty pharmacy networks.

inv-105: PA (definition repeat)

PA — prior authorizationPrior Authorization — clinical review required before coverage when noted in product listing (PA in Notes).

WorkflowSubmit PA per Anthem's procedures to support coverage for PA‑flagged products.

PrevalencePA is widely applied to Tier 4 specialty, oncology and infusion therapies in the document.

inv-106: QL (definition repeat)

QL — quantity limitsQuantity Limit — maximum units allowed in a specified period; indicated by 'QL' in Notes for many entries.

Effect on claimsClaims exceeding QL may be limited or denied; check product QL details on the full formulary.

Common usageQL appears on specialty injectables, inhalers, topical agents and device sensors in this segment.

inv-107: SP (definition repeat)

SP — specialty pharmacySpecialty — requires dispensing via specialty pharmacy or specialized distribution channel when 'SP' is noted.

ExamplesSP appears alongside PA/QL/LD on biologic products (e.g., COSENTYX, SKYRIZI, TREMFYA).

Operational noteSpecialty routing may affect member access and prior authorization processes.

inv-108: PA (definition repeat)

PA — prior authorizationPrior Authorization — approval required before coverage for products flagged 'PA' in Notes.

Clinical implicationPA often accompanies ST or QL for antidiabetic and incretin mimetic agents in this excerpt.

Provider actionFollow Anthem PA submission procedures to avoid denial at point of service.

inv-109: QL (definition repeat)

QL — quantity limitsQuantity Limit — maximum units allowed; 'QL' is used for many pulmonary hypertension and related agents.

ExampleSildenafil and tadalafil PAH formulations show Notes = PA; QL; SP in some entries.

Check formularyRefer to the product-specific formulary entry for exact QL values (not enumerated in this excerpt).

inv-110: SP (definition repeat)

SP — specialtySpecialty Pharmacy — 'SP' indicates specialty handling or dispensing channel for the product.

ExamplesPulmonary hypertension prostacyclins and SGC agents show SP alongside PA/LD/QL notations.

ImplicationMay require specialty pharmacy routing or coordination with infusion centers/manufacturers.

inv-111: ST definition (repeat)

ST — step therapyStep Therapy — 'ST' indicates the product requires prior trial and failure of preferred alternatives before coverage.

ExamplesST appears for some GLP‑1 and SGLT2 agents and other classes where step edits apply.

DocumentationProviders must document prior trials per plan rules when ST is required; specifics not listed in excerpt.

inv-112: PA (definition repeat)

PA — prior authorizationPrior Authorization — administrative requirement for coverage when 'PA' appears in Notes.

Provider instructionSubmit PA requests per Anthem procedures (phone or PA form) for PA‑flagged products.

Frequent contextsUsed across oncology, specialty, and infusion product listings in the formulary.

inv-113: QL (definition repeat)

QL — quantity limitQuantity Limit — plan restriction on amount dispensed/covered when 'QL' appears in Notes.

EffectMay limit refill quantities or frequency; check product entry for details.

OccurrenceQL is common across many therapeutic classes in the document.

inv-114: LD (definition repeat)

LD — limited distributionLimited Distribution — product dispensed through limited channels as denoted by 'LD'.

Operational noteLD entries often coincide with PA/QL/SP on specialty and infusion therapies.

ExamplesLD appears with agents like bosentan, OPSUMIT, GENOTROPIN and others.

inv-115: SP (definition repeat)

SP — specialty pharmacySpecialty Pharmacy — indicates requirement for specialty dispensing or handling when 'SP' is in Notes.

ExamplesMany biologic and injectable products (e.g., SKYRIZI, SELARSDI, COSENTYX) include SP in Notes.

ImpactSpecialty designation influences site-of-care and claims processing pathways.

inv-116: ST definition (repeat)

ST — step therapyStep Therapy — prior use of preferred agent(s) required before coverage for the ST‑flagged product.

Where seenST notes appear for select agents across classes (e.g., febuxostat, some topical agents, insulin supplies).

Provider implicationDocument prior trials and failures per plan when ST applies; specifics are in the full PA/step criteria not included here.

inv-117: PA (definition repeat)

PA — prior authorizationPrior Authorization — clinical review required before coverage when 'PA' is noted; submit required documentation.

