CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Standard Control with Advanced Control Specialty Formulary (pharmacy drug list) - Coverage Criteria

Lists medications, tier assignments, and utilization management (prior authorization, step therapy, quantity limits) for BlueCross BlueShield of Tennessee members enrolled in the Standard Control with Advanced Control Specialty Formulary administered by CVS Caremark.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyStandard Control with Advanced Control Specialty Formulary (pharmacy drug list) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain and submit prior authorization and supporting documentation when a drug entry is flagged 'PA' and ensure quantity requests do not exceed listed QL limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5drug tiers (Tier 1–Tier 5)

90 MME/dayopioid quantity limit (up to)

04/01/2026policy effective date

CVS Caremarkpharmacy benefits administrator

PA notedPA requirement appears for many products

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria & Formulary Stance

General PA/QL coverage stance (excerpt)

Coverage is conditional with prior authorization and quantity limits for many specialty agents; some products are preferred for specified indications.

General specialty drug coverage requirements (excerpt): Drug coverage is subject to formulary tier, prior authorization (PA) and quantity limits (QL) where indicated; some biologics list preferred clinical indications; specific PA criteria details are not in this excerpt.

See full policy for exact clinical PA criteria and documentation requirements.

General coverage with utilization management

Covered when formulary requirements (PA, QL, ST where noted) are satisfied for each product

General formulary condition: Drug is covered subject to its listed Requirements/Limits (PA, QL, ST) and tiering; specialty biologics commonly require PA and have QL

Individual product rows provide the specific requirement flags

No explicit exclusion statements are present in the provided formulary excerpt. The document shows drug-level Requirements/Limits fields (for example, PA and QL flags) but does not provide standalone exclusion language in the cited sections.

Within the supplied chunks there are no affirmative coverage exclusions stated; instead individual products are annotated with utilization controls such as PA (prior authorization) and QL (quantity limits). These flags indicate conditions for coverage rather than explicit exclusion statements.

VOSEVI is listed with Requirements/Limits = PA, QL and a treatment-experience restriction: it is indicated for patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1–6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). Prior authorization and applicable quantity limits apply as shown.

The clobetasol listing includes an explicit exception: the Requirements/Limits field for clobetasol notes Except clobetasol emollient foam, indicating that the emollient foam formulation is treated differently than other clobetasol topical formulations in this excerpt.

No conditions labeled as 'not medically necessary' are provided in the supplied excerpt. The entries shown focus on formulary tiering and utilization management flags (e.g., PA, QL) rather than explicit noncoverage determinations.

Coding, Identifiers and Key Limits

Referenced NDC exceptionsNDC

NDCs 61314-XXXX-XX

NDC exceptions referenced for HYRIMOZ

Formulary drug listings (no procedure/diagnosis codes present in these chunks)mixed

No codes listed

Formulary drug listings (generic and combination agents)mixedCovered

Multiple generic and combination antihypertensive products

Examples include candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan, amlodipine-benazepril combinations, amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan, and numerous hydrochlorothiazide combinations listed with tiers.

Other therapeutic classesmixedCovered

aliskiren	Direct renin inhibitor, tabs 150mg, 300mg
eplerenone	Selective aldosterone receptor antagonist, tabs 25mg, 50mg
hydralazine hcl	Vasodilator, solution and tabs 10mg-100mg
atovaquone-proguanil; chloroquine; hydroxychloroquine; mefloquine; pyrimethamine	Antimalarial agents listed with tiers/notations (pyrimethamine shows 'PA')

Antimyasthenic/cholinergic agentsmixed

FIRDAPSE 10mg	amifampridine brand (listed under antimyasthenic/cholinergic agents)
pyridostigmine bromide 60mg/5ml; tabs 60mg; tbcr 180mg	antimyasthenic/cholinergic agent (generic)

