PA/ST required for listed drugs

Prior authorization (PA) or step therapy (ST) is required for many drugs listed in this formulary; clinical and/or administrative criteria must be met before coverage is provided.

Adbry PA criteria (summary)

Adbry requires prior authorization for atopic dermatitis in patients ≥12 years with moderate to severe disease and a trial and failure of one listed topical or systemic therapy; reauthorization requires documentation of positive clinical response and dosing for patients <100 kg is limited after 16 weeks unless justified.

• Age ≥ 12 years; diagnosis of moderate to severe atopic dermatitis
• Trial and treatment failure of one: high‑potency topical corticosteroid, tacrolimus, pimecrolimus, cyclosporine, azathioprine, or mycophenolate mofetil
• Reauthorization: documentation of positive clinical response; dosing limit for <100 kg after 16 weeks (300 mg q4w) unless rationale provided

Prior authorization and duration

Prior authorization is required for the listed Part D specialty drugs and, unless specified otherwise, coverage durations are commonly set to one year.

• Coverage duration default: 1 year for many products

Combination biologic/DMARD restriction

Biologic and targeted DMARD agents cannot be used in combination with another biologic or targeted DMARD indicated for the same condition; such combination use is an exclusion and may trigger denial.

• Applies across multiple biologic/targeted DMARD product entries

Prior authorization and coverage duration

Prior authorization is required for many Part D drugs listed and, unless otherwise specified, approval is generally granted for one year.

• Some products have different durations where noted (e.g., Praluent: 3 years; select products: lifetime)

Prior authorization and coverage duration

Many Part D specialty products require prior authorization with coverage typically granted for one year and may require documented trials of prerequisite Part D drugs where specified.

• Providers must document required prior trials when indicated to avoid denial

Lynparza PA requirements

Lynparza (tablets) requires prior authorization with a one‑year coverage duration and indication-specific prerequisite therapies (for example, prior platinum‑based chemotherapy for BRCA‑mutated ovarian cancer).

• Document prior platinum‑based chemotherapy where applicable

Mekinist PA requirements

Mekinist (tablet and liquid formulations) requires prior authorization with one‑year duration; BRAF V600E/V600K mutated indications are provided as monotherapy only for BRAF‑inhibitor–treatment–naive patients otherwise combination use or prior trials of specified BRAF/MEK regimens are required.

• Liquid/solution covered only if patient unable to swallow tablets
• For many BRAF‑mutant indications, combination with dabrafenib or other BRAF/MEK regimens is required

Mektovi combination and prerequisite therapy

Mektovi prior authorization requires combination use with encorafenib for specified melanoma indications and prior trial of vemurafenib + cobimetinib for unresectable or metastatic melanoma with BRAF V600E or V600K.

• Document prior trial of vemurafenib + cobimetinib where required

Nucala indication-specific PA

Nucala prior authorization requires indication‑specific diagnostic criteria (e.g., eosinophil thresholds for EA, EGPA features, HES thresholds) and reauthorization requires documentation of positive clinical response.

• EA: eosinophil criteria and failure to maintain control after appropriate steroid/controller trials
• HES: eosinophil ≥1000 cells/µL and stability on HES therapy
• Reauthorization: documentation of clinical response

Nexletol/Nexlizet prerequisite statin trial

Nexletol and Nexlizet prior authorization require trial of one high‑intensity statin unless statin intolerance or contraindication is documented.

• Provide documentation of statin trial or intolerance/contraindication

Opfolda — authorization requirement

Opfolda coverage for certain indications requires documentation that the patient achieved first complete remission (CR) or CRi after intensive induction chemotherapy and cannot complete intensive curative therapy; authorization duration is one year.

• For Pompe disease: require serum assay and genetic testing confirming GAA mutation and symptomatic disease

Posaconazole DR — step requirements

Posaconazole DR prior authorization for IFI prophylaxis or treatment requires trial with two alternative azoles (e.g., fluconazole, itraconazole, voriconazole) before coverage.

