CurrentBaylor Scott & White Health PlanPolicy N/A

Health Insurance Marketplace Formulary (prescription drug coverage)

Defines the Health Insurance Marketplace prescription drug formulary for Baylor Scott & White Health Plan members, describing which medications are covered, formulary management, and patient/provider processes for exceptions and access; applies to members served by Baylor Scott & White Health Plan products.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyHealth Insurance Marketplace Formulary (prescription drug coverage)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization or exception requests when product listing shows PA, QL, PV, or ST flags; ensure documentation supports quantity, age, and clinical rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Quarterlyformulary update frequency

30/90standard supply rules

2 attemptssmoking cessation attempts

$0Naloxone copay

2 weekssplit-fill initial supply

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

~120+items listed (approx.)

Formulary Coverage and Conditions

Covered when criteria met

Formulary coverage and exception conditions

Formulary coverage basic: Drug is listed on the Health Insurance Marketplace Formulary and is covered when medically necessary and plan rules are followed.

Drugs not listed are not covered unless an approved exception is granted; the formulary is updated periodically.

Formulary program coverage criteria

Formulary coverage and program rules applicable when listed conditions are met

ACA preventive medications: Medications noted as ACA/PV are covered as zero cost-share preventive drugs when filled at a network pharmacy with a prescription from a healthcare professional.$0 cost-share where ACA/PV applies

PV denotes HDHP preventive drugs where the deductible does not apply

Smoking cessation medications: All FDA-approved tobacco cessation medications (prescription and OTC) are available at $0 cost-share per PPACA, limited to two cessation attempts per year with a combined maximum of 180 days; some agents may require step therapy or prior authorization.2 attempts per year; up to 180 days total

OTC items must be filled at a network pharmacy with a prescription to obtain the benefit

Naloxone $0 Copay Program: Naloxone formulations (injectable and nasal spray) are available at $0 copay; supply may be obtained from a pharmacy without a prescription where allowed.$0 copay

Program materials show ZC/ACA annotations for eligible products

Split-fill program for specialty oral drugs: Specialty oral medications included in the split-fill program are limited to a 2-week supply per fill for the first two months of therapy to reduce waste and support counseling and outreach.2-week supply for first 2 months

Targets drugs with high discontinuation rates

Formulary conditional coverage

Coverage entries include product-specific limits and flags; coverage is conditional based on these limits and prior authorization where indicated.

Formulary conditions: Product coverage is subject to the listed quantity limits (for example, '60 30 DAYS'), minimum age requirements (for example, 'At least 18 yrs old'), and authorization flags such as 'QL', 'PA', 'AL', 'SF'.See product-specific listing for numeric limits and age restrictions

Prior authorization is required where PA or QL PA flags are present; specific PA criteria are handled via the plan's authorization process.

Formulary coverage entries (opioids, related agents)

Coverage entries include tier, quantity limits (per 30 days), and occasional minimum age requirements.

Opioid analgesic coverage entries: Opioid and related analgesic products are listed with a formulary tier and a numeric quantity limit per 30 days; certain strengths or formulations also include minimum age requirements (e.g., at least 16 or 18 years).Per-product 30-day limits as specified in the formulary

Many extended‑release and other opioid products include QL and PA flags (e.g., 'QL PA AL'); prescribers must follow PA/stewardship requirements when indicated.

Prior Authorization products

Coverage is managed product‑by‑product with controls; examples below reflect the listed rules.

PA required antifungals and specialty agents: Coverage for specified antifungals and selected specialty agents (examples in the formulary: CRESEMBA, posaconazole oral formulations, voriconazole) requires prior authorization as indicated in the product listing.PA required where indicated

Follow the plan's prior authorization submission requirements; documentation of indication and appropriate supporting clinical information should be provided.

Quantity limits

Quantity limits apply as listed per product.

Quantity limits: Products that include numeric limits are limited to the specified quantity per time period (examples from the formulary: ondansetron lines, granisetron, EMEND, terbinafine).Per-product numeric limits (see formulary listing)

Examples include ondansetron 30/30 days, granisetron 14/30 days, EMEND 6/30 days; requests for quantities above limits require prior authorization.

Age restrictions

Age or allergy/label restrictions where specified.

Age restrictions: Coverage for some products is limited to patients who meet the minimum age specified in the formulary (examples: 'At least 12 yrs old' for select antiemetics; other products note 'At least 2 yrs old' or 'At least 18 yrs old').Age as specified per product

Age restrictions are listed adjacent to product entries and must be documented on the prior authorization or claim where required.

Please refer to Plan Benefit Documents for specific exclusions and limitations. Generally, many over-the-counter (OTC) medications and herbal products are not covered under the prescription drug benefit and may only be covered if specifically listed or if a covered prescription is provided (see network fill rules). Additionally, most medications administered by healthcare professionals are not covered under the prescription drug benefit and may instead be covered under the member's medical benefit, so confirm the correct benefit channel before pursuing pharmacy coverage.

If a medication is not listed on the formulary, coverage may still be possible through an exception request when clinical justification shows formulary alternatives are inappropriate; exception requests must be submitted by the member, authorized representative, or prescriber and determinations will be provided in writing.

The formulary uses inline flags and tiering to indicate coverage rules. Items annotated ACA or PV denote preventive or HDHP preventive drugs (zero cost-share where applicable) and many nicotine replacement and smoking cessation products are designated ACA/PV and listed with that annotation. Products without ACA/PV/ZC annotations remain subject to standard benefit design (tiered cost-share) and the utilization controls shown in the Limits & Restrictions field (for example, QL, PA, PV, ST).

To obtain the ACA preventive or smoking cessation benefit (and the Naloxone $0 copay program), prescriptions must be filled at a network pharmacy and follow any prescription/documentation requirements shown on the formulary entry; OTC nicotine products often require a prescription to receive the ACA/PV benefit.

Within the provided excerpts there are no blanket exclusion statements that remove broad classes of drugs from coverage. Coverage is determined at the product level using the formulary entries and their associated utilization controls (tier, QL, PA, PV, AL, SF).

Providers should consult the specific product listing for any coverage restrictions; absence of an explicit exclusion here does not guarantee coverage — per-product limits and authorization flags drive coverage decisions.

