CurrentAnthemPolicy N/A
Four Tier Drug Plan (Formulary) — Coverage Criteria
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This document governs the prescription drug list (formulary) for Anthem members, describing covered drugs, tier placement, restrictions (e.g., prior authorization, step therapy, quantity limits), and member resources; it affects members and providers using Anthem pharmacy benefits.
Policy Summary
PayerAnthem
PolicyFour Tier Drug Plan (Formulary) — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material change
Effective DateApr 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization when a drug line is marked 'PA' before prescribing or dispensing.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
4tiers described
quarterlyformulary update frequency
PA; QL; LD; SPutilization management notes present
ACA preventive coveragepreventive drugs $0 when applicable
4/1/2026current as of
Coverage Criteria and Formulary Scope
Some drugs listed on the formulary may not be covered for a particular member depending on the member's specific plan design and benefit exclusions. Members and providers should consult the member's Certificate/Evidence of Coverage or Summary Plan Description for plan‑level limitations and exclusions that determine actual coverage.
The document excerpt is primarily a formulary drug listing that assigns medications to tiers (Tier 1 through Tier 4) and annotates entries with plan-level flags (for example, PA, QL, SP). This portion does not present standalone medical‑necessity criteria; instead, tier placement and notes indicate preferred status and any utilization management that may apply.
In the provided segment there are no explicit clinical exclusion rules stated; the lines focus on formulation‑specific tier assignments, equivalence mappings, and Notes annotations (for example, PA or QL) rather than prescriptive clinical exclusion criteria.
Provider Actions — Authorization, Step Therapy, Documentation
Prior Authorization
Prior Authorization Required
Certain drugs on the formulary require prior authorization (PA) before benefits will be approved. If PA is not obtained, claims may be denied. This applies across multiple classes including specialty, injectable, high‑tier, oncology, and selected oral agents.
- Examples include specialty agents (e.g., OTEZLA XR, ORENCIA, ENBREL) and many biologics/injectables (PA; LD; QL; SP noted).
- Antineoplastic agents (oral and IV) commonly carry PA, LD, QL and/or SP flags (e.g., LYNPARZA, RUBRACA, TALZENNA, ZEJULA).
- High‑tier specialty products (e.g., DIACOMIT, EPIDIOLEX, FINTEPLA, TEZSPIRE) are noted with PA; LD; QL; SP.
Prior Authorization
Prior Authorization and Utilization Management for Stimulants
Stimulant products and other selected ADHD agents are frequently subject to PA, quantity limits (QL), dose optimization (DO), and sometimes step therapy (ST). Prescribers should obtain PA when Notes indicate PA or ST to avoid denial.
- Examples: amphetamine/dextroamphetamine formulations, methylphenidate ER products, lisdexamfetamine — many formulations show Notes = PA; QL; DO or ST.
- Utilization management for stimulants may include diagnosis requirements, QL limits, and ST pathways for certain formulations (chewable/transdermal forms often flagged ST).
Prior Authorization
Prior Authorization on Specialty / High‑Tier Products
Specialty, injectable, and select Tier 3–4 agents frequently require PA and may also be limited distribution (LD), have quantity limits (QL), and require specialty pharmacy (SP) dispensing. These flags together can affect coverage, fulfillment, and timing of therapy.
- Examples: FASENRA, NUCALA, TEZSPIRE, OTEZLA XR — Notes = PA; LD; QL; SP.
- Incretin mimetics and GLP‑1 agents (MOUNJARO, OZEMPIC, TRULICITY) are noted PA; QL and may follow specialty or step pathways.
- Pulmonary hypertension and certain cardiac agents (e.g., CAMZYOS, ambrisentan, bosentan, OPSUMIT, UPTRAVI) include PA; LD; QL; SP flags.
Prior Authorization
Prior Authorization for Specific IV/Formulated Products
Some IV/infusion and reconstituted formulations have specific PA requirements (and may be limited distribution). Verify product formulation notes (e.g., reconstituted cefazolin solutions) before ordering or billing to ensure authorization and appropriate dispensing channel.
- Examples: multiple cefazolin sodium reconstituted/dextrose IV solutions are listed; specific reconstituted/packaged IV cefazolin entries may carry PA or special handling.
- Many oncology IV agents and reconstituted injectables are annotated SP and/or LD — plan prior authorization and specialty dispensing rules apply.