Common in specialtyPA commonly accompanies LD/QL/SP for infusion and oncology therapies listed in Tier 4.

ActionFollow Anthem PA submission instructions to avoid claim denial.

inv-118: QL (definition repeat)

QL — quantity limitsQuantity Limit — maximum units allowed; 'QL' indicates the product is subject to amount/frequency constraints.

ExamplesQL applied to pulmonary hypertension agents, G‑CSF products, topical therapies and many systemic agents.

Check specificsExact QL numeric values are provided on the full formulary per product; not enumerated in this excerpt.

inv-119: LD (definition repeat)

LD — limited distributionLimited Distribution — product dispensed through specified channels; 'LD' appears on many specialty listings.

ExamplesLD accompanies PA/QL/SP for products such as TALTZ, COSENTYX, and certain oncology agents.

ImpactMay restrict point of sale and require coordination with manufacturer or specialty vendor.

inv-120: DO — Dose Optimization definition

DO meaningDO = Dose Optimization — management intended to ensure appropriate dosing (e.g., switch to higher strength once‑daily instead of multiple daily doses).

ContextDO appears in Notes for some products (e.g., eltrombopag entries) where dosing edits or optimization may be required.

Provider implicationProviders may need to adjust prescriptions per DO guidance or follow plan-specified dosing workflows.

inv-121: PA; QL combined note

PA + QL combinedWhen Notes show 'PA; QL' the drug requires prior authorization and is subject to quantity limits; both controls must be satisfied for coverage.

ExamplesDexcom/FreeStyle devices and many G‑CSF products show combined PA; QL flags in Notes.

Provider actionSubmit PA with documentation addressing requested quantity within plan QL to support approval.

inv-122: ST; QL combined note

ST + QL combinedWhen Notes show 'ST; QL' the product is subject to step therapy requirements and quantity limits; documentation of prior step(s) and quantity justification may be required.

ExamplesMany insulin needles/syringes and some GLP‑1 combinations show 'ST; QL' in Notes.

Provider implicationProviders should document prior steps and request quantities consistent with plan QL when submitting coverage requests.

inv-123: $0 — cost-sharing note

$0 meaning$0 indicates products that may be covered with $0 member cost‑sharing when specified criteria are met (e.g., certain preventive drugs and some contraceptives).

ExamplesSeveral contraceptives and laxative preparations in the listing include $0 notes where applicable.

ActionMembers should confirm eligibility and criteria via their benefit summary or member portal to obtain $0 coverage.

Step Therapy Details

Drug / Formulation	Notes
clonidine hcl er oral tablet (extended release 12 hour)
Notes = PA
guanfacine hcl er oral tablet (extended release 24 hour)
Notes = PA
atomoxetine hcl oral capsule
Notes = PA
amphetamine-dextroamphetamine oral capsule ER (5–30 mg strengths)
Notes = PA; DO or PA; QL depending on strength
amphetamine-dextroamphetamine oral tablet (various strengths)
Notes = PA; DO
dextroamphetamine sulfate ER oral capsule (various strengths)
Notes = PA; QL or PA; DO depending on strength
lisdexamfetamine dimesylate (capsules/tablets, multiple strengths)
Notes = PA; DO or PA; QL depending on strength
procentra oral solution
Notes = PA; QL
zenzedi oral tablet (various strengths)
Notes = PA; QL or PA; DO depending on strength

Drug / Formulation	Notes
methylphenidate hcl ER (XR) oral capsule/tablet (multiple strengths, patches)
Notes include PA; DO; PA; QL; select entries show ST; DO (patches and some strengths) — ST present for some formulations
methylphenidate hcl oral solution and immediate‑release tablets/chewables
Notes = PA; QL or PA; DO depending on formulation
modafinil oral tablet 100 mg, 200 mg
Notes = ST; DO or ST; QL for select entries

Tiering note	Implication for step therapy
Products assigned to Tier 2–4 (examples: TEZSPIRE Tier 4)
Tier assignment present; step therapy may apply per plan benefit but explicit sequencing rules are not provided in this excerpt

Drug / Class	Notes (step therapy)
MOUNJARO (tirzepatide) subcutaneous pen-injector and other GLP-1 agents (e.g., liraglutide, Ozempic)
Notes include PA; QL and some GLP-1 entries show ST; QL — step therapy applies to select incretin mimetic agents
SGLT2 agents and combinations (e.g., dapagliflozin, Jardiance, Synjardy)
Notes = ST; QL for several SGLT2 agents and combinations indicating step therapy applies to select products

