Anthem Medicaid PDL Coverage & Prior Auth

Coverage Criteria and Formulary Flags

Prior authorization (PA) products

Coverage annotations and utilization controls in this segment:

PA_products: Drugs labeled 'PA' require prior authorization prior to coverage (examples in this segment include multiple DPP-4/biguanide combinations (JENTADUETO, JANUMET), select GLP-1 receptor agonists and incretin mimetics [liraglutide, OZEMPIC, TRULICITY, VICTOZA], and certain combination diabetes products)

See product-specific PA notes in the formulary entries (e.g., 'Notes = PA' after specific products)

Quantity-limited products

QL_products: Products annotated 'QL' are subject to quantity limits (examples in these chunks include ondansetron oral tablet, ondansetron oral solution, ondansetron dispersible tablet, and selected antifungal presentations)per product as specified

Requests exceeding the listed QL require justification/documentation of medical necessity

The excerpt does not include explicit clinical exclusion rules. Instead, individual products are listed with formulary annotations such as PA (prior authorization), QL (quantity limit), AL (additional/age labeling) and OTC (over‑the‑counter), which indicate administrative controls that govern coverage and dispensing but are not written as clinical exclusion criteria in this segment.

Entries annotated OTC identify products available over‑the‑counter. These OTC designations (for example, emergency contraceptives and many antacid/antidiarrheal items) indicate the product is marketed without a prescription and may be excluded from prescription drug coverage or handled differently under the benefit, depending on plan rules.

This extract contains no standalone clinical coverage criteria or exclusionary text. Coverage status is communicated via formulary flags (e.g., PA, QL, AL, SP, DO) attached to product entries rather than through narrative clinical criteria in this segment.

Within the provided segment there are no products explicitly described as excluded. Product entries instead carry administrative notes (such as OTC and QL) that inform how coverage or benefit processing should be applied.

The segment does not present explicit exclusion conditions tied to clinical circumstances. Coverage guidance is conveyed through product‑level annotations (for example PA, QL, AL, SP), which signal utilization management requirements rather than listing clinical exclusions.

No clinical exclusion conditions are listed for the products shown in this extract. The formulary displays product names with notes such as PA, QL, OTC and SP that indicate administrative controls or benefit status but do not state exclusion language.

This excerpt does not include explicit clinical exclusion criteria. It lists products with coverage annotations (for example PA, QL, OTC) that identify prior authorization, quantity limits or over‑the‑counter status rather than describing conditions that would exclude a product from coverage.

No explicit clinical exclusions are shown in these product lists. The entries are annotated with administrative flags (such as OTC, PA, QL and SP) which indicate how the plan manages coverage for each item rather than providing exclusionary clinical text.

What Providers Must Do / Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed across the formulary, including numerous specialty biologics, select oral agents (e.g., certain GLP‑1 receptor agonists, insulin formulations, antineoplastics, antipsychotics, selected antivirals, and specialty injectables). Providers must obtain PA before dispensing PA‑marked products to avoid claim denials.

Examples include specialty biologics and long‑acting injectables, many insulin products and GLP‑1 agents (OZEMPIC, TRULICITY), selected antineoplastics and antiretrovirals, and numerous specialty dermatologic and endocrine injectables.

Note

Authorization Flags and What They Mean

Products annotated with PA, QL, AL, SP or ST in the formulary carry affirmative authorization or control requirements. When a drug is marked PA the provider must request and receive prior authorization; items marked QL have quantity limits; AL indicates age or additional limitations; SP indicates specialty handling or specialty pharmacy.

PA = prior authorization required; QL = quantity limit; AL = age/additional limit; SP = specialty pharmacy; ST = step therapy required.
Failure to follow the annotation (for example dispensing a PA product without approval or exceeding a QL) may result in claim denial.

Denial Risk

Denial Risk if Authorization or Limits Not Met

Claims for PA‑ or QL‑marked items (including opioid and opioid‑combination products, certain migraine therapies, select insulin pump kits/pods, and many specialty agents) may be denied if prior authorization is not obtained or quantity/age limits are exceeded. Providers should verify authorization status before prescribing or dispensing.