Selected antineoplastic/antimycobacterial agentsmixed

cyclophosphamide soln 1gm/2ml, 2gm/4ml, 500mg/ml	antimyocobacterical/antineoplastic agent (brand and generic forms listed)
temozolomide caps 5mg-250mg	antimetabolite (generic/brand listed with PA indicated)
capecitabine tabs 150mg, 500mg	antimetabolite (generic/XELODA brand) with PA indicated
methotrexate tabs 2.5mg; methotrexate sodium inj/soln	antimetabolite with some PA/QL indicated for brand forms
imatinib mesylate tabs 100mg, 400mg	tyrosine kinase inhibitor (generic) with PA/QL noted
sunitinib caps 12.5mg-50mg	tyrosine kinase inhibitor (generic) with PA/QL noted

Selected brand antineoplastic agents with tiers and limitsmixed

GILOTRIF (afatinib) tabs 20mg, 30mg, 40mg	EGFR inhibitor — Drug Tier 5; Requirements/Limits = PA, QL
TAGRISSO (osimertinib) tabs 40mg, 80mg	EGFR inhibitor — Drug Tier 4; Requirements/Limits = PA, QL
TARCEVA (erlotinib) tabs 100mg	EGFR inhibitor — Drug Tier 5; Requirements/Limits = PA, QL
ERIVEDGE (vismodegib) caps 150mg	Hedgehog pathway inhibitor — Drug Tier 4; Requirements/Limits = PA, QL
VENCLEXTA (venetoclax) tabs 10mg-100mg	BCL-2 inhibitor — Drug Tier 5; Requirements/Limits = PA, QL
IBRANCE (palbociclib) caps/tabs 75-125mg	CDK4/6 inhibitor — Drug Tier 4; Requirements/Limits = PA, QL
LYNPARZA (olaparib) tabs 100mg, 150mg	PARP inhibitor — Drug Tier 4; Requirements/Limits = PA, QL
VERZENIO (abemaciclib) tabs 50-200mg	CDK4/6 inhibitor — Drug Tier 5; Requirements/Limits = PA, QL
VITRAKVI (larotrectinib) caps 25mg, 100mg; soln 20mg/ml	TRK inhibitor — Drug Tier 4; Requirements/Limits = PA, QL
XALKORI (crizotinib) CPSP 20mg, 50mg, 150mg	ALK inhibitor — Drug Tier 5; Requirements/Limits = PA, QL

1–10 of 11

1/2

Formulary entries (no billing codes)mixed

N/A	No CPT/HCPCS/ICD-10/NDC codes are listed in these chunks; the content is a formulary listing with drug names, strengths, tiers, and requirement flags.

Formulary product identifiers and OTC/QL notesmixed

ACCU-CHEK AVIVA PLUS STRIPS AND KITS	listed with QL/OTC
CREON CAP 3000UNIT	Digestive enzyme product entry with unit limits
acetazolamide cp12 500mg	carbonic anhydrase inhibitor entry

Electrolyte mixturesmixed

D5W/NACL INJ 0.9%	Electrolyte mixture listed
KCL/D5W/NACL INJ	Electrolyte mixture listed

inv-20: Opioid morphine milligram equivalents — <= 90 MME per day

Opioid MME limitOpioid-containing products (including combinations with acetaminophen/aspirin/ibuprofen) limited to up to 90 morphine milligram equivalents (MME) per day based on a 30‑day supply.

Opioid-naive sequencingOpioid‑naive members required to use an immediate‑release (IR) formulation before escalation to an extended‑release (ER) formulation.

Applies to combosLimit applies to opioid products whether single‑entity or combined with acetaminophen, aspirin, or ibuprofen.

Provider Requirements, Prior Authorization & Documentation

Documentation Required

Provider Requirements — overview

Some medications listed on the formulary require prior authorization (PA), quantity limits (QL), and/or step therapy (ST) before they will be covered. Inclusion on the list does not guarantee coverage. A valid prescription from a licensed health care provider is required for all prescriptions; when a drug is designated "PA" or "PA, QL" the prescriber must submit a prior authorization request and supporting documentation per BlueCross BlueShield of Tennessee/CVS Caremark processes. Failure to obtain required PA or to adhere to QL/ST requirements may result in denial of payment.

