Obtain prior authorization or request an exception

Prior authorization is required for certain drugs; prescribers must obtain approval before dispensing or submit a formulary/ tiering exception request with the prescriber's supporting medical rationale as described in the formulary exception process.

• If approval is not obtained, Medicare Plus Blue PPO may not cover the drug.

PA required for VOQUEZNA packs

Certain listed medications are designated 'PA' and require prior authorization before coverage—examples in this excerpt include VOQUEZNA dual and triple therapy packs which show QL(336 EA per 90 days) and PA.

• VOQUEZNA Dual Pak and Triple Pak: Requirements/Limits = QL(336 EA per 90 days); PA

PA required for LIBERVANT FILM, VALTOCO, vigabatrin, rufinamide

Multiple products list 'PA' in Requirements/Limits; examples include LIBERVANT FILM and VALTOCO which also have quantity limits—prescribers must obtain PA prior to dispensing to avoid denial.

• LIBERVANT FILM: QL(10 EA per 30 days); PA
• VALTOCO (all strengths listed): QL(10 EA per 30 days); PA
• vigabatrin: QL(186 EA per 31 days); PA
• rufinamide entries: PA (and QL on some strengths)

Submit PA documentation for drugs marked 'PA'

Numerous formulary rows are annotated 'PA'—prescribers must submit required prior authorization documentation per the plan for drugs marked PA to secure coverage.

• Examples across tables show many entries with 'PA' requiring pre-approval before the claim is covered.

PA required for oncology and specialty oral agents

Many oncology and specialty oral agents are shown with 'PA' (and often OVM); prescribers must obtain prior authorization prior to dispensing these high-cost agents.

• Examples: BRUKINSA, CABOMETYX, CALQUENCE, IMBRUVICA, IBRANCE — Requirements/Limits = PA; OVM

Adhere to specified quantity limits (QL)

Quantity limits (QL) are specified for many products; prescribers and pharmacies must follow the QL when prescribing and dispensing (claims may be denied or require override if QL is exceeded).

• Example QL values: LORBRENA 25mg = QL(93 EA per 31 days); ROZLYTREK 200mg = QL(93 EA per 31 days)
• See multiple product lines for exact QL entries (per-product QL must be respected)

Obtain PA for select products listed with 'PA'

Multiple other drugs in the formulary are flagged 'PA' in the Requirements/Limits column; prescribers must request prior authorization for those products before dispensing to avoid denial.

• Examples: FANAPT titration packs (PA), LIVTENCITY (PA), PREVYMIS (PA)

Follow table annotations (PA, ST, QL) when submitting PA

Table annotations mark some products with 'PA' and others with 'ST' or QL; prescribers must follow the Requirements/Limits shown (e.g., GLP-1 receptor agonists and select antidepressants carry PA or ST annotations).

• Liraglutide, MOUNJARO, OZEMPIC, RYBELSUS appear with PA in Requirements/Limits
• EXXUA and TRINTELLIX examples show ST (step therapy) in Requirements/Limits

PA required for concentrated insulin products

Concentrated insulin products and other insulin formulations may carry 'PA' in Requirements/Limits; prescribers must obtain prior authorization where shown.

• HUMULIN R U-500 (CONCENTRATED) INJECTION 500UNIT/ML — Requirements/Limits = PA
• HUMULIN R U-500 KWIKPEN — Requirements/Limits = PA

Obtain PA for select cardiovascular/lipid agents

Certain cardiovascular and lipid agents are labeled 'PA' and/or have QL entries; prescribers must obtain PA for drugs so marked before coverage (examples include NEXLETOL, NEXLIZET, PRALUENT, KERENDIA).

• NEXLETOL/NEXLIZET entries show PA and QL patterns
• PRALUENT injection = QL(2 ML per 28 days); PA
• KERENDIA = QL(90 EA per 90 days); PA

PA required when 'PA' is listed

Where 'PA' appears in the Requirements/Limits column, prior authorization is required prior to coverage; prescribers must secure authorization for those listed products to avoid claim denial.

• Examples in this segment include multiple drugs annotated with PA (NEXLETOL, NEXLIZET, PRALUENT, KERENDIA, VERQUVO, betaseron, fingolimod, glatiramer products)

PA required for OTEZLA and other listed agents

A range of agents (including OTEZLA formulations) are labeled 'PA' in Requirements/Limits; prescribers must obtain prior authorization before these products will be covered.

• OTEZLA XR 75MG — QL(31 EA per 31 days); PA
• XIFAXAN 550MG — QL(93 EA per 31 days); PA (where listed)

Request PA for genetic/enzyme disorder and depot products

Multiple listed products require prior authorization (PA) per their Requirements/Limits; examples include l‑glutamine packet and nitisinone—prescribers must request PA for those items.