Opioid/opioid‑combination products (many list PA; QL; AL) require PA and adherence to age/quantity limits.
Migraine agents (NURTEC, QULIPTA, UBRELVY) and CGRP monoclonal antibodies (AIMOVIG, AJOVY, EMGALITY) are marked PA; QL and may require specialty dispensing.
Insulin pump supplies and Omnipod kits/pods are PA; QL — documentation must be provided for these devices.

Prior Authorization

Specialty Topical and Dermatologic Products

Specialty dermatologic and topical agents (for example: podofilox solution, pimecrolimus, tacrolimus, EUCRISA, SKYTROFA, PYZCHIVA, SELARSDI) are designated PA and/or SP in many cases. Prior authorization and, when indicated, specialty pharmacy dispensing are required for coverage.

Topical agents requiring PA include podofilox (PA; QL), pimecrolimus (PA), tacrolimus (PA), and EUCRISA (PA).
Specialty injectables/biologics for dermatology (PYZCHIVA, SELARSDI, SKYTROFA) are PA and often SP.

Documentation Required

Required Documentation for PA/QL Requests

Documentation supporting medical necessity is required for items with PA and/or QL flags. Submit clinical rationale, indication, dosing, prior trials (when applicable), and any required supporting records with the PA request to expedite review.

For QL requests exceeding limits, include justification and dosing history.
For specialty agents, include diagnosis, prior treatment history, and prescriber specialty where applicable.

Step Therapy

Step Therapy and Access Restrictions

Some therapeutic categories impose step therapy (ST) or other prior‑trial requirements; where ST is noted the member may need to try preferred medications before a non‑preferred product will be approved. However, several segments of this excerpt do not specify a step sequence — providers should consult the full policy for step algorithms when ST is indicated.

ST = step therapy; when present follow the policy's required sequence.
When step therapy is not specified in this segment, check the complete policy for any class‑specific step edits.

Prior Authorization

Kits, Pump Supplies and Device Authorization

Certain devices, kits and insulin administration supplies (for example Accu‑Chek meter kits, True Metrix meter kits, Omnipod Dash pods and pod kits) are marked PA and/or QL. Prior authorization and device‑specific documentation (e.g., diabetes education, pump prescription) may be required for coverage.

Accu‑Chek Guide Kit and some meter kits list PA; OTC status may vary.
Omnipod Dash pods and related pump supplies are PA; QL and require prior authorization documentation.

Billing Rule

Prescriptions, OTC Annotation, and Submission Tips

Prescription entries should indicate OTC status where applicable (OTC flag) and must conform to PA/QL/AL/SP annotations. Failure to annotate prescriptions correctly or to obtain required prior authorization may result in claim denial or coverage delay.

Prescribers: mark OTC on prescriptions for OTC‑available products.
Ensure PA is obtained for PA‑flagged products and QL/AL limits are respected at submission.

Key Flags and Definitions

PA — Prior authorization

Definition — Prior authorization (PA)PA: Prior authorization is required; approval of benefits must be obtained before certain prescriptions are filled.

Implication for providersProviders must obtain PA before pharmacy fills for products annotated 'PA' to avoid claim denial.

DocumentationPA requests typically require clinical rationale and supporting documentation as indicated in product-specific entries.

QL — Quantity limits

Definition — Quantity limits (QL)QL: Quantity limits; certain prescription medications have specific quantity limits per prescription or per month.

Ondansetron exampleOndansetron oral solution and oral tablets/dispersible are explicitly listed with 'QL'.

Provider actionDispensing must conform to listed QL; requests exceeding QL require justification and documentation.

SP — Specialty Pharmacy

Definition — Specialty Pharmacy (SP)SP: Specialty Pharmacy designation for products managed through specialty dispensing channels.

Pulmonary hypertension agentsExamples (sildenafil, tadalafil for PAH) are noted PA; SP indicating specialty management.

Site-of-care implicationProducts marked SP may require specialty pharmacy dispensing or restricted site of care per formulary notes.