This excerpt does not include explicit exclusions. Several topical anesthetic products are shown with utilization flags (for example, QL PA for patches and solutions) and quantity limits, but no broad exclusion language is provided in this segment.

Coverage determinations for these products will follow the formulary entry flags and applicable prior authorization or quantity‑limit processes as indicated.

The product listings in this excerpt primarily present tier assignments and Limits & Restrictions values (for example, many nicotine replacement therapy items are annotated ACA). The excerpt does not state additional coverage criteria or explicit exclusions beyond those per-product flags.

Where an item shows an ACA/PV/ZC annotation, it reflects preventive program coverage; otherwise, coverage is subject to the normal utilization controls (quantity limits, prior authorization, PV, ST) displayed on the formulary entry.

No broad exclusion statements appear in this document portion. Instead, coverage decisions are determined product‑by‑product using the formulary controls present in each line (e.g., PA, PV, QL, tiering and age limits).

Providers should review the specific formulary entry for each drug to identify applicable utilization requirements and any product‑level restrictions that could affect coverage.

The excerpts reviewed do not include any statements declaring therapies or services as Not Medically Necessary. The formulary uses utilization flags (QL, PA, PV, AL, ST) and tier assignments to manage coverage rather than explicit NMN language in these chunks.

When clinical questions arise about medical necessity, follow standard prior authorization and exception processes described elsewhere in the plan materials to document medical necessity for coverage consideration.

No explicit 'Not Medically Necessary' conditions are stated in this excerpt. Several products are flagged with utilization controls (for example, topiramate ER lines show QL PA) and age or quantity notes, but explicit NMN determinations are not present here.

Coverage denials risk arises when utilization controls are not met (e.g., missing PA, exceeding QL); follow the plan's authorization processes to request coverage when clinically indicated.

This excerpt does not include explicit 'Not Medically Necessary' statements. The document organizes coverage via product listings with flags for prior authorization, quantity limits, pharmacy validation, step therapy, and age restrictions rather than NMN text in these sections.

For determinations about medical necessity, utilize the plan's prior authorization and exception workflows and supply supporting clinical documentation as required.

Formulary Coding and Quantity Flags

Opioid analgesics - coveredmixedCovered

HYDROCODONE-ACETAMINOPHEN 10-325 MG/5ML SOLUTION	Tier 3; Limits: QL AL; 2700 per 30 days; age >=2 yrs
hydrocodone-acetaminophen 2.5-108 mg/5ml solution	Limits: QL; 2700 per 30 days
hydrocodone-acetaminophen 2.5-325 MG TAB	Limits: QL; 240 per 30 days
hydrocodone-acetaminophen 5-325 MG TAB	Limits: 240 per 30 days
hydrocodone-acetaminophen 7.5-325 MG TAB	Limits: 180 per 30 days
hydrocodone-acetaminophen 7.5-325 MG/15ML SOLUTION	Limits: 2700 per 30 days
hydrocodone-ibuprofen 10-200 MG TAB	Tier 3; Limits: QL AL; 150 per 30 days; age >=16
hydromorphone hcl 1 mg/ml liquid	Limits: QL AL; 1440 per 30 days; age >=18
hydromorphone hcl 2 mg tab	Limits: QL; 180 per 30 days
hydromorphone hcl 4 mg tab	Limits: QL AL; 180 per 30 days; age >=18

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Local anesthetics / topical agents - coveredmixedCovered

lidocaine 5% ointment	Limits: 100 per 30 days; QL PA
lidocaine 5% patch	Limits: 90 per 30 days; QL PA
lidocaine hcl 4% solution	Limits: 150 per 30 days; QL PA
lidocaine-prilocaine 2.5-2.5% cream	Limits: 60 per 30 days; QL
lidocan 5% patch	Limits: 90 per 30 days; QL PA
SYNERA 70-70 MG PATCH	Tier 3; Limits: 4 per 30 days; QL PA
tridacaine ii 5% patch	Limits: 90 per 30 days; QL PA

Opioid reversal agents / Naloxone products - coveredmixedCovered

KLOXXADO 8 MG/0.1ML LIQUID	Product listing
NALOXONE HCL 0.4 MG/ML SOLN CART	Tier 3; ZC
naloxone hcl 0.4 mg/ml soln prsyr	ZC
naloxone hcl 2 mg/2ml soln prsyr	Product listing; ZC
naloxone hcl 4 mg/0.1ml liquid	Product listing; ZC
KLOXXADO 8 MG/0.1ML LIQUID (alternate)	90 per 30 days (where specified)

Opioid dependence agents & smoking cessation - coveredmixedCovered

buprenorphine hcl-naloxone hcl 8-2 mg SL tab	Limits: QL; 90 per 30 days
lofexidine hcl 0.18 mg tab	Product listing
LUCEMYRA 0.18 MG TAB	Tier 3
naltrexone hcl 50 mg tab	Product listing
bupropion hcl er (smoking det) 150 mg tab ER	Smoking cessation listing; ACA
varenicline tartrate (starter) 0.5 mg x11 & 1 mg x42	Product listing

Formulary product lines (partial list) - neutralmixed

fluoxetine hcl 20 mg tab	Tier 3; Limits: QL PV; 120 per 30 days
fluoxetine hcl 40 mg cap	Tier 3; Limits: QL PV; 60 per 30 days
fluoxetine hcl 90 mg cap dr	Tier 3; Limits: QL PV; 4 per 28 days
fluvoxamine maleate 100 mg tab	Tier 3; Limits: QL PV; 90 per 30 days
fluvoxamine maleate 25 mg tab	Tier 3; Limits: QL PV; 30 per 30 days
fluvoxamine maleate 50 mg tab	Limits: QL PV; 30 per 30 days
paroxetine hcl 10 mg tab	Limits: QL PV; 30 per 30 days
sertraline hcl 100 mg tab	Limits: QL PV; 60 per 30 days
venlafaxine hcl 100 mg tab	Limits: QL PV; 90 per 30 days
TRINTELLIX 5 MG TAB	Tier 3; Limits: QL PV; 30 per 30 days

