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List of Covered Drugs (Drug List) — Coverage Criteria

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Defines which drugs, OTC products, and non-drug items are covered under HAP CareSource MI Coordinated Health and explains rules, restrictions, and member/provider actions for obtaining covered drugs.

Policy Summary

PayerCareSource

PolicyList of Covered Drugs (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Last ReviewSep 11, 2025

Next Review DateN/A

Key ActionObtain prior authorization from HAP CareSource before dispensing drugs flagged 'PA' to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

05/18/2026Drug list last updated

30-dayTemporary new-member supply

90-dayNew-member transition period

1-833-230-2057Member Services

PA; MO; QL; NDSAuth/restriction codes

$0Copay when rules followed

Coverage Criteria and General Rules

General coverage conditions

Covered when ALL of the following are met

Medical necessity and network fill: Drug is covered if the prescriber states it is medically necessary, HAP CareSource MI Coordinated Health agrees it is medically necessary, and the member fills the prescription at a HAP CareSource MI Coordinated Health network pharmacy.

See page 15 onward (Drug List) for covered products and network pharmacy definition.

New member temporary coverage

Temporary transition supply for new members

30-day temporary supply: Plan may cover a temporary 30-day supply during the first 90 days of membership when the drug is not on the Drug List, the plan rules limit the amount ordered, the drug requires prior authorization, or the drug is subject to step therapy.30 days

If prescription is written for fewer days, multiple refills may be allowed to reach the 30-day supply; nursing home residents may qualify for a one-time 31-day supply if needed.

Policy Summary

PayerCareSource

PolicyList of Covered Drugs (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Last ReviewSep 11, 2025

Next Review DateN/A

Key ActionObtain prior authorization from HAP CareSource before dispensing drugs flagged 'PA' to avoid denial.

SourceLink

On This Page

Covered when listing conditions are met

Coverage entries for listed anti-infectives include tier level, and may be subject to utilization controls. Coverage is indicated by listing and tier but constrained by the following controls where specified.

Formulary listing with controls: Individual anti-infective drug entries are listed with a Tier Level and may include one or more utilization controls: PA (prior authorization), MO (medical override/medical-only), QL (quantity limit), NDS (non-extended days' supply) or LA (limited availability). Coverage is available when the specified administrative requirements on the drug row are satisfied.

See the drug-specific row for exact controls and QL values.

Sample coverage criteria by drug (excerpt)

Drugs listed are covered when member/claim meets payer's utilization controls indicated on each row (examples below reflect excerpted entries).

Example - AUGTYRO ORAL CAPSULE 160 MG: Coverage requires prior authorization (PA) and a quantity limit of 60 per 30 days; NDS is noted on the formulary row.QL 60/30 days

Follow PA submission process and provide clinical rationale as requested.

Example - AUGTYRO ORAL CAPSULE 40 MG: Coverage requires prior authorization (PA) and a quantity limit of 240 per 30 days; some presentations may also indicate B/D PA or MO.QL 240/30 days

Confirm benefit/setting (B/D PA) when applicable.

Example - BOSULIF ORAL CAPSULE/TABLET: Coverage requires prior authorization (PA) and medical-only (MO) designation; quantity limits vary by strength (e.g., QL 180 per 30 days) and NDS may apply.varies by formulation

Submit PA with supporting documentation for requested strength/quantity.

Example - DASATINIB oral tablets: Coverage requires prior authorization (PA), may require MO, and has a quantity limit of 30 per 30 days; NDS may be indicated.QL 30/30 days

Provide clinical indication and prior therapy information per PA requirements.

Formulary Codes, Abbreviations, and Quantity Limits (coding references)

Formulary action codesmixed

MCD	Non-Part D drugs or OTC items that are covered by Medicaid only
B/D PA	This prescription drug may be covered under Medicare Part B or D depending upon the circumstances; information about use/setting may be required
LA	Limited availability — may be available only at certain pharmacies
MO	Mail-Order Drug — available through mail-order service and retail network pharmacies
NDS	Non-Extended Days' Supply — limited to 30 days' supply at retail or mail-order
PA	Prior Authorization required — approval must be obtained before filling
QL	Quantity Limit — the Plan limits the amount of the drug covered
ST	Step Therapy required — trial of specified drugs may be required first
V	Vaccine provided at no cost when used per CDC/ACIP recommendations