Denial Risk
Authorization Flags and Utilization Management Triggers
Utilization management flags (PA, ST, QL, LD, SP, AL, DO) are present throughout the drug list and can trigger coverage denials or changes in fulfillment. When any of these flags appear in the Notes column, follow the plan’s utilization and dispensing requirements.
- PA = prior authorization; ST = step therapy; QL = quantity limits; LD = limited distribution; SP = specialty pharmacy; AL = age limits; DO = dose optimization; BE = benefit exclusion.
- Entries with PA/LD/QL/SP require administrative follow‑up — obtain prior authorization, document clinical rationale, and coordinate with specialty/limited distributors as needed.
- PA/LD/QL/SP flags increase risk of denial if requirements are not met.
Documentation Required
Required Documentation for Authorization Requests
Providers must submit required documentation with PA/QL/LD/SP requests. Documentation supports medical necessity, prior treatment attempts (for ST), dosing justification (DO), age or diagnosis criteria (AL), and supply/distribution needs for LD/SP products.
- Provide clinical notes, prior therapy history, relevant labs or diagnostic records, and prescriber rationale when requesting PA.
- Quantity limit (QL) requests should include proposed duration and total supply justification.
- For limited distribution (LD) or specialty pharmacy (SP) products, include preferred or required dispensing pharmacy and any enrollment forms the manufacturer requires.
Note
How to Request Prior Authorization
How to request prior authorization: prescribers can call the Member Services number on the member’s ID card or submit a prior authorization form via the Anthem website. Initiate PA before dispensing when a Notes entry indicates PA, ST, LD, or SP to avoid denials.
- Call Member Services or download and submit the PA form from the payer website.
- Start PA early for limited distribution or specialty drugs to allow time for coordination with the distributing pharmacy.
Step Therapy
Step Therapy and Therapeutic Equivalence Guidance
Step therapy (ST) and therapeutic substitution guidance appear on multiple entries. When Notes indicate ST or show equivalence mappings (’=’), the plan may require trial of preferred/step agents before approving higher‑tier or nonpreferred drugs.
- ST flags appear for some antipsychotics, antidiabetics, and stimulant/transdermal formulations. Follow required step pathways before requesting PA for later‑line agents.
- ’=’ mappings in the list suggest therapeutic equivalence or preferred alternatives that should be tried per step therapy rules.
Abbreviations and Formulary Definitions
Formulary / Drug list definition
DefinitionA list of prescription medicines your plan covers, reviewed and maintained via the Pharmacy & Therapeutics (P&T) process.
PurposeGuides coverage and member cost‑share by assigning drugs to tiers and applying utilization controls (PA, QL, LD, SP, ST, DO, BE).
MaintenanceReviewed regularly by an independent P&T committee of clinicians who assess safety, effectiveness and value.
Tiers (Tier 1–Tier 4)
Tier 1Lowest member cost share; typically generic drugs (may be split into Tier 1a and 1b for lowest vs low cost share).
Tier 2Higher cost share than Tier 1; often preferred brand drugs or newer generics with moderate cost share.
Tier 3Higher cost share; non‑preferred brands or generics, recently approved drugs, or specialty drugs that may need special handling.
Tier 4Highest cost share; usually specialty brand/generic drugs, recently approved agents, or drugs requiring special handling.
PA — Prior authorization (short definition)
PAPrior authorization — certain drugs require plan approval before the prescription can be filled.
ActionProviders must request pre‑approval via Member Services or the prior authorization form on the Anthem website (see policy documentation).
ConsequenceClaims may be denied if PA is not obtained when required.
QL — Quantity limit (short definition)
QLQuantity limit — plan limits on the amount or frequency of a drug that will be covered in a given time period.
UsageApplied at the product level (e.g., specific strengths or formulations note 'QL' on the formulary).
DocumentationPharmacy requests or claims may require documentation to support exceptions or overrides to QL.
DO — Dose optimization / Dispense as ordered (short definition)
DODose optimization / Dispense as ordered — may require switching to a different strength or dosing frequency (e.g., switching twice‑daily to once‑daily at higher strength).
PurposeEncourages use of optimized dosing or preferred formulations before covering alternate presentations.
Formulary noteAppears as 'DO' in the Notes column for affected formulations.
LD — Limited distribution (short definition)
LDLimited distribution — product is available only through specific channels or designated wholesalers/specialty pharmacies.
ImplicationMay require dispensing through a specialty or limited distribution pharmacy and additional logistics/documentation.