• Prophylaxis: patient at high risk (HSCT with GVHD or prolonged neutropenia) or prior fungal infection
• Document trials of two alternative azoles

Praluent — lipid management requirements

Praluent prior authorization requires documentation of ASCVD/HeFH/primary HLD criteria, LDL measured while on a high‑intensity statin within the last 120 days meeting specified thresholds, and at least 12 weeks of high‑intensity statin unless intolerant; reauthorization requires continued statin and LDL reduction on Praluent.

• ASCVD: LDL ≥ 55 mg/dL (while on high‑intensity statin)
• Without ASCVD: LDL > 70 mg/dL (while on high‑intensity statin)
• Document 12 weeks of high‑intensity statin or intolerance

Bisphosphonate trial required (Jubbonti and Stoboclo mention)

Coverage for Jubbonti and Stoboclo requires trial of an oral bisphosphonate or, if intolerant, an IV bisphosphonate; coverage is also provided if the patient is unable to be treated with both oral and IV bisphosphonates.

• Document trial or intolerance to oral bisphosphonate (or IV if oral intolerant)
• Coverage duration noted where specified

Diagnostic and prior therapy requirements for Retevmo

Retevmo prior authorization requires documentation of RET gene fusion or RET mutation detected by an FDA‑approved test; for some thyroid indications, prior radioactive iodine trial is required when appropriate.

• Provide FDA‑approved test result for RET fusion/mutation
• Document prior radioactive iodine trial for thyroid indications when applicable

Step/prior therapy requirements for Rinvoq

Rinvoq coverage requires prior trials specific to the indication (e.g., trial of a DMARD such as methotrexate for RA; trial of an NSAID for AS/axSpA) and reauthorization requires documentation of positive clinical response and avoidance of combination with potent immunosuppressants or another biologic/targeted DMARD.

• RA: trial of one DMARD (methotrexate, leflunomide, or sulfasalazine)
• AS/axSpA: trial of one NSAID
• Reauthorization: documentation of response and no disallowed combinations

Prior authorization required

Prior authorization is required for the listed Part D specialty drugs; coverage durations and prerequisite therapy requirements differ by product and must be documented per product‑specific criteria.

Tafinlar (liquid) prior auth

Tafinlar liquid formulation requires prior authorization; coverage for the liquid is limited to patients unable to swallow the capsule and is subject to the same indication‑specific prior therapy requirements as the capsule.

• Document inability to swallow capsule formulation

TOCILIZUMAB prior authorization

Tocilizumab (tocilizumab) requires prior authorization; many indications require trials of specified alternative biologic or targeted DMARD therapies and reauthorization requires documentation of positive clinical response.

• Cannot be used in combination with another biologic/targeted DMARD for the same condition

VERZENIO prior authorization

Verzenio requires prior authorization; coverage for adjuvant or advanced/metastatic breast cancer mandates combination with specific endocrine agents or prior endocrine/chemotherapy per the indication.

• Document combination partner (tamoxifen or aromatase inhibitor) or prior therapies as specified

Vanflyta prior authorization

Vanflyta coverage for newly diagnosed FLT3‑ITD positive AML requires prior authorization and must be used in combination with standard cytarabine and anthracycline induction and cytarabine consolidation.

• Document combination with standard induction/consolidation regimens

Prior authorization and coverage duration

Many listed products require prior authorization with coverage commonly set to one year; providers must follow the product‑specific prerequisite therapy and documentation requirements to obtain approval.

Voquezna — prerequisite therapy

Voquezna coverage for H. pylori requires documented diagnosis of H. pylori infection and a trial of a guideline‑recommended, generic first‑line regimen (clarithromycin triple therapy or bismuth quadruple therapy) prior to coverage.

• Document prior trial of clarithromycin triple or bismuth quadruple therapy

Abiraterone 250 mg trial required

Coverage for several abiraterone products requires prior trial of abiraterone 250 mg tablet strength before coverage of other formulations.

• Document trial of abiraterone 250 mg tablet

Antidepressant step therapy

Exxua/Exxua Titration Pack and Trintellix require trial of at least two listed generic antidepressants prior to coverage.

