Prior authorization required for specified drugs — overview

Certain drugs listed on the formulary require prior authorization (PA) from the plan before the prescription will be covered. Providers must obtain plan approval when the Requirements/Limits column for a product includes the PA flag; failure to obtain PA may result in noncoverage.

• PA = Prior Authorization required before filling the prescription; lack of approval may result in noncoverage (see introduction/definitions).

Prior authorization required — example ARIKAYCE marked PA

ARIKAYCE Suspension 590mg/8.4mL is listed with Requirements/Limits = PA; providers must submit a prior authorization request to the plan for coverage of ARIKAYCE.

• ARIKAYCE SUSPENSION 590MG/8.4ML — Requirements/Limits = PA

Prior authorization and quantity limits present — providers must submit PA requests and adhere to QL

Many formulary entries combine prior authorization (PA) and explicit quantity limits (QL); providers must submit PA requests where indicated and ensure requested quantities do not exceed the listed QL values.

• Examples: IMPAVIDO QL(84 EA per 28 days); linezolid suspension QL(1680 ML per 28 days); VOQUEZNA packs QL(336 EA per 90 days) with PA.

Prior authorization required — multiple products include 'PA' in Requirements/Limits

Multiple product rows in the formulary include 'PA' in the Requirements/Limits column, indicating prior authorization is required before coverage; providers should follow the plan's PA process for those products.

• PA appears alongside many high-tier and specialty products in the formulary table.

Prior authorization required for specific listed drugs — PA flags in Requirements/Limits

Selected listed drugs explicitly show 'PA' in the Requirements/Limits field (for example, DRIZALMA, FETZIMA, TRINTELLIX and several antifungals/antineoplastics); providers must obtain prior authorization for these specific products per the formulary.

• Examples include DRIZALMA entries with QL and PA; voriconazole and posaconazole entries marked PA.

Prior authorization indicated on multiple products; specific PA criteria not provided in these chunks

Numerous formulary rows are flagged PA but the extract does not include the detailed clinical PA criteria; providers must submit PA requests using the plan's PA process and supply supporting documentation as requested.

• PA is shown on many lines without full clinical criteria in this extract; follow the plan's prior authorization program for required information.

Prior authorization required — multiple listed drugs require PA

Multiple high-tier and specialty agents are annotated with PA in the formulary (e.g., eltrombopag formulations, PROCRIT, VOYDEYA, ZARXIO); providers must obtain prior authorization before dispensing these products to ensure coverage.

• Examples: eltrombopag olamine packet/tablet entries include QL and PA; PROCRIT injections list PA.

Prior authorization required for select drugs — providers must submit PA per plan rules

For select formulary drugs marked PA, providers must submit a prior authorization request per plan rules; absence of an approved PA may lead to claim denial at time of adjudication.

• PA flags appear next to many specialty products — obtain authorization before dispensing.

PA required for select formulary drugs — examples include liraglutide injection and others

Several GLP‑1 / antidiabetic and weight‑loss injectables and oral GLP‑1 products are listed with PA (examples include liraglutide injection, MOUNJARO, OZEMPIC, RYBELSUS); providers must obtain prior authorization for those products as indicated.

• liraglutide injection 6mg/mL — Requirements/Limits = QL(27 ML per 90 days); PA
• MOUNJARO and OZEMPIC entries include QL and PA requirements

PA required for listed products — examples include eltrombopag formulations

Eltrombopag formulations are listed with both quantity limits and PA (e.g., packet and tablet forms); providers must request prior authorization and adhere to the stated QL when prescribing eltrombopag.

• Eltrombopag olamine packet 25mg — QL(186 EA per 31 days); PA

PA required for select tier 3-4 specialty drugs (examples: NEXLETOL, PRALUENT, VERQUVO)

Several tier 3–4 specialty agents are annotated with PA (for example NEXLETOL, PRALUENT, VERQUVO); providers must obtain prior authorization prior to dispensing these higher‑tier specialty drugs.

• NEXLETOL, NEXLIZET, PRALUENT, VERQUVO entries include PA in Requirements/Limits.

