Obtain prior authorization for PA‑listed drugs

Prescribers must obtain prior authorization (PA) from Blue Retiree Rx before dispensing drugs that are marked 'PA' in the Requirements/Limits column; claims for these products may be denied if PA is not approved.

• PA is defined in the Requirements/Limits Key as Prior Authorization.
• Failure to obtain PA may result in the plan not covering the drug.

Request PA for select products (e.g., fentanyl lozenges)

Some specific products in the formulary require prior authorization as shown in the Requirements/Limits listing (examples include fentanyl citrate oral transmucosal lozenges marked PA; NDS may also apply).

• Fentanyl citrate oral transmucosal lozenge on a handle entries show 'PA; NDS'.
• Check the Requirements/Limits field on the product row for PA indication.

PA required and adhere to quantity limits

Prior authorization is required for products designated 'PA' and many entries also include quantity limits (QL); providers must secure PA and ensure dispensing does not exceed the listed QL to avoid claim denial.

• Examples show lidocaine products with both QL and PA (e.g., QL(30 GM per 30 days); PA).
• Vancomycin capsules include QL values (QL(120 EA per 30 days) and QL(240 EA per 30 days)).

Obtain PA for PA NSO anticonvulsants

Certain anticonvulsant products are marked 'PA NSO' in the table; prescribers must obtain prior authorization for these anticonvulsants for coverage to be approved.

• Examples with PA NSO include BRIVIACT and EPIDIOLEX.
• PA NSO notation indicates prior authorization is required (see introduction pages).

Submit PA when product row shows PA or PA NSO

Drugs shown with 'PA' or 'PA NSO' in the Requirements/Limits column require prior authorization before coverage; review each product row for PA notation and submit PA accordingly.

• The Requirements/Limits Key lists PA and PA NSO as authorization annotations.
• Many specialty and higher‑tier products are annotated PA or PA NSO and will not be covered without approval.

PA required for specialty/oncology agents

Many oncology, specialty, and high‑cost agents are designated 'PA' or 'PA NSO' and require prior authorization before they will be covered; providers should submit PA per plan processes for these agents.

• Examples include PHESGO, ALECENSA, ALUNBRIG and multiple other oncology agents marked PA NSO.
• Specialty injectable entries commonly show PA and may carry QL annotations as well.

PA required for multiple specific products (e.g., INBRIJA, NUPLAZID)

Multiple listed products are marked with 'PA' or 'PA NSO' (e.g., INBRIJA, NUPLAZID, OPIPZA); prescribers must obtain prior authorization for these products to ensure coverage.

• INBRIJA and NUPLAZID are examples shown with PA or PA NSO.
• Check the product entry's Requirements/Limits field and follow PA submission requirements.

PA required for MOUNJARO, OZEMPIC and related agents

GLP‑1 receptor agonists and related agents (e.g., MOUNJARO, OZEMPIC) are listed with PA in Requirements/Limits; prescribers must obtain prior authorization for these products.

• MOUNJARO and OZEMPIC entries show QL values and PA annotations.
• Submit PA per formulary instructions for GLP‑1 agents to avoid claim denial.

Seek PA for PA‑designated eltrombopag products

Certain thrombopoietin receptor agonists (example: eltrombopag oral formulations) are marked 'PA' in the Requirements/Limits column; prescribers must request prior authorization for coverage.

• Eltrombopag olamine tablet strengths are listed with Requirements/Limits = PA.

PA required for metyrosine 250 mg

Metyrosine 250 mg capsules are listed with 'PA' in the Requirements/Limits column; prescribers must obtain prior authorization for this product to be covered.

• Metyrosine capsule 250mg — Requirements/Limits = PA.

PA and QL required for REPATHA (3 mL/28 days)

Both presentations of REPATHA (420 mg/3.5 mL Pushtronex and 140 mg/mL) are listed with prior authorization and a quantity limit of QL(3 mL per 28 days); prescribers must obtain PA and prescribe within this QL.

• REPATHA PUSHTRONEX SYSTEM INJECTION 420MG/3.5ML — QL(3 ML per 28 days); PA.
• REPATHA INJECTION 140MG/ML — QL(3 ML per 28 days); PA.

PA and QL required for TRYNGOLZA (3 mL/28 days)

TRYNGOLZA injection (80 mg/0.8 mL) requires prior authorization and has a quantity limit of QL(3 mL per 28 days); submit PA and ensure prescribed volume does not exceed the QL.