Definition: PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy.
Prescribers should be prepared to document diagnosis/indication, prior therapies tried (when applicable), requested strength/dose, and clinical rationale when submitting PA.
Inclusion on the formulary/excerpt is informational and does not guarantee that an individual member’s plan will cover the medication; check member benefit design and prior authorization outcomes.

Prior Authorization

Prior Authorization Required — ADHD & related agents

Initial Therapy & Formulary Tiering Notes

Formulary tiering notes

Formulary tiers are assigned per product; generic formulations are frequently Tier 1 while branded formulations and certain specialty agents are higher tiers and may require PA/QL.

Tiering and preferred product notes: Formulary assigns drug tiers (Tier 1–5). Some biosimilars and generics are designated preferred for specific indications while branded or certain package sizes are higher-tier and flagged with PA and/or QL (examples: ADALIMUMAB-ADAZ, HYRIMOZ show Preferred indications but also PA/QL flags).

See product rows for tier and Requirements/Limits details.

Initial therapy utilization management

Utilization management markers applicable at therapy initiation are noted on product rows (PA, QL, and where applicable initial PA for higher strengths).

Initial PA/QL markers: Many opioid and other analgesic products list quantity limits (QL) and prior authorization (PA); higher strengths may require initial PA. Similar PA/QL flags appear across other classes (PA* indicates initial PA may apply to higher strengths).

Step Therapy Rules & Examples

Policy point	Details
Step therapy may apply (ST)
Some medications may be subject to step therapy; if step therapy requirements are not met a prior authorization may apply (PA**).

Observation	Source detail
No explicit step sequences provided in excerpt
Formulary shows tiering (generics often Tier 1) and PA/QL flags but does not list multi-step failure requirements; generics preferred before brands implied by tiers.

Product	Notes
ENBREL
Listed as Preferred for Ankylosing Spondylitis, Psoriatic Arthritis, Rheumatoid Arthritis and other conditions; Requirements/Limits = PA, QL (preferred indication documented).

Drug group / examples	Requirements/Limits
Incretin mimetics / GLP-1 agonists (e.g., MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY)
Entries show Requirements/Limits = PA, QL for many of these agents (examples: MOUNJARO: PA, QL; OZEMPIC: PA, QL; RYBELSUS: PA, QL; TRULICITY referenced with PA/QL).

Product	Specific requirement
VOSEVI
Requirements/Limits = PA, QL; indicated for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).

Flag indicator	Implication
ST or ST, QL present on entries (e.g., ZORYVE, VTAMA)
Where entries are marked ST or ST, QL, step therapy is required prior to coverage; PA may apply if ST is not met (examples: VTAMA entry references ST, ZORYVE entries show ST, QL).

Migraine agent	Requirements/Limits
AJOVY, EMGALITY, NURTEC ODT, QULIPTA, UBRELVY
Listed migraine products include Requirements/Limits = ST, QL; PA** noted — step therapy is required for these agents (examples: AJOVY: ST, QL; EMGALITY: ST, QL; NURTEC ODT: ST, QL; QULIPTA, UBRELVY similarly flagged).

Quantity Limits & MME Rules

inv-108: opioid-containing products (including combos with acetaminophen/aspirin/ibuprofen) — up to 90 MME

Opioid-containing products MME capOpioid-containing products (including combinations with acetaminophen/aspirin/ibuprofen) limited to up to 90 MME per day based on a 30‑day supply.

IR before ER for opioid‑naiveMembers who are opioid‑naive must use an immediate‑release formulation before progressing to an extended‑release formulation.

Formulation and QL flagsMany opioid formulations (transdermal, ER, IR, combinations) are annotated with QL and may require PA* or initial PA for higher strengths.

inv-109: multiple (class-level QL flags) — unspecified

Class-level QL flags presentMultiple therapeutic classes and numerous individual products include a QL flag in the Requirements/Limits column; numeric limits are not shown in the excerpt.