PA required for select agents — list includes many high-tier/specialty agents

A broad list of high‑tier and specialty agents throughout the formulary carry PA flags; for these agents providers must submit PA requests via the plan’s authorization process to secure coverage.

• Examples include VERQUVO tablets and multiple specialty injectable agents noted with PA.

Prior authorization required — indicated in formulary table

The formulary table includes PA annotations on many product lines; when a product shows PA in Requirements/Limits, providers must obtain prior authorization before filling to avoid coverage denial.

• Refer to each product row for PA flag and follow plan prior authorization procedures.

Prior authorization required for selected high-tier drugs (e.g., GATTEX, MYALEPT)

Selected high‑tier specialty agents (e.g., GATTEX, MYALEPT) are shown with PA in the Requirements/Limits column; providers must obtain PA for these products as specified in the formulary.

• GATTEX and MYALEPT entries include PA and other utilization flags.

PA required for selected specialty and high-tier agents — examples provided

Multiple specialty and high‑tier agents are annotated with PA (examples include octreotide injections, ORGOVYX, RECORLEV); providers must secure prior authorization per the formulary to ensure coverage.

• Octreotide acetate injection entries — Requirements/Limits = PA; OVM

Step therapy requirements — overview

Step therapy (ST) may require trying one or more specified drugs first before the plan will cover an alternative; providers should check the Requirements/Limits column for an ST flag and follow the plan's step therapy process.

• ST = Step Therapy: plan may require trying a specified drug first before covering another.

Step therapy (ST) — plan may require preferred drug trial first

The formulary uses the ST flag to indicate step therapy; when ST appears for a product, the plan may require a trial of a preferred agent before covering the listed drug.

• Example: EXXUA entries show ST alongside QL indicating step therapy applies.

Step therapy present — EXXUA examples marked 'ST'

Some specialty products include 'ST' in Requirements/Limits (for example EXXUA titration pack and EXXUA product lines); providers must follow the step therapy requirement indicated in the formulary when seeking coverage.

• EXXUA TABLET EXTENDED RELEASE entries — Requirements/Limits = QL(...); ST

Step therapy indicated for select drugs (febuxostat, FETZIMA, TRINTELLIX)

Certain products are annotated with ST (e.g., febuxostat, FETZIMA, TRINTELLIX), indicating the plan requires step therapy prior to coverage; providers should submit documentation of prior trials when requesting coverage of the nonpreferred drug.

• FETZIMA entries show QL and PA and ST for some formulations; febuxostat entries list ST.

OVM noted — oncology utilization management noted for some agents

Several oncology and other agents are subject to Oncology Value Management (OVM) in addition to PA; providers may need to follow the OVM process for authorization of these agents.

• OVM appears alongside PA for many antineoplastics and oncology supportive care drugs.

Step therapy applies to some long-acting injectables and specialty agents

Step therapy flags apply to several long‑acting injectables and specialty agents (e.g., ARISTADA, INVEGA series, REXULTI) — when ST is indicated providers must document prior use of required agents per the plan's step therapy rules.

• ARISTADA, INVEGA HAFYERA/INVEGA SUSTENNA/INVEGA TRINZA entries include QL and ST.

Step therapy applies to selected agents — antipsychotics and injectables marked 'ST'

Selected antipsychotics, long‑acting injectables and other specialty agents are marked ST in the Requirements/Limits column; providers must follow the plan's step therapy sequence (trial of required agents) before the plan will cover the listed product.

• REXULTI, PERSERIS, risperidone/injectable antipsychotic entries show ST and QL.

Step therapy not listed in extract — absence of explicit ST sequences

This extract does not include explicit step therapy sequences or detailed step‑by‑step algorithms; absence of step order in these pages means providers must consult the plan's PA/ST documentation or contact the plan for the required sequence.

• No explicit step therapy steps/sequences are provided in this excerpt.

Step therapy not specified — products annotated with PA/QL but no sequences

Many products in the extract are annotated with PA and/or QL but do not show ST sequences; when ST is not specified, providers must still follow PA and QL requirements as listed and contact the plan for any step therapy details.

