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CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Pharmacy Drug List and Coverage Guidance (Formulary with Utilization Management)

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This document is the Blue Cross Blue Shield of New Mexico pharmacy drug list and accompanying coverage guidance for members and providers, including specialty drug processes, prior authorization, step therapy, quantity limits, and exception processes. It affects BCBSNM members and their prescribing providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPharmacy Drug List and Coverage Guidance (Formulary with Utilization Management)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when 'PA' is indicated on a drug line before dispensing to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~140distinct drug entries in fragments

PAPrior authorization present

QLQuantity limits present

Accredospecialty pharmacy services

NMapplicable state

Coverage Criteria and Product Listings

General outpatient drug coverage with utilization management

Coverage and utilization management (tiering, PA, QL, SP) as listed per product

Formulary listing: Individual drugs are listed with a Drug Tier and Requirements/Limits; coverage is determined by the drug's tier and any listed requirements (PA, QL, SP, AC).

Each product line specifies its own flags; see product entry.

Per-drug formulary coverage

Coverage is determined per-drug according to listed Drug Tier and Requirements/Limits fields

Per-drug coverage: Drug is covered according to its Drug Tier but only when any listed Requirements/Limits (PA, QL, SP, AC) are metas listed per drug

Individual drugs list exact QL and PA flags

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPharmacy Drug List and Coverage Guidance (Formulary with Utilization Management)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when 'PA' is indicated on a drug line before dispensing to avoid denial.

SourceLink

On This Page

Formulary-based coverage controls

Coverage is governed by drug tier and specific Requirements/Limits listed per product

Formulary coverage controls: Drugs listed include a Drug Tier and may have Requirements/Limits indicating PA, QL, and SP; adherence to those controls is required for coverage.

No specific diagnosis-level criteria present in these chunks

Formulary entries with utilization controls

Coverage and utilization controls are listed per product; coverage is implied by formulary tier and presence/absence of PA/QL flags.

Formulary entry: Each drug line lists the product name, strength, Drug Tier, and Requirements/Limits (e.g., PA, QL, SP). Coverage requires adherence to those utilization controls.

No clinical criteria or detailed medical necessity rules are present in these chunks.

Formulary coverage controls (excerpt)

Coverage and utilization controls are applied as listed per product

Formulary control tags: Each product entry includes a Drug Tier and Requirements/Limits (AC, PA, QL). Coverage requires compliance with those controls.

No clinical criteria tree provided in this excerpt

Listed drugs with requirement flags

Drug coverage entries with conditions when specified

example_entry: Many drugs are listed with tier and, where present, Requirements/Limits such as PA, QL (with specific quantities/periods), and SP (specialty).

This section enumerates products and their authorization/limitation flags; no explicit clinical criteria provided in this part.

General coverage with utilization management

Covered when meeting plan requirements noted (PA, QL, SP as applicable).

Formulary coverage conditions: Drug is covered subject to the Requirements/Limits field which may include prior authorization (PA), quantity limits (QL), and specialty pharmacy (SP).

See individual drug entry for specifics.

Coverage contingent on utilization management

Covered when PA and QL requirements (if listed) are met for the specific drug

Formulary coverage preconditions: Prescriber must follow drug-specific utilization management: obtain prior authorization when PA is listed; adhere to quantity limits (QL) per period; follow step therapy (ST) sequences if specified.

Examples: IMCIVREE (PA, QL, SP); WEGOVY (PA, QL); FANAPT titration packs (QL, ST).

Coverage conditions (administrative)

Coverage requires adherence to listed claim controls for each product

Formulary coverage conditions: For a listed drug to be covered, the claim must meet the product's listed requirements/limits (e.g., PA must be obtained when 'PA' is indicated; quantity billed must not exceed QL).

This fragment does not include medical necessity clinical criteria or step failure definitions; it only lists controls.

Coverage exclusions include products that are cosmetic in use, non–FDA‑approved drugs, repackaged medications, and some compounded preparations. The formulary also notes that prescription products with available over‑the‑counter equivalents may not be covered; members should consult plan materials for specifics. (Examples and flags are presented on the drug list and benefit documentation.)

When a drug is listed on the formulary, its coverage is determined by the listed Drug Tier and any Requirements/Limits shown on that product line (for example: PA, QL, SP, AC). Coverage is therefore product‑specific and contingent on meeting those utilization controls noted for the exact formulation and strength.

If a product’s listed Requirements/Limits include administrative controls (e.g., PA or QL), coverage is contingent on satisfying those requirements; failure to obtain required prior authorization or to adhere to the stated quantity limits may result in denial of coverage until the requirements are met.

Formulary product lines identify tiering and requirement flags for each listing. Examples from the drug list include items marked with PA (prior authorization), QL (quantity limits such as 8 tablets/180 days or 14 vials/28 days), SP (specialty pharmacy), and ST (step therapy) where applicable; the specific QL values and flags are shown on the product line for the exact presentation.

The extract does not provide broad ‘not medically necessary’ exclusion language for clinical scenarios. Instead, vaccine and biologic entries may show administrative review flags (e.g., AC) that indicate clinical review is required for coverage of those products.

Within the contraceptive and related product listings in this excerpt, coverage is shown by tier and administrative annotations (e.g., AC, QL, PA where listed); no separate explicit exclusion criteria are provided in these chunks.

The portions of the formulary in this excerpt list products with tier and utilization flags but do not state standalone exclusion rules; coverage decisions are driven by whether product‑level Requirements/Limits are satisfied.

Several entries in the vaccine and biologic sections are annotated with administrative review or specialty flags (e.g., AC, SP), but the excerpt does not include explicit medical necessity criteria — the lines are administrative in nature.