Biosimilar Preferences & References

Note

Background & Scope

This formulary excerpt is used to determine drug coverage and utilization management for members enrolled in the specified BlueCross BlueShield of Tennessee plan. It documents drug listings, tier assignments, and when utilization controls apply (for example PA, QL, and where noted, ST), and highlights that opioid-containing products have specific quantity considerations (see policy for detailed thresholds).

Definitions & Abbreviations

inv-78: PA = Prior Authorization (review required for some medications).

PA definitionPA = Prior Authorization — a review that is required for some medications; the prescriber must provide information on why the medication is being prescribed.

PA* and PA**PA* = If Quantity Limit is exceeded, Prior Authorization may apply; PA** = If Step Therapy requirements are not met, Prior Authorization may apply.

inv-79: QL = Quantity Limit (maximum amount covered for a period).

QL definitionQL = Quantity Limit — the highest amount of medication covered by your plan for a period of time (for example, 30 tablets per month).

Purpose of QLQL is a utilization control used to limit dispensing frequency or total units within a defined time frame; exact numeric QL values appear on individual product rows or plan details.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyStandard Control with Advanced Control Specialty Formulary (pharmacy drug list) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain and submit prior authorization and supporting documentation when a drug entry is flagged 'PA' and ensure quantity requests do not exceed listed QL limits.

SourceLink

On This Page

inv-21: Quantity Limit (QL) — Not specified numerically in excerpt; QL indicated where applicable

Quantity Limit (QL) presenceMany drug entries include a QL flag indicating a quantity limit applies; specific numeric limits are not provided in this excerpt.

Examples of classes with QLAntiretrovirals and other specialty tablets (e.g., abacavir‑lamivudine, BIKTARVY) show 'QL' in Requirements/Limits.

Interpreting QLQL denotes the highest amount covered for a period (e.g., per month) as defined in plan details; exact counts require the full formulary record.

inv-22: Quantity Limit examples — examples include '1 = 2', '1 = 5' as per product lines

ACCU‑CHEK exampleACCU‑CHEK test strips and kits listed with pack multiplier '1 = 2' and QL, OTC noted.

Digestive enzyme exampleCREON and ZENPEP capsule products presented with '1 = 2' multipliers (package/unit mapping) in listing.

Other pack mappingsSome products show '1 = 5' (e.g., SUCRAID, DEPEN TITRATABS examples elsewhere) to denote unit-to-pack conversions used for QL calculations.

inv-23: pack or unit multipliers — examples: '1 = 1', '1 = 5' indicated for certain products

Pack/unit multiplier '1 = 1'Some generic products and injectables are listed with '1 = 1' indicating one package equals one billing unit (seen across multiple product rows).

Pack/unit multiplier '1 = 2'Many test strips and digestive enzyme capsules list '1 = 2' to indicate packaging conversions used for quantity limits (e.g., ACCU‑CHEK, CREON).

Pack/unit multiplier '1 = 5'Selected oral specialty tablets and chelating agents are shown with '1 = 5' for certain package sizes (example: DEPEN TITRATABS '1 = 5').

Prior authorization is required for multiple ADHD agents, histamine H3 antagonists/inverse agonists, and many stimulant products as indicated by "PA" or "PA, QL" in the formulary. Examples include extended‑release and short‑acting amphetamine and dextroamphetamine products, lisdexamfetamine formulations, dexmethylphenidate, armodafinil, AZSTARYS, WAKIX, and other agents noted in the ADHD/anti‑narcolepsy category. Claims for these agents may be denied without prior authorization.

ADHD class: many entries show "PA" or "PA, QL" for specific strengths and brands.
HISTAMINE H3 and stimulant class entries (e.g., WAKIX, AZSTARYS, armodafinil) include PA and/or QL flags.