• Products annotated with PA/QL but lacking ST sequences require PA or QL adherence; check plan resources for ST details.

Step therapy (ST) on select products — PANCREAZE example

PANCREAZE capsule strengths are listed with 'ST' in Requirements/Limits — providers must follow the plan's step therapy requirement for coverage of specific PANCREAZE strengths.

• PANCREAZE CAPSULE DELAYED RELEASE PARTICLES — Requirements/Limits = ST

Exception request documentation — prescriber must provide supporting medical reasons; decision timeframe 72/24 hours

When requesting an exception (formulary/tiering or to waive PA/ST/QL), the prescriber must provide supporting medical reasons; the plan will decide within 72 hours for standard requests and within 24 hours for expedited requests when warranted.

• Prescriber must explain medical reasons and provide supporting statement.
• Standard decision timeframe = 72 hours; expedited = 24 hours if criteria met.

B/D documentation — Part B vs Part D determination may require supporting info

Some entries are labeled B/D (benefit/dispense or Part B/Part D designation); providers may need to submit information describing the drug's use and setting to determine Part B versus Part D coverage.

• B/D flag indicates coverage determination may require additional information about setting/use.

PA/QL documentation note — PA and QL entries require supporting documentation

Formulary rows that include PA and/or QL indicate that prior authorization documentation and adherence to quantity limits must be provided when requesting coverage; providers should submit clinical supporting documentation with PA/QL requests.

• Submit diagnosis, dose, quantity requested, prior therapy and medical rationale when seeking PA/QL exceptions.

Documentation for PA/NDS — prescribers should supply diagnosis, dose, quantity, and rationale

When Requirements/Limits list PA or NDS, prescribers should supply supporting documentation per the plan's PA process (including diagnosis, dose, quantity, prior therapy) to meet authorization criteria.

• NDS = Non-Extended Day Supply; when NDS or PA appears, include rationale for requested supply/days.

Follow plan-specified PA/QL/ST rules — symbols PA/QL/ST/OVM appear in Requirements/Limits

Providers must follow the plan‑specified Requirements/Limits codes (PA, QL, ST, B/D, OVM) shown in the formulary rows; prescribing or dispensing must comply with these plan rules to obtain coverage.

• Check the introduction pages for symbol definitions and follow plan PA/QL/ST/OVM processes.

Reference to legend for symbol meanings — introduction pages contain abbreviations

The formulary introduction pages define the abbreviations used in the Requirements/Limits column (e.g., PA, QL, ST, OVM); providers should reference those introduction pages for official definitions.

• See introduction for PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; OVM = Oncology Value Management.

Supporting documentation for QL/ST — injectables and specialty products require documentation

Some injectable and specialty products that carry QL or ST flags require supporting documentation of medical necessity, dosing frequency, and prior therapy when seeking authorization; include such documentation with PA requests.

• Examples: injectable long‑acting antipsychotics and specialty injectables list QL and ST and typically require supporting documentation.

PA noted for select insulins — concentrated insulins may require PA

Concentrated insulin products such as HUMULIN R U‑500 are listed with PA; providers must submit prior authorization documentation for these insulin formulations before coverage will be approved.

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

Documentation hints — injectable biologics marked PA/OVM require additional review

Injectable biologics and supportive agents marked with PA and/or OVM often require additional documentation or on‑site verification/management review at authorization; providers should include required clinical and site‑of‑care details with PA submissions.

• NEULASTA / NEULASTA ONPRO entries — Requirements/Limits = PA; OVM

Align dispensing with QL — ensure dispensed amount matches QL entries

Prescribers and pharmacies should ensure dispensed amounts align with the formulary quantity limits (QL) shown for each product; requests that exceed the stated QL may be denied or require an override/exception.

• Example QLs to follow when dispensing: QL(180 EA per 90 days), QL(31 EA per 31 days), QL(360 GM per 90 days).