Quantity limit notations present in tablemixed

QL (84 per 56 days)	Quantity limit example for azithromycin or related entry as shown
QL (20 per 10 days)	Quantity limit example (e.g., DIFICID / fidaxomicin)
QL (224 per 56 days)	Quantity limit example (e.g., TOBI PODHALER mapping)
QL (280 per 28)	Quantity limit example for tobramycin mapping (example formatting shown)
QL (9 per 30 days)	Quantity limit example for vancomycin IV piggyback or related entry
QL (80 per 10 days)	Quantity limit example for vancomycin IV piggyback presentation

Drug entries (no explicit billing codes in excerpt)mixed

N/A	No explicit CPT/HCPCS/ICD-10/NDC codes listed in this excerpt; entries are drug name, presentation, and utilization controls.

Utilization abbreviationsmixed

NDS	Non-Extended Days' Supply — notation shown in list
PA	Prior Authorization — approval required before coverage
MO	Medical Oncology or Mail-Order/medical-only modifier (as listed)
QL	Quantity Limit — numeric cap shown (value specified separately)
LA	Limited Access — may be available only at certain pharmacies
B/D PA	May be covered under Medicare Part B or D depending on setting/use; additional information may be required

Quantity limits (examples)mixed

0.5 per 28 days	Quantity limit example for INVEGA SUSTENNA (0.5 per 28 days)
150 per 30 days	Quantity limit example for INVEGA SUSTENNA (150 per 30 days)

Additional QL entriesmixed

2 per 28 days	Quantity limit for some long-acting injectables (e.g., risperidone microspheres)
120 per 30 days	Quantity limit example (e.g., RALDESY)

Quantity limits referenced — examples

Examples shown in headerQL (96 per 30 days); QL (120 per 30 days)

Itraconazole exampleitraconazole oral capsule — MO; QL (120 per 30 days)

Amphotericin B liposome examplePA; MO; QL (96 per 30 days); NDS

Quantity limits — examples

Common per-period formatsExamples: QL (28 per 28 days); QL (56 per 28 days); QL (84 per 28 days); QL (120 per 30 days)

Repeated small-limit exampleQL (11 per 30 days) appears on multiple antiviral entries

MAVYRET examplesMAVYRET ORAL PELLETS — QL (168 per 28 days); MAVYRET ORAL TABLET — QL (84 per 28 days)

Quantity limits examples (short intervals)

Short interval QL examplesQL (30 per 10 days); QL (20 per 10 days)

Monthly examplesQL (60 per 30 days)

Longer interval inhalation exampleTOBI PODHALER — QL (224 per 56 days)

Quantity limits examples — varied across table

Large IV piggyback rangesVANCOMYCIN IV piggyback examples: QL (4000 per 10 days); QL (80 per 10 days); QL (1000 per 10 days)

Tobramycin injection examplestobramycin sulfate injection recon soln — QL (9 per 14 days); alternate QL (10 per 10 days)

Meropenem IV examplesmeropenem IV recon soln — QL (30 per 10 days) or QL (60 per 30 days) depending on row

Quantity limits (examples) per drug row

Per-row QL examplesMultiple oncology/antineoplastic rows show QL per strength such as 60 per 30 days; 240 per 30 days; 112 per 28 days

Bortezomib exampleBORTEZOMIB injection recon soln — QL (30 per 30 days) or B/D PA/NDS variants

Bosulif examplesBOSULIF ORAL TABLET — QL (180 per 30 days); BOSULIF TABLET (400/500 mg) — QL (56 per 28 days)

Quantity limits examples — e.g., 120/30, 21/28, 1260/30

High/varied QL examplesGemcitabine IV solution — QL (120 per 30 days); IMBRUVICA 70 mg — QL (28 per 28 days)

Lumakras examplesLUMAKRAS various strengths shown with QL — 240/30; 120/30; 90/30 depending on strength

LUNSUMIO exampleLUNSUMIO — QL (1260 per 30 days)

Quantity limits examples — 240/30; 120/30; 90/30; 1260/30

Lumakras strength-specific limitsLUMAKRAS 120 mg — QL (240 per 30 days); 240 mg — QL (120 per 30 days); 320 mg — QL (90 per 30 days)

LUNSUMIO repeatLUNSUMIO — QL (1260 per 30 days)

LYNPARZA exampleLYNPARZA — QL (120 per 30 days)

