Prior Authorization required

Prior authorization is required for drugs marked "PA" in the formulary; obtain plan approval before dispensing or the plan may not cover the drug.

• Examples in the formulary include ARIKAYCE Suspension (Requirements/Limits = PA) and many specialty agents flagged PA.

Prior authorization

Obtain prior authorization per the plan's Requirements/Limits for products labeled "PA"; lack of approval may lead to noncoverage.

• Prescribers must follow the PA process described in the plan materials and may be asked to submit clinical justification, diagnosis, and quantity information.

PA required for select specialty/high-tier drugs

For high‑tier and specialty products flagged "PA" (e.g., ARIKAYCE, VOQUEZNA), submit prior authorization prior to dispensing because these products require plan approval.

• VOQUEZNA dual/triple pak: Requirements/Limits = QL(336 EA per 90 days); PA.
• ARIKAYCE Suspension 590mg/8.4mL: Requirements/Limits = PA.

PA required for selected formulary items

Obtain prior authorization for formulary items marked "PA"; multiple products across therapeutic areas in the formulary are PA‑flagged and require approval before coverage.

• Examples include brivaracetam products (QL and PA), EPIDIOLEX (QL; PA) and many anticonvulsant listings with PA noted.

Prior authorization required (examples)

Prior authorization is required for medications annotated with "PA" in the Requirements/Limits column; follow the plan PA procedures before filling.

• Examples in this excerpt: AUVELITY, EXXUA, ZURZUVAE and other listed agents with PA flags.

Prior authorization required (multiple listed drugs)

Multiple listed drugs include a "PA" flag; providers must obtain prior authorization per each product's Requirements/Limits prior to coverage.

• Selected oncology and targeted agents (e.g., VALCHLOR Gel, ZEPZELCA, ROZLYTREK, RUBRACA) show PA and often OVM requirements.

PA required for flagged drugs (LYBALVI example)

Products flagged with PA and a QL (e.g., LYBALVI) require submission of prior authorization and adherence to the stated quantity limit for coverage.

• LYBALVI Tablet: Requirements/Limits = QL(30 EA per 30 days); PA.

Antivirals and specialty agents requiring PA

Antivirals and other specialty antiviral agents shown with "PA" require prior authorization before coverage; submit supporting documentation per PA process.

• Examples include LIVTENCITY, PREVYMIS, MAVYRET, VOSEVI and selected coronavirus antivirals with QLs and PA.

Prior authorization required for select agents (liraglutide example)

Certain GLP‑1 and related antidiabetic agents are marked with PA and specific ML QLs; obtain prior authorization and document quantity requested.

• liraglutide injection: QL(27 ML per 90 days); PA.
• MOUNJARO injection: QL(2 ML per 28 days); PA.

Prior authorization required for select specialty agents

Select specialty agents and topical products in this section carry a "PA" requirement; secure prior authorization per the formulary entry prior to dispensing.

• EUCRISA ointment and EBGLYSS injection list QLs and PA; deferasirox products shown with PA.

Prior authorization required for select products (PRALUENT/VERQUVO examples)

Certain high‑cost specialty products (examples: PRALUENT, VERQUVO) are indicated with "PA" and specific QLs; submit PA and respect the stated quantity limits.

• PRALUENT Injection: QL(2 ML per 28 days); PA.
• VERQUVO Tablet 10mg: QL(30 EA per 30 days); PA.

Prior authorization required (PRALUENT, VERQUVO examples)

Drugs labeled "PA" require prior authorization before coverage; review each product's Requirements/Limits and submit PA documentation when present.

• Examples include PRALUENT and multiple specialty cardiology and oncology agents with PA flags.

Prior authorization required (topical and others)

Topical dermatologic agents and other listed products showing QL/PA must follow stated PA and quantity controls; obtain PA when the Requirements/Limits column lists "PA".

• EUCRISA ointment: Requirements/Limits include QL and PA; clobetasol and other topicals show QLs which must be observed.

PA for select electrolyte/modifier agents

Electrolyte/mineral modifiers such as deferasirox and tolvaptan are indicated with PA (and QL); secure prior authorization and adhere to quantity limits.

• deferasirox tablet formulations: Requirements/Limits = PA.
• tolvaptan tablet 15mg (generic Jynarque): QL(124 EA per 31 days); PA.

Prior authorization required for listed PA drugs

Multiple agents in the extract are shown with a "PA" flag; providers must request prior authorization per each product's Requirements/Limits prior to coverage.

