Prior authorization required when PA column indicated

Some drugs on the Value Plus formulary require prior authorization; commonly required PAs are indicated with a dot in the Prior Authorization column of the drug list. Providers must submit an authorization request when a drug shows the PA indicator and follow any plan-specific authorization procedures.

• If authorization is required, the provider must submit a request for coverage and receive approval before the drug will be covered.
• Some plans may require additional authorizations beyond those noted in the formulary; verify the member's specific plan materials.

Check drug list UM indicators (PA, ST, QLL)

The formulary drug list uses columns to indicate which utilization management programs apply: Prior Authorization, Step Therapy, and Quantity Level Limits. Presence of an indicator (dot) in a column means that the corresponding UM program applies to that drug.

• Check Columns 4–6 on the drug list for PA, Step Therapy, and Quantity Level Limits indicators.
• Verify the member's specific plan materials because some plans may have UM on additional drugs not indicated in this document.

No PA rules in this antiviral/antiretroviral listing

This segment of the formulary lists branded antiretroviral and antiviral products and formulations but does not specify prior authorization requirements for these entries. Providers should refer to the PA indicators on the drug list or the member's plan materials for authorization requirements.

• Product names and strengths are listed without explicit PA rules in this excerpt.
• Use the PA column on the full drug list to determine if authorization is required.

Product names/strengths listed only — no PA specified

The product listings in these chunks show drug names and strengths only and do not state prior authorization requirements in-text; providers must rely on the drug list PA column or the member's plan documents to determine PA applicability.

• Listings present product names/strengths without embedded PA instructions.
• Confirm PA status via the drug list columns or the member's benefit materials.

Formulary listing: no PA rules stated here

This formulary-style listing of drug names and presentations does not include explicit prior authorization rules in the text. Providers should check the PA indicator column on the drug list or plan-specific documentation to determine authorization needs.

• No explicit PA rules are stated in these chunks; use the drug list columns for PA determination.
• Some plans may require authorizations beyond what is shown in the formulary excerpt.

Drug entries shown without PA instructions

The text in these referenced chunks lists drug entries without stating prior authorization requirements; providers must consult the PA column on the drug list or the member's plan documents to determine if prior authorization is required.

• No PA requirements are stated in these chunks' content.
• Verify PA applicability using the formulary's PA column or plan materials.

Formulary listing — no explicit PA rules in excerpt

These formulary listings present drug names and formulations but do not include explicit prior authorization rules in this excerpt. Providers should rely on the drug list's PA column or the member's benefit details to confirm authorization requirements.

• No explicit PA rules appear in this excerpt.
• Check the PA indicator on the full drug list or plan-specific documentation.

No PA instructions in this product/formulation listing

No prior authorization requirements are specified in this segment; content is primarily product names, strengths, and presentations. Providers must use the PA column on the drug list or the member's plan materials to determine authorization obligations.

• This segment lists products and strengths without PA instructions.
• Confirm PA status via the formulary columns or benefit booklet.

No PA instructions or codes provided here

The listed chunks do not include prior authorization instructions or affected codes. Providers should check the PA indicator on the drug list or refer to the member's prescription plan materials to determine whether authorization is required.

• No PA instructions or affected codes are listed in these chunks.
• Use the drug list PA column and the member's plan materials for authorization requirements.

PA not specified in these product listings

Prior authorization requirements are not specified in these product listings. Providers must consult the formulary's Prior Authorization column or the member's plan documents to confirm whether PA is required for a given drug.

• These chunks contain drug/strength/formulation listings without PA rules.
• Confirm PA applicability through the drug list indicators or plan-specific materials.

PA not specified — product listings only

This segment contains enumerated drug names and formulations but does not state prior authorization requirements. Providers should refer to the PA column on the drug list or the member's prescription plan documents to determine if authorization is needed.

• No PA requirements stated in this segment; only product names/formulations are listed.
• Verify PA via the formulary columns or the member's benefit booklet.

No PA stated in this listing

No prior authorization requirements are specified in these chunks; they present drug names and formulations only. Providers must check the PA indicator on the formulary or the member's plan materials for authorization guidance.

• This excerpt lists drug products without PA rules.
• Use the drug list PA column or plan materials to determine authorization needs.

PA not specified in this excerpt

These chunks list drugs and formulations without stating prior authorization requirements. Providers should confirm PA requirements by checking the PA column on the drug list or the member's specific plan documentation.