• Document trials of two listed generics (e.g., bupropion, citalopram, escitalopram, sertraline, etc.)

Aripiprazole trial required

Abilify Asimtufii and Abilify Maintena require prior trial of oral aripiprazole before approval; coverage duration is lifetime.

• Document trial of oral aripiprazole

Products requiring PA

Products such as Caplyta, Rexulti, Vraylar CAPS, and Zyprexa Relprevv require prior authorization per their product‑specific criteria as listed.

Aristada PA

Aristada requires prior authorization with documentation of trial of listed oral or injectable antipsychotics per criteria.

• Document trials or intolerances as specified in the Aristada entry

Aristada Initio PA

Aristada Initio requires prior authorization with trial or documented intolerance to Abilify Maintena or oral aripiprazole.

• Document trial or intolerance to Abilify Maintena or oral aripiprazole

Supply products PA

Coverage for specified supply products (gauze, alcohol prep pads) is subject to the criteria in this section; for certain supply products, an insulin claim within the prior 180 days is required.

• For insulin‑related supplies: document insulin claim within prior 180 days

Pancreatic enzyme PA

Pancreaze CPEP formulations require prior authorization with documented trial or intolerance to Zenpep before coverage is approved.

• Document trial of Zenpep or documented intolerance

Rasuvo prior authorization

Rasuvo requires prior authorization and a documented trial of generic injectable methotrexate for coverage; coverage duration is lifetime.

• Document trial of generic injectable methotrexate

Rhopressa prior authorization

Rhopressa requires trial of any generic formulary ophthalmic glaucoma medication or Lumigan prior to approval; coverage duration is one year.

• Document trial of generic ophthalmic glaucoma med or Lumigan

Risperidone ER prior authorization

Risperidone ER requires prior trial of oral risperidone before coverage; coverage duration is lifetime.

• Document trial of oral risperidone

Rocklatan prior authorization

Rocklatan requires prior trial of any generic formulary ophthalmic glaucoma medication or Lumigan; coverage duration is one year.

• Document trial of generic ophthalmic glaucoma med or Lumigan

Rykindo prior authorization

Rykindo requires prior trial of oral risperidone for coverage; coverage duration is lifetime.

• Document trial of oral risperidone

Rytary prior authorization

Rytary requires prior trial of generic oral extended‑release carbidopa & levodopa before approval; coverage duration is one year.

• Document trial of generic ER carbidopa/levodopa

Farxiga/Jardiance prior authorization

Farxiga and Jardiance require trial of generic dapagliflozin before approval; exception: step therapy does not apply for Jardiance when used to reduce risk of cardiovascular death in adults with T2DM and established cardiovascular disease.

• Document trial of generic dapagliflozin unless exception applies

Febuxostat prior authorization

Febuxostat requires prior trial of allopurinol or documentation of contraindication to allopurinol; coverage duration is lifetime.

• Document allopurinol trial or contraindication

Prerequisite therapy requirements (general)

Certain agents require prior trial of specified alternatives or Part D drugs before approval; providers must document trials and failures or contraindications per the product entry.

Anticonvulsant step therapy

Some anticonvulsant products require documented trial of divalproex or valproic acid and lamotrigine prior to coverage.

• Document specific anticonvulsant trials as listed

Prior therapy trials required for many products

Multiple products require documented trials of specified prior therapies (examples: two second‑generation antipsychotics for schizophrenia; trials of generic anticonvulsants for seizure disorders); lack of documentation may trigger denial.

• Document drug names, durations, and reasons for failure/intolerance

Required trials of prior therapies

Providers must document prior trials of specified generic alternatives or classes (e.g., two generics for migraine prevention, two generic anticonvulsants for seizures) before coverage is approved.

Step/ prerequisite therapy requirements

Several products require step or prerequisite therapy trials (e.g., Kevzara and Kineret require trials of two specified agents for RA); document those trials to support the PA request.

Libervant step requirements

Libervant coverage requires trial of levetiracetam oral solution and documentation that the patient is unable to swallow tablets or capsules.