Prior Authorization

Prior Authorization Required — Specialty biologics

Specialty biologic agents and many anti‑TNF products are subject to prior authorization and quantity limits. Several biosimilars and branded biologics are listed as PA, QL and in some cases noted as "Preferred" for particular indications. Prescribers should expect utilization management review for these specialty injectables.

Examples: adalimumab biosimilars (PA, QL; preferred indications listed), HYRIMOZ, ENBREL, COSENTYX, TREMFYA, BENLYSTA — many require PA and QL.
Preferred indications are documented on some entries; preferred status does not remove PA/QL requirements.

Prior Authorization

Prior Authorization Required — flagged formulary products

Numerous formulary products across categories are flagged with PA and/or QL. For these products, submit a prior authorization request and include clinical documentation to support medical necessity and any requests for quantities above standard limits. Quantity limits and exceptions (by NDC) are noted where applicable.

Examples across formulary: NUCALA, TYVASO, VIVITROL, many oncology and antiviral agents (EPCLUSA, HARVONI, SOVALDI, VOSEVI), specialty hematology/infusion products, and select dermatology/topical agents (e.g., RETIN‑A, tretinoin, VALCHLOR).
Some entries list NDC exceptions to QL — prescribers/pharmacies should check the specific NDC when submitting a claim or PA.

Documentation Required

Documentation and Prior Authorization (PA/QL)

When the Requirements/Limits column lists "PA, QL" or "PA" the provider must obtain prior authorization before dispensing/claim submission. Documentation must justify the need for therapy and support dosing/quantity requests that exceed the documented QL. For specialty injectables and high‑cost agents, provide relevant prior treatment history and indication-specific documentation.

PA/QL documentation should include: indication, prior treatments tried and outcomes, member weight/diagnostic/genotype information when relevant (for example HCV agents), and the exact product, dose, and frequency requested.
HCV agents (EPCLUSA, HARVONI, SOVALDI, VOSEVI) frequently require genotype and treatment‑experience documentation; VOSEVI has a stated treatment‑experience requirement (prior NS5A exposure or specific sofosbuvir history) — include this in the PA.
Specialty injectables (e.g., BENLYSTA, coagulation factor products, ALTUVIIIO, etc.) require PA; follow submitter instructions for infusion/administration documentation.

Prior Authorization

Prior Authorization Required — selected dermatology drugs

Certain dermatology topical and other skin products are noted as requiring prior authorization or having PA/QL. Submit PA with indication and prior topical/systemic therapy history where requested. Step therapy may apply for some topical agents as indicated.

Examples: RETIN‑A topical formulations and some tretinoin entries are marked PA; VALCHLOR and other topical antineoplastics list PA and QL.
VTAMA topical entry shows ST, QL and PA** (PA may apply if step therapy not met) — follow step therapy logic and submit PA only if ST requirements documented or bypass criteria met.

Step Therapy

Step Therapy / QL / PA — migraine products

Some migraine products (CGRP mAbs and certain acute agents) are subject to step therapy (ST), quantity limits (QL), and prior authorization (PA or PA** when ST not met). For these products, ensure step‑therapy requirements are documented or submit PA with rationale for exceptions.

Examples: AJOVY, EMGALITY, NURTEC ODT, QULIPTA, and UBRELVY are listed with ST, QL and PA** flags — PA may be required if ST criteria are not satisfied.
Prescribers should include prior migraine preventive/acute therapy history when submitting PA for these agents.

Documentation Required

Quantity Limits (QL) — documentation and exceptions

Quantity limits apply to many products (e.g., naloxone presentations, inhalers, certain opioids, and numerous chronic therapies). Some QL entries have specific NDC exceptions. Requests for quantities above QL require supporting clinical justification in the PA submission.

Naloxone: liquid and other naloxone formulations may have QL; VIVITROL (intramuscular naltrexone) requires PA and QL.
Opioid products: opioid-containing products have MME based quantity limits and may require initial or higher‑strength PA (noted as PA*).