Formulary noteDenoted as 'LD' in the Notes column for affected products.
BE — Benefit exclusion / Bioequivalence (short definition)
BEBenefit exclusion — drug may not be covered depending on the member's plan design; coverage depends on the specific plan benefits.
ActionMembers/providers should check the member portal or drug list to confirm coverage for BE‑flagged products.
Formulary noteShown as 'BE' in the Notes column when applicable.
SP — Specialty pharmacy requirement (short definition)
SPSpecialty pharmacy requirement — product is managed through specialty pharmacy channels and often used for complex, long‑term conditions.
ImplicationDispensing, distribution and administration may follow specialty pharmacy processes and documentation requirements.
Formulary noteMarked as 'SP' in the Notes column for affected specialty products.
ST — Step therapy (short definition)
STStep therapy — member may need to try a recommended alternative drug(s) first before the prescribed drug is covered.
ApplicationAppears as 'ST' in the Notes column (e.g., on certain antidepressants, ADHD formulations); absence of required steps can lead to denial.
Provider actionFollow step therapy sequence or submit documentation for exception/override per plan rules.
PA — Prior authorization (alternate listing)
PA (listing)Prior authorization — listed in the Notes column; requires pre‑approval before dispensing (repeated in formulary listings).
ExampleMany specialty and higher‑tier products show 'PA' adjacent to the drug name/strength in the formulary listings.
ConsequenceClaims may be denied if PA is not obtained for PA‑flagged products.
QL — Quantity limit (alternate listing)
QL (listing)Quantity limit — appears in Notes column; specifies that an amount/frequency limit applies to the listed formulation.
ExampleFormulary lines frequently annotate QL for specific strengths or presentations (e.g., insulins, antivirals, anticonvulsants).
Provider actionRequests exceeding QL may require documentation or prior authorization per plan rules.
SP — Specialty pharmacy (alternate listing)
SP (listing)Specialty — noted in Notes column when a product must be dispensed via specialty pharmacy or managed under specialty channels.
ExamplesMany biologics, antineoplastics and select injectables include 'SP' in their Notes (see specialty product listings).
ImplicationMay require specialty pharmacy enrollment and specific fulfillment pathways.
LD — Limited distribution (alternate listing)
LD (listing)Limited distribution — repeated in multiple listings to indicate restricted distribution through specific channels.
ExamplesAppears on high‑cost injectables and specialty oncology/biologic agents (e.g., JATENZO, TEZSPIRE, various PARP inhibitors).
Provider actionCoordination with designated distributors or specialty pharmacies is typically required for LD products.
PA — Prior authorization (alternate listing 2)
PA (repeat)Prior authorization — reiterated across formulary sections where 'PA' appears in Notes; indicates pre‑approval requirement.
EvidenceMultiple formulary lines show 'PA' beside drug names and strengths (see specialty and oncology sections).
ResultNoncompliance with PA requirements may lead to claim denial.
QL — Quantity limit (alternate listing 2)
QL (repeat)Quantity limit — reiterated in listings for insulins, incretin agents, antivirals and others where 'QL' appears in Notes.
ExamplesInsulins (Lantus, Tresiba), GLP‑1 agents (Ozempic, Mounjaro) and antivirals often show QL in the Notes column.
Provider actionClaims or pharmacy fills may be limited to the plan's QL without additional authorization/documentation.
LD — Limited distribution (alternate listing 2)
LD (repeat)LD appears repeatedly for select neurologic and addiction treatment products and certain injectables (e.g., DIACOMIT, EPIDIOLEX, SUBLOCADE).
ImplicationIndicates limited suppliers and potential specialty handling requirements for these formulations.
DocumentationDispensing of LD products may require coordination with the designated distributor and supporting documentation.
SP — Specialty pharmacy (alternate listing 2)
SP (repeat)Specialty designation repeated for high‑cost biologics, injectables and antineoplastics where 'SP' appears in Notes.
ExamplesORENCIA, ENBREL, many IL‑5/TSLP agents and oncology products are annotated with SP in the formulary listings.
EffectProducts with 'SP' typically follow specialty pharmacy processes and may require PA, LD or QL controls.
PA — Prior authorization (alternate listing 3)
PA (repeat 3)Prior authorization — reiterated across multiple form sections; 'PA' denotes the need for pre‑approval for coverage.