ST — Step therapy

Definition — Step therapy (ST)ST: Step therapy is required; members may need to use one medication before benefits for another medication can be authorized.

Provider implicationDrugs marked 'ST' require trial of preferred agents before alternatives are authorized; check product entry for ST flag.

DocumentationStep requirements and prior-step documentation should be submitted with PA when applicable.

OTC — Over-the-counter

Definition — Over-the-counter (OTC)OTC: Over-the-counter — product available without prescription and marked OTC in the list; prescribers should indicate OTC on prescriptions.

Contraceptive examplesEmergency contraceptives (Afterpill, levonorgestrel) are marked OTC; QL applies where noted.

OTC suppliesMany glucose-monitoring supplies and lancets are listed OTC (often with QL).

PA — Prior Authorization (product requires PA)

PA flag — prescription requirementPA: Prior Authorization — product requires prior authorization for coverage as indicated by 'PA' next to entries (e.g., many opioid formulations, selected injectables).

Opioid examplesNumerous opioid products and formulations are annotated 'PA' (see hydrocodone, morphine, fentanyl entries).

Contraceptives and othersSelected oral contraceptives and specialty products in the list are also noted 'PA' and require prior approval before dispensing.

QL — Quantity Limit (product is subject to QL)

Definition — Quantity Limit (QL)QL: Quantity Limit — product is subject to a quantity limit as indicated by 'QL' in product entries (e.g., many lancets, insulin syringes, topical agents).

Device examplesLancets and many insulin syringes/pen needles are annotated OTC; QL is frequently applied to these supplies.

Topical agentsMany topical corticosteroids and antifungals are noted with QL in the dermatology section.

AL — Additional / age-related labeling

AL (age/access limits) — definitionAL: Additional Labeling or age-related labeling indicated by 'AL' for certain pediatric or specialized formulations (e.g., some oral solutions, pediatric products).

Paxlovid examplePAXLOVID therapy packs are noted 'AL; QL' indicating age/access limits plus quantity controls.

IUD/device noteLILETTA (52 MG) IUD is noted SP and device entries may carry AL or other access qualifiers.

PA — Prior authorization (coverage may require approval)

PA — prior authorization requiredPA: Prior authorization is required; approval must be obtained before certain prescriptions are filled. Products annotated 'PA' will not be covered without authorization.

Examples — specialty and topical agentsSelect topical agents (EUCRISA, pimecrolimus, tacrolimus) and specialty biologics are listed with 'PA'.

Provider actionSubmit PA with clinical rationale and prior therapy when indicated by the product-specific entry.

QL — Quantity limit (restrictions on amount covered)

QL — quantity limit definitionQL: Quantity Limit — a restriction on the amount of medication covered within a defined time period; listed per product as 'QL'.

Antiemetic examplesOndansetron oral solution and tablets are explicitly marked QL in the antiemetics section.

Device examplesCertain devices (e.g., optichamber, pocket chamber) are noted with QL restrictions.

OTC — Over-the-counter (payer-designated)

OTC — payer designationOTC: Over-the-counter — product available without a prescription and designated as such by the payer; prescribers should indicate OTC on prescriptions where applicable.

Contraceptives and suppliesMany emergency contraceptives and glucose-monitoring supplies are listed as OTC (some with accompanying QL).

Coverage implicationOTC designation may affect coverage under prescription benefits; check product entry for OTC status and any QL/PA notes.

ANTIMYASTHENIC/CHOLINERGIC AGENTS — class label

Therapeutic class labelANTIMYASTHENIC/CHOLINERGIC AGENTS appears as a therapeutic class heading in the formulary list (e.g., pyridostigmine/Mestinon).

Representative productsPyridostigmine bromide ER tablet and oral solution (Mestinon) are listed under this class.

PurposeClass headings group related agents and indicate where utilization notes (PA/QL/etc.) would appear in product entries.

PA — Prior authorization required (denotation)

PA — prior authorization required (entry annotation)PA: Prior authorization required as denoted on entries with 'PA' (seen across antipsychotics, antiretrovirals, and other classes).

ExamplesSeveral antipsychotic long-acting injectables and antiretroviral packs include 'PA' in their notes.