Step Therapy

Step Therapy — general note

Step therapy specifics are not comprehensively listed in this excerpt; many entries show PA and/or QL flags without an explicit step sequence. When ST is indicated (ST or ST, QL), follow the payer’s step‑therapy algorithm or submit PA documenting why step therapy is not appropriate.

Some entries include ST or PA** indicating PA may be required if step therapy requirements are not met.
If step therapy requirements are unknown for a member, contact the pharmacy benefits administrator or use the PA portal to confirm required trials.

Documentation Required

Operational expectations for prescribers

Providers should verify member coverage and the plan‑specific formulary via the payer or CVS Caremark channels prior to prescribing, and include requested product strength, NDC (if available), indication, prior therapy history, and any genotype or clinical test results required by the drug’s PA criteria.

Preferred indications are shown on some formulary lines — these do not replace PA/QL requirements and should be used to inform selection when clinically appropriate.
Prescribers should be prepared to justify requests for higher strengths or non‑preferred products in the PA submission to reduce denial risk.

Denial Risk

Provider action — final reminder

Summary: prior authorization and quantity limit markers on the formulary will trigger utilization management review and may require documentation of prior therapies, diagnoses, genotype or weight (where applicable), and other clinical details. Check member benefits and follow BlueCross/CVS Caremark PA submission instructions. Inclusion on the formulary does not guarantee coverage.

PA/QL presence = potential denial risk if not addressed.
For expedited or complex specialty approvals, allow additional processing time and provide full clinical records as requested.

Providers should follow PA processes where indicated.

Initial formulary flags

Initial formulary flags identify products requiring prior authorization and/or quantity limits at initiation of therapy.

PA/QL flags (examples): Selected branded and generic agents are flagged for prior authorization (PA) and/or quantity limits (QL) as shown next to the drug entries; examples include vigabatrin (PA, QL), ZURZUVAE (PA, QL), liraglutide (PA, QL), MOUNJARO (PA, QL), OZEMPIC (PA, QL), RYBELSUS (PA, QL), TRULICITY (PA, QL), VIVITROL (PA, QL), and naloxone presentations with QL.

Use PA process where indicated

Initial coverage rules

Initial coverage is granted only when the utilization management flags listed for the product are satisfied.

Initial drug coverage: Agent is covered if PA (when listed) is approved and QL (when listed) is not exceeded; where ST is listed, step therapy requirements must be met prior to approval. Specific clinical or genotype/prior-treatment restrictions for some agents (e.g., HCV, biologics) are shown on product rows.

See individual product rows for PA/QL/ST flags and any indication-specific restrictions (e.g., VOSEVI prior-treatment requirement).

Examples of affected categories

Antimycobacterial and antineoplastic agents frequently display 'PA, QL' or 'PA' and 'QL' markers.

Action for providersWhen QL is shown, prescribers should anticipate quantity checks and prepare justification or PA requests if exceeding the plan limit.

inv-110: fentanyl transdermal, various opioids and opioid combination products — Quantity Limits applied (QL)

Fentanyl transdermal QLFentanyl transdermal patches listed with '1 = 1' and QL; higher strengths may require initial PA.

Other opioid productsVarious opioids and opioid combination products (hydrocodone ER, morphine ER, methadone, etc.) include QL flags and PA* for higher strengths.

Opioid partial agonists/alternativesProducts such as BELBUCA and ZUBSOLV are noted with QL (and PA where indicated) — see respective rows for packaging and strength details.

inv-111: BELBUCA, ZUBSOLV and similar products — Quantity Limits applied (QL)

BELBUCA QL and PA*BELBUCA (buprenorphine film) entries indicate Requirements/Limits = QL and PA*; initial PA may apply to higher strengths.

ZUBSOLV QLZUBSOLV sublingual entries show Requirements/Limits = QL, indicating a quantity limit applies.

Provider actionWhen QL or PA* appears for these opioid partial agonists, submit PA documentation per payer processes for higher strengths or quantities.

inv-112: NUCALA — QL

NUCALA QL/PANUCALA (mepolizumab) is listed with Requirements/Limits = PA, QL; lyophilized powder formulation is excepted from this note.

