Obtain prior authorization when indicated

Obtain prior authorization when the drug line shows 'PA' in the Requirements/Limits column; approval must be received before the medication may be covered under the plan.

• PA flag appears on formulary lines to indicate prior authorization is commonly required.

Follow PA and specialty program requirements

For select specialty or high‑cost anti‑infective and antiviral agents follow PA and any Special Program (SP) requirements noted on the formulary line prior to dispensing.

• Examples in the list (e.g., HARVONI, tobramycin nebu) show PA and SP designations that must be satisfied.

PA required for select antivirals and specialty drugs

Prescribers must request prior authorization for antiviral and other specialty medications flagged with 'PA' on the drug list; these entries may also carry QL or SP designations.

• Examples include PAXLOVID and PEGASYS which list PA and/or QL and SP on the formulary lines.

PA required for many oncology agents

Prior authorization is required for many antineoplastic and other oncology agents when 'PA' (often with QL and SP) appears in Requirements/Limits; obtain authorization before coverage.

• Multiple oncology entries (e.g., abiraterone, ALECENSA) list PA, QL and SP that must be met.

PA for listed oncology products

Obtain prior authorization for listed oncology drugs when Requirements/Limits includes 'PA' — each strength/pack may require its own authorization.

• Several oral oncology entries (e.g., GAVRETO, GOMEKLI) show PA and QL per formulation.

Obtain PA where specified on the formulary line

When a formulary line shows 'Requirements/Limits = PA' the provider must secure prior authorization before the plan will cover the specified product/formulation.

• This applies to individual drug formulations where PA is stated (examples: TIBSOVO, VENCLEXTA, XPOVIO).

PA required for select antidiabetics/GLP‑1 agents

Certain antidiabetic and GLP‑1 agents (e.g., MOUNJARO, OZEMPIC, TRULICITY) are designated 'PA' and often include quantity limits — submit PA requests and supporting documentation as required.

• MOUNJARO: Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on strength).
• OZEMPIC: Requirements/Limits include PA and QL per pen strength.

PA for specialty endocrine/metabolic drugs

Prior authorization is required for select specialty endocrine/metabolic agents that show 'PA' and often 'SP' on the formulary; secure PA and follow specialty handling as indicated.

• Examples include ACTHAR and GENOTROPIN with Requirements/Limits = PA, SP.

PA required for listed specialty agents

For specialty agents listed with 'PA' (and often 'SP') obtain prior authorization before dispensing; follow any quantity limits shown on the drug line.

• Examples: Forteo (teriparatide) lists PA and QL (2.24 mls/28 days); TRYNGOLZA lists PA and QL (1 device/28 days).

PA and QL for FUROSCIX

FUROSCIX requires prior authorization and is limited to QL 8 kits per 180 days; failure to obtain PA or exceeding the QL may result in denial.

• FUROSCIX formulary line: Requirements/Limits = PA, QL (8 kits/180 days).

PA and QL for select lipid and biologic agents

Obtain prior authorization and adhere to the listed quantity limits for select lipid‑modifying and specialty biologic agents (e.g., NEXLETOL/NEXLIZET: PA, QL 30 tablets/30 days; REPATHA: PA, QL 6 syringes/28 days).

• Follow PA + QL as stated on each product line prior to coverage.

PA + QL + SP for PAH and specialty cardiovascular agents

Many pulmonary arterial hypertension and specialty cardiovascular agents require prior authorization and often include quantity limits and specialty designation; obtain PA and comply with QL/SP as shown.

• Examples: ADEMPAS (PA, QL 90 tablets/30 days), UPTRAVI (PA, QL 60 tablets/30 days), OPSUMIT/ORENITRAM entries show PA, QL, SP.

Obtain PA when product lists 'PA'

When a product is marked 'PA' on the formulary (for example XHANCE) the provider must obtain prior authorization before the plan will cover the medication.

• Check the Requirements/Limits field on the drug line for PA status.

Specialty biologics require PA and SP handling

Specialty biologics and cystic fibrosis modulators marked with 'PA' or 'PA, SP' require prior authorization and specialty pharmacy handling; submit PA and arrange specialty routing as required.