• TRYNGOLZA INJECTION 80MG/0.8ML — QL(3 ML per 28 days); PA.

PA and QL required for KERENDIA (30 EA/30 days)

KERENDIA tablets (10 mg, 20 mg, 40 mg) are listed with PA and a quantity limit of QL(30 EA per 30 days); prescribers must obtain prior authorization and adhere to the 30‑unit monthly limit.

• KERENDIA TABLET 10MG, 20MG, 40MG — QL(30 EA per 30 days); PA.

PA and QL required for VERQUVO (30 EA/30 days)

VERQUVO tablets (2.5 mg, 5 mg, 10 mg) are listed with prior authorization and a quantity limit of QL(30 EA per 30 days); prescribers must obtain PA and order within the QL.

• VERQUVO TABLET 10MG, 2.5MG, 5MG — QL(30 EA per 30 days); PA.

Submit PA for select specialty products (e.g., SPEVIGO, OTEZLA, LIVMARLI)

Select products in the specialty section (for example SPEVIGO injection, OTEZLA, LIVMARLI) are shown with 'PA' and often a QL; prescribers must submit prior authorization for these items.

• SPEVIGO INJECTION — QL(4 ML per 28 days); PA.
• OTEZLA TABLET — QL and PA noted in specialty entries.
• LIVMARLI TABLET/SOLUTION — QL and PA indicated.

PA required for select specialty/high‑cost drugs

Specialty/high‑cost drugs throughout the formulary are designated 'PA' in Requirements/Limits; prescribers must request prior authorization before dispensing these specialty agents.

• Examples include FABRAZYME, ONPATTRO, RIVFLOZA entries with PA and QL annotations.
• Check each specialty product row for PA notation.

Obtain PA for listed specialty and select agents

The formulary marks many specialty injectables and select oral agents with 'PA' or 'PA NSO'; prescribers must obtain prior authorization for those listed products to secure coverage.

• Selected biologics and specialty agents show PA and product‑specific QLs.
• PA NSO appears frequently on oncology and specialty lines.

PA plus QL for biologic injectables

Many biologic injectables have both quantity limits and prior authorization (e.g., DUPIXENT, ORENCIA, ADALIMUMAB biosimilars); prescribers must obtain PA and follow the product QL when ordering.

• DUPIXENT and ORENCIA entries include QL values and PA annotations.
• Adalimumab biosimilars list QL per presentation and require PA.

PA required for multiple specialty biologics

Numerous biologics and specialty drugs throughout the table are annotated with 'PA' or QL; prescribers must follow the PA process for these high‑tier medications before dispensing.

• ADALIMUMAB entries show QL and PA across multiple presentations.
• PEGASYS and other immunological agents are marked PA or PA NSO.

PA required for select specialty medications

High‑tier specialty medications are marked 'PA' in the formulary; prescribers must request prior authorization for coverage of these medications.

• Examples include RIVFLOZA entries and cystic fibrosis agents (KALYDECO, TRIKAFTA) showing QL and PA.
• Refer to product rows for PA and QL specifics.

Follow step therapy — try preferred agents first

Step therapy (ST) may require trying specified preferred drugs first before the plan will cover an alternate drug; prescribers must document prior therapy failure or intolerance when requesting exceptions to a step requirement.

• The formulary explains step therapy: the plan may not cover Drug B unless Drug A was tried first.
• For exceptions, prescriber must provide a supporting statement explaining the medical reason.

Adhere to ST and ST NSO rules when annotated

Step Therapy (ST) and ST NSO (Step Therapy for New Starts Only) are defined in the Requirements/Limits key and may apply to products marked with those annotations; providers must follow the formulary's step rules where indicated.

• ST NSO appears on specific product rows (e.g., AUVELITY, EXXUA, FETZIMA therapy packs).
• Refer to the Requirements/Limits field for ST or ST NSO notation.

ST NSO applies to specified products (AUVELITY, EXXUA, FETZIMA)

Products annotated 'ST NSO' in the table indicate step therapy applies for new starts (examples include AUVELITY, EXXUA and FETZIMA); prescribers should follow the formulary's step requirements for these items.

• AUVELITY TABLET — Requirements/Limits = QL(60 EA per 30 days); ST NSO.
• FETZIMA therapy pack and capsules include ST NSO annotations.