Drug / Formulation	Notes
fenofibric acid and fenofibrate formulations
Notes = QL (some entries) — select fibrate formulations annotated; some combination agents (eg, ezetimibe‑simvastatin) noted elsewhere with ST
ezetimibe‑simvastatin combination
Notes = ST; QL (ezetimibe‑simvastatin) indicating step therapy for combination products

Agent / Note	Interpretation
Multiple specialty/limited distribution products (examples in antineoplastic entries)
Entries marked SP or LD may imply additional sequencing or handling requirements though explicit step rules are not provided in this excerpt

Drug / Class	Notes
Selected antipsychotics (examples include agents with DO or AL notes)
Notes include DO or AL for some antipsychotics — DO/AL may accompany utilization edits or step sequencing though explicit step rules are not shown

Drug / Formulation	Notes
levamlodipine maleate oral tablet 2.5 mg and 5 mg
Notes = ST; DO (2.5 mg) and ST; QL (5 mg) — step therapy flagged for select levamlodipine entries

Marker	Presence / Limitations
SP, LD, QL markers
Step/specialty/limited distribution/quantity‑limit markers (SP, LD, QL) are present for many agents; specific sequencing or step rules are not provided in the excerpt

Annotation	Meaning
'ST' annotation on product entries (examples across topical and systemic agents)
Products annotated 'ST' require step therapy per the formulary notes

Topical product / Formulation	Notes
ketoconazole external foam; ketodan external foam
Notes = ST; QL for foam formulations — step therapy applies to select topical antifungal foams
imiquimod pump external cream; pimecrolimus external cream; tacrolimus external ointment
Notes include ST; QL (imiquimod pump, pimecrolimus, tacrolimus) indicating step therapy applies for select topical immunomodulators

Formulary note	Implication
Formulary entries include 'ST' in Notes for multiple agents (example: febuxostat)
Step therapy may be required per the formulary note where 'ST' is present

Agent group / Example	Notes
Selected hemostatics and cytotoxic agents (examples: systemic hemostatics entries)
Some formulations include 'ST' in Notes indicating step therapy may apply to indicated formulations

Product	Notes (coverage)
Multiple insulin pen needles and syringe products (examples: 1ST TIER UNIFINE PENTIPS PLUS; ADVOCATE INSULIN PEN NEEDLE)
Notes = ST; QL — step therapy and quantity limits apply to many insulin administration supplies
BD VEO insulin syringe and other pen needles (CAREFINE, CAREONE, CARETOUCH, COMFORT EZ, etc.)
Notes = QL or ST; QL depending on product — many marked ST implying sequencing requirements though explicit step sequence not listed

Quantity Limits

inv-138: Various stimulant and ADHD agents — QL indicated for specific strengths/formulations

Stimulant QL indicationsQuantity limits (QL) are indicated for many stimulant and ADHD formulations across multiple strengths/formulations as noted in the product Notes.

ExamplesAmphetamine/dextroamphetamine and dextroamphetamine entries include Notes = PA; QL or PA; DO depending on strength/formulation.

Provider implicationCheck product-specific QL on the formulary before prescribing larger quantities or extended supplies.

inv-139: Multiple stimulant and specialty agents — QL applied across many products

QL applied broadlyQuantity limits (QL) are applied across many stimulant and specialty agents and other therapeutic classes; exact numeric limits are provided on the full formulary per product.

ExamplesEntries such as RINVOQ, XELJANZ and various antiretrovirals/hepatitis agents include QL in Notes.

ActionWhen prescribing these agents, verify QL and any PA/ST requirements to ensure coverage and appropriate quantity dispensing.

inv-140: ELIQUIS — multiple presentations have QL

ELIQUIS QL entriesELIQUIS (apixaban) multiple presentations (starter packs, soluble, sprinkle) are noted with 'Notes = QL', indicating quantity limits apply to these presentations.

Formulary placementELIQUIS presentations are listed at Tier 2 with QL on several package types (1.5 mg pack, 2 mg pack, DVT/PE starter pack, sprinkle capsule).