• No explicit PA requirement is described in these chunks.
• Confirm authorization needs using the formulary columns or benefit documents.

Follow step therapy when Step Therapy column indicated

Step therapy may require trying a proven, cost‑effective alternative before coverage is available for certain drugs; drugs commonly requiring step therapy are marked with a dot in the Step Therapy column of the drug list. Providers must follow step therapy program requirements when the Step Therapy indicator is present.

• If the Step Therapy column shows an indicator, the pharmacy step therapy program applies and prior trials of specified alternatives may be required.
• Refer to the member's plan materials for any plan‑specific step therapy details.

Check drug list for Step Therapy indicator

Step therapy applicability is shown on the drug list: if the Step Therapy column contains an indicator (dot), the pharmacy step therapy program applies to that prescription. Providers should verify the Step Therapy indicator before prescribing.

• Check Columns 4–6 on the drug list (including Step Therapy) to see if step therapy applies.
• Some plans may include step therapy on additional drugs beyond those shown here; confirm with the member's plan materials.

No step therapy rules in this product listing

These product name–only chunks do not provide step therapy rules. Providers must consult the formulary's Step Therapy column or the member's plan materials to determine whether step therapy applies to a given drug.

• No step therapy rules are provided in these chunks; only product names and strengths are listed.
• Determine step therapy applicability via the drug list columns or benefit booklet.

Product listings only — provider actions not specified

Product names and strengths are listed without provider action details in these chunks. Providers should consult the formulary columns and member plan documents for PA, step therapy, and quantity limit requirements related to these drugs.

• No explicit PA/step therapy rules are present in these entries.
• Use the drug list UM indicator columns and the member's plan materials for requirements.

No UM or documentation instructions in these listings

These chunks list drugs and formulations but do not include prior authorization, step therapy, or documentation instructions. Providers must reference the drug list columns and the member's plan materials to determine any required actions.

• No PA/step therapy/documentation requirements present in these chunks.
• Verify UM and documentation obligations via the formulary columns or benefit booklet.

No explicit authorization triggers shown here

This segment contains product entries without explicit authorization or denial triggers. Providers should use the PA/Step Therapy/Quantity Limits columns on the drug list and the member's plan documents to determine required actions and potential denial risks.

• No explicit authorization or denial criteria are provided in this excerpt.
• Confirm any UM program applicability using the formulary indicator columns and plan materials.

Formulary tier reconsideration and appeals — submit request to P&T

These chunks provide drug/formulation listings without documentation requirements for coverage or submission. When documentation is required (e.g., for PA or exception requests), providers must follow the plan's instructions and submit necessary clinical information.

• No documentation requirements are stated in these chunks; they are product listings.
• For PA or nonformulary exception requests, provide clinical justification per plan procedures.

Submit nonformulary (formulary exception) request on member's behalf

To request coverage for a nonformulary drug, the provider must submit a nonformulary consideration (formulary exception) request on behalf of the member. Exception requests are required for drugs not listed on the formulary to be considered for coverage.

• Providers must submit the nonformulary consideration request on the member's behalf.
• Nonformulary exceptions entail review and follow the dispute and appeal process if patient‑specific review is requested.

Coverage subject to PA, ST, QLL — failure to obtain PA may cause denial

Coverage is subject to utilization management programs including prior authorization, step therapy, and quantity level limits; failure to obtain required prior authorization may result in denial of coverage.

• If an authorization is required and not obtained, the drug may be denied.
• Quantity above permitted limits may be the member's financial responsibility if dispensed beyond the limit.

Nonformulary drugs are not covered without approved exception

Prescriptions for drugs that are not listed on the formulary are not covered unless a nonformulary (formulary exception) request is approved; providers should submit exception requests on behalf of members when appropriate.

• Nonformulary drugs may be denied if no exception is approved.
• Providers must submit a nonformulary consideration request to seek coverage for drugs not on the formulary.

Specialty drugs dispensed via Accredo (plan specialty pharmacy)

Specialty drugs are dispensed through the plan's contracted specialty pharmacy, Accredo; limited distribution drugs may restrict which pharmacies can dispense them. Providers and members can contact Accredo for initiation or distribution details.

• Call Accredo at 833.721.1626 (TTY: 711) or fax 888.302.1028 for specialty distribution and billing information.
• Limited Distribution indicates restrictions on which pharmacies may dispense a drug; members may be required to use another pharmacy for limited distribution drugs.