1–10 of 17

1/2

Selected opioid product listings - neutralmixed

BELBUCA 750 MCG FILM	Limits: QL PA AL; 60 per 30 days; age >=18
BELBUCA 900 MCG FILM	Limits: QL PA AL; 60 per 30 days; age >=18
fentanyl patch formulations	Multiple strengths listed; typical limits 15 per 30 days for some strengths

Quantity limits - examplesmixed

Common 30-day limits	Examples include 30, 60, 90, 120, 300 units per 30 days depending on product
Examples shown elsewhere	60/30 days; 90/30 days; 15/30 days; 180, 270, 360, 5400, 2700 depending on product

Prescriber and Pharmacy Requirements

Prior Authorization

Prior Authorization Required

Many covered drugs on the formulary are subject to utilization management. Providers must verify plan coverage flags (PA, QL, QVT, PV, ST, AL, SF) on the formulary entry prior to dispensing or submitting claims. Failure to obtain required approvals or to adhere to specified quantity/age/day‑supply limits may result in claim denial or member financial liability.

PA = Prior Authorization required; prescriber must submit clinical information for review.
QL / QVT = Quantity limits or Quantity‑over‑time limits; claims exceeding limits may be denied.
PV = Pharmacy Verification / Prior Verification required for some products (PV / QL PV).
ST = Step Therapy; trial of lower‑cost alternative(s) may be required before coverage of the requested agent.
AL = Age Limit; coverage only if member meets specified minimum/maximum age.
SF = Specialty Fill; specialty agents may have special fill or two‑week supply restrictions.

Prior Authorization

Prior authorization requirements

Key Terms and Flags

inv-93: Specialty drugs — Specialty drugs: drugs used to treat complex or chronic conditions that usually require close monitoring and may require special handling...

DefinitionSpecialty drugs: drugs used to treat complex or chronic conditions that usually require close monitoring and may require special handling or limited prescribing/pharmacy availability

ExamplesIncludes therapies for multiple sclerosis, hepatitis, rheumatoid arthritis, cancer and other high-cost agents

Program implicationSpecialty drugs may be subject to prior authorization, specialty fill (SF), and split-fill rules per formulary entries

inv-94: Generic drug — Generic drug: FDA-approved medication equivalent to a brand-name drug in dosage, safety, strength, route, quality, and performance; typic...

DefinitionGeneric drug: FDA-approved medication equivalent to a brand-name drug in dosage, safety, strength, route, quality, and performance; typically lower cost

Split-fill and Starter Supply Rules

Split-fill initial therapy

Split-fill initiation for select specialty oral drugs

Split-fill initiation: For specialty oral medications included in the split-fill program: limit each prescription fill to a two‑week supply for the first two months of therapy.2 weeks; first 2 months

Program is intended to reduce waste and support counseling and adherence outreach for drugs with high early discontinuation rates.

Step Therapy Indicators and Tables

Step therapy summary
Step therapy may be required for certain drugs; an exception can be requested if clinically appropriate alternatives cannot be used.

Step therapy requirement
When a formulary entry is annotated with 'ST', a trial of lower-cost medication(s) is required before a higher‑cost agent is covered; documentation of trial/failure of alternatives is required for exceptions.

Observation
No explicit step therapy sequences are provided in these product listings; entries instead show utilization control flags such as QL, PA, AL, PV or QVT that govern coverage and may imply prior controls.

Buprenorphine products — step therapy
Buprenorphine and buprenorphine‑naloxone formulations are listed with quantity limits (examples: 6/90 days, 60/30 days, 120/30 days) but the excerpt does not state explicit step therapy requirements.

Tiering vs step logic
Tier assignments are shown for many products, but explicit step‑therapy logic is not specified in the excerpt; tiering may suggest formulary sequencing but step rules are not defined here.

PV / QL PV indicators
Some products carry 'PV' or 'QL PV' flags (e.g., antidepressant and antidiabetic listings), indicating pharmacy verification or quantity‑verification processes that may act as utilization controls before coverage.

Antiemetic age/step notes
Certain antiemetic entries include age and restriction annotations (for example: perphenazine and promethazine entries list 'AL PV' and minimum ages; aprepitant and ANZEMET entries list 'At least 12 yrs old' with quantity limits).

Specialty oncology flags
Multiple specialty oncology oral agents are annotated with flags such as QL PA SF or QL PA AL (examples: LUMAKRAS, RETEVMO, KOSELUGO) indicating prior authorization and special‑fill or additional authorization controls prior to coverage.

AL / SF flags implications
Entries showing 'AL' (age limit) or 'SF' (special fill) indicate additional authorization or specialty pharmacy requirements (e.g., age limits noted for KISQALI and VERZENIO); explicit step‑therapy sequences are not provided in this excerpt.

Examples: AL / SF constraints
Some products list 'AL' or 'AL SF' alongside PA (for example VERZENIO, ZEJULA, ZYKADIA, and other oncology agents) to denote age limits or specialty fill requirements that constrain coverage; step edits are not explicitly described.

Antiviral / HIV product controls
Several antiviral and HIV products are annotated with QL, PA and PV flags (examples: EPCLUSA, BIKTARVY, MOUNJARO entries show QL PA PV), indicating prior authorization, quantity limits, or pharmacy validation may apply prior to coverage.

KERENDIA / ST example
KERENDIA is listed with a 'QL ST' notation in the formulary (ST = step therapy), indicating a step‑therapy requirement must be verified during authorization for coverage.

Tiering and PA/PV imply edits
Tier assignments (e.g., Tier 2 or Tier 3) together with PA or PV flags for branded agents imply that step edits or other pharmacy‑benefit utilization controls may be applied, although explicit step sequences are not provided here.