Certain products in the formulary are designated NP or Non‑Preferred for specific formulations; where a product is non‑preferred the drug line still relies on the same Requirements/Limits annotations (PA, QL, SP) to govern coverage.

This fragment contains many product entries but does not include explicit exclusion statements; the listings focus on tiering and utilization controls rather than listing conditions that are categorically excluded.

No explicit clinical exclusion lists are present in these chunks; rather, coverage is tied to fulfillment of the advertised utilization controls (for example, obtaining PA, staying within the stated QL, or routing via SP when indicated).

The available fragments primarily show administrative controls for each product (PA, QL, SP, AC, ST) and do not provide additional clinical exclusion language in this excerpt; coverage is therefore contingent on meeting those controls.

The formulary explicitly states that non–FDA‑approved drugs are not covered under the pharmacy benefit. Providers and members should verify coverage for such products in plan materials.

See per‑product entries for tier and Requirements/Limits; coverage is determined by the specific drug line and whether the noted utilization management controls (PA, QL, SP, AC) are met. The document does not include additional fallback clinical criteria in these excerpts.

The extract does not include discrete ‘not medically necessary’ determinations for specific drugs. Coverage guidance in this fragment is presented as product lines with utilization control flags rather than NMN statements.

Across the included segments there are no explicit ‘not medically necessary’ (NMN) rulings in the extract; the listings use administrative requirement flags (PA, QL, AC) to control coverage.

The sampled formulary lines in this extract do not present standalone NMN statements; product coverage is governed by the listed utilization controls and specialty handling instructions.

In these chunks no explicit ‘not medically necessary’ determinations are present; the document relies on product‑level utilization controls (PA/QL/SP) to define coverage conditions.

Review of the fragment shows no NMN declarations; rather, coverage is tied to fulfillment of plan requirements for the listed products (e.g., prior authorization, quantity limits, step therapy where flagged).

This excerpt does not include ‘not medically necessary’ statements. Product coverage and limitations are presented as tier and Requirements/Limits fields that must be met for benefit payment.

There are no explicit ‘Not medically necessary’ determinations in the fragment; formulary control flags (PA, QL, SP, ST, AC) govern coverage at the product level.

Formulary Entries and Code Groups

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required

Prior authorization (PA) is required for many drugs in this Drug List. When a medication is designated with a "PA" in the Special Requirements column, an approved prior authorization must be obtained before the medication is eligible for coverage. Requests without the required PA may be denied.

PA flag indicates prior authorization is required before coverage
Many specialty and antineoplastic agents are PA- and SP-flagged (specialty pharmacy)
Select high-cost biologics, vaccines and inhaled therapies carry AC or PA flags

Prior Authorization

Prior authorization required where marked 'PA'

Prior authorization is required for drugs marked with "PA" in the Special Requirements column. Providers must submit a prior authorization request per the plan process before dispensing. Failure to obtain PA where indicated can result in a claim denial or full member liability.

Look for "PA" next to product entries (Special Requirements column)
Some plans may require PA for additional medications beyond those listed — verify member-specific benefits

Prior Authorization

Prior authorization required for many specialty/antineoplastic drugs

Many specialty, high-cost, and antineoplastic (oncology) drugs require prior authorization and are often managed through a specialty pharmacy (SP). Examples in this list include targeted therapies, PARP inhibitors, kinase inhibitors, and other oncology agents. Quantity limits (QL) commonly apply to these products.

Oncology/specialty agents frequently show PA, QL, and SP flags
Examples: ALUNBRIG, ERLEADA, VENCLEXTA, RUBRACA, STIVARGA, many others

Prior Authorization

Prior authorization required for multiple specialty drugs

Prior authorization is required for multiple specialty drugs across therapeutic categories (e.g., biologics, enzyme replacement, gene or rare disease therapies, and high-cost injectables). These entries are often flagged SP and may have additional QL requirements.

Specialty (SP) flag indicates specialty pharmacy management
Many specialty products also require PA and have specific quantity limits

Prior Authorization

Prior authorization required for specific products

Certain specific products are called out with PA requirements (examples include selected contraceptives, GLP-1 agents for diabetes and weight management, and others). Review the Special Requirements column for AC (access control), PA, and QL notes for each product.

Examples: ELLA, certain contraceptives (AC/PA), MOUNJARO, OZEMPIC, TRULICITY, SAXENDA, WEGOVY, ZEPBOUND
AC indicates access control/coverage criteria may apply in addition to PA

Prior Authorization

Prior authorization required for listed PA entries

A number of listed PA entries across the Drug List require prior authorization. Providers should check each product's Special Requirements column; entries showing PA must have authorization approved prior to coverage.

If an entry shows "PA" — submit PA prior to dispensing
Some entries show combinations (PA, QL, SP, AC) — all listed requirements must be met

Prior Authorization

PA required for select products

Select products require PA (examples throughout the list include UPTRAVI, NUCALA, TRIKAFTA and other high-cost therapies). When PA is indicated, documentation supporting medical necessity and prior treatment history may be requested.

UPTRAVI, NUCALA, TRIKAFTA appear with PA/QL/SP flags
Specialty pharmacy (SP) may be required for dispensing and administration

Prior Authorization

Prior authorization required for selected agents

Prior authorization is required for selected agents listed in the Drug List (for example: TRIKAFTA, SYMDEKO, CREON, and other specialty products). Providers should follow the plan's PA submission process and include all required clinical documentation.