Denial riskClaims for PA-marked products may be denied if PA is not obtained prior to dispensing.

QL — Quantity limit (entry annotation)

QL — quantity limit annotationQL: Quantity limit applied to products as denoted by 'QL' (examples include many antiretroviral combinations and digoxin strengths).

Antiretroviral examplesMultiple antiretroviral combinations (GENVOYA, STRIBILD, TRIUMEQ, etc.) are noted with QL in the formulary.

Cardiac agent exampleDigoxin formulations show DO and QL annotations for certain strengths.

SP — Specialty / site restriction

SP — specialty/site restrictionSP: Specialty or site restriction as denoted by 'SP' (used for pulmonary hypertension agents and other specialty products).

ExamplesAgents for pulmonary hypertension (sildenafil, tadalafil) and some oncology/biologic agents carry 'PA; SP' notes.

ImplicationSP designation may require specialty pharmacy dispensing or restricted administration settings.

AL — Age limit / access limitation

AL — age/access limitationAL: Age limit or similar authorization qualifier indicated by 'AL' on certain product entries (e.g., imiquimod 3.75% noted AL).

ExamplesImiquimod 3.75% and some pediatric formulations include AL in their notes, indicating age-related access limits.

ActionRequests for AL-marked products should include documentation that the patient meets age or access criteria.

OTC; QL — Over-the-counter with quantity limits

OTC with QL — combined annotationSome products are designated OTC and also subject to QL (e.g., certain emergency contraceptives and select OTC antidiarrheals).

Emergency contraceptivesAfterpill and levonorgestrel OTC emergency contraceptives are listed OTC; QL applies (notes: OTC; QL).

OTC supplies with limitsMany lancets, pads, and other OTC supplies are listed OTC but have QL annotations to limit quantities dispensed.

SP — Specialty designation (devices)

SP — specialty designation for devicesSP: Certain devices (e.g., LILETTA IUD listed as SP) are designated specialty and may have restricted distribution channels.

IUD exampleLILETTA (52 MG) IUD is specifically noted with SP in the contraceptive/device listings.

Insulin pump suppliesSome Omnipod kits/pods are marked PA; QL and may also be managed through specialty channels depending on the item.

PA — Prior Authorization (product requires PA)

PA — prior authorization required (product-level)PA: Certain migraine and specialty agents (e.g., UBRELVY, NURTEC, QULIPTA) are annotated 'PA' indicating prior authorization is required.

Migraine agentsNURTEC, QULIPTA, and UBRELVY entries include PA; QL in the migraine products section.

BiologicsCGRP monoclonal antibodies (AIMOVIG, AJOVY, EMGALITY) are listed PA; QL indicating PA is required for coverage.

QL — Quantity Limit (product subject to QL)

QL — quantity limit for supplies and devicesQL: Many needles, syringes, pen needles, and insulin administration supplies are annotated QL to limit dispensed quantities.

Omnipod exampleOmnipod Dash pods and related kits are annotated PA; QL (Omnipod Dash PODS Notes = PA; QL).

BD / Embecta syringesBD and Embecta insulin syringes and pen needles are listed with OTC and/or QL notes depending on presentation.

OTC — Over-the-counter (listed items)

OTC — over-the-counter designationOTC: Numerous items (e.g., many contraceptives and pediatric acetaminophen formulations) are designated OTC in the formulary list.

Contraceptive examplesMultiple emergency contraceptives and several oral contraceptive product listings carry OTC notes where applicable.

Pediatric productsMany pediatric formulations (acetaminophen children/infant suspensions) are noted AL; OTC; QL in the list.

SP — Specialty Pharmacy (product management)

SP — specialty pharmacy for biologicsSP: Certain injectable biologics and specialty agents are managed via specialty pharmacy (SP) and are annotated accordingly in product entries.

Dermatologic biologicsAgents such as PYZCHIVA and SELARSDI are noted PA; SP indicating specialty handling.

Site-of-care implicationSP designation may require dispensing through specialty channels and can affect prior authorization routing.