Quantity limits examples — 224/28; 120/30; 28/28

High QL oncology examplesRYDAPT — QL (224 per 28 days); RYLAZE — QL (120 per 30 days); sunitinib malate — QL (28 per 28 days)

VENCLEXTA exampleVENCLEXTA 100 mg — QL (180 per 30 days)

ROZLYTREK examplesROZLYTREK oral capsule 100 mg — QL (150 per 30 days); alternate QL entries exist by strength

Quantity limits examples across entries (10/30 to 1200/30)

Observed high maximumsExamples include QL (1200 per 30 days); QL (720 per 30 days); QL (360 per 30 days); QL (60 per 30 days)

Briviact examplesBRIVIACT IV — QL (600 per 30 days); BRIVIACT oral/tablet listings include 60/30, 300/30, 600/30 depending on formulation

Clobazam/gabapentin high QLsclobazam — QL (480/30) or 360/30; gabapentin solution — QL (2160 per 30 days)

Quantity limits examples — QL 8/28, 30/30, 120/30, 24/180

Common small-to-large QLsExamples include QL (8 per 28 days); QL (30 per 30 days); QL (120 per 30 days); QL (24 per 180 days)

AUSTEDO XR titration kitAUSTEDO XR TITRATION KT — QL (28 per 180 days); other formulations QL (30 per 30 days)

Valproic acid solutionValproic acid oral solution — QL (1100 per 30 days) for specified concentrations

Quantity limits examples — 10/30, 60/30, 360/30, 240/30, 900/30

Opioid analgesic rangesExamples: fentanyl patch — QL (10 per 30 days) (alternate mapping QL 2400/30); hydrocodone-acetaminophen solution — QL (5550 per 30 days) with alternate QL (180 per 30 days)

Hydromorphone ERhydromorphone ER 24 hr — QL (60 per 30 days)

Methadone rangesmethadone formulations — QL examples include 90/30; 120/30; 240/30; 900/30; 1200/30 depending on presentation

Observed quantity limits — up to 1200/30

Highest observed QLsEntries include QL up to 1200 per 30 days (e.g., diazepam oral solution QL 1200/30) — observed maximums in table reach 1200/30

INVEGA examplesINVEGA SUSTENNA/TRINZA IM formulations show fractional QLs (e.g., 0.5 per 28 days; 0.88 per 90 days) and higher per‑period caps where listed

ASIMTUFII examplesASIMTUFII IM formulations show QL examples such as 30/30; 60/30; 4.8/365; 1.6/28; 3.2/56

Common QL examples — 30/30, 60/30, 2/28, 28/365

Frequent QL patternsCommon QL examples include QL (30 per 30 days); QL (60 per 30 days); QL (2 per 28 days); QL (28 per 365 days)

Risperidone microspheresrisperidone microspheres IM extended — QL (2 per 28 days)

Yearly caps examplesSome oral agents show annual caps such as QL (28 per 365 days) or QL (14 per 365 days)

What Providers and Pharmacies Must Do

Note

Member ID — present card at pharmacy

Present the member's ID card at the pharmacy when filling prescriptions — pharmacies will verify eligibility and plan coverage before dispensing.

Call Member Services at 1-833-230-2057 (TTY: 1-833-711-4711 or 711) for help with prior authorization, exceptions, appeals, or questions about the Drug List.

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required where the table or drug entry lists PA, B/D PA, or similar PA markings. Providers must obtain authorization from CareSource before dispensing or the Plan may deny coverage.

Prior authorization is required for many specialty/oncology agents and select anti-infectives, injectables, and certain formulations (see table entries marked PA, B/D PA, PA; MO, etc.).
Failure to obtain required PA may result in non-coverage or claim denial.
Verify PA requirements for the exact NDC/formulation before dispensing — entries sometimes indicate PA for a specific formulation only.

Prior Authorization

Prior Authorization — formulary‑mandated (B/D PA)

Some drugs are formulary‑mandated or otherwise require prior authorization as a condition of coverage (B/D PA entries indicate drugs that may be billed to Part B or Part D depending on setting and documentation).

If an entry shows B/D PA, submit documentation describing the drug use and setting so the Plan can determine Part B vs Part D coverage.
Formulary-mandated PA means the drug may not be covered without prior approval even if clinically appropriate.

Prior Authorization

Prior Authorization and Medical‑Only (MO) Flags

Certain drugs carry Medical‑Only (MO) flags or limited‑availability (LA) routing; where MO appears, medical benefit review or a medical claim route may be required instead of retail pharmacy billing.