TRIKAFTA and SYMDEKO are PA- and QL-flagged
CREON and certain enteric enzyme products may have specific requirements

Prior Authorization

Prior authorization required for listed PA drugs

Many listed PA drugs are high-cost or specialty agents; they are frequently managed with PA, SP, and QL controls. Providers must meet all applicable requirements (PA, QL, SP) shown for a product to avoid coverage denials.

High-cost specialty products are commonly PA-required and SP-managed
Examples include disease-modifying therapies, specialty injectables, and enzyme replacement therapies

Documentation Required

PA/AC/SP flagged products

Products in the Drug List may carry flags for PA (Prior Authorization), AC (Access Control), and SP (Specialty Pharmacy). Each flag indicates a separate management requirement that must be satisfied for coverage.

AC = access control or additional coverage criteria may apply
SP = specialty pharmacy management for dispensing and adherence

Prior Authorization

Prior authorization and specialty pharmacy flags

Several entries include both prior authorization and specialty pharmacy flags. When both are present, the provider must obtain prior authorization and use the designated specialty pharmacy channel as required by the plan.

Follow specialty pharmacy enrollment and dispensing instructions where SP is indicated
Combined PA + SP entries often also include quantity limits

Denial Risk

Quantity limit overage

Quantity limits (QL) apply to many products; dispensing a quantity above the QL may trigger a denial or member liability. Providers should verify QL noted for each product and include rationale and clinical documentation when requesting amounts exceeding limits.

QL examples: 60 tablets/30 days, 56 containers/56 days, 120 capsules/30 days
Requests exceeding QL typically require supporting documentation and prior authorization

Prior Authorization

Authorization required for many vaccines/biologics

Authorization and coverage controls apply to many vaccines and biologics (AC flag). Providers should confirm whether AC or PA is noted for vaccines/biologics before administering to ensure coverage.

Vaccines listed with AC may have coverage criteria or age restrictions
Biologics often carry PA, QL, and SP flags — confirm requirements prior to administration

Denial Risk

Prior authorization and quantity limit denials

Prior authorization and quantity limit noncompliance can lead to claim denials or full member financial responsibility. Providers should review Special Requirements and submit PA plus supporting documentation when required.

Claims lacking required PA may be denied
Dispensing beyond QL without approval may result in no benefits applied

Prior Authorization

Prior authorization required for some products

Some products require PA but are noted only for select formulations or pack sizes. Always review the specific product row and Special Requirements to determine whether PA applies to the exact NDC/formulation being prescribed.

Examples: posaconazole formulations, tobramycin nebulized solutions, EPCLUSA formulations may differ in PA status

Prior Authorization

PA/SP required for certain listed drugs

Certain listed drugs (for example LUPRON DEPOT-PED and other specialty injectable agents) are managed with PA and/or SP requirements. Providers must check the product-level notes and follow PA/SP procedures.

PA/SP entries commonly include QL and kit/pack limits
Pediatric or depot formulations may be SP-managed

Prior Authorization

PA/QL triggers for specialty cardiovascular drugs

PA and QL criteria can be triggers for cardiovascular specialty drugs (e.g., REPATHA, ADEMPAS, UPTRAVI) — these products often require PA with documented diagnoses and may carry QL/pack limits.

REPATHA (evolocumab) requires PA and QL limits
UPTRAVI and other pulmonary hypertension agents often show PA, QL and SP

Denial Risk

PA/SP/QL enforcement

PA, SP, and QL enforcement is applied across the Drug List. Providers must meet all indicated requirements (PA approval, specialty pharmacy routing, and quantity limits) to avoid denials. Where multiple controls are present, all must be satisfied.

All flags shown for a product (PA, QL, SP, AC) must be satisfied for coverage
Verify member-specific benefit plan for any additional PA/ST requirements

Prior Authorization

Prior authorization required (general)

Prior authorization is required in general for many entries in this Drug List. Providers should routinely check the Special Requirements column and follow the payer's PA submission and documentation instructions.

Verify product-level Special Requirements before prescribing or dispensing
Contact the number on the member ID card or use payer portals for PA submission

Documentation Required

Exception request documentation and timelines

Exception requests may be submitted when coverage criteria are not met. The prescriber (or authorized representative) can request a Drug List exception; standard review decisions are issued within three business days. Expedited reviews (for urgent clinical situations jeopardizing life, health, or function) are decided within 24 hours.

Standard exception decision timeframe: 3 business days
Expedited exception decision timeframe: 24 calendar hours for urgent requests
Call the number on the member's ID card to initiate an exception request

Documentation Required

Documentation expectations

Documentation expectations: prior authorization and exception requests should include relevant clinical information such as diagnosis, prior therapies tried (and reasons for failure or intolerance), lab results, and expected duration of therapy. For quantity limit overrides provide dosing rationale and clinical justification.

Include prior treatment history and reason alternative therapies are inappropriate
Provide lab values, imaging, or test results when applicable
State the requested quantity and clinical rationale for exceeding QL

Documentation Required

Support for requirements

Support for requirements: when PA/AC/SP/QL are shown, the plan may request supporting clinical documentation as part of the authorization review. Ensure documentation is contemporaneous and clearly links the requested therapy to medical necessity.

Attach clinical notes, prior authorization forms, and relevant test results
For specialty drugs include prior authorization forms and required specialty pharmacy enrollment

Documentation Required

PA/QL/SP requirements for oncology and specialty drugs

PA, QL, and SP requirements for oncology and specialty drugs commonly demand documentation of diagnosis, line of therapy, prior regimens, biomarker status (if applicable), and treatment intent. Providers should be prepared to submit detailed clinical records for these agents.