QL — Quantity Limit (formulary annotation)

QL — quantity limit annotationQL: Quantity limits are applied to many migraine and device products; QL appears after individual items to indicate per-product limits.

UBRELVY / NURTEC examplesUBRELVY, NURTEC and other migraine products are annotated PA; QL in the migraine products section.

Device exampleOptichamber and other respiratory devices include QL notes for limited dispensing quantities.

PA — Designated items requiring prior authorization

PA — designated PA itemsPA: Designated items require prior authorization as noted in the formulary (e.g., certain meter kits, insulin pump supplies, and opioid-containing products).

Opioid-containing productsSeveral antitussive/opioid combination products include 'PA; AL; QL' indicating PA is required plus age/quantity restrictions.

Meter kits and pumpsAccu-Chek guide kits and Omnipod pods/kits are examples of items marked PA requiring authorization before coverage.

QL — Items subject to quantity limits (devices)

QL — devices and suppliesQL: Numerous lancets, syringes, and devices are annotated QL to limit quantities dispensed (examples include Easy Touch lancets, BD SafetyGlide syringes).

Lancet examplesMultiple lancet SKUs (30G, 32G, 33G, 28G) are listed with OTC; QL notes in the formulary.

Insulin syringe examplesBD SafetyGlide and other insulin syringes are annotated OTC; QL or QL depending on presentation.

OTC — Over-the-counter items (listed)

OTC — over-the-counter suppliesOTC: Many over-the-counter items (alcohol prep pads, condoms, lancets) are listed as OTC, sometimes with QL to limit quantities.

ExamplesAlcohol prep pads, condoms (noted OTC; QL), and many lancets are included under OTC with QL where specified.

Coverage noteOTC designation with QL may influence whether items are covered under prescription benefits and the allowable quantity per fill.

PA / QL / SP / OTC — annotation key

Combined annotations (PA / QL / SP / OTC)Formulary annotations after items indicate: PA = prior authorization required; QL = quantity limit; SP = specialty program; OTC = over-the-counter. Use the flags on each product to determine required actions.

Interpretation guidanceCheck each product entry for its combination of flags (e.g., PA; QL or PA; SP; QL) to identify authorization, dispensing site, and quantity restrictions.

Provider actionObtain PA when 'PA' is present; adhere to QL quantities; use specialty pharmacy channels for 'SP' items; indicate OTC on prescriptions where noted.

Coverage note	Summary
ST
Medications marked 'ST' require trial of preferred agents before alternatives are authorized.

Coverage note	Summary
PA; AL; QL (examples)
Certain medication‑assisted treatment (e.g., SUBLOCADE) and specialty products are listed with utilization management flags (PA; AL; QL); explicit step therapy sequencing is not provided in the excerpt.

Coverage note	Summary
PA
Some branded diabetes agents and GLP‑1 agonists (e.g., OZEMPIC, TRULICITY, VICTOZA) are annotated 'PA' and may be managed within step edits in the full policy; the excerpt shows PA flags but not detailed step sequencing.

Coverage note	Summary
PA; SP; QL
Some antineoplastic/oncology agents (e.g., imatinib, gefitinib) are noted 'PA; SP; QL', which may reflect specialty or utilization controls; explicit step sequences are not provided in the excerpt.

Coverage note	Summary
PA; QL; AL
This segment shows products annotated with PA and QL (and sometimes AL), but does not provide explicit step therapy sequences or prior‑step requirements in the excerpt.

Coverage note	Summary
PA
Some oral contraceptives are annotated 'PA' indicating prior authorization is required before coverage; the excerpt does not present a formal multi‑step algorithm.

Coverage note	Summary
PA; QL; OTC
Certain systemic antipsoriatics and select topical antineoplastics are shown with 'PA' (and sometimes QL or OTC), suggesting utilization controls; explicit step sequences are not provided in the excerpt.

Coverage note	Summary
AL; PA; QL; SP
Some agents have access‑limited or prior authorization flags that imply step/access controls (examples in the excerpt: imiquimod 3.75% = AL; MYFEMBREE noted AL; ORIAHNN and SKYTROFA annotated PA/AL/QL or PA; SP), though explicit step sequences are not shown.