No explicit step algorithms in this segment — consult introduction

This excerpt does not include explicit step‑therapy algorithms or step sequences; where only PA and QL flags are present, follow PA/QL rules and consult the formulary introduction for step algorithms.

• No step sequences are documented in this extract; step rules are defined elsewhere in the formulary introduction.

Step therapy applies to FANAPT, INVEGA and similar items

Some products are labeled 'ST NSO' (e.g., FANAPT titration packs and INVEGA HAFYERA) indicating step therapy requirements for those items; providers must follow the plan's step therapy process for these products.

• FANAPT titration packs — Requirements/Limits include ST NSO and QL values.
• INVEGA HAFYERA injection entries show ST NSO.

Include prescriber's supporting statement for exceptions

When requesting an exception to a formulary requirement (PA, QL, ST or tiering), the prescriber must provide a supporting statement explaining the medical reasons why the exception is needed; plan decisions are generally made within 72 hours (24 hours expedited).

• Prescriber supporting statement is required to request exceptions.
• Standard decision timeline is 72 hours; expedited decisions within 24 hours when warranted.

Document requirement types per Requirements/Limits key

The formulary uses requirement type codes (PA, QL, NDS, ST and related NSO annotations); providers must follow the documentation and submission instructions referenced in the formulary introduction when seeking authorization or exception.

• PA = Prior Authorization; QL = Quantity Limits; NDS = Non‑Extended Day Supply; ST = Step Therapy; ST NSO/PA NSO defined on introduction pages.

Consult formulary introduction for required documentation

Refer to the formulary introduction pages for the exact meanings and the plan's required documentation for PA NSO, QL, ST NSO and related annotations before submitting authorizations or exceptions.

• The introduction pages define PA NSO and ST NSO and list required documentation and operational rules.

Dispense within listed quantity limits (QL) or obtain exception

Quantity limits (QL) are specified for many products (for example, TRINTELLIX QL(30 EA per 30 days) and Cablivi QL(30 EA per 30 days)); providers must ensure prescriptions and dispensing do not exceed the listed QL unless an approved exception/PA is granted.

• TRINTELLIX TABLET — QL(30 EA per 30 days).
• CABLIVI EXAMPLE — 30 tablets per 30 days.

Follow the product Requirements/Limits field for coverage rules

Providers must follow the Requirements/Limits key on each product row when submitting claims or requests; the product row lists the exact QL, PA, ST or other annotations that govern coverage for that drug.

• Each entry row includes drug name, strength, Drug Tier and Requirements/Limits field which drive coverage decisions.
• Use the product row values when preparing PA or exception submissions.

Ensure prescriptions conform to listed QL values

Ensure prescriptions conform to the listed quantity limits for the product; claims exceeding the QL may be denied unless prior authorization or an approved exception is obtained.

• Examples include dabigatran QL(60 EA per 30 days) and XARELTO QL values.
• Exceeding a QL without approval can trigger denial or reduced coverage.

Lack of PA can lead to denial or non‑coverage

Failure to obtain required prior authorization may result in the plan not covering the drug; prescribers should obtain PA before dispensing PA‑flagged drugs.

• The formulary explicitly states lack of PA may result in non‑coverage.
• Submit PA prior to fill to avoid denial at claim adjudication.

Non‑compliance with Requirements/Limits may trigger denial

Prescriptions that do not meet the listed Requirements/Limits (e.g., lacking PA, exceeding QL, or requesting non‑extended day supply when not allowed) may be denied; verify the product's Requirements/Limits before submitting claims.

• Denial triggers include exceeding quantity limits, missing prior authorization, or incorrect supply types (NDS).
• Review the Requirements/Limits field on the formulary entry to confirm requirements.

PA/QL flags create denial risk without proper authorization

Requests for products flagged 'PA' or for quantities above the stated QL may be denied if authorization or documentation supporting medical necessity is not provided; obtain PA or submit supporting documentation to mitigate denial risk.

• PA/QL flags are explicit denial risk triggers in the formulary.
• Provide requested documentation (diagnosis, prior therapy) when submitting PA.

PA NSO entries — obtain PA for listed anticonvulsants

Products marked 'PA NSO' (prior authorization for new starts only) indicate prior authorization is required for coverage of those anticonvulsant or specialty items; prescribers must obtain the PA as specified to avoid denial.

• Examples include BRIVIACT, EPIDIOLEX and FINTEPLA shown with PA NSO.
• PA NSO notation is defined on the formulary introduction pages.