• l‑glutamine packet 5gm = QL(180 EA per 30 days); PA
• nitisinone capsule = QL(24 EA per 90 days); PA
• GENOTROPIN, SOMATULINE DEPOT, lanreotide, leuprolide depot items = PA

PA required for specialty depot and hormonal agents

Many specialty and hormonal depot agents used in oncology/antagonist therapy are marked 'PA'—prescribers must obtain prior authorization prior to administration or dispensing.

• Examples: FIRMAGON, lanreotide acetate, leuprolide acetate, ORGOVYX, SOMATULINE DEPOT — Requirements/Limits include PA

PA required for specified GI and specialty injections

Some other specified products (e.g., budesonide ER tablet 9mg; JUBBONTI injection) list 'PA' in Requirements/Limits—prescribers must obtain prior authorization where indicated.

• budesonide ER tablet 9mg = PA
• JUBBONTI injection = QL(1 ML per 180 days); PA

Step therapy — try preferred agent first or request exception

Step therapy (ST) may require trying preferred drugs first; prescribers may request an exception by submitting clinical rationale and a supporting statement—plan decisions generally within 72 hours (24 hours if expedited).

• If the prescriber documents that the preferred alternative is ineffective or causes adverse effects, an exception may be granted.
• Standard decision timeframe: 72 hours; expedited (fast) decisions: 24 hours when clinically necessary.

Follow step therapy for EXXUA and TRINTELLIX

Some products are explicitly marked 'ST' (step therapy) in Requirements/Limits—examples include EXXUA and TRINTELLIX; prescribers must follow step therapy rules where indicated or request an exception with supporting rationale.

• EXXUA: Requirements/Limits = QL(...); ST
• TRINTELLIX: Requirements/Limits = QL(...); ST

Step therapy applies to febuxostat

Certain products include 'ST' in Requirements/Limits (e.g., febuxostat) indicating step therapy applies; prescribers should document prior trials or submit an exception request if clinically appropriate.

• febuxostat tablet 40mg, 80mg = QL(90 EA per 90 days); ST

RYTARY formulations include QL and ST requirements

Some RYTARY entries list both QL and ST in Requirements/Limits—prescribers must comply with step therapy requirements and quantity limits or provide documentation supporting medical necessity.

• RYTARY extended-release formulations: QL(300–360 EA per 30 days) or QL(360 EA per 30 days); ST

Step therapy applies to select antipsychotics and LAIs

Selected antipsychotics and long-acting injectables are designated with 'ST' in Requirements/Limits; prescribers must document prior treatment steps or request an exception with clinical justification.

• Examples: ABILIFY ASIMTUFII, ABILIFY MAINTENA, ARISTADA, INVEGA SUSTENNA/TRINZA, REXULTI, VRAYLAR, ZYPREXA RELPREVV—many entries show ST and QL

No explicit step therapy rules in this excerpt

No explicit step therapy sequences or step order rules are provided in this extracted portion of the formulary; where ST appears on product lines, follow the product-level note or request an exception.

• When no explicit sequence is present in the excerpt, rely on product Requirements/Limits or contact the plan for step details.

Branded products may be subject to step edits

Branded products in this segment may be subject to step edits even when explicit step rows are not shown; prescribers should check the product Requirements/Limits and submit PA/exception documentation as needed.

• If unsure whether ST applies, include prior-treatment history in PA/exception requests.

PA and QL are primary controls when step sequences absent

This excerpt does not provide explicit step therapy sequences; prior authorization and quantity limits are the primary utilization controls—prescribers should follow PA/QL requirements or request an exception with supporting rationale.

• When ST is not specified, focus on meeting PA and QL requirements shown for each product.

Follow PA/QL when ST not specified

Many product rows show PA and QL tags but do not list step therapy; prescribers must meet the PA and QL requirements listed or provide documentation when requesting an exception.

• Examples: multiple products across genitourinary and GI sections show PA and QL without explicit ST sequencing

PA and QL are enforceable where ST not listed

This segment primarily shows PA, QL, OVM, B/D and other requirement tags on product rows; where ST is absent, PA and QL remain the enforceable provider actions.

• Refer to the introduction pages for full definitions of these symbols when preparing PA/exception requests.

Comply with ST for products explicitly marked 'ST'

Some products are labeled 'ST' in the Requirements/Limits column (e.g., ROCKLATAN and ALCOHOL PREP PADS); prescribers must comply with step edits where indicated or submit supporting rationale for an exception.

• ROCKLATAN = ST; ALCOHOL PREP PADS = ST (as shown in Requirements/Limits)

Provide prescriber supporting statement; expect 72-hour standard decision

When requesting a tiering or formulary exception, the prescriber's supporting statement is required; the plan generally makes a decision within 72 hours for standard requests and within 24 hours if expedited.