Provide pathology reports, mutation testing, or biomarker results when relevant
Document prior chemotherapy, targeted therapy or immunotherapy and reasons for discontinuation

Documentation Required

Documentation to support PA

Documentation to support PA should be specific and complete: include diagnosis, relevant labs/tests, prior medication trials and dates, intolerances or contraindications to preferred agents, and planned monitoring. Specialty products may also require manufacturer- or payer-specific forms.

Use payer-specific PA forms where available
Include copies of prior authorization denials or failure documentation for step therapy exceptions

Documentation Required

Quantity limits and clinical documentation

Quantity limits and clinical documentation: when requesting quantities above a QL, submit clinical justification including dosing schedule, weight-based dosing calculations (if applicable), and expected treatment course. Some therapies have pack/kit limits that must be adhered to unless an exception is approved.

Examples: pack/kit limits for inhaled treprostinil starter kits, oncology pack limits, and vials/pens per period
Provide dosing calculation for weight- or BSA-based regimens

Documentation Required

Supportive documentation for PA/SP

Supportive documentation for PA/SP: for specialty or SP-managed drugs, include prior authorization forms, patient consent (if required), enrollment into a specialty pharmacy (when mandated), and any REMS or monitoring plans required by the manufacturer or payer.

Enroll patient in specialty pharmacy when SP flag present
Include REMS certification or monitoring plan documentation if applicable

Documentation Required

Examples of documentation of PA/QL

Examples of documentation that support PA/QL: prior therapy records, lab values, pathology reports, genetic or biomarker testing, documentation of intolerance or contraindication to preferred alternatives, and manufacturer-specific forms. For QL overrides include dosing schedule and clinical justification.

Pathology or mutation testing (oncology)
Prior treatment failure notes and dates
Monitoring plans and dosing rationale for QL overrides

Denial Risk

Quantity limits enforcement

Quantity limits are actively enforced; dispensing beyond stated QL without prior approval can lead to denial of coverage or full member financial responsibility. Providers should request PA for any expected ongoing need above the QL with supporting clinical evidence.

Common QLs: tablets/capsules per 30 days, kit or cartridge per 30/180 days
State the requested duration and clinical justification when requesting overrides

Documentation Required

Suspension/packet QL documentation

Some QL entries reference suspension/packet/kit limits (for example, starter kits, inhalation packs, pellet packets). When those limits exist, supporting documentation for clinical need and dosing schedule should accompany any request to exceed the limit.

Starter/titration packs and pellet packets often have specific QL limits
Provide clinical rationale if more than the kit/packet limit is clinically necessary

Step Therapy

Step therapy not specified / Step therapy requirements

Step therapy is mentioned as a possible program in benefit plans but specific step algorithms are not detailed in this excerpt. Where "ST" appears in Special Requirements, a step therapy requirement applies and an exception process is available.

ST flag indicates step therapy — required trial of preferred agent(s) before coverage of the requested drug
If step therapy fails or is contraindicated, prescribers may submit a step therapy exception with supporting documentation

Documentation Required

Access control / formulary restrictions

Access control (AC) and formulary restrictions are used for some products (e.g., select contraceptives, vaccines, or drugs with age/safety restrictions). When AC is shown, additional coverage criteria or age-based limitations may apply and must be met for coverage.

AC indicates coverage criteria beyond PA (age limits, indication restrictions, preventive coverage rules)
Refer to member benefit materials for ACA preventive coverage exceptions

Step Therapy

Step therapy indicated — provider actions

Step therapy may be required for certain therapeutic classes (not fully enumerated here). Items marked "ST" should be treated as requiring trial and failure of preferred medications before PA for the non-preferred agent will be approved.

Examples: certain antipsychotics and antidepressants show ST flags
Providers should document prior trials and reasons for failure when seeking exceptions

Initial Therapy, Starter and Titration Pack Controls

Initial therapy considerations

Formulary entries indicate typical outpatient formulations and any management flags for initiation.

Initiation rules: Initiation of listed outpatient therapies follows formulary tiering; drugs with 'PA' require prior authorization before initiation; drugs with 'QL' have quantity limits at initiation; specialty products flagged 'SP' must be dispensed via specialty pharmacy.

Specific clinical criteria for PA are not present in this extract; see full policy for PA clinical criteria.

Initial therapy authorization signals

Initial coverage/authorization signals

PA required where listed: If a drug's Requirements/Limits field includes 'PA', prior authorization is required before coverage.

Specific clinical criteria for PA are not included in these chunks

Titration pack requirements

Titration and starter packs have specific QL and ST flags

Titration pack rules: Titration packs (e.g., FANAPT titration packs) list specific QL limits and are subject to step therapy (ST) where indicated.

FANAPT Pack A QL 8 tablets/180 days; Pack B QL 1 pack/180 days; Pack C QL 1 pack/180 days.

Starter/titration pack controls

Starter packs and titration packs listed with QL/PA where applicable

Starter/titration pack controls: Starter and titration packs (e.g., MAYZENT STARTER PACK, REBIF TITRATION PACK, MAVENCLAD therapy packs) have PA and specific QL limits as listed and require adherence to those limits for coverage.

No clinical initiation criteria included in fragment.

Step Therapy Programs and Tables

Policy element	Summary
Step therapy (ST)	Step therapy programs may require trying a first-line, cost‑effective medication before coverage is available for a non‑preferred drug. If a step therapy is commonly required it is generally noted with 'ST' in the Special Requirements column. Prescribers may submit a step therapy exception request if the preferred agent is not appropriate.
Exceptions	Providers may request a step therapy exception; the prescriber (or authorized representative) must submit the request for review.