Provider implicationPharmacists should apply QL edits at dispensing and providers should account for plan QL when writing prescriptions.

inv-141: Enoxaparin prefilled syringe — Tier 4 with PA; LD; QL; SP

Enoxaparin prefilled syringe flagsEnoxaparin sodium prefilled syringe entry is designated with Notes = QL for most presentations and a specific prefilled syringe entry is listed with Notes = PA; LD; SP when Tier 4 is applied.

TieringSome enoxaparin prefilled syringe presentations are Tier 1/1b with QL; a specified prefilled syringe presentation is shown at Tier 4 with PA; LD; SP.

Operational impactPA/LD/SP on certain enoxaparin presentations may require limited distribution and prior authorization for coverage.

inv-142: Multiple listed products — QL reference

Refer to QL notesMultiple drug entries across classes include 'QL' notation; refer to the formulary Notes per product for applicability and limits.

ExamplesFenofibrate formulations, cholestyramine packets, REPATHA, XIFAXAN and many topical/specialty agents show QL in the Notes.

ActionProviders should verify QL and any co‑occurring PA/ST requirements before prescribing larger quantities.

inv-143: Cholestyramine (packet/powder) — QL

Cholestyramine QLCholestyramine (packets/powder) entries are listed with 'Notes = QL' indicating quantity limits apply to these formulations.

Formulary tieringCholestyramine packets/powder are commonly shown at Tier 2 with QL annotations in the listing.

Provider implicationCheck product-specific QL when prescribing cholestyramine to ensure quantities align with plan limits.

inv-144: Fenofibrate formulations — QL

Fenofibrate formulations QLFenofibrate formulations across strengths and dosage forms are noted with 'Notes = QL', indicating quantity limits apply.

ExamplesMicronized fenofibrate and fenofibric acid delayed release forms include QL in Notes across several strengths.

Provider actionVerify QL before prescribing or dispensing to avoid quantity edits at point of sale.

inv-145: REPATHA products — QL

REPATHA QLREPATHA (evolocumab) prefilled syringe / auto‑injector entries show 'Notes = PA; QL', indicating prior authorization and quantity limits apply to these products.

TieringREPATHA presentations are listed at Tier 3 with PA; QL noted in the formulary entries.

Provider implicationProviders must submit PA and adhere to QL rules for REPATHA to obtain coverage.

inv-146: XIFAXAN — QL

XIFAXAN QLXIFAXAN (rifaximin) oral tablet entries include 'Notes = PA; QL' or 'Notes = QL' depending on presentation, indicating quantity limits (and in some cases PA) apply.

TieringXIFAXAN appears at Tier 2–3 with QL and sometimes PA noted for certain treatment indications.

Provider implicationConfirm QL and PA applicability for the intended indication (e.g., hepatic encephalopathy vs. IBS‑D) before prescribing.

inv-147: Multiple listed drugs — QL reference

Multiple QL entriesNumerous listed drugs across therapeutic areas include QL notes; see the product-specific formulary rows for QL applicability.

ExamplesLinezolid, REPATHA, fenofibrate, cholestyramine and others are annotated with QL in the Notes column.

Operational noteExact numeric QL values are not shown in this excerpt; consult the full formulary for specific limits per product.

inv-149: STRIBILD, TRIUMEQ, antiretrovirals/hepatitis agents — QL

Antiretrovirals/hepatitis QLAntiretroviral and hepatitis C/B agents (e.g., STRIBILD, TRIUMEQ, EPCLUSA, HARVONI) show 'Notes = QL' or 'PA; QL; SP' indicating quantity limits and other controls apply.

ExamplesSTRIBILD and TRIUMEQ entries are Tier 4 with Notes = QL; EPCLUSA/HARVONI are Tier 4 with Notes = PA; QL; SP.

Provider implicationProviders prescribing these agents should confirm QL and PA/SP requirements for coverage and dispensing.

inv-150: Various listed topical and specialty products — QL indicated

Topical/specialty QLMany topical and specialty dermatologic agents are noted with 'QL' in the Notes indicating quantity limits apply to those presentations.

ExamplesCalcipotriene, ketoconazole foams, imiquimod pump, and certain topical antivirals show QL or ST; QL in the formulary rows.