Product-Specific Quantity Limits (examples)

inv-129: unspecified (categories such as antibiotics, antivirals, most topical medications)

30-day standardStandard short-course categories (e.g., antibiotics, antivirals, most topical medications) are available in 30-day supplies

Maintenance supplyMaintenance drugs for chronic conditions may be filled as a 90-day supply if prescriber writes for three months and drug is covered as maintenance

ExceptionsSome categories (opioids, testosterone, specialty drugs) may be excluded from maintenance fill rules

inv-130: BELBUCA (various strengths)

BELBUCA limitsBELBUCA (750 mcg, 900 mcg films) — quantity limit 60 per 30 days; flagged QL PA AL and minimum age At least 18 yrs old

DisplayListed as '60 30 DAYS At least 18 yrs old' in product entries

Pharmacy and Dispensing Requirements

Note

Context and Policy Scope

Specialty drugs are defined as therapies for complex or chronic conditions that typically require close monitoring, special handling, or limited prescribing and pharmacy availability. The Pharmacy & Therapeutics Committee evaluates these agents for formulary placement based on clinical safety, effectiveness, and appropriate use.

Because specialty agents often have additional handling and utilization requirements, many are managed with product‑level controls such as prior authorization (PA), quantity limits (QL), and specialty‑fill designations (SF or AL). Providers should expect case‑by‑case management and follow the payer's PA and documentation processes for coverage.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyHealth Insurance Marketplace Formulary (prescription drug coverage)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization or exception requests when product listing shows PA, QL, PV, or ST flags; ensure documentation supports quantity, age, and clinical rationale.

SourceLink

On This Page

Prior authorization (PA) is required for numerous listed products across therapeutic classes — examples include many opioid extended‑release products, specialty oncology and molecular targeted oral agents, antifungals (CRESEMBA, posaconazole, voriconazole), antiviral/HCV regimens (EPCLUSA, HARVONI, MAVYRET), and many injectable/specialty diabetes and weight‑management agents (MOUNJARO, OZEMPIC, TRULICITY). Prescribers should submit PA requests with indication, prior medication trials when applicable, and supporting clinical documentation.

Specialty/oral oncology agents often show QL PA or QL PA SF — PA must be obtained to avoid denial.
Antifungals flagged with PA (CRESEMBA, posaconazole, voriconazole) will be denied without authorization.
Many injectables and specialty agents show combined flags (PA, PV, QL) — obtain PA and complete pharmacy validation as required.

Documentation Required

ARIKAYCE utilization control

ARIKAYCE (amikacin liposome inhalation suspension) has a specified quantity limit indicated in the formulary. Verify and document the prescribed quantity and day supply on the PA/claim to ensure it matches the plan limit.

ARIKAYCE 590 MG/8.4ML SUSPENSION = QL 235.2 /28 DAYS — ensure claims do not exceed this limit.

Documentation Required

Prior authorization / quantity verification

Products marked PV or QL PV require pharmacy verification or prior verification. Pharmacies and prescribers must supply the required clinical documentation (indication, dosing, prior therapy, member age) to complete validation and avoid dispensing delays or denials.

Examples: multiple antidepressants and select HIV agents are annotated with QL PV / PV — include quantity/day supply and clinical rationale on authorization requests.
For items with QVT or QL PV, include timeframe justification (e.g., QVT 30/180 days) when requesting overrides.

Documentation Required

Prior authorization required for listed products

Claims for products flagged with PA, QL, PV, QVT, AL, or SF must be supported by documentation matching the formulary entry. Providers should confirm tier, limits, age restrictions, and specialty fill requirements before submission. Noncompliance may trigger denials or require member out‑of‑pocket payment.

Document: diagnosis/indication, prior medication trials (for ST or exception requests), dosing regimen, requested quantity and day supply, member age, and any specialty fill rationale.
Formulary fields to reference on PA: TIER, LIMITS & RESTRICTIONS (flags like QL PA SF), numeric limits (e.g., 30 30 DAYS, 120 30 DAYS), and age constraints (e.g., At least 18 yrs old).

Prior Authorization

Prior authorization required for many agents

Many agents (especially oral oncology, molecular targeted inhibitors, and specialty biologics) are subject to PA and additional specialty-level controls. Obtain PA and follow specialty fill processes where indicated to ensure continuity of therapy and to prevent claim reversal.

Examples: KOSLEUGO, LUMAKRAS, IBRANCE, LONSURF, VERZENIO, and others list QL PA, QL PA SF or QL PA AL SF.
Specialty flags (SF) may limit initial fill quantities (two‑week supply restrictions) — check the SF notes on the formulary entry.

Denial Risk

Prior authorization/quantity limits required

Quantity limits and prior authorization requirements are enforcement points for coverage. Requests that exceed quantity limits, do not include prior authorization when required, or omit required verification information risk denial. Confirm limits before prescribing or dispensing.

Quantity limits may be expressed as numeric units per time (e.g., 60 / 30 DAYS, 235.2 / 28 DAYS) or as day supply constraints.
Examples of QL triggering denial if exceeded: ARIKAYCE, many opioid ER formulations, antifungals, oncology agents, and selected chronic therapy products.

Prior Authorization

PA required for selected injectables

Certain branded injectables and GLP‑1 receptor agonists are subject to PA/PV and quantity limits. Prescribers should include prior trial history and supporting clinical rationale with PA requests for these agents.

Examples include MOUNJARO, OZEMPIC, TRULICITY, RYBELSUS, and other GLP‑1/antidiabetic injectables showing PA, PV and QL flags.
Some strengths/formulations (e.g., RYBELSUS 3 mg with QVT 30/180 days) have specific QVT or QL timing requirements — document accordingly.

Denial Risk

Coverage restrictions and possible denial triggers

Coverage may be restricted and subject to prior authorization, step therapy, quantity limits, safe‑use, or specialty fill requirements. Before prescribing, check the formulary for all applicable flags and advise the member about potential coverage limits and their financial responsibility if requirements are not met.

An exception process exists: member, authorized representative or prescriber may request a formulary exception with clinical justification if step therapy or formulary alternatives are not appropriate.
Exception approval results in coverage at the applicable benefit copayment; denial leaves the member responsible for full cost.

Step Therapy

Prior auth/step therapy risk

Step therapy (ST) is applied to some drug classes. Where ST is indicated, the prescriber must document trials of required lower‑cost alternatives or submit a step‑therapy override/exception with clinical rationale.

Formulary entries annotated with ST require evidence of prior trial(s) unless a documented contraindication or intolerance exists.
If no explicit step algorithm is provided on the formulary excerpt, consult the plan's PA/step therapy criteria resources or contact Customer Service for details.