When MO or LA is shown, contact the Plan for guidance on medical benefit billing or site‑of‑care requirements.
Medical override/review (MO) may be required to authorize coverage.
Some entries include MO plus PA — both actions must be completed as indicated.

Prior Authorization

Prior Authorization Required for Some Anti‑infectives

Some anti‑infectives and injectables are subject to PA, MO, QL, and/or NDS. Review each anti‑infective entry for its specific controls before dispensing.

Examples in the anti‑infective sections include amphotericin formulations, cephalosporins, vancomycin, tobramycin, and others marked PA; MO; QL; NDS.
Quantity limits (QL) for IV/infusion products are common and must be observed; exceeding QL may require documentation and can trigger denial.

Note

Legend Required — table symbol definitions

Table entries use symbols (PA, MO, QL, ST, NDS, LA, B/D PA, MCD) to indicate required actions and utilization controls. Refer to the table legend at the start of the drug list for definitions.

Legend definitions: PA = Prior Authorization; MO = Mail‑Order/Medical routing or Medical‑only; QL = Quantity Limit; ST = Step Therapy; NDS = Non‑Extended Days' Supply; LA = Limited Availability; B/D PA = Part B/Part D determination; MCD = Medicaid (non‑Part D) item.

Note

Follow Table‑Specified Controls and Name‑of‑Drug Mapping

Follow all table‑specified controls (PA, MO, QL, ST, NDS, LA, B/D PA) exactly as listed for each drug entry. When a table row shows 'Name of Drug = [other drug]', interpret that as an alternate mapping and apply the controls shown (e.g., Name of Drug = PAXLOVID indicates mapping to the listed OTC or antiviral entry).

If a row lists 'Name of Drug = [other drug]', the restrictions and controls for the referenced product apply.
Providers should not assume controls are the same across formulations; check the exact listed formulation and its controls.

Documentation Required

Quantity Limits (QL) and Documentation

Quantity limits (QL) are specified for many drugs and formulations. If a requested quantity exceeds the published QL, include supporting clinical documentation with the PA request; requests to exceed QL may be denied without justification.

Examples: various oral and IV oncology agents and anti‑infectives list QL values (e.g., QL (28 per 28 days), QL (120 per 30 days), etc.).
Quantity limit documentation should state the clinical rationale and duration requested.
Exceeding QL without documentation may trigger denial or require an exception request.

Documentation Required

Prior Authorization Documentation Required

Prior authorization documentation is required when PA, B/D PA, B/D PA; MO or similar markers appear. Include clinical justification, supporting prescriber statement, relevant prior therapies (for ST), and quantity/duration rationale.

The prescriber's supporting statement is required for exception and expedited requests — see Member Services contact information.
Keep copies of submitted documentation; the Plan may request additional information during review.

Documentation Required

Quantity Limit Documentation — supporting evidence required

Quantity‑limit and utilization management requests may require additional supporting documentation. Examples include justification to exceed a QL, evidence of failure/intolerance for step‑therapy requirements, or clinical reasons for non‑standard days' supply.

Examples cited in the drug list include QL (e.g., 96 per 30 days, 240 per 30 days) where documentation can support a higher quantity.
Document prior trials, lab results, and prescriber rationale when requesting overrides.

Step Therapy

Step Therapy (ST) — try required agents first or request exception

Step therapy (ST) is specified for some products. When ST appears, the Plan requires trial of specified preferred products before covering the non‑preferred product. Providers may request an exception with clinical justification if the preferred agent is inappropriate.

ST examples include AUVELITY and select sedative/hypnotic agents; follow the table row for which agent(s) must be tried first.
If a prescriber requests an exception because a step drug is expected to harm or has failed, submit the supporting statement; standard and expedited timelines apply.

Step Therapy

Step/Benefit Design Indicators — follow specified rules

Some entries show step or benefit design indicators such as B/D PA, MO, LA, or NDS; follow the step/brand rules when they are specified for an entry. If no explicit step algorithm is listed, use the preferred alternatives listed in nearby entries or contact the Plan.

Benefit/design routing (B/D PA) may determine whether a drug is payable under medical or pharmacy benefits.
When step therapy or brand rules are present, ensure prior trials and dates are clearly documented in the PA submission.

Denial Risk

Authorization and Denial Triggers — denial risk if controls not followed

The Drug List includes denial and authorization triggers. Missing a required PA, exceeding QL, noncompliance with ST, or failure to follow MO/LA billing routes can result in claim denial.