• Examples include FASENRA, NUCALA, XOLAIR, TRIKAFTA which list PA and SP on their formulary lines.

PA required for specified high‑cost products

Obtain prior authorization for the products identified with 'PA' on the formulary; many high‑cost agents list PA as a coverage requirement.

• PA is indicated for numerous specialty biologics and high‑cost drugs in this segment.

Secure prior authorization when listed

When a drug line shows 'PA' you must secure prior authorization before the plan will cover the medication; follow the Requirements/Limits on the formulary entry.

• Examples include PROCYSBI and tasimelteon entries showing PA (and sometimes SP/QL).

PA required for listed specialty and biologic drugs

Prior authorization is required for many listed specialty and biologic drugs (e.g., PLEGRIDY, ZEPOSIA, adalimumab products, ENBREL, HUMIRA); obtain PA and comply with any QL/SP noted on the drug line.

• These entries commonly include PA, QL and SP flags that must be satisfied for coverage.

Step therapy may be required (ST)

When a drug line includes 'ST' the benefit may require step therapy — try the required cost‑effective alternative first per the plan before coverage for the requested agent is available.

• Step Therapy (ST) is noted next to medications where the program commonly applies.

Step therapy sequences not specified here

The formulary listing in these excerpts does not provide explicit step therapy sequences for most agents; check the benefit materials or plan resources for specific ST algorithms.

• Only flags (PA, QL, SP, ST) are shown; full step details may be maintained separately.

Submit PA/exception requests to the number on the member ID card

Providers must submit PA or exception requests to the phone number on the member ID card; standard decisions are provided within 15 calendar days and expedited requests within 72 hours.

• Use the member ID card contact for PA/submission and timing inquiries.

Specialty (SP) designation may trigger program requirements

Products labeled with SP may be managed through specialty pharmacy pathways and could require enrollment in a specialty program; follow PA/SP routing indicated on the formulary line.

• SP designation (e.g., PALFORZIA levels) signals specialty program management.

No explicit step therapy details on these lines — confirm plan rules

Where no explicit step therapy rules are provided on the formulary lines, providers should still check plan materials — many entries only show PA, QL, SP or AC flags without step sequences.

• Absence of ST on a line does not guarantee the plan has no step requirements elsewhere.

Follow access (AC) indicators for applicable products

Some formulary lines include access or administrative codes (AC) for contraceptives or related agents; follow the payer's access criteria and submission processes where AC is shown.

• Examples: multiple contraceptive entries list AC and QL (28 tablets/21 days).

When ST not shown, confirm PA/QL still apply

Where step therapy is not specified in the excerpt, providers should assume PA and QL requirements listed on the drug line still apply and confirm any step requirements via plan resources.

• Many agents show PA and QL even when ST is not listed (e.g., MOUNJARO entries).

Follow ST or SP pathways when flagged

Products flagged with 'ST' or 'SP' (e.g., KERENDIA) may indicate step‑therapy or specialty pharmacy pathways; obtain authorization and follow pathway requirements where present.

• KERENDIA lists QL (30 tablets/30 days) and ST — follow the ST requirement if present on the member's plan.

ST applies to select CNS and psychiatric agents

Certain formulary entries note step therapy for specific CNS and related drugs (examples include AUVELITY, FETZIMA, FLUOXETINE DR and clozapine ODT) — follow ST requirements prior to coverage of the requested agent.

• Check the Requirements/Limits field for 'ST' and the member's benefit for required prior agents.

Document prior therapy for ST when requesting PA

When step therapy is noted for agents (ST), try the specified proven, cost‑effective medication first per the program; documentation of prior therapy may be required with PA.

• ST flags indicate the member may need to fail or be intolerant to the step medication before authorization is granted.

Confirm step therapy via plan resources when not listed

If no step therapy is documented in the excerpt for a product, verify benefit‑specific step requirements with the plan; many formulary lines only display PA/QL/SP codes without full ST detail.

• The formulary often lists PA/QL/SP but not the failure criteria or step sequence.

Specialty designation may require specialty pharmacy routing

SP designation on a formulary line may require routing through a specialty pharmacy and could trigger additional PA or program steps — coordinate with the plan's specialty pharmacy processes.