• Examples across sections include trientine, AURYXIA, ferric citrate and many specialty/orphan drugs requiring PA.

Prior authorization required for listed products (tadalafil/growth hormones examples)

Some listed products (e.g., tadalafil 2.5mg/5mg, growth hormone/fertility agents) require prior authorization; check the Requirements/Limits column and submit PA if shown.

• tadalafil 2.5mg: QL(180 EA per 90 days); PA.
• GENOTROPIN injections: Requirements/Limits = PA.

Step therapy requirement

When a product is marked "ST" (step therapy) in the formulary, the member must try the required preferred agent(s) first and the provider must document trial/failure or request an exception.

• Step therapy examples in the formulary include EXXUA titration pack and TRINTELLIX tablets which are annotated ST.

Step therapy

If a drug line includes the "ST" flag, follow the plan's step‑therapy sequence; document trial and failure of required agent(s) or submit an approved exception.

• EXXUA Titration Pack: Requirements/Limits = QL(32 EA per 14 days); ST.
• TRINTELLIX tablets: Requirements/Limits include ST designation.

Step therapy (placeholder/empty label)

Medications annotated "ST" require the plan's step‑therapy sequence to be met prior to coverage; providers must document prior therapy or request an exception.

• Examples: EXXUA products (ST); TRINTELLIX tablets (ST).

Step therapy (placeholder/empty chunk_indices)

Medications with "ST" flagged in the formulary require that the member try the specified preferred agent(s) first; submit documentation of trial/failure or an exception request for coverage.

• INVEGA SUSTENNA and PERSERIS injections are also listed with ST where applicable.

Step therapy required (EXXUA/TRINTELLIX examples)

Step therapy applies to products marked "ST"; document prior use of preferred agents or request a formulary/tiering exception with prescriber rationale when necessary.

• PANCREAZE entries show ST for certain strengths; providers must follow the ST requirement for coverage.

Utilization management note (OVM present)

Some oncology agents include an OVM flag in addition to PA; follow the Oncology Value Management process (OncoHealth) and submit required documentation for PA/OVM as indicated.

• Many antineoplastics list Requirements/Limits = PA; OVM and require submission through the Oncology Value Management program.

Step therapy required for ST-flagged drugs (Invega/Perseris examples)

ST‑flagged antipsychotic long‑acting injectables and related products require step therapy where shown; obtain documentation of required prior therapy or submit an exception.

• INVEGA SUSTENNA injections and PERSERIS injection: Requirements/Limits include ST and QLs.

Step therapy not specified in this segment

No explicit step‑therapy algorithm is provided in this extract; where ST is listed, follow the formulary's step requirements and document trials or request exceptions.

• The introduction pages and plan PA/ST documents provide procedural details for exceptions and step therapy.

Exception supporting documentation required

When requesting an exception (formulary or tiering), the prescriber must provide a supporting statement explaining medical reasons; the plan typically decides within 72 hours of receiving the prescriber's statement (24 hours for expedited requests).

• Prescriber supporting statement is required to request waiving PA, ST, or QL; timelines: 72 hours standard, 24 hours expedited if requested and approved.

B/D documentation (Part B vs Part D determination)

For drugs that may be covered under Part B or Part D, submit information describing the drug’s use and setting (B/D documentation) so the plan can determine appropriate coverage.

• The B/D designation in the formulary indicates additional information may be required to adjudicate coverage under Part B vs Part D.

Quantity limits documented (buprenorphine/naloxone, naloxone examples)

Adhere to stated quantity limits (QL) when dispensing products; for QL‑flagged drugs (e.g., buprenorphine/naloxone, naloxone, many others) provide quantities consistent with the QL or obtain PA to exceed limits.

• Buprenorphine/naloxone tablet QLs: QL(360 EA per 90 days) or QL(630 EA per 90 days) depending on strength.
• KLOXXADO liquid: QL(12 EA per 90 days).

Prior authorization documentation (examples)

When a formulary entry lists "PA" in Requirements/Limits, providers must submit prior authorization documentation (clinical justification, diagnosis, and quantity) per the plan’s PA process before the drug will be covered.

• Examples: brivaracetam listings require QLs and PA; the plan's prior authorization procedures are referenced in the introduction material.

PA process reference

Use the plan's prior authorization process for items marked "PA"; follow the procedural instructions in the formulary introduction and submit requested supporting documentation.

• Refer to the introduction pages for symbols/abbreviations and to the plan's PA process for required submission details.

Formulary requirements (Requirements/Limits fields)

Formulary entries list Requirements/Limits fields (PA, QL, ST); providers must meet these per‑drug requirements when submitting claims or prior authorization requests.