Coverage note	Summary
PA; OTC; QL
The listed device and supply entries include annotations such as PA, OTC, and QL; no step therapy sequencing is specified in these chunks.

Coverage note	Summary
PA; QL; SP
For specialty agents (e.g., CGRP agents, certain immunosuppressants and chelators) the excerpt shows PA/QL/SP annotations but does not list explicit step therapy requirements or sequences.

Products with Quantity Limits (QL)

multiple stimulant products — per prescribing entry QL indicated

Stimulant products — QL per entryMultiple stimulant products (amphetamines, methylphenidate, modafinil, etc.) are annotated with PA; AL; QL — quantity limits apply per prescribing entry.

ExamplesAdderall XR, Vyvanse, methylphenidate ER formulations and related products show PA and QL flags in the stimulant sections.

Provider implicationWhen prescribing stimulants, verify QL and PA requirements on the specific formulation to ensure coverage and appropriate quantity dispensed.

multiple opioids and certain formulations — see QL flag

Opioids and formulations — QL notedMultiple opioid products and certain formulations are annotated with PA and/or QL (e.g., hydrocodone, morphine, oxycodone), indicating quantity limits apply.

ExamplesHydrocodone combinations, hydromorphone, morphine sulfate solutions/tablets and fentanyl patches include PA; QL notes as applicable.

RiskClaims may be denied if PA is not obtained or QL exceeded for opioid products; follow product-specific flags.

ondansetron (oral forms) — QL

Ondansetron oral forms — QLOndansetron oral solution, oral tablet and dispersible tablet are explicitly marked QL in the 5-HT3 receptor antagonists section.

Provider actionAdhere to quantity limits for ondansetron oral formulations; requests above QL require justification.

Related notesInjectable ondansetron formulations are listed separately and may not carry the same QL annotations as oral forms.

selected antidiarrheals (loperamide, Kaopectate variants) — OTC; QL where indicated

Selected antidiarrheals — OTC with QL where notedProducts such as Kaopectate and related antidiarrheal suspensions/tablets are marked OTC; QL appears where indicated for specific presentations.

ExamplesKaopectate oral suspension and related diarrhea suspensions are annotated AL; OTC; QL in the formulary listing.

Provider noteOTC designation plus QL may affect coverage and allowable quantity per fill — check the specific product line entry.

multiple listed products — see QL note

Multiple listed products — QL presentMany listed products across therapeutic classes include QL annotations; review the formulary entry for product-specific limits.

Antiemetics & antifungalsSeveral antiemetics (aprepitant, fosaprepitant) and some antifungal dosages carry QL annotations.

Antineoplastics/devicesCertain oncology agents and devices are also annotated with QL in their entries.

multiple listed products — see entries marked 'QL'

Various products — QL where markedAcross antipsychotics, antiretrovirals and antiviral therapy packs, entries marked 'QL' impose product-level quantity limits to be followed.

Antiretroviral examplesGENVOYA, STRIBILD, TRIUMEQ and other ARV combos are noted with QL in their product lines.

Paxlovid packsPAXLOVID therapy packs are annotated AL; QL indicating age/access and quantity limits.

Aftera / levonorgestrel OTC emergency contraceptives — QL

Emergency contraceptives — OTC with QLAfterpill and levonorgestrel oral emergency contraceptives are listed OTC; QL applies to limit quantity per course/fill.

Formulary noteEntries explicitly show 'OTC; QL' for several emergency contraceptive brands indicating both OTC status and quantity restriction.

Provider implicationCoverage and quantity per course are limited; adhere to QL when dispensing OTC emergency contraceptives.

Selected antitussive/opioid products — QL

Selected antitussive/opioid products — QLCertain antitussive and opioid-containing cough products are annotated 'PA; AL; QL' or 'QL' indicating quantity limits and prior authorization/age restrictions.

ExamplesHydrocodone-containing antitussives (Hycodan, Hydromet) and dextromethorphan-guaifenesin combinations include AL; OTC; QL annotations as applicable.