Submit PA and respect QL — items marked PA/QL require prior authorization and adherence to limits

For products annotated with PA and/or QL, providers must submit the required prior authorization and supporting clinical documentation; failure to obtain PA or to adhere to QL may result in denial of coverage at claim adjudication.

• Not obtaining required PA may result in the plan not covering the drug.
• Claims exceeding QL without authorization may be denied.

PA documentation examples — calcipotriene, deferasirox examples

Examples in the formulary show PA documentation is required for specific products (e.g., calcipotriene topical formulations, deferasirox, AURYXIA, tolvaptan, trientine); providers should include clinical rationale and requested quantity when submitting PA requests.

• CALCIPOTRIENE OINTMENT/SOLUTION entries — QL with PA; include indication and quantity in PA submission.

Prior authorization/step therapy documentation — PA or ST require documentation as specified

Products labeled with PA or ST will require the corresponding prior authorization or step therapy documentation as specified on the formulary table; submit the requested clinical information to support authorization.

• PANCREAZE (ST) and PROLASTIN‑C (PA) illustrate ST vs PA documentation needs.

Documentation for QL/PA requests — providers must submit supporting clinical documentation

When requesting authorization for agents annotated with QL and PA, the provider must submit documentation supporting the requested quantity and medical necessity consistent with the payer's prior authorization process.

• Include diagnosis, dose, frequency, prior therapies tried, and rationale for quantity exceeding standard QL when applicable.

Prior Authorization requirement — not obtaining required PA may result in noncoverage

Prior authorization is required for many products in the formulary; not obtaining an approval when PA is indicated may cause the plan to deny coverage for the drug.

• PA requirement is defined in the formulary introduction: lack of approval may result in noncoverage.

Prior Authorization requirement — failure to obtain PA may result in noncoverage

If prior authorization is required for a drug and the provider does not secure approval, the plan may not cover the drug and the claim can be denied; obtain PA before dispensing where the Requirements/Limits column shows PA.

• Check each product row for PA flags and follow the plan's prior authorization procedures.

PA required for select agents — ARIKAYCE example

ARIKAYCE Suspension 590mg/8.4mL is listed with Requirements/Limits = PA; dispensing without an approved PA may trigger denial of coverage for ARIKAYCE.

• ARIKAYCE SUSPENSION 590MG/8.4ML — Requirements/Limits = PA

Quantity limits and PA may cause denial — examples where QL/PA not met may trigger denial

When QL or PA requirements are not met (for example, prescribing beyond the stated QL or dispensing a PA‑flagged product without approval), the claim may be denied; providers should check QL values and obtain PA ahead of dispensing.

• Examples: VOQUEZNA packs, linezolid suspension, IMPAVIDO, DIFICID show QL and/or PA that, if not followed, may cause denial.

Prior authorization indicated — PA flag requires authorization

Products listed with 'PA' in the Requirements/Limits field require prior authorization; failure to obtain PA may result in claim denial at time of adjudication.

• Refer to the Requirements/Limits column for PA flags and follow the plan's PA submission process.

Quantity limit exceedance — exceeding QL may trigger denial or require override

If the requested quantity exceeds the stated quantity limit (QL) without an approved override or exception, the claim may be denied or require prior authorization to exceed the limit.

• Example QLs: QL(1080 EA per 90 days); requests beyond these limits need justification or PA.

Prior authorization required for some products — DRIZALMA, FETZIMA, TRINTELLIX examples

Several commonly prescribed agents (e.g., DRIZALMA, FETZIMA, TRINTELLIX) are designated PA in the formulary; dispensing these formulations without PA may lead to coverage denial.

• DRIZALMA sprinkle capsule entries list QL and PA across strengths.

Presence of 'PA' indicates authorization required — absence implies no PA on that line

The presence of 'PA' next to a product line signals that prior authorization is required for that product; if 'PA' is absent for a line there is no PA indicated on that line.

• Check the Requirements/Limits column for PA to determine whether PA is required for a given product.

PA/QL noncompliance may trigger denial — unmet PA/QL can be denied

Requests for drugs listed with PA or QL may be denied if authorization is not obtained or the requested quantity exceeds the plan's limit; providers should secure PA and document adherence to QL to avoid denial.