Policy element	Summary
Overlap with PA/AC/SP	Certain agents are managed with prior authorization (PA), access control (AC) or specialty program (SP) designations; these utilization controls may be applied alongside step therapy where indicated, though specific step sequences are not detailed in the formulary extract.
Examples	Selected high‑cost anti‑infective and antiviral agents (e.g., tobramycin nebulized preparations, posaconazole, EPCLUSA) show PA and/or SP flags indicating PA/AC/SP management may accompany step requirements.

Policy element	Summary
Step therapy presence	Step therapy sequences are not explicitly enumerated for hepatitis C (HCV) or HIV agents in these chunks. Several HCV/HIV products are marked with PA and/or SP, which suggests they are subject to utilization management but without defined ST algorithms in this excerpt.
Examples	EPCLUSA and MAVYRET list PA and QL and SP; emtricitabine and other HIV agents show QL/AC flags—no step‑by‑step algorithm provided here.

Policy element	Summary
Oncology / specialty entries	Many oncology and specialty agents list prior authorization (PA), quantity limits (QL) and are designated SP. These flags imply the drugs are managed as specialty products and may be subject to step or specialty routing, though explicit ST sequences are not shown in the excerpt.
Examples	Agents such as abiraterone, alectinib, and alunbrig include PA, QL and SP designations indicating specialty management alongside utilization controls.

Policy element	Summary
Explicit ST steps	The provided document fragments do not include explicit step therapy step definitions or the required prior agents/failure criteria. The formulary lists ST flags on specific products but not the underlying step algorithms in these chunks.
Implication	Where 'ST' appears on a product line it indicates a plan‑defined sequence must be followed; details are available in benefit plan materials or full policy documentation.

Policy element	Summary
GLP‑1 and related agents	Step therapy specifics are not provided for GLP‑1/GLP/GIP agents in the excerpt. Several agents (e.g., MOUNJARO, OZEMPIC, RYBELSUS) include PA and QL flags, indicating prior authorization and quantity controls apply, but ST algorithms are not detailed.
Provider action	Obtain PA where listed and consult benefit plan materials for any step therapy requirements or exception processes.

Policy element	Summary
Access control (AC)	Some products (e.g., raloxifene) are listed with 'AC' (access control) in Requirements/Limits; AC may reflect an administrative/clinical review or access step that must be satisfied prior to coverage and can function similarly to a step/access requirement.
Implication	AC‑flagged products require documentation or review per the formulary entry; consult the plan's authorization process for specifics.

Policy element	Summary
Fallback guidance	When step therapy is not specified in the extract, coverage is determined by the drug tier and any listed Requirements/Limits (PA, QL, SP, AC). Providers should follow the drug‑specific flags and submit PA or request exceptions as needed.
Action	Refer to benefit plan materials or contact the payer for full step therapy algorithms or exception procedures when ST details are not present.

Policy element	Summary
PA/QL without ST	Some products have prior authorization (PA) and quantity limits (QL) but no explicit ST flag in the excerpt. For example, CIMZIA (certolizumab) is shown with PA and QL (2 kits/28 days) and SP but no ST designation in the referenced chunk.
Implication	Coverage requires meeting PA and QL requirements; absence of an ST flag in the excerpt means step therapy sequencing is not indicated for that line in these chunks.

Policy element	Summary
Antipsychotics/antidepressants ST	Step therapy (ST) is explicitly applied to certain antipsychotics and antidepressants. Multiple aripiprazole formulations, FANAPT titration packs, risperidone ODT lines, and clozapine ODT/suspension entries carry ST designations in the formulary fragments.
Examples and limits	Aripiprazole formulations show QL and ST (e.g., QL 60 tablets/30 days; solution QL 900 mL/30 days). FANAPT titration packs list specific QL and ST flags. Risperidone ODT and clozapine ODT entries also list QL and ST as applicable.

Policy element	Summary
ST applies to select products	When an 'ST' flag appears on a product line, step therapy applies and the prescriber must follow the plan‑defined sequence before the non‑preferred agent will be covered. The ST flag is shown next to affected products in the Special Requirements column.
Examples	Examples in the extract include antipsychotic titration packs (FANAPT) and multiple aripiprazole/clozapine formulations marked with ST; full step sequences are not provided in these fragments.

Policy element	Summary
Specific products marked ST	Certain products such as Gralise (gabapentin once‑daily formulations) are marked 'ST' in the formulary extract, indicating step therapy applies. The fragment lists the ST flag but does not define the required prior agents or failure criteria.
Coverage note	Coverage for ST‑marked products requires adherence to plan‑defined step therapy rules; providers should submit exception requests when a first‑line agent is inappropriate.

Quantity Limits and Supply Rules

maintenance medications — standard 30-day supply; up to 90-day for maintenance

Standard covered supply for outpatient medsMost plans provide coverage for up to a 30-day supply; maintenance medications may be covered up to a 90-day supply (plan dependent)

Maintenance medication definitionMaintenance medications are drugs taken on an ongoing basis for conditions such as hypertension, diabetes, or high cholesterol

Plan exceptionsSome plans may exclude certain categories (e.g., erectile dysfunction, weight loss) or limit coverage by age or other plan rules

Multiple quantity limit examples by product

Multiple QL examples (summary)Varies by product — e.g., QL 60 tablets/180 days; QL 28 tablets/30 days; QL 235.2 mLs/28 days; QL 30 tablets/30 days

Product-specific limitsEach formulary line lists exact QL values where applicable — refer to product entry for precise limit

EnforcementDispensing beyond QL may result in member responsibility for full cost or claim denial unless PA/override is obtained

DOVATO quantity limit example

DOVATO (dolutegravir-lamivudine)Requirements/Limits = AC, QL (30 tablets/30 days)