• Document trial of levetiracetam oral solution and swallowing inability

Lumakras step/combination requirements

Lumakras coverage for KRAS G12C‑mutated locally advanced or metastatic NSCLC requires trial of at least one prior systemic therapy; for certain colorectal indications additional combination requirements apply.

• Document prior systemic therapy trial(s)

Motpoly XR step therapy

Motpoly XR coverage for seizures requires trial of two generic anticonvulsant alternatives prior to approval.

• Document trials of two generic anticonvulsants

Ninlaro combination/step requirement

Ninlaro for multiple myeloma requires at least one prior therapy and use in combination with lenalidomide and dexamethasone.

• Document prior therapy and combination use

Orenitram — prerequisite agent

Orenitram coverage requires trial and failure or contraindication to sildenafil prior to approval.

• Document trial/failure or contraindication to sildenafil

Jubbonti / Stoboclo — bisphosphonate trial

Jubbonti and Stoboclo require trial of an oral bisphosphonate or, if intolerant, an IV bisphosphonate; coverage is also provided if patient unable to be treated with both.

• Document bisphosphonate trial or intolerance

Step therapy for NASH/MASH

For NASH/MASH, coverage requires a trial of semaglutide prior to approval and documentation of advanced fibrosis (stage F2–F3) by FibroScan or other imaging‑based non‑invasive assessment.

• Document semaglutide trial and fibrosis staging

Formulation trial for Secuado

Secuado coverage for schizophrenia requires trial of asenapine sublingual tablet or documentation of inability to use oral/ODT formulations.

• Document trial of sublingual asenapine or difficulty with oral/ODT

Step therapy examples

The formulary includes multiple examples of step therapy requirements—providers must document trials and failures of specified alternatives (e.g., Sunosi requires prior armodafinil trial).

• Provide records of prior trials and reasons for failure/intolerance

Tymlos step therapy

Tymlos requires prior trials of JUBBONTI or STOBOCLO and either an oral bisphosphonate (or IV bisphosphonate if intolerant) before approval; document BMD T‑score ≤ −2.5.

• Document BMD T‑score ≤ −2.5 and bisphosphonate trial or intolerance

Ubrelvy step therapy

Ubrelvy for acute migraine requires trial of at least two generic triptans (e.g., sumatriptan and rizatriptan) unless contraindicated or not tolerated.

• Document trials of two triptans or contraindication/intolerance

Xifaxan — step requirements

Xifaxan 550 mg coverage depends on indication‑specific prior trials: hepatic encephalopathy requires prior trial of lactulose; IBS‑D requires trial of loperamide, dicyclomine, or diphenoxylate/atropine; recurrent C. diff requires trial of vancomycin.

• Document the specific prior trial relevant to the indication

Winrevair — step requirements

Winrevair for pulmonary arterial hypertension requires trials of both a generic PDE5 inhibitor (sildenafil or tadalafil) and an ERA (bosentan or ambrisentan) prior to approval.

• Document trials of both required drug classes

Depression step therapy

Depression step therapy entries require trial of at least two specified generic antidepressants before coverage of agents like Trintellix/Exxua; failure to document these trials may trigger denial.

• Provide documentation of two generic antidepressant trials and outcomes

Antidepressant step therapy

Antidepressant step therapy: coverage of certain antidepressant products requires documented trial of at least two listed generic antidepressants before approval.

Antipsychotic step therapy

Antipsychotic step therapy: several antipsychotic products require trial of at least one listed conventional antipsychotic agent prior to approval.

• Document trial of at least one conventional antipsychotic listed

Paliperidone step therapy

Prior to approval of Invega Hafyera, document trial of paliperidone palmitate once‑monthly for ≥4 months or the three‑month formulation for at least one three‑month cycle.

• Provide dates and duration of prior paliperidone palmitate formulation trials

SGLT2 inhibitor step therapy

SGLT2 inhibitor step therapy requires trial of generic dapagliflozin before Farxiga or Jardiance except Jardiance requests for reducing risk of cardiovascular death in adults with T2DM and established CVD are exempt.