Denial Risk

Coverage flags and potential denials

Formulary coverage flags such as QL, PA, PV, QVT, ST, AL, and SF indicate operational requirements that must be met. Review these flags for each product to determine whether prior authorization, quantity verification, age checks, or specialty processes are required before dispensing.

Products flagged with QL PA, QL PA SF, or PA will require pre‑authorization and adherence to quantity limits.
PV and QL PV entries require pharmacy verification steps and inclusion of specified documentation on the claim.

Documentation Required

Age restriction documentation

Some formulary entries include age restrictions and day‑supply constraints that must be documented on the PA or claim. Confirm the member meets any age limits and that the requested day‑supply aligns with the formulary numeric limits.

Age limits example: several opioid and specialty oncology agents list 'At least 18 yrs old' or other minimum ages.
Day‑supply example: many oncology and antiviral products are listed with 28‑ or 30‑day supply constraints; HCV regimens often specify 28 day(s).

Documentation Required

Formulary listing fields

Formulary listings include structured fields (TIER; LIMITS & RESTRICTIONS) that should be referenced on prior authorization requests and claims. Include the exact formulary product, strength/formulation, tier, numeric quantity limits, and any special flags to support adjudication.

Record the formulary TIER and the LIMITS & RESTRICTIONS flags (e.g., QL PA SF, QL PV, QVT) on PA submissions.
Include numeric limits (e.g., '60 30 DAYS', '120 30 DAYS', '235.2 /28 DAYS') and any AL (age limit) text in documentation.

Documentation Required

Documentation to support dispensing/PA

When requesting prior authorization, provide complete documentation: diagnosis/indication, past medication trials (for ST or exception), dosing and duration, requested quantity/day supply, member age, and any specialty handling requirements. Incomplete PA submissions increase processing time or may be denied.

Documentation should reference formulary flags and numeric limits (e.g., QL, QVT values).
For PV / QL PV items include pharmacy validation data (e.g., member deductible status, preventive benefit codes, or high‑cost drug handling notes) as applicable.

Documentation Required

Prior verification/quantity verification on PV/QL PV items

Some products are designated PV or QL PV indicating prior verification is required before claim payment. Pharmacies must complete verification steps and capture required fields on the claim; prescribers may need to supply supporting clinical records.

Examples include selected antidepressants, HIV agents, and antidiabetic agents annotated throughout the formulary with QL PV / PV.
Failure to complete PV verification can result in rejection or reversal of reimbursement.

Prior Authorization

Prior authorization triggers

Providers must be aware that many specialty and high‑cost agents show combined authorization triggers (QL PA, QL PA SF, PA SF). Confirm whether PA is required and whether specialty pharmacy routing or two‑week initial supply rules apply.

Examples: LUMAKRAS, ICLUSIG, JAKAFI, and many molecular target inhibitors show QL PA or QL PA SF.
If a specialty fill (SF) flag is present, follow plan specialty dispensing requirements to avoid denial.

Denial Risk

Quantity limit may trigger denial

To avoid denials, ensure PA is obtained for any item flagged with PA/QL PA and that claims do not exceed stated quantity limits or violate age/day‑supply constraints. If PA is not available at the time of dispensing, advise the member of possible financial responsibility.

Products flagged as PA will be denied without authorization — confirm approval before filling when possible.
Quantity limits that are exceeded on the claim may be paid only up to the limit or denied; submit supporting justification if medically necessary.

Documentation Required

Prior authorization / verification and quantity limits present

Some entries include special notes (e.g., specialty fill, age limits, QVT values, or numeric day supplies). Verify those details and include them in PA submissions to align the request with the formulary's requirements.

Examples: oncology products with 'QL PA SF' often have 30/30 or 60/30 day constraints and minimum age requirements.
HCV and HIV regimens commonly include QL PA AL flags with explicit 28‑day or 90‑day supply rules.

Prior Authorization

PA/PV required for many injectables and specialty agents

Many formulary items require combined PA and PV processes (PA + PV) especially for injectables and specialty therapies. Coordinate with the pharmacy and plan to ensure both authorization and pharmacy validation are completed.

Examples: GLP‑1 injectables (MOUNJARO, TRULICITY), certain HIV products, and specialty oncology agents list PA QL PV or PA PV flags.
When both PA and PV are required, provide all requested clinical documentation at the time of PA submission to minimize back‑and‑forth.

Step Therapy

Step therapy flags present

If the formulary indicates Step Therapy flags (ST) or age/step requirements, document prior trials and age criteria or request an exception if clinically justified. Where no explicit step algorithm is present in the excerpt, consult plan resources for the specific step requirements.

Some products list ST on the limits field — a trial of formulary alternatives may be required before approval.
Age/step combinations (AL with ST) require both age verification and prior therapy documentation for adjudication.

Display noteIn the formulary, generic drugs are displayed in lowercase italicized lettering while brand drugs are in UPPERCASE

SubstitutionSome brand drugs have generic equivalents; others do not

inv-95: PV / ACA — PV indicates High Deductible Health Plan preventive drug (deductible does not apply); ACA/PV denotes zero cost-share preventive medicatio...

PV / ACA meaningPV: High Deductible Health Plan preventive drug — deductible does not apply; ACA/PV: zero cost-share preventive medications under the Affordable Care Act per plan benefits

Program examplesAspirin low-dose and nicotine replacement therapy entries show ACA or PV annotations to indicate preventive coverage

Member requirementTo obtain ACA preventive or smoking cessation benefits and Naloxone $0 copay, prescriptions must be filled at a network pharmacy as specified

inv-96: QL PA AL — Formulary flags appearing in the listing that denote Quantity Limit (QL), Prior Authorization (PA), and Additional Limitation (AL) as app...

Flag definitionsQL = Quantity Limit; PA = Prior Authorization; AL = Age Limit — formulary flags appearing alongside products indicate these utilization controls

Combined flagsComposite flags such as 'QL PA AL' indicate quantity limits with prior authorization and an age restriction may apply

ImplicationWhen these flags appear for a product, providers should submit authorization or documentation as required to avoid denial

inv-97: Opioid reversal agents / Naloxone — Medications intended to reverse opioid overdose effects; multiple naloxone formulations (intranasal, injectable, prefilled syringes) are ...

