Initiate PA or ST via Member Services or form

Notes column indicates if prior authorization (PA) or step therapy (ST) is required; providers can initiate prior authorization by calling the Member Services number on the back of the member ID card or by downloading and submitting a prior authorization form from the website.

Request coverage review for non‑formulary drugs

If a drug is not on the drug list, the prescriber can request a coverage review (preapproval/prior authorization) by calling the Member Services number on the back of the member ID card or by downloading and submitting a prior authorization form from the website; members may have to pay full cost if not covered until approval is granted.

• Coverage review initiated by prescriber via Member Services phone number or prior authorization form
• If approved, patient cost depends on the plan's benefit

Request medical exception for contraceptives

If the contraceptive a member is taking is not on the formulary, the prescriber may contact the plan to request coverage when medically necessary; the plan will waive the member's cost share if preferred contraceptives are inappropriate.

TOC entries — categories only (no PA rules)

Table of contents entries list drug categories and page references for the National Direct Plus Drug List; these TOC fragments do not include prior authorization rules or coverage criteria.

TOC: therapeutic categories (navigation only)

Therapeutic category headings (e.g., Antifungals; Antihistamines; Antihyperlipidemics; Antihypertensives) are provided in the Table of Contents as navigation only; they do not contain authorization instructions in these excerpts.

TOC fragment — no authorization info

This Table of Contents fragment contains only section headings and page numbers and does not describe prior authorization or provider actions.

TOC listing of drug classes (partial)

Table of Contents lines list drug classes and page numbers for the National Direct Plus Drug List; no provider action guidance appears in this partial TOC.

TOC fragment — no PA guidance

This TOC fragment contains section headings only and does not include prior authorization or provider action guidance.

TOC: class headings (navigation)

Table of Contents entries name drug classes (e.g., Beta Blockers; Calcium Channel Blockers; Contraceptives; Corticosteroids) and page references; these entries are for navigation and do not include authorization instructions in this segment.

TOC: additional therapeutic categories

Table of contents lists therapeutic categories (e.g., Cough/Cold/Allergy; Dermatologicals; Endocrine and Metabolic Agents) as section headings; no authorization steps are described here.

TOC segment — navigation headings

This TOC segment lists endocrine, fluoroquinolones, gastrointestinal, anesthetic, and genitourinary categories among others for document navigation; it does not present PA criteria in the excerpt.

TOC fragments — no PA guidance

Table of contents pages in this window are navigation-only and contain no prior authorization guidance.

TOC: drug categories (index entries)

Table of Contents lists drug categories and page references for the National Direct Plus Drug List; these fragments are index headings and do not include provider action language in the excerpt.

Watch for 'PA' indicator in tier listings

Some drug list entries include 'PA' in the Notes column indicating prior authorization is required for that product (example: guanfacine ER shows 'PA' adjacent to its listing).

Check Notes column for utilization controls

Many product listings include plan note abbreviations that indicate utilization management controls (PA = prior authorization, QL = quantity limits, DO/LD/SP/BE/ST are plan-specific notes); providers should check the Notes column on the drug list for applicable controls.

• PA = Prior Authorization
• QL = Quantity Limit
• ST = Step Therapy
• LD = Limited Distribution
• SP = Specialty

Follow utilization-control annotations (PA/QL/SP/LD)

Certain products in the list are annotated with utilization-control abbreviations next to the drug entry (e.g., PA, QL, SP, LD); providers should follow those controls when prescribing and dispensing.

Otezla requires PA, QL, and specialty handling

Otezla and related therapy packs are listed with Notes = PA; QL; SP, so prior authorization, quantity limits, and specialty handling apply to these PDE4 inhibitor products.

Opioid entries commonly have PA, QL, and AL

Multiple opioid products are listed with annotations such as AL (age/abuse limit), PA, and QL; prescribing or dispensing opioids without following these controls risks denial or coverage limitation.

• Some opioid formulations (e.g., fentanyl patch) show 'PA; QL' next to the entry
• Age/abuse limits (AL) may apply to certain codeine products

Methadone oral forms require PA and QL

Methadone oral formulations are shown with Notes = PA; QL, indicating prior authorization and quantity limits apply to methadone HCl oral concentrate, solution, and tablet.

Combination opioids and tramadol may need PA and QL

Several opioid combination products and tramadol ER entries include Notes indicating PA and/or QL requirements; providers should obtain any required prior authorization and adhere to quantity limits to avoid claim denials.

Testosterone products require PA and QL (some LD)

Multiple testosterone products (transdermal gels and other presentations) are listed with Notes = PA; QL (and some flagged as LD), so prior authorization and quantity limits apply when prescribing androgen/testosterone therapies.