• PA/QL noncompliance is a common denial trigger at adjudication.

Denial triggers from utilization controls — PA/ST/QL presence may cause denial

Utilization controls shown in the formulary (PA, ST, QL) are potential denial triggers; when a drug is listed with these controls providers must obtain authorization or adhere to limits to avoid claim denials.

• Claims may be denied or require prior authorization when PA, ST, or QL are present and not satisfied.

Prior authorization required for some agents — liraglutide injection example

Products annotated with PA (examples: liraglutide injection, MOUNJARO, OZEMPIC) require prior authorization; dispensing without PA may cause a denial or noncoverage determination.

• GLP‑1 injectables in the extract show both QL and PA requirements.

PA-required items — coverage may be denied if PA not obtained

If a product line lists 'PA' the plan may deny coverage if the provider does not obtain prior authorization; providers should obtain PA prior to dispensing to prevent denials.

• PA requirement defined in formulary introduction: lack of approval may result in noncoverage.

PA required for selected products — NEXLETOL, PRALUENT, VERQUVO examples

Many high‑tier specialty drugs (e.g., NEXLETOL, PRALUENT, VERQUVO) are annotated with PA in the formulary; providers must secure prior authorization for coverage of these medications.

• NEXLETOL and PRALUENT entries include QL and PA flags.

PA indicated in table rows — some rows show PA flag without full detail

Some formulary table rows show PA without accompanying clinical detail; providers should treat any PA flag as requiring authorization and consult plan resources for specific PA submission requirements.

• PA = . entries indicate PA may apply and require follow-up to determine clinical criteria.

PA and QL triggers — coverage may be denied or limited when PA/QL present

When products are marked with PA and/or QL, coverage may be denied or limited if prior authorization is not obtained or quantities exceed the listed limits; providers should verify PA and QL before dispensing.

• Examples of denial risk include OTEZLA QL/PA and other calcipotriene QL/PA entries.

Denial risk for unmet QL/PA — claims may be denied if QL/PA requirements are not met

Claims may be denied if QL or PA requirements listed for a drug are not met; providers should confirm authorization status and ensure quantities conform to the QL to reduce denial risk.

• Denial examples include OTEZLA, calcipotriene topical formulations and other PA/QL products.

Authorization/denial triggers noted by product — presence of PA/ST/OVM/QL drives authorization

Presence of utilization controls (PA, ST, OVM, QL) on specific products determines whether authorization is needed; providers should treat these flags as actionable requirements and follow the plan's processes to obtain authorization.

• PA, ST, OVM and QL flags drive authorization requirements and site‑of‑care considerations (e.g., infusion center/OVM).

Prior authorization required for specified agents — PA or PA; OVM require authorization

Drugs listed with 'PA' or 'PA; OVM' will require prior authorization; providers must obtain the required PA prior to dispensing or risk denial at adjudication.

• Examples: octreotide acetate injections and NEULASTA ONPRO listed with PA; OVM.

Infusion center / OVM notes — OVM applied to some injectables indicating site/administration oversight

Some formulary injectables require infusion‑center oversight or OVM review (OVM flag); providers should coordinate site‑of‑care documentation and OVM submission requirements when seeking authorization for these agents.

• OVM = Oncology Value Management — administered by OncoHealth; additional information required for antineoplastics/supportive care.

Original biological product — plan may add interchangeable biosimilar and move original product between tiers

The plan may immediately add an interchangeable biosimilar and move or remove the original biological product from the formulary or change its tier; providers should be aware that such substitutions can occur without advance notice and may affect coverage.

• Interchangeable biosimilars may be substituted at the pharmacy without a new prescription depending on state law.

NEULASTA / ZARXIO — biosimilar included but may require PA/OVM

ZARXIO (a biosimilar to NEULASTA) is listed with PA and OVM in the formulary; providers should anticipate that biosimilars may require PA/OVM review and include necessary documentation when requesting authorization.

• ZARXIO INJECTION entries — Requirements/Limits = PA; OVM