• Examples: multiple high‑cost agents marked SP are managed through specialty channels.

Execute step therapy when 'ST' is shown

Step therapy is indicated for certain products using the 'ST' flag; when present, providers must follow the specified step requirements before the requested drug will be covered.

• Examples of ST‑flagged products include AUVELITY, FETZIMA, FLUOXETINE DR, CLOZAPINE ODT and others.

Examples of products with ST noted

Examples of step therapy noted on the formulary include AUVELITY, FETZIMA, FLUOXETINE DR, RISPERIDONE ODT and CLOZAPINE ODT; follow the ST requirement before seeking coverage for the requested agent.

• Check the Requirements/Limits field for 'ST' on the specific line item.

ST noted for select agents (examples)

Step therapy is noted for select agents (e.g., VERSACLOZ clozapine suspension, gabapentin formulations) — providers must follow the ST pathway where indicated.

• VERSACLOZ lists QL (540 mls/30 days) and ST on the formulary line.

No ST algorithm in this excerpt — confirm with plan

When no explicit step therapy algorithm is provided on a formulary segment, rely on the PA, QL and SP flags shown and confirm step requirements through the plan's clinical criteria or provider resources.

• Many entries only display administrative flags; full step criteria may be available via plan tools.

Provide clinical documentation to support PA

Submit documentation to support prior authorization requests when the drug line lists 'PA'; the PA request should include clinical rationale and any required prior‑therapy or diagnosis information.

• Examples: oncology drugs listed with PA will require supporting documentation to meet the PA criteria.

Adhere to documented quantity limits (QL)

Adhere to quantity limits indicated with 'QL' on each drug line; dispensing quantities that exceed the listed QL will likely require additional documentation or prior authorization.

• Examples include azithromycin QL (60 tablets/180 days) and itraconazole QL (120 capsules/30 days).

Do not exceed QL without authorization

When a QL is specified for a product (e.g., many insulin and inhaler entries), dispense only up to the listed quantity unless PA is obtained; claims exceeding QL may be denied without authorization.

• Insulin examples: QL (100 mls/30 days) is noted for multiple insulin products.

Follow Requirements/Limits codes shown on drug lines

Document and follow the Requirements/Limits codes (AC, PA, QL, SP, ST) shown on each formulary line; these designators indicate authorization, access, quantity, specialty routing, or step requirements that must be met for coverage.

• AC = access/administrative control; PA = prior authorization; QL = quantity limit; SP = specialty; ST = step therapy.

Submit supporting clinical evidence with PA requests

Provide the clinical documentation required to meet PA when the entry lists 'PA' for a specific drug and strength; include any requested prior‑therapy history, diagnoses, or test results to support approval.

• Examples: PA entries for VENCLEXTA and VITRAKVI imply submission of supporting clinical information.

Document both clinical need and requested quantity for PA+QL entries

When PA and QL are listed for a product, include documentation addressing both the clinical need and the requested quantity in the PA submission; failing to document appropriately may result in denial.

• Examples: NEXLETOL/NEXLIZET and REPATHA list PA plus QL that must be satisfied.

Lack of PA may result in denial

Many formulary lines include PA — absence of required authorization may lead to claim denial; verify PA status on the drug line and obtain approval prior to dispensing.

• Claims for drugs listed with 'PA' can be denied if PA is not obtained.

Ensure dispensed NDC/form matches QL on formulary line

Adhere to QL values tied to specific NDCs or product forms; claims that exceed the listed QL for the NDC/product form may be rejected during adjudication unless PA authorizes the excess.

• Example: omeprazole cap delayed release shows QL (60 capsules/30 days).

Follow specialty pharmacy PA documentation and routing

For specialty drugs designated 'SP' and 'PA', follow the specialty drug PA documentation process and route the prescription through the specialty pharmacy as required on the formulary line.

• Examples: AVONEX and other interferons list PA, QL and SP — submit PA and route through specialty pharmacy.

Provide PA documentation for specialty drugs

Prescribers must provide documentation to support PA requests for specialty agents (examples include TRYNGOLZA, TYMLOS, VOXZOGO); include clinical justification and quantity requested.