• Document trial of generic dapagliflozin or document qualifying exception

Adbry reauthorization and dosing documentation

Adbry reauthorization requires documentation of positive clinical response to therapy; dosing restriction applies for patients <100 kg after 16 weeks unless clinical rationale is provided.

• Submit clinical response documentation at reauthorization
• Note dosing limitation (300 mg every 4 weeks) for <100 kg responders after 16 weeks unless justified

Bronchitol test documentation

Bronchitol requires documentation that the member has passed the Bronchitol tolerance test prior to coverage.

• Submit Bronchitol tolerance test results

Dalfampridine T25FW requirement

Dalfampridine initiation requires submission of a baseline timed 25‑foot walk (T25FW) test; reauthorization requires documentation of stability or improvement on the T25FW.

• Provide baseline T25FW and follow‑up results at reauthorization

Weight requirement for Ebglyss

Ebglyss requires documentation that the patient weighs at least 40 kilograms prior to coverage.

• Provide weight documentation (≥40 kg)

Dupixent eosinophil requirement

Dupixent for eosinophilic asthma requires an eosinophil count ≥150 cells/µL at initiation as part of the prior authorization criteria.

• Document eosinophil count at initiation (≥150 cells/µL)

Required supporting documentation

Submission of supporting medical records is required for certain products (examples: T2DM labs for GLP‑1 agents, BMD T‑score for teriparatide, prior chemotherapy documentation for Lynparza).

• Include lab values, imaging, or prior therapy records as specified per product

Reauthorization response documentation

Reauthorization for many biologic and specialty products generally requires documentation of a positive clinical response to therapy.

• Provide objective or clinical notes demonstrating improvement

Reauthorization and required documentation

Reauthorization requests commonly require documentation of continued positive clinical response; some products also require specific diagnostic mutation or prior therapy documentation at renewal.

• Follow product‑specific reauthorization requirements (e.g., genetic tests, prior therapy evidence)

T2DM documentation

For liraglutide used to treat type 2 diabetes, submit medical records or labs confirming T2DM diagnosis (A1c ≥6.5% or FPG ≥126 mg/dL or 2‑hr OGTT ≥200 mg/dL).

• Provide A1c or glucose lab values or chart notes confirming T2DM

Prior chemotherapy documentation

For Lynparza in certain oncology indications, prior platinum‑based chemotherapy or other specified prior therapies must be documented to support coverage.

• Include chemotherapy regimen and dates demonstrating prior platinum‑based chemotherapy

Reauthorization documentation (Nucala)

Nucala reauthorization requires documentation of a positive clinical response to therapy for all indications.

• Provide clinical outcome evidence at renewal

Diagnostic and clinical documentation (Opfolda)

Opfolda coverage requires diagnostic confirmation by serum assay showing decreased acid alpha‑glucosidase activity and genetic testing demonstrating a GAA mutation; symptomatic manifestations and lack of improvement on ERT must be documented.

• Submit serum assay, genetic test results, and clinical symptom documentation

Diagnostic confirmation for Opfolda

Opfolda diagnostic confirmation requires serum assay showing decreased acid alpha‑glucosidase activity followed by genetic testing showing a GAA mutation.

Laboratory and medication history for Praluent

Praluent initial approvals require LDL values measured while on a high‑intensity statin within the last 120 days and documentation of statin trials or statin intolerance.

• Provide LDL value while on high‑intensity statin and evidence of 12 weeks trial or intolerance

Baseline laboratory requirements (Eltrombopag Olamine)

Eltrombopag Olamine coverage requires baseline platelet counts: ITP <30,000/mcL; thrombocytopenia with chronic hepatitis C <75,000/mcL; severe aplastic anemia <30,000/mcL.

• Document baseline platelet count meeting the specified threshold

Genetic test requirement (Rivfloza)

Rivfloza (lumasiran) requires genetic testing confirming AGXT mutation for diagnosis of primary hyperoxaluria type 1; coverage exclusions include history of kidney or liver transplant and combination use with OXLUMO.