Exceeding QL may result in denial — observe QL(...) values

Quantity limits shown as QL(...) (for example, NAYZILAM QL(10 EA per 30 days), gabapentin QLs) represent maximum covered amounts; dispensing beyond these limits without authorization may be denied.

• NAYZILAM SOLUTION — QL(10 EA per 30 days).
• Gabapentin capsule and solution entries list specific QL values.

PA, B/D or PA NSO annotations can trigger billing/authorization actions

Drugs annotated with 'PA', 'B/D' (billing/designation) or 'PA NSO' may have special prior authorization or billing requirements that, if not met, can trigger denial or incorrect benefit application.

• B/D indicates potential Part B vs Part D billing determination and may require plan review.
• PA NSO and PA annotations signal prior authorization obligations.

PA is required for many formulary agents — obtain approval

Numerous listed drugs are marked 'PA' across the formulary; prescribers must obtain prior authorization for PA‑listed products to reduce the risk of claim denial.

• The Requirements/Limits table repeatedly annotates specialty agents and many biologics with PA.
• Obtain PA in advance where required.

PA/QL annotations imply authorization or quantity requirements

The presence of 'PA' or 'QL' on a product row indicates the drug requires prior authorization or is subject to a quantity limit; claims lacking PA or exceeding QL may be denied or require retrospective review.

• Check product rows for PA and QL annotations before prescribing or dispensing.
• High‑tier and specialty drugs commonly carry PA/QL notations.

PA/QL non‑compliance can lead to denials

Products listed with 'PA' or with specific QL values may be denied if prior authorization is not obtained or if the quantity exceeds the stated limit; providers should secure PA and document need before dispensing.

• SPEVIGO example: QL(4 ML per 28 days); PA — may be denied without PA.
• Formulary notes that PA/QL non‑compliance can lead to denial.

Obtain PA for PA‑listed specialty products (e.g., CERDELGA, FABRAZYME)

Claims for PA‑listed products such as CERDELGA, CHOLBAM or FABRAZYME will require prior authorization per the Requirements/Limits field; submit PA prior to dispensing to avoid claim denial.

• FABRAZYME INJECTION — Requirements/Limits = PA.
• CERDELGA and CHOLBAM are listed with PA in the specialty section.

Submit PA for products marked PA or PA NSO

Selected agents throughout the table are annotated 'PA' or 'PA NSO'; prescribers must obtain prior authorization per the product's Requirements/Limits before dispensing.

• Multiple entries across therapeutic classes show PA or PA NSO flags.
• Follow the PA process for these agents to secure coverage.

Quantity limits are enforced — exceeding QL risks denial

Formulary QL listings indicate enforcement of maximum supplies (e.g., QL(91 EA per 91 days)); exceeding these QLs without approval may result in denial or reduced coverage.

• Examples include contraceptive QLs (91 EA per 91 days) and other product‑specific QLs.
• Obtain PA or exception for amounts beyond the QL.

Claims without approved PA are subject to denial

Claims for drugs listed with 'PA' will be subject to denial or non‑coverage if an approved prior authorization is not on file; obtain PA prior to dispensing PA‑flagged medications.

• The formulary notes claims without approved PA will be subject to denial.
• Submit PA documentation following plan procedures.

PA indicated for select high‑tier medications (e.g., RIVFLOZA)

Several high‑tier medications (for example RIVFLOZA) are annotated 'PA' in the formulary; prescribers must obtain prior authorization to ensure coverage of these high‑cost specialty drugs.

• RIVFLOZA INJECTION entries include QL and PA annotations.
• High‑cost specialty entries commonly require PA.

Verify site‑of‑care — retail, mail order, and LTC have different rules

Mail order, long‑term care (LTC) and retail settings have different coverage, copay and supply rules; verify the site‑of‑care (retail vs mail vs LTC) because coverage and supply limits (e.g., LTC 31‑day supply) and cost‑sharing vary by setting.

• Long‑term care entries note a 31‑day supply and differing copays/coinsurance.
• Mail order and retail copays differ by tier and setting.

Biosimilar substitutions and tier changes possible — monitor formulary updates

The plan may add biosimilar versions and change tiering or restrictions for original biologics; providers should expect possible immediate substitution or tier changes per the formulary and follow state substitution rules for interchangeable biosimilars.

• When adding an interchangeable biosimilar, the plan may move the original biologic to a different tier or add restrictions.
• Substitution of interchangeable biosimilars may occur according to state law.