PlacementAppears on diverse agents including specialty, oncology, antidiabetic and CNS products in the formulary listings.
Provider stepProviders should follow the plan's PA submission process for PA‑flagged items.
QL — Quantity limit (alternate listing 3)
QL (repeat 3)Quantity limits are reiterated in many sections; 'QL' flags limit covered quantity or dosing frequency for listed products.
ExamplesAntivirals (valacyclovir, oseltamivir), anticonvulsants, and some inhaled steroids show QL across the formulary.
Provider noteRequests above QL may require clinical justification or PA per plan rules.
LD — Limited distribution (alternate listing 3)
LD (repeat 3)Limited distribution is noted repeatedly for specialty injectables and high‑cost agents (e.g., NUCALA, FASENRA, TEZSPIRE).
ImplicationDistribution constraints may require specific fulfillment channels and additional administrative steps.
Formulary noteDisplayed as 'LD' next to affected product entries.
SP — Specialty pharmacy (alternate listing 3)
SP (repeat 3)Specialty pharmacy — shown across multiple sections where products are managed under specialty channels (noted as 'SP').
ExamplesMany IL‑5, TSLP, oncology and antiviral agents carry the SP flag in listings.
ConsequenceMay require specialty pharmacy enrollment and associated processes for dispensing and reimbursement.
ST — Step therapy (alternate listing)
ST (repeat)Step therapy — appears as 'ST' where members must try recommended alternative therapies before coverage of the requested drug.
ExamplesNoted on select antidepressants, ADHD chewables and other agents indicating step requirements.
Provider actionProviders can request exceptions or submit documentation to support bypassing ST per plan procedures.
DO — Dose optimization (alternate listing)
DO (repeat)Dose optimization — noted as 'DO' when switching to an optimized strength or schedule is expected before covering alternate presentations.
ExampleCommon on stimulant and analgesic formulations where dose consolidation or strength substitution is preferred.
Formulary noteShown as 'DO' in the Notes column for affected entries.
PA — Prior authorization (alternate listing 4)
PA (repeat 4)Prior authorization — reiterated across listings; when present in Notes it indicates plan pre‑approval is required.
ScopeApplies to specialty, oncology, select antidiabetics, CNS agents and others as shown in the formulary.
Operational noteFollow Anthem's PA submission channels to request approval before dispensing PA‑flagged drugs.
LD/QL — Quantity limit (alternate listing 4)
QL (repeat 4)Quantity limit — reiterated in many formulary lines; plan‑defined limits apply to amount/frequency for the listed product.
ExamplesTopiramate ER, insulins, GLP‑1/GIP agents and many anticonvulsants show QL notes in the formulary listings.
Provider actionRequests above QL require documentation/PA as specified by the plan.
QL — Quantity limit (alternate listing 5)
QL (repeat 5)Quantity limit — reiterated where 'QL' appears; limits may be product/strength specific.
Provider notePharmacy claims may be adjudicated against QL rules; supporting documentation required for exceptions.
ExamplesMultiple entries across the formulary include 'Notes = QL' on product lines.
SP — Specialty pharmacy (alternate listing 4)
SP (repeat 4)Specialty pharmacy — repeated annotation of 'SP' indicates specialty management for many high‑cost or complex therapies.
ImplicationSpecialty designation frequently co‑occurs with PA, LD and QL notes in the formulary.
Provider actionCoordinate dispensing through specialty channels and submit required documentation for coverage.
Prior Authorization required (alternate)
PA (alternate)Prior authorization — listed repeatedly in the Notes column; pre‑approval requirement reiterated across sections.
Operational impactAbsence of PA for PA‑flagged drugs can cause claim denials; providers must use Anthem's PA processes.
Common co‑flagsPA often appears with QL, LD and SP in formulary listings for specialty and oncology agents.
Limited Distribution (alternate)
LD (alternate) Limited distribution — restated in multiple listing contexts to indicate restricted supply channels for certain products.
ExamplesLD is present for products like SUBLOCADE, DIACOMIT, EPIDIOLEX and selected oncology agents.
Provider actionCoordinate with designated distributors or specialty pharmacies for LD products; documentation may be required.
Quantity Limit (alternate)
QL (alternate)Quantity limits repeatedly noted for many products; 'QL' flags amount/frequency limits for dispensing.
ExamplesValacyclovir, oseltamivir and many anticonvulsant formulations show QL in the formulary listings.