Naloxone agentsNaloxone formulations (intranasal and injectable prefilled syringes/carts) are listed and include ZC/ACA annotations; naloxone is available at $0 copay

ExamplesProducts include naloxone HCl 0.4 mg/mL solution (cartridge), 2 mg/2 mL prefilled syringe, 4 mg intranasal formulations, KLOXXADO, ZIMHI

Program noteNaloxone may be obtained from a pharmacy without a prescription where allowed and is covered at $0 copay per program description

inv-98: LIMITS & RESTRICTIONS = ACA — Indicates products subject to Affordable Care Act-related coverage requirements or classification within the formulary (document uses 'AC...

ACA flag use'ACA' or 'PV' in Limits & Restrictions indicates products subject to Affordable Care Act preventive coverage (zero cost-share when conditions met)

ExamplesNicotine replacement therapy products and certain low-dose aspirin entries are marked 'ACA' or 'PV' in the formulary

Member actionOTC smoking-cessation products may require a prescription and network fill to claim the ACA benefit

inv-99: QL 235.2 /28 DAYS — Explicit quantity limit shown for ARIKAYCE in this excerpt (235.2 units per 28 days).

Explicit ARIKAYCE QLQL 235.2 /28 DAYS is shown for ARIKAYCE 590 MG/8.4ML SUSPENSION in the product listing

InterpretationThis numeric QL denotes the allowed units in a 28-day period and may trigger utilization controls if exceeded

Associated flagsARIKAYCE line appears in the antibacterial/aminoglycoside section and marked with the QL value

inv-100: GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS — GABA augmenting agents

Class nameGAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS — formulary therapy class heading

ExamplesIncludes clobazam, diazepam gels, gabapentin and related agents listed under this class

UseClass headings group therapeutically related agents and may carry QL/PV flags per product

inv-101: SODIUM CHANNEL AGENTS — Sodium channel agents

Class nameSODIUM CHANNEL AGENTS — formulary therapy class heading

ExamplesIncludes APTIOM, carbamazepine and other sodium-channel active anticonvulsants

NotesProducts under this class are listed with their respective limits and flags where applicable

inv-102: PA — Prior Authorization — coverage requires prior approval from the plan.

PA definitionPA = Prior Authorization — coverage requires prior approval from the plan

ActionWhen PA appears in a product's 'Limits & Restrictions' the prescriber must submit additional information for review

OutcomeCoverage may be denied if PA is not obtained where indicated

inv-103: PV / QL PV — Prior Verification or Quantity Limit with verification — product is subject to verification/quantity controls.

PV / QL PV meaningPV or QL PV = Prior Verification / Quantity Limit with verification — products are subject to pharmacy verification or preferred vendor/verification controls

Operational notePV flags indicate pharmacy-level edits; QL PV indicates quantity limits that require verification prior to approval

ImplicationLack of required verification may result in denial or override requirement

inv-104: QL — Quantity Limit (day/30-day supply restrictions indicated alongside product)

QL meaningQL = Quantity Limit — day or 30-day supply restrictions are indicated alongside the product

DisplayShown as numeric limits (e.g., '30 30 DAYS', '120 30 DAYS') in Limits & Restrictions field

EnforcementPharmacy adjudication enforces the listed QL unless authorization grants exception

inv-105: PA — Prior Authorization — coverage requires prior approval from the plan.

PA (short)PA = Prior Authorization required for coverage

Provider actionSubmit required documentation via the plan's prior authorization process when PA is indicated

ConsequenceCoverage may be denied without an approved PA

inv-106: SF — Specialty Fill or specialty pharmacy requirement

SF definitionSF = Specialty Fill — indicates specialty pharmacy requirement or specialty fill process for the product

Operational noteProducts marked SF may require specialty pharmacy dispensing and administrative handling

Associated flagsSF often appears with QL PA (e.g., 'QL PA SF') for specialty oral oncology agents

inv-107: AL — Authorization Level or additional authorization flag as shown in listing

AL definitionAL = Authorization Level or Additional Limitation — denotes extra authorization or age/special handling constraints

ExamplesAL commonly appears with QL PA flags on oncology and specialty agents indicating age limits or administrative locks

Provider implicationProviders must document age or other qualifiers when AL is present to support PA requests

inv-108: QL PA — Formulary flag indicating quantity limit with prior authorization (as used in the product listings).

QL PA meaningQL PA = Quantity Limit plus Prior Authorization — product requires prior approval for quantities at or above the limit

UsageCommonly used for oncology, specialty, and high-cost oral agents in the formulary listings

ImplicationClaims exceeding QL or without PA will be denied unless an exception is approved

inv-110: Formulary flags indicating Quantity Limit (QL), Prior Authorization (PA), Prior Verification (PV), or additional Approval/Limit (AL)

Flag summaryFormulary flags include QL, PA, PV, AL (Quantity Limit, Prior Authorization, Prior Verification, Additional Limitation)

InterpretationThese flags appear inline with products and indicate utilization controls that must be satisfied for coverage

Provider actionSubmit PA or verification documentation when these flags appear on a product line

inv-111: QL / QL PV / QVT / PV / PA / ST — Formulary flags indicating Quantity Limit (QL), Prior Authorization (PA), Prior Verification (PV), or additional Approval/Limit (AL)

Composite flagsQL / QL PV / QVT / PV / PA / ST — formulary flags indicating quantity limits, verification, quantity-over-time, prior authorization, and step therapy

Operational noteEach flag prescribes a specific adjudication or prior-approval process used by pharmacy claims systems

ExamplesKERENDIA shown with 'QL ST'; RYBELSUS with 'QVT 30/180 days'; many injectables with 'PA QVT PV'

inv-112: PV — Pharmacy validation — pharmacy-level edit/requirement noted on product lines in the formulary listing.

PV (pharmacy validation)PV = Pharmacy validation — a pharmacy-level edit/requirement noted on product lines that may require verification before dispensing

ExampleMetformin ER and many injectables are noted with QL PV indicating pharmacy verification is required for quantity overrides

EffectPV may block adjudication until validation or prior authorization is completed

inv-113: QL / QVT — Quantity Limit (QL) or Quantity by Time (QVT) specifying dispensing maximums (e.g., 2 per 28 days, 100 units per 30 days).