Formulation noteListed as Drug Tier = P with QL indicated for outpatient dispensing

Coverage conditionCoverage requires adherence to the listed QL and any AC requirements

EMTRIVA solution QL example

EMTRIVA (emtricitabine) oral solutionRequirements/Limits = QL 720 mLs/30 days

Formulation detailSolution presentation has a milliliter-based QL rather than tablet count

Coverage implicationClaims must not exceed the listed mL limit without prior authorization/override

MAVYRET QL example

MAVYRET (glecaprevir-pibrentasvir)Requirements/Limits = PA, QL 90 tablets/30 days (pellet pack variants may show alternate QL)

Packet pack noteSome presentations listed as pellet/packet may have different QLs (e.g., 140 tablets/28 days) and specialty routing

Coverage requirementPA and QL must be met for benefit coverage

SUNLENCA QL example

ContextSmall tablet counts reflect dosing/regimen-specific QL rather than monthly supply

Coverage noteAdhere to listed QL and PA/SP where indicated for specialty regimens

NORVIR powder packets QL example

NORVIR powder packetsRequirements/Limits = QL 360 packets (per listed period)

FormulationPacket formulations are assigned packet-based QL rather than tablet counts

Coverage implicationClaims must respect packet QL or may require PA for excess quantities

Oncology specialty QL examples

Oncology/specialty titration or starter packsMany specialty oncology products have PA and pack-based QLs (e.g., UPTRAVI TITRATION PACK QL pack/180 days)

Sample: ERIVEDGE cap 150 mgRequirements/Limits = PA, QL 30 capsules/30 days, SP

High-cost oncology QLsExamples include QL 60–240 tablets/30 days depending on agent (e.g., ALUNBRIG, SCEMBLIX)

ERIVEDGE cap 150 mg QL example

ERIVEDGE (vismodegib) cap 150 mgRequirements/Limits = PA, QL 30 capsules/30 days, SP

Therapy contextListed as Drug Tier = P with PA and QL

Coverage implicationPA and QL required for coverage of this oncology agent

TALZENNA QL examples

TALZENNA (talazoparib)Requirements/Limits = PA, QL examples include 30–120 tablets/30 days depending on presentation

RUBRACA (rucaparib)Requirements/Limits = PA, QL 120 tablets/30 days

SCEMBLIX (asciminib) 40 mgRequirements/Limits = PA, QL 240 tablets/30 days

RUBRACA QL example

RUBRACA (rucaparib camsylate)Requirements/Limits = PA, QL 120 tablets/30 days

Formulation noteHigh tablet-count QLs are applied to some PARP inhibitors and require PA

Coverage implicationClaims beyond QL may be denied without PA

SCEMBLIX QL example

SCEMBLIX (asciminib) 40 mgRequirements/Limits = PA, QL 240 tablets/30 days

Other strengthsASCIMINIB also listed with QL 60 and 120 tablets/30 days for other strengths

Specialty routingSP designation shown for many oncology entries

TAGRISSO QL example

TAGRISSO (osimertinib)Requirements/Limits = PA, QL 30 tablets/30 days

Coverage requirementPA and QL must be met for benefit coverage

Formulary contextListed among oncology targeted therapies with SP where applicable

TALZENNA talazoparib QL example (capsules)

TALZENNA talazoparib (capsule presentation)Requirements/Limits = PA, QL 30 capsules/30 days (selected listing)

Packaging noteCapsule vs tablet presentations may have different QLs per product line

Coverage implicationPA required for many PARP inhibitors with specified QLs

TRUQAP capivasertib QL example

TRUQAP (capivasertib)Requirements/Limits = PA, QL 64 tablets/28 days, SP

Therapy pack noteTherapy pack presentations include pack-based QLs (e.g., 64 tablets/28 days)

Coverage implicationPA and SP routing indicated for many therapy-pack oncology drugs

VITRAKVI oral solution QL example

VITRAKVI oral solutionRequirements/Limits = PA, QL 300 mLs/30 days

VITRAKVI 25 mg capsulesRequirements/Limits = PA, QL 180 capsules/30 days

VITRAKVI 100 mg capsulesRequirements/Limits = PA, QL 60 capsules/30 days

VITRAKVI 25 mg capsules QL example

VITRAKVI 25 mg capsulesPA, QL 180 capsules/30 days

Pack/capsule distinctionsDifferent capsule strengths have distinct QLs listed per product line

Specialty routingSP designation present for many targeted agents

VITRAKVI 100 mg capsules QL example

VITRAKVI 100 mg capsulesPA, QL 60 capsules/30 days

Therapy contextHigh-cost oral oncology agents commonly have PA and SP flags alongside QL

Claims implicationAdherence to listed QL required or claim may be denied

XTANDI QL example

XTANDI (enzalutamide)Requirements/Limits = PA, QL 120 tablets/30 days for 40 mg presentation

Alternate strength80 mg listed with PA and QL 60 tablets/30 days

Specialty designationSP may be shown for oncology agents where administration or handling differs

ALORA patch QL example

ALORA estradiol transdermal patchRequirements/Limits = QL 30 patches/30 days

Patch dispensingTransdermal patches are subject to patch-count QLs per month

Plan implicationExceeding QL may require PA or result in member cost responsibility

Most oral contraceptives QL example (28)

Most oral contraceptivesRequirements/Limits = AC, QL 28 tablets (typical packaging/period)

Extended-cycle formulationsSome 84/91-tablet regimens are listed but QL references still show 28 tablets/21 days packaging conventions

Coverage noteAC flags indicate authorization/clinical review may apply in addition to QL

Levonorgestrel emergency QL example (2)