If a cover rule (PA, QL, ST, MO) is not followed, the request may be denied.
Providers and pharmacies should verify UM controls prior to dispensing to avoid coverage risk.

Prior Authorization

Prior Authorization and Utilization Management Flags — required UM actions

Required utilization management (UM) actions include following PA, MO, ST, QL, NDS and LA as listed. The Plan may require medical review or routing of certain claims to the medical benefit.

Follow the listed UM flags for each drug entry; UM noncompliance may lead to denial.
When multiple flags appear (e.g., PA; MO; QL; NDS), complete all required actions before dispensing.

Note

Medical Override / Review Where Indicated (MO)

When a drug entry includes Medical Override (MO) or indicates medical‑only billing, contact the Plan's provider helpdesk for authorization direction and billing pathway. Some items may be available via mail order or medical benefit only.

MO may indicate mail‑order or that medical benefit billing is required rather than retail pharmacy.
Medical override/review may be available where clinically indicated; submit documentation per Plan instructions.

Denial Risk

Requests May Be Denied If Prior Authorization or Documentation Is Missing

Requests for PA, exceptions, or to exceed QL may be denied if the required PA, documentation, prior therapy trials, or clinical justification are not submitted. Expedited reviews are available when prescriber attests that delay may harm the member.

Standard exception decision timeline: up to 72 hours after receiving prescriber's supporting statement.
Expedited exception: decision within 24 hours if prescriber supports urgent need.
Denials for noncompliance with UM controls may be appealed per Member Handbook.

Prior Authorization

Rescue Medications — PA + QL may apply

Some drugs listed as 'rescue' or emergency rescue medications carry both PA and QL controls; review the entry carefully and obtain PA when indicated and document quantity limits.

Example entries: intranasal or rectal rescue benzodiazepines and certain seizure rescue meds (e.g., NAYZILAM, VALTOCO) list PA; MO; QL values.
Ensure adequate documentation if requesting quantities above listed QL for rescue therapy.

Note

Table Restriction Flags — NDS and days' supply limits

When following the table, ensure you observe Non‑Extended Days' Supply (NDS) restrictions — some products are limited to 30 days supply at retail or mail‑order and may have stricter refill rules.

NDS entries often accompany PA/MO/QL flags; confirm days' supply rules during PA submission.
Failure to observe NDS limits can lead to pharmacy claim rejection.

Note

When a Drug Entry Lists 'Name of Drug = ...' — apply referenced controls

If a table row shows coverage mappings such as 'Name of Drug = [other drug]', providers should treat the mapping as an equivalence and apply the listed controls and restrictions of the referenced product.

These mappings are used for alternate formulations or branded/generic cross‑references — apply the controls from the referenced name.
When mappings are ambiguous, contact Member Services for clarification before dispensing.

Step Therapy

Follow Step/Brand and Benefit/Design Controls

Follow step/brand routing and benefit/design controls (B/D PA, MO, ST) when they are specified. Some entries use routing flags to determine preferred agents or benefit responsibility.

Benefit/Design or step controls may affect prior authorization requirements and coverage determination.
Providers should document prior trials and reasons for brand use when requesting PA or exception.

Documentation Required

Quantity Limits Require Supporting Documentation

Quantity limits require supporting documentation when requesting a quantity above the published QL. Examples in the list include oncology, anti‑infective, and chronic therapy QLs — include dosing schedule and clinical rationale in the PA.

Examples: QL (240 per 30 days), QL (120 per 30 days), QL (28 per 28 days) — these are product‑specific.
Supporting documentation examples: dosing charts, treatment plan, prior authorization forms, and prescriber notes.

Prior Authorization

Required Utilization Management Actions — follow PA, MO, ST, QL, NDS

Required UM actions (PA, MO, ST, QL, NDS) must be completed per the table. Noncompliance with utilization controls or failure to obtain PA can result in denial or non‑coverage.

Verify all applicable flags on the drug entry before dispensing.
If unsure, contact Member Services to confirm required UM steps.

Note

Non‑Narcotic Analgesics and Alternatives — follow MO/MCD/QL controls

Some non‑narcotic analgesics and alternative therapies have MO/MCD designations and quantity limits listed; follow the entry controls and submit documentation when seeking coverage exceptions.