Provider actionCheck product-specific QL before prescribing topical agents to ensure dispensed quantity aligns with plan limits.

inv-151: Many topical and specialty agents — QL where noted

Topical biologics QLNumerous biologic and dermatologic agents (e.g., TREMFYA, COSENTYX, SKYRIZI, TALTZ) include 'Notes = PA; QL; SP' indicating quantity limits plus other utilization controls apply.

TieringThese products are commonly listed at Tier 4 with combined utilization flags.

Provider implicationPA and QL must be addressed when requesting coverage for these specialty/topical biologics.

inv-152: Desmopressin — QL indicated

Desmopressin QLDesmopressin formulations include 'Notes = QL' for certain presentations, indicating quantity limits apply.

TieringDesmopressin entries are listed at Tier 1/1b with QL noted for some forms.

Provider implicationVerify QL prior to prescribing desmopressin products to ensure quantities align with plan limits.

inv-153: ENTYVIO — QL indicated

ENTYVIO QLENTYVIO (vedolizumab) IV and pen entries include 'Notes = PA; LD; QL; SP' indicating quantity limits along with PA, LD and SP apply.

TieringENTYVIO is listed at Tier 4 with multiple utilization flags noted.

Operational impactCoverage for ENTYVIO will require prior authorization and adherence to limited distribution/specialty pharmacy pathways and QL rules.

inv-154: Multiple specialty agents — QL applied

Specialty agents QLMultiple specialty agents (C1 esterase inhibitors, plasma kallikrein inhibitors, G‑CSF, IV iron, eltrombopag) show 'QL' in Notes often alongside PA, LD, SP flags.

ExamplesIcatiabant, TAKHZYRO, BERINERT, NEULASTA, UDENYCA, eltrombopag entries include QL annotations in the formulary rows.

Provider implicationProviders must address QL and other utilization controls (PA/LD/SP) when requesting coverage for specialty agents.

inv-155: Dexcom G6/G7 and FreeStyle Libre sensors — refer to plan QL

CGM sensor QL referenceDexcom G6/G7 sensors and FreeStyle Libre sensors/readers are listed with 'Notes = PA; QL' indicating prior authorization and quantity limits apply to these devices/sensors.

Device tieringSensors/readers and some pump kits are typically listed at Tier 2 with PA; QL noted in product rows.

Provider actionSubmit PA and follow QL guidance when ordering CGM sensors/receivers or associated pump kits to ensure coverage.

Site of Care and Specialty Distribution

Note

Route infused/specialty agents via SP or LD channels

Infused or specialty agents noted with 'SP' or 'LD' require specialty pharmacy or limited distribution handling — route prescriptions to the appropriate infusion center or specialty pharmacy per Notes.

AVASTIN, INLYTA, LENVIMA and other infused agents include PA; LD; SP notes indicating specialty handling.

Note

Adhere to LD and SP handling for specialty agents

Follow limited distribution and specialty pharmacy handling for flagged specialty agents; ensure prescriptions are dispensed through designated channels when Notes include 'LD' or 'SP'.

Multiple specialty agents are annotated LD and SP — confirm distribution pathway before ordering.

Billing Rule

Use specialty pharmacy when Notes indicate SP

Specialty pharmacy (SP) may be required for certain injectable or complex specialty products; use the specialty pharmacy channel for dispensing and PA coordination when Notes indicate 'SP'.

COSENTYX, SKYRIZI, NORDITROPIN and similar products list Notes = PA; QL; SP.

Documentation Required

Coordinate PA and SP dispensing for specialty injectables

Specialty injectables and solutions often require specialty pharmacy handling; coordinate PA and specialty dispensing per product Notes to ensure proper site‑of‑care and fulfillment.

TREMFYA and other specialty injectables include PA; QL; SP and sometimes LD flags.

Note

Follow Notes to determine site‑of‑care for specialty agents

Site‑of‑care routing (infusion center, specialty pharmacy, or home) depends on the agent and Notes; follow the entry's SP/LD flags and plan procedures to determine appropriate administration and dispensing location.

Some agents may be administered in infusion centers or routed through specialty pharmacies or home delivery depending on their utilization flags.

Policy Summary

PayerAnthem

PolicyAnthem Four-Tier Drug Formulary (Partial) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when the formulary Notes column lists PA before dispensing the drug.

SourceLink

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