QL / QVT meaningQL = Quantity Limit; QVT = Quantity by Time — indicates dispensing maximums such as '2 per 28 days' or '100 units per 30 days'

Formulary examplesRYBELSUS: QVT 30/180 days; some opioid and anticancer lines use QVT to express time-based caps

AdjudicationPharmacies enforce QL/QVT during claims processing; exceptions require PA or documentation

inv-114: PA — Prior Authorization required before coverage for certain products.

PA reminderPA = Prior Authorization required before coverage for certain products — submit clinical rationale per plan process

Common usageUsed for many specialty, oncology, and high-cost agents where clinical review is required

Denial riskAbsence of PA when listed will typically result in claim denial

ImplicationPrescribers should document age and may need PA if coverage beyond limit is requested

inv-131: Ketorolac tromethamine 10 mg tab

Ketorolac QLKetorolac tromethamine 10 mg tab — listed with QVT 20 (20 per time period) in formulary entries

ContextShown as 'QVT 20' in Limits & Restrictions indicating a capped quantity for short-course analgesic use

Typical useReflects short-term therapy limits for NSAID/ketorolac products

inv-132: Fentanyl patches (various mcg/hr)

Fentanyl patchesFentanyl transdermal patches (various mcg/hr) — typical limit shown as 15 per 30 days in product lines

FlagsEntries show QL PA (quantity limit with prior authorization) and minimum age where applicable

ExamplesFentanyl 12, 25, 50, 100 mcg/hr patches display '15 30 DAYS' as common cap

inv-133: Methadone HCl 10 mg tab

Methadone 10 mg QLMethadone HCl 10 mg tab — quantity limit 90 per 30 days (displayed as '90 30 DAYS')

Methadone solutionMethadone 10 mg/5 mL solution shows 450 per 30 days in listings

FlaggingMethadone entries carry QL flags and are subject to formulary quantity controls

inv-134: Methadone HCl 5 mg tab

Methadone 5 mg QLMethadone HCl 5 mg tab — listed with a 90 per 30 days limit

ContextDisplayed as '90 30 DAYS' in product line limits

ImplicationSubject to quantity-limit enforcement at pharmacy adjudication

inv-135: Acetaminophen-codeine solutions/tabs

Acetaminophen-codeine examplesAcetaminophen-codeine formulations show variable 30-day caps (examples: 2700, 360 per 30 days depending on formulation and strength)

Formulary displayNumeric limits appear adjacent to each strength entry (e.g., '2700 30 DAYS', '360 30 DAYS')

Age notesSome formulations include minimum-age annotations (e.g., At least 12 yrs old)

inv-136: Xtampza ER formulations

Xtampza ER limitsXtampza ER formulations — quantity limits vary by strength (examples: 30 or 240 per 30 days depending on strength)

FlagsEntries include QL PA or QL PA AL flags for many Xtampza strengths

Example displayShown as '30 30 DAYS' or higher numeric caps for specific strengths in the formulary

inv-137: hydrocodone-acetaminophen 2.5-325 mg tab

Hydrocodone-acetaminophen capHydrocodone-acetaminophen 2.5-325 mg tab listed with limit 240 per 30 days

Formulary flagEntries carry QL or QL AL flags depending on formulation

Clinical noteSome formulations have higher per-30-day numeric limits for younger age categories noted separately

inv-138: hydromorphone HCl 1 mg/mL liquid

Hydromorphone liquid limitHydromorphone HCl 1 mg/mL liquid — quantity limit 1440 per 30 days

FlaggingListed with QL AL and minimum-age annotations for certain strengths

ImplicationLarge-volume liquid packs are capped at high numeric limits as shown in listings

inv-139: morphine sulfate (various forms)

Morphine sulfate examplesMorphine sulfate products show variable caps such as 270, 360, 180 per 30 days depending on formulation (concentrate, solutions, tablets)

Displayed asFormulary entries use numeric 'XXX 30 DAYS' values (e.g., 270 30 DAYS, 360 30 DAYS)

Age/flagsSome strengths include age limits (e.g., At least 18 yrs old) and QL/AL flags

inv-140: oxycodone HCl products

Oxycodone examplesOxycodone HCl products show examples of 30-day caps such as 180, 270, 360, up to 5400 depending on form (tablets, solutions)

Formulary notationLimits appear as '180 30 DAYS', '360 30 DAYS', '5400 30 DAYS' for specific formulations

AuthorizationHigher quantities may require PA when flagged with QL PA or QL AL

inv-141: buprenorphine HCl sublingual products

Buprenorphine SL productsBuprenorphine HCl sublingual products and buprenorphine–naloxone films/tabs show QL entries such as 6/90 days, 60/30 days, 120/30 days, 90/30 days

FlaggingMany formulations include QL or QVT flags and may require pharmacy verification

Program noteUsed for opioid dependence treatment; prescribers should be aware of specified dispensing caps

inv-142: lidocaine 5% patch

Lidocaine 5% patchLidocaine 5% patch — quantity limit 90 per 30 days (displayed as '90 30 DAYS') and flagged QL PA for some entries

Other topical lidocaineLidocaine 5% ointment and lidocaine-prilocaine cream list other numeric 30-day caps (e.g., 100 or 60 per 30 days)

AuthorizationSome topical anesthetic patches and solutions are marked 'QL PA' indicating PA may be required for quantities

inv-143: ARIKAYCE 590 MG/8.4ML SUSPENSION

ARIKAYCE listingARIKAYCE 590 MG/8.4ML SUSPENSION — QL 235.2 /28 DAYS (explicit per-28-day quantity limit)

Class placementListed under anti-bacterials/aminoglycosides with specific QL value

Utilization implicationQuantity limit may be enforced via PA or pharmacy validation processes

inv-144: topiramate er 100 mg cap er 24h

Topiramate ER 100 mgTopiramate ER 100 mg capsule ER 24h — quantity limit 30 per 30 days

Topiramate ER 200 mgTopiramate ER 200 mg cap ER 24h — quantity limit 60 per 30 days