Levonorgestrel (emergency contraception)Requirements/Limits = AC, QL 2 tablets/365 days

Coverage implicationEmergency contraceptive QL is annual (2 tablets per 365 days) as listed

Authorization noteAC flags present for some contraceptive entries indicating clinical review may be required

GLP-1/antidiabetic pens and some insulins QL varies

GLP-1 and insulin pen/solution limitsQL varies by product — examples include QL 4 pens/28–180 days for tirzepatide/semaglutide products and QL 100 mLs/30 days for some insulins

HUMALOG / LYUMJEV / NOVOLOGRequirements/Limits = QL 100 mLs/30 days for many pen/solution presentations

Weight-management injectablesMOUNJARO/OZEMPIC/ZEPBOUND/WEGOVY show PA and product-specific QLs (e.g., 1–4 pens per period)

MENOPUR QL example

MENOPUR (menotropins)Requirements/Limits = QL 60 vials/30 days, SP

Fertility injectablesMany require SP routing and have vial/syringe-based QLs

Coverage implicationPA/SP and QL must be met for benefit coverage of reproductive therapies

OVIDREL QL example

OVIDREL (choriogonadotropin alfa)Requirements/Limits = QL 2 syringes/30 days, SP

Fertility injectables packagingSyringe-based QLs are commonly applied to clinician- or specialty-dispensed fertility agents

Coverage notePA or SP may also be required per product line

SOMAVERT QL example

SOMAVERT (pegvisomant)Requirements/Limits = PA, QL 30 vials/30 days, SP

High-cost endocrine injectablesOften require PA and are managed via specialty pharmacy with vial-based QLs

Claims implicationAdhere to listed QL or seek PA for quantities exceeding limits

TYMLOS QL example

TYMLOS (abaloparatide)Requirements/Limits = PA, QL 1.56 mLs/30 days

Injectable volume-based QLsSome pen/solution products have mL-based QLs rather than count-based limits

Specialty routingSP designation common for these biologic/peptide therapies

YORVIPATH QL example

YORVIPATH (palopegteriparatide)Requirements/Limits = PA, QL 2 pens/28 days, SP

Pen-count QLSome long-acting peptide therapies use pen-count QLs per 28-day period

Coverage implicationPA and SP routing typically required

REPATHA 140 mg syringe QL example

REPATHA 140 mg prefilled syringeRequirements/Limits = PA, QL 6 syringes/28 days

REPATHA PUSHTRONEX 420 mgRequirements/Limits = QL 2 cartridges/30 days

Specialty injectablesSyringe/cartridge QLs applied and PA/SP often required

REPATHA PUSHTRONEX 420 mg QL example

REPATHA PUSHTRONEX 420 mg systemRequirements/Limits = QL 2 cartridges/30 days

Dose form noteCartridge-based systems have cartridge-count QLs rather than syringe counts in some listings

Coverage implicationPA may be required for some presentations

NEXLETOL QL example

NEXLETOL (bempedoic acid)Requirements/Limits = PA, QL 30 tablets/30 days

Oral cardiovascular agentsMany have 30-tablet-per-month QLs listed

Coverage notePA indicated for select lipid-lowering specialty agents

Bosentan QL example

Bosentan (Tracleer)Requirements/Limits = PA, QL 60 tablets/30 days, SP

PAH agent QLsPA and high tablet-count QLs (e.g., 60–120 tablets/30 days) commonly applied to PAH therapies

Specialty routingSP designation often accompanies PA for PAH agents

VYNDAMAX QL example

VYNDAMAX (tafamidis) 61 mgRequirements/Limits = PA, QL 30 capsules/30 days

VYNDAQEL (tafamidis meglumine) 20 mgRequirements/Limits = PA, QL 120 capsules/30 days

Coverage implicationPA and QL required for tafamidis cardiac indications

VYNDAQEL QL example

VYNDAQEL tafamidis meglumine 20 mgRequirements/Limits = PA, QL 120 capsules/30 days

Higher QL for some cardiac formulationsListed QL reflects long-term dosing and packaging differences

Specialty routingSP designation present for tafamidis products

ORENITRAM titration kit QL example

ORENITRAM titration kitRequirements/Limits = PA, QL 1 pack/180 days

Titration kit contextTitration/starter kits have pack-based QLs over extended periods (e.g., 180 days)

Coverage notePA and SP often accompany titration kits

FUROSCIX QL example

FUROSCIX furosemide subcutaneous cartridge kit 80 mgRequirements/Limits = QL 8 kits/180 days

Home-administered cartridge kitsLonger period QLs reflect infrequent dispensing cycles

Coverage implicationPA/SP may be required depending on product

UPTRAVI TITRATION PACK QL example

UPTRAVI TITRATION PACKRequirements/Limits = PA, QL pack/180 days, SP

Titration pack notePack-based QLs and PA shown for selexipag titration packs

Coverage requirementAdhere to QL and PA for claim coverage

ADVAIR HFA QL example

ADVAIR HFA inhalerRequirements/Limits = QL 1 inhaler/30 days

Inhaler dispensing limitsMany inhalers list QL per 30-day period (1–3 inhalers/30 days depending on product)

EnforcementClaims exceeding inhaler QL may be denied or require PA

NUCALA QL example

NUCALA (mepolizumab)Requirements/Limits = PA, QL 3 mL/28 days or 1 syringe/28 days depending on presentation, SP

Dose/presentation dependent QLSyringe vs multi-mL vial presentations have different QLs listed

Coverage implicationPA and SP commonly required for biologic injectables

TRIKAFTA QL example (packets/28 days)

TRIKAFTA (packet presentations)Requirements/Limits = PA, QL 56 packets/28 days for certain presentations, SP