Formulation exceptionLyophilized powder formulation of NUCALA is explicitly excepted from the PA/QL notation in the listed row.

Provider implicationPA and QL apply to most NUCALA presentations; providers should request prior authorization and adhere to quantity restrictions when billed.

inv-113: gabapentin / NEURONTIN — QL; PA* (for some branded/generic entries)

Gabapentin QL and PA*Gabapentin entries show Requirements/Limits = QL and PA* (PA may apply if quantity limit is exceeded).

NEURONTIN notedNEURONTIN (gabapentin brand) included in the same grouping with QL and PA* notations for some presentations.

Action when exceeding QLIf quantity limits are exceeded, prior authorization (PA*) may be required — prescribers should document clinical need when submitting PA.

inv-114: naloxone (certain presentations) — QL noted

Naloxone QL notedCertain naloxone presentations (e.g., naloxone liquid 4mg/0.1mL) show Requirements/Limits = QL in the formulary listing.

Multiple naloxone forms listedOther naloxone formulations (intranasal, solution) appear in the listing; some entries show QL and others show no limit flag depending on presentation.

VIVITROLVIVITROL (naltrexone for injection) is listed with Requirements/Limits = PA, QL.

inv-115: vigabatrin, selected GLP-1 agents, VIVITROL — QL noted

Vigabatrin QL notedVigabatrin entries are annotated with Requirements/Limits = PA, QL indicating quantity limits and prior authorization apply.

Selected GLP‑1 agents QL/PAGLP‑1 agonists (e.g., MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) are listed with Requirements/Limits = PA, QL.

VIVITROL QL/PAVIVITROL injection is specifically noted with Requirements/Limits = PA, QL among opioid antagonist entries.

inv-116: DEMSER CAPS 250MG — QL

DEMSER CAPS 250MG QL/PADEMSER capsules 250 mg are listed with Requirements/Limits = PA, QL in the formulary excerpt.

Therapeutic areaDEMSER appears under ACE inhibitor / related sections in the listing where PA/QL are applied.

Provider implicationPrior authorization and adherence to quantity limits required when billing DEMSER CAPS 250MG per listing.

inv-117: multiple listed brands/generics — Not numerically specified in excerpt; QL flag indicates presence of quantity limits

Multiple products flagged QLMany branded and generic agents across antimyco/antineoplastic categories show a QL flag; numeric limits are not provided in the excerpt but the presence of QL indicates plan limits apply.

ExamplesBrand agents such as GILOTRIF, TAGRISSO, sunitinib, VITRAKVI and others display 'PA, QL' or 'PA' and 'QL' in their Requirements/Limits fields.

Provider actionWhen QL appears for these agents, prescribers should follow PA processes and document dosing and duration per plan requirements.

inv-118: Various antiretroviral tablets — QL indicated

Antiretroviral tablets QLVarious antiretroviral tablets (e.g., abacavir‑lamivudine, atazanavir, darunavir, emtricitabine‑tenofovir) are marked 'QL' in the Requirements/Limits field.

Package mappingsSeveral antiretroviral entries include '1 = 1' or other pack multipliers reflecting dispensing units used to compute QL.

Provider implicationPrescribers should anticipate quantity checks for antiretrovirals and request PA if QL would be exceeded.

inv-119: Multiple listed (e.g., FUZEON, EPCLUSA, HARVONI, SOVALDI, VOSEVI, CAMZYOS, OPSYNVI, TYVASO) — Marked as QL in Requirements/Limits field

Branded antivirals QL/PAMultiple branded antiviral agents (e.g., FUZEON, EPCLUSA, HARVONI, SOVALDI, VOSEVI, TYVASO) are marked with PA and/or QL in the Requirements/Limits field.

Genotype or prior‑treatment notesSome HCV agents include genotype‑specific or prior‑treatment restrictions alongside PA/QL (e.g., EPCLUSA for genotypes 1–6; VOSEVI for previously treated patients).