Provider actionRequests exceeding QL require plan review and may need documentation or PA.
Specialty pharmacy requirement (alternate)
SP (alternate)Specialty pharmacy requirement — reiterated where specialty handling is needed for dispensing and fulfillment.
ExamplesAppears alongside PA, LD and QL on many biologic and oncology agents (e.g., TEZSPIRE, MEKINIST).
ConsequenceMay require specialty pharmacy enrollment and associated administrative steps for coverage.
PA — Prior authorization (alternate listing 2)
PA (alternate 2)Prior authorization — repeated definition where PA appears in listing headers and Notes; requires pre‑approval for coverage.
Provider guidanceProviders should initiate PA via Member Services or the Anthem PA form on the website.
Denial riskClaims for PA‑flagged drugs may be denied if PA is not obtained.
QL — Quantity limit (alternate listing 2)
QL (alternate 2)Quantity limit — reiterated across sections; enforces limits on permitted supply for listed products.
ExamplesTopiramate ER, ZTALMY, vigabatrin packets and other anticonvulsants are shown with QL notes.
Operational notePharmacists and prescribers should check the formulary QL for each product before dispensing.
LD — Limited distribution (alternate listing 2)
LD (alternate 2)Limited distribution — reiterated across multiple product listings where supply is restricted to select channels.
ExamplesLD flags appear on DIACOMIT, EPIDIOLEX, FINTEPLA and select high‑cost agents.
Provider actionCoordinate fulfillment with designated distributors and provide supporting documentation as required.
SP — Specialty pharmacy (alternate listing 2)
SP (alternate 2)Specialty pharmacy — repeated to indicate products managed through specialty channels (noted as 'SP').
ExamplesCommon on antineoplastic, biologic and high‑cost injectable agents across the formulary.
ImplicationSpecialty items typically require coordination with specialty pharmacies and adherence to plan processes.
Equivalence mapping — '=' denotes mapping / equivalence
Equivalence mapping ('=')The '=' symbol denotes mapping or equivalence between the listed formulation and a comparator (e.g., cefazolin IV mapped to cefuroxime or oral cephalosporins).
UsageUsed to indicate therapeutic substitution or equivalence for formulary placement and step guidance.
ExampleCefazolin IV solution entries show '=' mappings to other cephalosporins in the formulary lines.
Step Therapy Rules and Affected Products
| Coverage note | Interpretation |
|---|---|
| ST or DO flag present on drug line (example: multiple amphetamine/dextroamphetamine entries) | |
| Presence of ST (step therapy) or DO (diagnosis override/dose optimization) in the Notes column indicates a step therapy or dose‑optimization requirement must be met before coverage is approved |
| Product / formulation | Notes (as listed) |
|---|---|
| methylphenidate hcl oral tablet chewable 2.5 mg / 5 mg / 10 mg | |
| Notes = ST; DO (for 2.5 mg: ST; DO shown) and PA; QL or PA; LD; QL for other chewable strengths as listed | |
| methylphenidate transdermal patch 10 mg/9hr, 15 mg/9hr, 20 mg/9hr, 30 mg/9hr | |
| Notes = ST; DO for 10/15 mg; ST; QL for 20/30 mg as shown in the formulary lines |
| Analgesic / related product | Notes indicating ST |
|---|---|
| Select nonnarcotic analgesic entries (example block shows analgesics with Notes) | |
| Notes include 'ST; QL' on specific analgesic lines indicating step therapy plus quantity limits may apply before coverage | |
| APLENZIN (antidepressant listed under misc antidepressants but referenced in analytic context) | |
| Notes = ST; DO or ST; QL for some strengths (APLNEZIN shown with ST; DO and ST; QL on higher strengths) as listed |
| Flag | Implication |
|---|---|
| SP (specialty) noted on multiple biologic/high‑tier lines (e.g., FASENRA, NUCALA, TEZSPIRE) | |
| SP indicates specialty pharmacy handling/distribution; explicit step sequences are not shown in the excerpt but specialty management pathways apply |
| Annotation | Possible implication |
|---|---|
| Entries annotated with SP and/or PA (e.g., TEZSPIRE Notes = PA; LD; QL; SP) | |
| These high‑tier/specialty annotations suggest utilization controls such as prior authorization, limited distribution, and specialty dispensing may apply though exact step rules are not provided in excerpt |