Packet QL noteSome TRIKAFTA presentations list packet-based QLs (56 packets/28 days)

Coverage requirementPA and QL must be met for coverage of CF modulators

TRIKAFTA (packets) QL example (56 packets)

TRIKAFTA (packet) typical QLQL 56 packets per 28 days for listed packet presentations

Specialty routingSP designation accompanies many cystic fibrosis modulators

PA requirementPA noted for many TRIKAFTA listings

SYMDEKO QL example

SYMDEKO (tezacaftor-ivacaftor)Requirements/Limits = PA, QL 60 tablets/30 days, SP

CF modulator QLsCommonly 60 tablets/30 days or packet-based QLs depending on formulation

Coverage implicationPA and SP routing often required

MOVANTIK QL example

MOVANTIK (naloxegol)Requirements/Limits = QL 30 tablets/30 days

Oral GI specialty agentsMany GI agents list 30-tablet monthly QLs

Coverage noteAdhere to QL or seek PA for larger quantities

ENTYVIO PEN QL example

ENTYVIO PEN (vedolizumab)Requirements/Limits = PA, QL 2 pens/28 days

Biologic pen QLsPen-count QLs are applied to many self-injectable biologics

Specialty routingSP designation commonly accompanies these entries

TREMFYA INDUCTION PACK QL example

TREMFYA INDUCTION PACKRequirements/Limits = PA, QL 3 kits/180 days, SP

Induction/titration kit QLInduction kits often have QLs over 180-day windows

Coverage implicationPA and SP routing required for induction kits listed

ZYMFENTRA formulations QL example

ZYMFENTRA formulations (infliximab-dyyb)Requirements/Limits = PA, QL 2 kits or 2 syringes/28 days, SP

Prefilled syringe/kit QLsSome biosimilar auto-injector kits list kit- or syringe-based QLs

Specialty routingSP designation and PA commonly apply

Aripiprazole/clozapine QL examples

Aripiprazole solutionRequirements/Limits = QL 900 mLs/30 days

Clozapine ODT/tablets (various strengths)Requirements/Limits = QL 90–270 tablets/30 days depending on strength — most actionable: ensure dispensing aligns with the listed tablet-range QL

ST flagMany entries include ST indicating step therapy applies to select behavioral health agents

Various QL examples across products

Examples across CNS and behavioral healthCommon QLs include 30 tablets/30 days; 60 tablets/30 days; 90 tablets/30 days; some suspensions list mL-based QLs (e.g., 540 mLs/30 days)

FANAPT titration packsQL examples: Pack A QL 8 tablets/180 days; Pack B/C QL 1 pack/180 days; ST applies

Sodium oxybate (XYWAV)Requirements/Limits = PA, QL 540 mLs/30 days, SP

Multiple QL examples (see code groups)

Formulary QL variabilityQuantity limits vary by product and presentation — see each product entry (examples: vials, pens, syringes, tablets, mLs, packets)

Specialty product enforcementMany specialty products list PA and SP along with QL — documentation required for PA/overrides

Time windowsQL periods include 28 days, 30 days, 180 days, 301 days and 365 days depending on product

Site of Care and Specialty Pharmacy Routing

Note

Confirm site‑of‑care (medical vs pharmacy benefit) for clinician‑administered drugs

Site‑of‑care guidance: medications administered by a health care professional may be covered under the medical benefit rather than the pharmacy benefit; confirm benefit routing before ordering or billing.

Billing Rule

Route SP‑designated drugs through specialty pharmacy

Specialty‑designation (SP) indicates the drug is managed through the plan's specialty pharmacy channel; providers should route SP products through the specialty pharmacy as required.

When 'SP' appears in Requirements/Limits, coordinate with the plan's specialty pharmacy (e.g., Accredo) for dispensing and support.

Billing Rule

Ensure specialty pharmacy dispensing for SP products

If a drug is designated 'SP' in the formulary, specialty pharmacy dispensing is expected; providers should ensure specialty pharmacy coordination when submitting PA and scheduling delivery.

Prior Authorization

Coordinate PA and specialty distribution for SP drugs

Specialty products marked 'SP' should be routed through the plan's specialty pharmacy channel and require coordination of PA and specialty distribution prior to dispensing.

Documentation Required

Confirm specialty handling and distribution for SP biologics

Specialty‑designated biologic and complex products (SP) often require specialty handling and distribution; providers must confirm SP routing and supply PA documentation as part of the specialty dispensing workflow.

Billing Rule

Dispense SP‑designated products through specialty pharmacy and meet PA/QL

Several listed specialty drugs are designated SP; when SP is shown, providers must ensure these products are dispensed via specialty pharmacy and that PA/QL requirements are met.

Note

Verify administration site and route for SP biologics

Biologic and other specialty products designated SP may require clinic administration or specialty pharmacy dispensing; providers should verify the appropriate site and route claims accordingly.

Billing Rule

Coordinate required specialty pharmacy distribution for SP drugs

When a drug is marked 'SP' specialty pharmacy is required for distribution; providers must coordinate with the specialty pharmacy for authorization and delivery logistics.

Prior Authorization

Enroll and coordinate with specialty pharmacy for SP products

Drugs designated SP in the formulary are expected to be managed through the specialty pharmacy channel; providers should ensure PA and SP program enrollment steps are completed before dispensing.

Definitions and Abbreviations

Background and Scope

Specialty drugs treat complex conditions and may require special handling, support services, or clinician administration. Some clinician‑administered products may be covered under the medical benefit rather than the pharmacy benefit; specialty‑designated drugs (marked SP) should be dispensed through the plan’s specialty pharmacy channel when required.