• Submit AGXT genetic test results
• Do not request coverage for patients with prior kidney or liver transplant

Fibrosis verification (unnamed product)

For NASH/MASH coverage, verify advanced liver fibrosis (stage F2–F3) by FibroScan or other imaging‑based noninvasive assessment and document a trial of semaglutide prior to approval.

• Provide fibrosis staging and semaglutide trial documentation

Reauthorization response documentation

Reauthorization for many biologic indications requires documentation of positive clinical response to therapy; submit objective or clinical notes demonstrating benefit.

CYP2D6 testing for tetrabenazine

Tetrabenazine documentation: CYP2D6 genotype testing is required for doses above 50 mg/day; coverage is excluded for hepatic impairment, active suicidal ideation, untreated/ inadequately treated depression, or concurrent MAO inhibitor or reserpine use.

• Provide CYP2D6 genotype when dose >50 mg/day
• Do not request coverage if exclusion conditions present

BMD requirement for Tymlos

Tymlos coverage requires documentation of bone mineral density with a T‑score ≤ −2.5 prior to approval.

• Submit BMD T‑score documentation (≤ −2.5)

Clinical documentation for Verquvo

Verquvo coverage requires documentation of chronic heart failure NYHA class II–IV with LVEF <45% and evidence of recent hospitalization for heart failure or outpatient IV diuretic use as specified.

• Provide LVEF and hospitalization or IV diuretic documentation

Diagnosis required (H. pylori)

Voquezna regimens for H. pylori require a documented diagnosis of H. pylori infection before coverage.

• Provide test results confirming H. pylori infection

Diagnostic confirmation (Demodex blepharitis)

Xdemvy for Demodex blepharitis requires confirmation of diagnosis via presence of collarettes on slit‑lamp exam.

• Submit slit‑lamp exam findings documenting collarettes

Laboratory/diagnostic requirements (Xolair)

Xolair for allergic asthma requires IgE within specified age‑based ranges and positive skin test or in vitro reactivity to a perennial aeroallergen; reauthorization requires positive clinical response and combination biologic use is excluded.

• IgE ranges: adults ≥12 yrs: >30 and <700 IU/mL; 6–12 yrs: >30 and <1300 IU/mL; CRSwNP: 30–1500 IU/mL
• Provide allergen reactivity testing and clinical response documentation

Zilbrysq required documentation

Zilbrysq coverage for myasthenia gravis requires documentation of anti‑AChR antibody positive MG plus one confirmatory test (edrophonium, clinical response to cholinesterase inhibitors, or electrophysiological evidence) and prior 12‑week courses of listed immunosuppressants unless contraindicated.

• Submit anti‑AChR antibody result and confirmatory test
• Document prior immunosuppressant therapy courses or contraindications

Zurzuvae required documentation

Zurzuvae for postpartum depression coverage requires documentation of onset in the third trimester or within 4 weeks postpartum and that the member is ≤12 months postpartum.

• Provide timing of symptom onset and postpartum status (≤12 months)

Insulin claim

A claim for an insulin product within the prior 180 days must be documented for coverage of specified supply/insulin‑related products.

Paliperidone trial documentation

Documentation of trial duration for paliperidone palmitate is required: once‑monthly formulation ≥4 months or three‑month formulation ≥1 three‑month cycle.

• Provide dates and duration of prior paliperidone palmitate use

Prior trial or intolerance documentation

Providers must document prior trials or intolerance to the specified alternative generic agents named for each product to support PA/ST requests.

• Include drug names, trial duration, and reason for discontinuation (failure or intolerance)

Required documentation of prior trial or contraindication

Documentation must show trial of the specified alternative medication (e.g., oral risperidone; generic injectable methotrexate; generic ophthalmic glaucoma medication or Lumigan; generic ER carbidopa/levodopa; generic dapagliflozin) or a documented contraindication as stated for each product.

• Provide records demonstrating trial, failure, or contraindication per product entry

hospital outpatient | infusion center | home (dependent on circumstances)

Coverage determination may depend on the drug use setting (Part B vs Part D); submit information describing use and setting (hospital outpatient, infusion center, or home) to determine appropriate benefit.

• Provide site‑of‑care details to clarify Part B vs Part D coverage