| Example product | ST noted? |
|---|---|
| APLENZIN oral tablet extended release 174 mg / 348 mg / 522 mg | |
| Notes = ST; DO (174 mg) and ST; QL (higher strengths) — ST applies where noted | |
| TRIJARDY XR oral tablet extended release 24 hour | |
| Notes = ST; QL indicating step therapy applies for TRIJARDY XR as listed |
| Annotation | Example / Interpretation |
|---|---|
| AL noted on product line (example: KOMZIFTI oral capsule Notes = AL; QL) | |
| 'AL' is used on some entries to indicate alternative/age/alignments or alternative/step edits — implying substitution or alternative therapy edits may apply (KOMZIFTI listed with AL; QL) |
| Agent / line | ST present? |
|---|---|
| FANAPT oral tablet and titration packs | |
| Notes include ST; DO or ST; QL on multiple FANAPT lines indicating step therapy applies | |
| Several antipsychotic and related agents (paliperidone, risperidone class lines) | |
| Notes include AL; QL or ST on some antipsychotic lines — some agents include 'ST' indicating step therapy applies |
| Product | Notes (ST examples) |
|---|---|
| ABILIFY MYCITE maintenance and starter kit therapy packs | |
| Notes = ST; DO (maintenance) and ST; QL (20 mg) — ST flagged on ABILIFY MYCITE entries | |
| SECUADO (transdermal patch) / thiothixene entries in antipsychotic group | |
| Notes include ST on specific entries (SECUADO and certain thiothixene lines show ST or AL/QL as applicable) indicating step edits before coverage |
| Specialty / high‑tier examples | Utilization controls noted |
|---|---|
| FASENRA, NUCALA, CINQAIR, other biologic injectables | |
| Notes = PA; LD; QL; SP — prior authorization required and distribution may be limited to specialty channels | |
| DIACOMIT, EPIDIOLEX, FINTEPLA and other anticonvulsant specialty agents | |
| Notes = PA; LD; QL; SP where listed — specialty agents require PA and may be limited to LD/SP channels |
| Therapeutic group / example | Tiering / equivalence note |
|---|---|
| Oral contraceptives (multiple combination oral contraceptive entries) | |
| Many oral contraceptives mapped to Tier 1 / 1a / 1b (preferred) as shown in the contraceptive listings and equivalence mappings | |
| Selected IV antibiotics / cephalosporins (cefazolin, cefepime, FETROJA) | |
| Listed at higher cost tiers (cefazolin and cephalosporin IV solutions shown Tier = 3) with '=' mappings indicating therapeutic equivalence/substitution guidance |
Quantity Limits and Affected Products
Various stimulant formulations — QL noted for specific strengths/formulations
Stimulant formulationsMultiple stimulant strengths and formulations are noted with QL and/or PA (e.g., amphetamine‑dextroamphetamine ER and dextroamphetamine products show 'PA; QL' or 'PA; DO').
ExamplesEntries list QL for specific strengths (20 mg, 30 mg) and show PA or DO on various amphetamine/dextroamphetamine lines.
Provider actionCheck the formulary Notes for PA/QL/DO on the specific stimulant presentation before prescribing or dispensing.
Multiple stimulant products subject to QL where noted
Multiple stimulant productsMany stimulant products are subject to QL and PA where noted (e.g., lisdexamfetamine, dextroamphetamine solutions/tablets show 'PA; QL' on certain strengths).
ExamplesLisdexamfetamine capsules 40–70 mg and chewable tablets show QL and PA/DO annotations in listings.
ImplicationPharmacy claims for these stimulants will be adjudicated against QL and PA rules; prescribers should verify requirements.
Multiple products with QL (examples)
Examples with QLMultiple non‑stimulant products also show QL in Notes (e.g., OTEZLA XR, ENBREL formulations, opioid ER products, testosterone products).
Provider actionReview product‑level Notes for QL and accompanying PA/LD/SP flags prior to prescribing or dispensing.
ConsequenceFailure to meet QL or PA requirements may result in claim denial or limited reimbursement.
Low‑dose aspirin OTC equivalents — $0 copay listed
OTC low‑dose aspirinCertain low‑dose OTC aspirin SKUs are listed at $0 copay (preventive coverage) on the formulary.
ExamplesChildren's aspirin chewable and multiple branded/store brands of low‑dose aspirin are annotated as $0 in Notes.
ImplicationWhere criteria for preventive coverage are met, these OTC aspirin products may be covered at no cost share.