Action for coveragePrior authorization and adherence to quantity limits are required for these antiviral agents per the listing.

inv-120: ACCU-CHEK test strips; Digestive enzyme caps examples such as '1 = 2', '1 = 5' indicated per product line

ACCU‑CHEK strips '1 = 2'ACCU‑CHEK Aviva, Guide, SmartView strips and kits listed with '1 = 2' and QL; OTC notation also appears.

Digestive enzymes '1 = 2'CREON and ZENPEP capsule strengths shown with '1 = 2' pack/unit multipliers used for quantity calculations.

Provider notePack/unit multipliers (e.g., '1 = 2') indicate how units map to billing/QL calculations; check product row for the applicable multiplier.

inv-121: biologics (COSENTYX, STELARA, TREMFYA, etc.) — Quantity Limits (QL) indicated; specific numeric limits not provided in this excerpt

Biologics QL presentBiologics such as COSENTYX, STELARA, TREMFYA and others are listed with Requirements/Limits = PA, QL; numeric quantity limits are not provided in this excerpt.

Preferred indications notedMany biologics include preferred clinical indications alongside PA/QL (e.g., COSENTYX preferred for psoriasis and spondyloarthritis conditions).

Provider implicationPrescribers should submit prior authorization and adhere to quantity restrictions for biologics per plan procedures.

inv-122: Multiple branded and specialty agents — QL indicated but specific numeric limits not shown in these chunks

Specialty agents QL indicatedMultiple branded and specialty agents (examples: VOWST, GATTEX, ADVATE, ALTUVIIIO, HEMLIBRA, EMPAVELI, TAKHZYRO, CERDELGA, ENDARI, NIVESTYM) are annotated with QL; specific numeric limits are not shown in the excerpt.

PA frequently co‑listedMany of these specialty products also show Requirements/Limits = PA or PA, QL indicating combined utilization controls.

Documentation neededProviders must follow PA processes and document clinical justification when requesting coverage for these specialty agents that carry QL/PA flags.

inv-123: BELSOMRA, QUVIVIQ, HETLIOZ, AJOVY, EMGALITY, BENLYSTA, others — QL indicated (quantity limits applied as specified elsewhere)

Hypnotics and migraine agents QLAgents such as BELSOMRA, QUVIVIQ, HETLIOZ and migraine biologics (AJOVY, EMGALITY) are listed with Requirements/Limits = PA, QL or ST, QL; quantity limits applied as specified elsewhere.

Examples of PA/QL entriesBELSOMRA and QUVIVIQ are explicitly shown with PA, QL; AJOVY and EMGALITY include ST, QL and PA** where step therapy conditions apply.

Provider actionWhen QL is indicated for these agents, submit PA and supporting documentation per plan requirements to avoid claim denial.

inv-80: ST = Step Therapy (defined conditions that must be met prior to coverage).

ST definitionST = Step Therapy — a defined set of conditions that must be met prior to a drug being covered (e.g., try preferred alternatives first).

PA relationshipIf step therapy requirements are not met, a prior authorization (PA**) may be required as noted in the legend.

inv-81: PA — Prior authorization — clinical approval required before coverage (flag appears next to many medications).

PA as clinical approvalPrior authorization — clinical approval required before coverage; flag appears next to many drug entries in this excerpt.

Provider documentationWhen PA is required, the prescriber must supply clinical rationale and supporting documentation per payer process.

Relation to QL/STPA often accompanies QL or ST flags (e.g., PA, QL or ST, QL) indicating combined utilization controls.

inv-82: QL = Quantity Limit (maximum amount covered for a period).

QL as utilization restrictionQL = Quantity Limit — a utilization restriction on the amount dispensed/covered; appears beside multiple products in the listing.

Examples where QL appearsTopical agents and biologics (e.g., calcipotriene, COSENTYX) list QL in Requirements/Limits indicating quantity controls.

Effect on claimsClaims exceeding QL may require PA or be denied without appropriate authorization/documentation.