• Check each product line in the formulary for its specific Requirements/Limits and follow those controls.

Supporting documentation for PA

Prescribers and pharmacies must supply documentation to support PA requests for drugs flagged "PA" in the formulary; this includes clinical justification and evidence of prior therapies where applicable.

• Products flagged PA (e.g., LYBALVI, eltrombopag, PROCRIT) require submission of clinical justification and quantity information.

Refer to introduction for symbols/abbreviations

Refer to the formulary introduction pages for the definitions of symbols and abbreviations (PA, QL, ST, EX, OVM, B/D) and for guidance on documentation standards for authorization requests.

• The introduction explains code meanings and procedural expectations for PA/ST/QL documentation.

Documentation for PA

When a product's Requirements/Limits show "PA" or a QL, submit prior authorization documentation consistent with the plan's requirements (clinical rationale, diagnosis, and quantity) to avoid denial.

• Products such as eltrombopag, PRALUENT, and VERQUVO list PA and QLs — documentation must support the request to obtain coverage.

Quantity limits present (operational note)

Quantity limits (QL) shown in the formulary specify maximum units per time period; do not exceed QLs without obtaining prior authorization to avoid claim adjustment or denial.

• Examples: QL(180 EA per 90 days), QL(2 ML per 28 days), QL(31 EA per 31 days).

Documentation for PA/QL (providers should supply consistent documentation)

When a product lists QL or PA, providers should submit consistent documentation (prescription details, clinical justification, and quantity) with the PA request to support coverage.

• Adhering to stated QLs and providing required PA documentation reduces risk of denial.

Provide PA and respect QL

Providers must obtain prior authorization where indicated and adhere to quantity limits; failure to do so may result in the plan not covering the drug or claims being denied.

• This is emphasized throughout the formulary: PA is required before filling certain drugs and absence of approval may lead to noncoverage.

Prior Authorization denials risk

Failure to obtain required prior authorization or to meet listed Requirements/Limits may result in coverage denial; obtain PA and document compliance with QLs/ST to avoid denials.

• The formulary states that drugs requiring PA will not be covered without approval and that missing PA may lead to denial.

Prior Authorization requirement (denial risk emphasis)

If prior authorization is required and not obtained, the plan may deny coverage for the drug; always verify PA status before dispensing PA‑flagged products.

• The plan explicitly states lack of approval may result in the plan not covering the drug.

Prior authorization / Exclusion flags present (examples)

PA, EX, and OVM flags in the formulary indicate coverage controls; drugs with these flags (e.g., ARIKAYCE, VOQUEZNA, products marked EX) require attention to PA or may be excluded/denied when criteria are unmet.

• ARIKAYCE Suspension: Requirements/Limits = PA.
• VOQUEZNA packs: QL(...) and PA.
• Entries marked EX are not normally covered.

PA requirement implies denial risk

Requests for drugs listed with 'PA' and without meeting PA requirements may be denied; ensure PA is approved before dispensing.

• The formulary warns that requests for PA‑flagged drugs not meeting requirements may be denied.

PA/QL triggers (denial risk)

Drugs flagged with PA and/or QL may be denied if authorization is not obtained or quantity limits exceeded; check each product's Requirements/Limits to determine necessary actions.

• Example: LYBALVI shows QL(30 EA per 30 days) and PA — both must be addressed when requesting coverage.

PA/EX/OVM triggers (denial/exclusion implications)

Drugs with PA, QL, or EX flags may trigger denials if PA is missing, QLs are exceeded, or exclusion criteria apply; ensure required authorizations or exceptions are in place.

• Examples include meprobamate (PA), deferasirox (PA), tolvaptan (QL and PA), and products marked EX.

Denial risk for missing PA or exceeding QL

Prescriptions lacking required prior authorization where the formulary lists "PA" (or exceeding stated QLs) risk being denied; obtain PA or file an exception before dispensing to avoid coverage denial.

• Examples called out: tadalafil tablets and testosterone pump gels may be denied without PA or if QLs are exceeded.

BIOSIMILAR (plan may substitute interchangeable biosimilars)

The plan may substitute an interchangeable biosimilar for an original biological product and change coverage or tiering; pharmacies may substitute interchangeable biosimilars per state law without a new prescription.

BIOSIMILAR (plan may substitute interchangeable biosimilars)

Plan may immediately add interchangeable biosimilars and change coverage or tiering of the original biological product; substitutions follow state law and may be made without a new prescription.