FlagsTopiramate ER formulations are noted with QL PA indicating prior authorization may apply

inv-145: topiramate er 200 mg cap er 24h

Topiramate ER 200 mgTopiramate ER 200 mg cap ER 24h — quantity limit 60 per 30 days

Formulary flagListed with QL PA in Limits & Restrictions indicating potential prior authorization requirement

Dispensing noteDisplayed as '60 30 DAYS' in the product line

inv-146: bupropion hcl 100 mg tab / other bupropion formulations

Bupropion limitsBupropion HCl 100 mg/tab and other bupropion formulations — limits vary by formulation: 120/30 days or 60/30 days or 30/30 days

FlaggingEntries display QL PV indicating quantity limits with pharmacy verification may apply

ExamplesBupropion 100 mg tab listed as '120 30 DAYS' while ER forms show 60/30 days

inv-147: FETZIMA (20/40/80 mg)

FETZIMA limitFETZIMA (20/40/80 mg) — quantity limit 30 per 30 days

FlaggingListed with QL PV in Limits & Restrictions for verification

DisplayShown as '30 30 DAYS' for each strength in product entries

inv-148: ZURZUVAE (20/25/30 mg)

ZURZUVAE limitsZURZUVAE (20/25/30 mg) — limits include 365 days or QVT 14/365 days depending on strength

InterpretationSome strengths are managed with annual quantity variance (QVT) rather than monthly QL

Provider noteCheck exact strength listing for applicable QVT/yearly caps when prescribing

inv-149: fluoxetine formulations

Fluoxetine limitsFluoxetine formulations — quantity limits range from 30 to 120 per 30 days depending on formulation; 90 mg DR cap: 4 per 28 days

FlaggingListed with QL PV where applicable for pharmacy verification

ExamplesFluoxetine 20 mg tab shown as '120 30 DAYS' in product entries

inv-150: escitalopram 10 mg/solution and tablets

Escitalopram limitsEscitalopram 10 mg tablets and solution — typical limits 30 per 30 days for tablets or 600 per 30 days for solution formulations

FlaggingEntries show PV/QL PV indicating verification on some formulations

DisplayShown as '30 30 DAYS' or numeric solution cap adjacent to product

inv-151: fluoxetine 20 mg tab

Fluoxetine 20 mg tabQuantity limit: 120 per 30 days (displayed as '120 30 DAYS')

FlaggingListed with QL PV in Limits & Restrictions for verification

UsageApply per-prescription adjudication limits at dispensing

inv-152: venlafaxine hcl 100 mg tab

Venlafaxine 100 mgVenlafaxine HCl 100 mg tab — quantity limit 90 per 30 days

FlaggingListed with QL PV in product entries

DisplayShown as '90 30 DAYS' in formulary limits

inv-153: granisetron 1 mg tab

Granisetron limitGranisetron 1 mg tab — quantity limit 14 per 30 days

Ondansetron limitOndansetron oral forms — typical limit 30 per 30 days for many formulations

EMEND limitEMEND 125 mg recon suspension — limit 6 per 30 days

inv-154: ondansetron (various oral forms)

Ondansetron (various)Ondansetron oral formulations — common quantity limit 30 per 30 days (many lines show '30 30 DAYS')

High-strength noteOndansetron 24 mg tablet is separately limited to 1 per 30 days (see high-strength entry)

DocumentationQuantity limits for antiemetics should be documented on claims when relevant

inv-155: EMEND 125 mg recon suspension

EMEND limitEMEND 125 mg recon suspension — quantity limit 6 per 30 days

FlaggingListed with QVT/QL indicating time-limited dispensing for antiemetic regimens

Use caseUsed to limit antiemetic supplies consistent with chemotherapy cycles

inv-156: terbinafine hcl 250 mg tab

Terbinafine 250 mgTerbinafine HCl 250 mg tab — quantity limit 30 per 30 days (QL 30)

DisplayShown as 'QL 30 / 30 DAYS' in formulary entries

ImplicationStandard one-month supply limitation for terbinafine tablets

inv-157: various (examples) — product‑specific (see listing)

Product-specific limitsMany products have product-specific numeric limits — see individual product lines for exact QL or QVT values

ExamplesOndansetron 30/30 days; granisetron 14/30 days; EMEND 6/30 days; terbinafine QL 30

Provider noteRefer to product listing for exact numeric limit before prescribing or requesting overrides

inv-158: terbinafine hcl 250 mg tab — QL 30

Terbinafine (repeat)Terbinafine HCl 250 mg tab — QL 30 per 30 days (reinforced listing)

AbirateroneAbiraterone acetate 250 mg tab — quantity limit 120 per 30 days

LenalidomideLenalidomide (various strengths) — typical limits 21–30 per 28–30 day cycle (e.g., 21/28 days)

inv-159: abiraterone acetate 250 mg tab

Abiraterone limitAbiraterone acetate 250 mg tab — quantity limit 120 per 30 days

DisplayShown as '120 30 DAYS' in product limits

PA/flagsOften appears with QL PA for specialty oncology handling

inv-160: lenalidomide (various strengths)

Lenalidomide limitsLenalidomide (multiple strengths) — typical dispensing limits 21–30 (21/28 days or 30/30 days) per regimen

FlaggingListed with QL PA indicating prior authorization and REMS/program requirements may apply

Cycle-basedLimits reflect cycle-duration dosing and are listed per 28–30 day periods

inv-161: LUMAKRAS (various strengths)

LUMAKRAS rangesLUMAKRAS dosing examples show quantity limits ranging from 90 to 240 per 30 days depending on strength and packaging

Specific entriesLUMAKRAS 320 mg tab listed with 90 per 30 days (and elsewhere 120 or 240 depending on pack) and flagged QL PA SF

Provider noteSpecialty oncology oral agents frequently include PA, SF, and AL flags in addition to numeric QL

inv-162: LUMAKRAS 320 MG TAB

LUMAKRAS 320 mgLUMAKRAS 320 mg tab — listed with limits such as 90 per 30 days (one entry) and 120 per 30 days (alternate entry) depending on pack/strength

FlaggingEntries include QL PA SF indicating prior authorization and specialty-fill handling

Check listingConfirm specific pack/strength for applicable limit before prescribing