Dispensing noteConfirm QL and any PA/AL requirements before dispensing antitussive/opioid formulations to avoid denials.

Multiple OTC and prescription entries — See QL annotation

Multiple OTC and prescription entries — check QL annotationMany OTC and prescription products in the contraceptive, cough/cold, and topical sections include QL annotations; follow product-specific quantity rules.

Topical agentsTopical corticosteroids and antifungals are frequently annotated with QL (see hydrocortisone, mometasone, clotrimazole entries).

Provider actionWhen dispensing OTC or prescription items, check the formulary entry for any QL and document justification for quantities above the limit.

Many topical agents — Quantity limits apply as noted (QL)

Topical agents — QL appliesMany topical agents (hydrocortisone, clotrimazole, miconazole, mometasone, triamcinolone) are annotated with QL indicating quantity limits per product.

Hydrocortisone examplesHydrocortisone external creams/ointments are noted OTC; QL or QL depending on strength and presentation.

Dispensing implicationAdhere to QL for topical agents; requests above QL require medical justification per formulary guidance.

SKYTROFA subcutaneous cartridges — PA; SP; QL

SKYTROFA cartridges — PA; SP; QLSKYTROFA subcutaneous cartridges are subject to prior authorization, specialty program designation (SP), and quantity limits (QL).

Therapeutic areaSKYTROFA is listed under calcitonins/hyperammonemia treatment with PA; SP; QL notes.

Provider actionSubmit PA and follow specialty pharmacy routing; adhere to QL for cartridge dispensing.

Various lancets, syringes, and devices — QL

Lancets, syringes, devices — QL notedVarious lancets, syringes, and devices are annotated OTC and/or QL to limit quantities dispensed; check each item for its note (OTC; QL or QL).

ExamplesEasy Touch, TruePlus, BD SafetyGlide, Embecta syringes and pen needles are listed with OTC and/or QL annotations.

Coverage noteMany home-use diabetes supplies carry QL to manage allowable amounts per benefit period.

Various OTC supplies — Referenced as QL on many items

OTC supplies — QL referencesVarious OTC supplies (insulin syringes, pen needles, peak flow meters) are referenced with QL annotations indicating quantity limits apply.

Peak flow / mask devicesPeak flow meters and mask devices (Optichamber, pocket chamber) are noted QL in the device listings.

Pen needles & syringesBD and Embecta pen needles/syringes show OTC; QL or QL depending on specific product presentation.

Selected migraine and biologic agents — Quantity limits noted

Migraine and biologic agents — QL notedSelected migraine (NURTEC, QULIPTA, UBRELVY) and CGRP biologic agents (AIMOVIG, AJOVY, EMGALITY) are annotated with QL — quantity limits apply per product.

PA co-annotationMany of these agents also include PA notes (PA; QL), indicating both prior authorization and quantity limits are required for coverage.

Provider implicationSubmit PA and follow QL when prescribing migraine preventive and acute agents listed with these annotations.

NARCAN	Naloxone hcl nasal liquid (brand listing)
KLOXXADO	Kloxxado nasal liquid
OPVEE	Opvee nasal solution

naloxone hcl injection solution	naloxone hcl injection solution
naloxone hcl injection solution cartridge	naloxone hcl injection solution cartridge
naloxone hcl injection solution prefilled syringe	naloxone hcl injection solution prefilled syringe
nalmefene hcl injection solution	nalmefene hcl injection solution
naltrexone hcl oral tablet	naltrexone hcl oral tablet

ondansetron hcl oral tablet	Ondansetron oral tablet
ondansetron hcl oral solution	Ondansetron oral solution
ondansetron oral tablet dispersible	Ondansetron oral tablet dispersible
ondansetron hcl injection solution	Ondansetron injection solution

OpenPayer

Medicaid-Approved Preferred Drug List — Coverage Criteria (PDL)

Coverage Criteria and Formulary Flags

Coding and Code Tables

What Providers Must Do / Authorization Rules

Policy Background and Scope

Key Flags and Definitions

Step Therapy Notes and Observations

Products with Quantity Limits (QL)

Specialty, Site-of-Care, and Dispensing Channels