• Prescribers should explain medical reasons why exception is necessary and submit supporting clinical documentation.
• Standard decision timeframe: 72 hours; expedited decisions: 24 hours.

Reference Formulary ID/Version/Effective Date on requests

Use the formulary identifiers when submitting requests: Formulary ID 26449, Version 17, Effective Date 06/01/2026.

• Include Formulary ID and Version/Effective Date on PA/exception correspondence when possible.

Follow defined formulary symbols (PA, QL, ST, B/D, OVM)

Follow the formulary symbol definitions when preparing claims and authorization requests—PA = prior authorization; QL = quantity limit; ST = step therapy; B/D and OVM meanings are in the introduction pages.

• Refer to the introduction pages of the formulary for exact symbol definitions.

Meet Requirements/Limits fields shown on product lines

Formulary entries include Requirements/Limits fields such as PA, QL, ST, B/D and OVM; prescribers must satisfy or document adherence to those requirements when seeking coverage or submitting authorizations.

• Provide medical necessity documentation when PA is required or when requesting QL overrides.

Include supporting medical documentation for PA/QL/ST requests

When a product is flagged with PA, QL, or ST, prescribers must include supporting documentation of medical necessity in the PA or exception request; the formulary notes these documentation expectations though specific forms are not included in this excerpt.

• Include clinical rationale and prior-treatment history where applicable to support exceptions to PA/ST/QL.

Adhere to PA/QL/ST on flagged prescriptions

Prescriptions flagged with PA, QL(...), or ST require adherence to the listed prior authorization, quantity limits, or step therapy rules as specified in the formulary; failure to meet these may result in denial.

• If a claim is submitted without required PA or exceeds QL, it may be denied or require an override.

Respect specified quantity limits when prescribing/dispensing

Quantity limits are specified for many products and must be respected in dispensing and claims (examples include dabigatran QL(180 EA per 90 days), ELIQUIS starter pack QL(148 EA per 365 days), and rivaroxaban suspension QL(2700 ML per 90 days)).

• Verify QL values on the product line before authorizing fill quantities.

Use product Requirements/Limits to prepare PA/exception submissions

Formulary rows list drug name, strength, tier, and Requirements/Limits (e.g., QL or PA) which providers should use to support coverage decisions and when preparing PA/exception requests.

• Use the listed Requirements/Limits as the source for PA/QL/ST compliance and documentation.

Provide medical necessity documentation for PA/QL

Where the formulary entry lists 'PA' and/or a QL, prescribers should provide documentation supporting medical necessity when submitting a prior authorization or exception request.

• Include clinical notes showing prior therapy, response, or contraindications to preferred alternatives when relevant.

Include clinical evidence with PA/QL requests (specifics per plan processes)

Formulary entries include QL and PA flags but specific required documentation fields are not detailed in this excerpt; prescribers should follow plan instructions for PA submissions and include supportive medical evidence.

• When in doubt, include relevant clinical history, diagnoses, and prior-treatment records with the PA request.

Supply documentation supporting PA for products with PA/OVM

Formulary product rows specify Requirements/Limits such as PA, QL, and OVM; providers should supply documentation supporting PA when required and follow the listed limits to avoid denials.

• Examples: PROLASTIN‑C, REVCOVI, sapropterin entries list PA; include relevant clinical justification for these agents.

Comply with product-specific Requirements/Limits (PA/QL/OVM/B/D)

Formulary rows include assorted instructions (PA, QL, OVM, B/D, Prefilled Syringe notes); providers must meet these requirements when submitting for coverage or administrating therapy.

• Check each product's Requirements/Limits field for any special handling or site-of-care indications.

Respect QL values in dispensing and claims

Quantity limit entries in the formulary (e.g., QL(1080 EA per 90 days), QL(360 EA per 90 days)) must be respected in dispensing claims; exceeding QL may trigger denial or require an override/PA.

• Pharmacists should confirm allowed quantities prior to dispensing multi-month supplies.

Denial risk if PA not obtained

Failure to obtain required prior authorization may result in the plan not covering the drug; prescribers must secure PA or request an exception with supporting clinical rationale.

• If PA is denied or not obtained, the claim may be denied and the member may be financially responsible.

PA and QL indicators require compliance

PA and QL indicators are present across many entries (e.g., VOQUEZNA, multiple anticonvulsant specialty products); prescribers must obtain PA and adhere to QLs where shown to avoid denial.

• Examples: VOQUEZNA packs = QL + PA; multiple anticonvulsant formulations show PA and QL flags.

PA + QL entries can trigger denial without compliance

Products listed with both 'PA' and 'QL' may be denied if prior authorization is not obtained or if the requested quantity exceeds the QL; include justification when requesting overrides.