• Many specialty products list PA and QL and will require documentation to meet PA criteria.

Non‑formulary or non‑FDA drugs: risk of denial — request exception

Coverage requests for non‑formulary, non‑FDA‑approved, repackaged or compounded medications may be denied; obtain an exception prior to dispensing if the drug is not on the list.

• Repackaged medications and non‑FDA‑approved drugs are not covered per the policy.

PA required for certain agents — risk of denial without PA

Drugs shown with 'PA' on the formulary (e.g., ARIKAYCE, posaconazole, HARVONI) require prior authorization and could be denied if PA conditions are not met.

• Check the Requirements/Limits field for PA and follow the PA process.

PA+QL entries: obtain PA and adhere to quantity limits to avoid denial

When a formulary line indicates PA and QL, failure to obtain authorization or exceeding the stated quantity may result in claim denial; secure PA and document necessity before dispensing.

• FUROSCIX and NEXLETOL/NEXLIZET are examples where PA and QL apply and must be met.

Confirm PA and SP for biologics to avoid denial

Prior authorization is indicated for many biologics and specialty products; lack of PA or not following SP routing can lead to denied coverage — confirm PA/SP on the drug line before prescribing.

• Adalimumab products and other biologics commonly list PA, QL and SP.

Document prior therapy when ST applies

If a product's Requirements/Limits include 'ST', the plan requires step therapy; document prior use of the required alternative(s) when submitting a PA or exception.

• ST is applied to products such as FETZIMA, FLUOXETINE DR, AUVELITY and some clozapine formulations.

Check and follow Requirements/Limits flags on each drug line

Provider actions: check the formulary line for PA, QL, SP, ST or AC flags and follow the corresponding process (obtain PA, comply with QL, route to specialty pharmacy, follow step therapy or access criteria) before dispensing.

• Use the drug list and member ID resources to confirm benefit‑specific requirements.

Include full clinical support with PA submissions

When PA is shown, include clinical documentation, prior‑therapy history, and quantity rationale with the PA request; incomplete documentation increases the risk of denial or delay.

• Oncology and specialty agents commonly require supporting clinical information to satisfy PA.

Dispense only up to the listed QL unless PA authorizes more

For products with QL, dispense the quantity shown on the formulary line; if a larger quantity is clinically necessary, obtain PA to authorize the excess prior to dispensing.

• Examples of QL values are provided inline (e.g., 60 tablets/180 days, 120 capsules/30 days).

PA+QL+SP entries: obtain PA, adhere to QL, and use specialty pharmacy

Many specialty products list both PA and QL; providers must obtain PA and request the permitted quantity per the formulary line — routing through specialty pharmacy may also be required.

• Examples: PLEGRIDY and OMVOH list PA, QL and SP on their entries.

PA indicated on formulary lines requires authorization before coverage

When a formulary line shows 'PA' providers must obtain prior authorization before the medication will be covered — confirm this requirement on each drug/strength listed.

• General rule across the formulary: 'PA' indicates authorization required prior to coverage.

Request PA for the exact listed formulation/strength

Prior authorization requests should reference the exact product, strength and pack shown on the formulary line; PA requirements can vary by formulation and NDC.

• Many oral oncology and antiviral lines list PA per strength/pack — submit PA for the exact formulation.

FUROSCIX requires PA and QL adherence

PA and QL are documented for FUROSCIX and exceeding the listed QL or dispensing without PA may result in claim denial; obtain PA and adhere to QL before dispensing.

• FUROSCIX: Requirements/Limits = PA, QL (8 kits/180 days).

Include requested quantity when submitting PA for PA+QL items

When a product line lists 'PA, QL', include the quantity requested in the PA submission and reference the QL on the formulary; missing this can delay review or lead to denial.

• Examples: REPATHA (PA, QL 6 syringes/28 days); ADEMPAS (PA, QL 90 tablets/30 days).

Coordinate with specialty pharmacy when 'SP' is listed

If a drug line includes 'SP', coordinate with the specialty pharmacy for dispensing and PA processes as specialty routing and program requirements may apply.

• High‑cost endocrine and metabolic agents commonly have SP and PA flags that trigger specialty management.