Multiple listed products subject to QL as indicated
Multiple QL entriesNumerous formulary lines repeat 'Notes = QL' indicating quantity limits on anticonvulsants, insulins, GLP‑1 agents and other drug classes.
ExamplesTopiramate ER, ZTALMY, many anticonvulsants and insulins carry QL flags across the listing sections.
Provider actionConfirm the product‑specific QL before authorizing refills or sending pharmacy requests.
Multiple listed products show 'Notes = QL'
Notes = QLMany product lines explicitly show 'Notes = QL' at the line level; quantity limits apply where indicated.
ScopeAppears throughout analgesics, anticonvulsants, antivirals, antidiabetics and specialty sections.
RecommendationProviders and pharmacies should reference the formulary Notes for QL details on each product and strength.
QL noted for anticonvulsants, insulins, GLP‑1 agents and others
QL across classesQuantity limits are noted for anticonvulsants, insulins, GLP‑1 agents and other classes throughout the formulary listings.
ExamplesInsulins (Lantus, Tresiba), OZEMPIC, MOUNJARO and many anticonvulsants include QL in Notes.
Provider actionCheck QL entries for product‑specific supply limits and required documentation for overrides.
XPOVIO therapy packs — dosing variations noted
XPOVIO therapy packsTherapy pack dosing variations are noted (e.g., XPOVIO 40/50/60/80 mg weekly or twice weekly) with Notes = PA; LD; QL for many pack presentations.
ImplicationDose pack variations may have separate QL and PA requirements — verify the exact therapy pack presentation on the formulary.
Provider actionConfirm the specific therapy pack dosing and applicable utilization controls prior to prescribing or ordering.
Multiple QL entries referenced where noted
Multiple QL entries referencedFormulary lines frequently reference QL at the line level — see QL notes for each product line to determine limits.
ExamplesMultiple product classes and strengths across the formulary carry QL annotations in their Notes.
Operational notePharmacies should validate QL before dispensing and request prior authorization/documentation when necessary.
QL indicated on multiple listed lines
Line‑level QL indicationsQL is indicated on many listed lines — check individual product entries for QL and co‑flags (PA, LD, SP).
ExamplesSee anticonvulsant, antiviral and antidiabetic sections where 'Notes = QL' appears repeatedly.
Provider actionWhen QL appears, follow plan processes for documentation or PA to exceed limits.
QL for valacyclovir, oseltamivir and others
Valacyclovir & oseltamivir QLValacyclovir and oseltamivir are listed with 'Notes = QL' indicating quantity limits apply to the oral antiviral presentations.
ExamplesValacyclovir HCl oral tablet and oseltamivir phosphate oral capsule/suspension show QL in their Notes.
Provider actionConfirm QL before authorizing antiviral therapy and supply; request PA/documentation if clinically necessary to exceed QL.
Dispensing and Administration Site Notes
Note
LD/SP indicate restricted distribution or specialty handling
LD or SP annotations indicate the medication may be dispensed only through specialty pharmacies or limited distributors; infusion center, specialty pharmacy, or office administration may be required depending on the product.
Note
Some PA/LD drugs require specialty/infusion/office site‑of‑care
Certain PA/LD drugs (examples in the list: SPRAVATO, ZTALMY, TZIELD, mifepristone) may require specialty pharmacy, infusion center, or office administration; follow product‑specific site‑of‑care guidance.
Billing Rule
Coordinate specialty pharmacy dispensing for SP/LD products
Many agents designated SP or LD imply specialty pharmacy dispensing; coordinate with the plan's specialty pharmacy channel and document fulfillment arrangements when requesting coverage.
Billing Rule
Follow site‑of‑care and dispensing rules for LD/SP products
Injectables and specialty products annotated LD or SP (e.g., oncology agents, biologics) imply specific site‑of‑care or dispensing channels (infusion center or specialty pharmacy); follow distribution and administration rules in PA/fulfillment.
Background and Formulary Overview
The formulary groups medications into therapeutic classes and assigns them to tiers based on clinical value, availability of OTC or generic alternatives, safety, and cost. A Pharmacy & Therapeutics (P&T) committee reviews and maintains the drug list, which informs tier placement and formulary decisions.
Policy Summary
PayerAnthem
PolicyFour Tier Drug Plan (Formulary) — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material change
Effective DateApr 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization when a drug line is marked 'PA' before prescribing or dispensing.
SourceLink
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