• Example: LIBERVANT FILM shows QL(10 EA per 30 days); PA — requests exceeding this must be justified.

Verify PA/OVM requirements to avoid denial

Many formulary agents require prior authorization and other limits (OVM); failure to obtain PA may trigger coverage denial—prescribers should verify Requirements/Limits before prescribing.

• Confirm PA/OVM requirements for oncology and specialty oral agents prior to initiating therapy.

Denial risk if PA/QL/ST requirements not met

Requests may be denied if the listed utilization controls (PA, QL, ST) are not met for specific products; prescribers should document compliance or provide medical rationale when requesting exceptions.

• Include prior-treatment history and intolerance or contraindication evidence to support exception requests.

PA indicated for GLP‑1 receptor agonists

Some GLP‑1 receptor agonists and other high-cost agents are annotated 'PA' in the Requirements/Limits field—prescribers must obtain prior authorization for these products (e.g., liraglutide, MOUNJARO, OZEMPIC, RYBELSUS).

• Liraglutide injection = QL(27 ML per 90 days); PA
• MOUNJARO, OZEMPIC, RYBELSUS entries show QL and PA

PA required for select concentrated insulin products

Concentrated insulin coverage may be restricted—HUMULIN R U‑500 products list 'PA' in Requirements/Limits; prescribers must obtain prior authorization for these concentrated insulin formulations.

• HUMULIN R U‑500 (Concentrated) Injection 500UNIT/ML = Requirements/Limits: PA

PA required for select hematology/oncology supportive agents

Some hematology/oncology supportive agents are marked PA and may include OVM; prescribers must request prior authorization and follow any site-of-care or administration instructions.

• Examples: FULPHILA, NEULASTA ONPRO, NEULASTA — Requirements/Limits = PA; OVM

Obtain PA for listed lipid/cardiovascular agents

Drugs labeled 'PA' (e.g., NEXLETOL, NEXLIZET, PRALUENT, KERENDIA) require prior authorization; claims submitted without the required authorization may be denied or not covered.

• PRALUENT injection: QL(2 ML per 28 days); PA
• KERENDIA: QL(90 EA per 90 days); PA

PA is required where shown in Requirements/Limits

Where entries include 'PA' in Requirements/Limits, coverage will require prior authorization; prescribers must secure approval to avoid denial.

• Multiple specialty injectables and depot products in this section show PA in Requirements/Limits.

Confirm and obtain PA for PA‑flagged drugs

Prior authorization is required for many formulary agents; claims submitted without required PA may be denied—prescribers should confirm PA needs and submit authorization requests before dispensing.

• Check each product's Requirements/Limits for PA indicators prior to initiating therapy.

PA and QL apply to OTEZLA formulations

Some products (e.g., OTEZLA formulations) are labeled with QL and PA; prescribers must obtain prior authorization and adhere to the QL for these agents.

• OTEZLA tablet 20/30mg = QL(62 EA per 31 days); PA
• OTEZLA XR 75mg = QL(31 EA per 31 days); PA

Obtain PA for listed specialty/genetic disorder agents

Multiple products in this segment are listed with PA; prescribers must obtain prior authorization per the Requirements/Limits column before coverage will be provided.

• Examples include genetic disorder agents, growth hormones, depot somatostatin analogs—many require PA.

Document prior-step therapy or request exception for ST products

Some products are explicitly marked 'ST' and require a prior step before coverage; prescribers should document prior use of preferred agents or request an exception with supporting clinical evidence.

• When requesting exceptions to ST, include documentation that preferred drug trial failed or was not tolerated.

ST applies to EXXUA and TRINTELLIX

EXXUA and TRINTELLIX are examples of products marked 'ST'—prescribers must follow step therapy rules indicated in the formulary or submit an exception with rationale.

• EXXUA Requirements/Limits = QL(...); ST
• TRINTELLIX Requirements/Limits = QL(...); ST

Step therapy flag on febuxostat requires prior-step evidence

Some products include 'ST' in Requirements/Limits (e.g., febuxostat), indicating step therapy requirements apply; prescribers must show trial of preferred therapy or request an exception.

• febuxostat entries show QL(...) and ST—document prior therapy as needed.

RYTARY entries include ST — document prior steps or request exception

Some RYTARY formulations list ST alongside QL; prescribers must follow step therapy requirements or provide supporting documentation for an exception.

• RYTARY extended-release entries show QL and ST—include prior-treatment history when submitting PA/exception.

ST applies to selected long‑acting injectables and antipsychotics

Certain long-acting injectable antipsychotics and oral agents are designated 'ST' in Requirements/Limits; prescribers must demonstrate prior use of preferred agents or request an exception with clinical rationale.

• Examples: ARISTADA, INVEGA SUSTENNA/TRINZA, ABILIFY ASIMTUFII, REXULTI — many show ST and QL