Examples include acetaminophen liquids, aspirin formulations, and other OTC analgesics flagged MCD; MO.
For Medicaid‑only (MCD) items, different appeal rules may apply — see the Member Handbook.

Step Therapy

Step Therapy Present for Some Agents — document prior trials or request exception

Step therapy is present for select agents across therapeutic areas (examples include AUVELITY, certain benzodiazepine liquid formulations, and RALDESY). When ST applies, document prior trials or request an exception with prescriber rationale.

ST entries require trial and failure or intolerance of preferred agents before covering the non‑preferred product.
Provide dates and outcomes of prior therapies in the PA or exception request.

Prior Authorization

Prior Authorization for Specialty/Oncology and Select Products

Some specialty and oncology agents are routinely PA‑required and may carry B/D PA, MO, LA, QL and NDS flags. Verify the listed controls for each specialty product and route PA and billing per Plan instructions.

Examples include ADCETRIS, DARZALEX, BORTEZOMIB, and many oral oncolytics (entries show PA; MO; QL; NDS).
Specialty products may require medical benefit routing or limited‑availability (LA) pharmacy fulfillment.

Step Therapy Rules and Tables

Step therapy where indicated

Where step therapy is indicated

Step therapy requirement: Products marked 'ST' require documented trial and failure of specified preferred agent(s) before coverage of the next-line agent will be provided.per product

Example: RALDESY is labeled with ST; prescriber must document prior trial of preferred therapy or request an exception.

Requirement	Detail
Member must try required step therapies unless an exception is granted
Plan allows prescriber to request an exception when first-line therapy is inappropriate; see exception process and timelines.

Policy statement	Example / implication
Plan may require trying specified drugs first (Step Therapy - ST) before covering alternatives.
Example: AUVELITY is marked ST in the drug list; Drug B may be covered only after trial/failure of the preferred agent(s).

Flag	Context in drug list
NDS
MO

Flags observed	Interpretation
MO; PA
Indicate medical-only routing and prior authorization processes; explicit step hierarchy is not shown in the excerpt—follow formulary entry and PA procedures.

Agent type	Notations / implications
Oncology and specialty agents
Annotated with B/D PA, NDS, LA — indicates benefit/design restrictions, prior authorization and specialty routing may apply.

Entry flags	Meaning
MO
LA or MO/LA — denote medical override or limited access, suggesting requirements prior to approval for certain lines or formulations.

Notation	Implication
B/D PA
B/D PA and MO imply additional benefit-design routing or specialty program requirements before coverage is granted.

Observed flags	Coverage implication
B/D PA; MO
These flags indicate benefit-design or medical-only controls that affect coverage pathways; follow drug-specific entries for actions required.

Flag	Operational effect
B/D PA; MO
Products marked with these flags require routing through benefit/diagnosis prior authorization or medical-only review before coverage.

Observation	Note
No explicit step therapy sequences shown in excerpt
'Name of Drug' mappings and ST flags on some rows imply preferred alternatives and where step requirements exist providers must follow the formulary listing.

Requirement	Examples
Prior Authorization and/or Medical Override required before coverage
Many specialty neurological agents (e.g., brivaracetam listings) show PA; MO and QL that must be met prior to coverage.

Product group	Formulary indication
Non-narcotic analgesics and OTC options
Listed with MCD or MO suggesting preference for non-narcotic first-line options and associated utilization controls (e.g., acetaminophen entries with MCD/MO).

Products with ST	Notes
AUVELITY; certain diazepam presentations; DRIZALMA
Listed with ST flags in the drug list—prescriber must meet step requirements for coverage where indicated.

ST examples	Requirement
RALDESY
Marked ST in the list; prescriber must satisfy step therapy requirements prior to coverage.

Authorization flags	Example
PA; MO; LA; NDS
Example: DOPTELET pack variants show PA; MO; LA; NDS — requirements depend on the specific pack/formulation.

Quantity Limits by Product and Formulation

Quantity limits — general (varies by drug)

General statementQuantity limits vary by drug — limits and required actions (PA, MO, NDS) are specified in each drug row of the Drug List

Where to find detailsSee the List of Covered Drugs tables for drug-specific QL values and related utilization controls

Provider actions linked to QLRequests exceeding QL require supporting documentation and may need PA or MO per formulary guidance

itraconazole oral capsule (example QL values)

Itraconazole exampleitraconazole oral capsule — MO; QL (120 per 30 days)

Alternate itraconazole noteSome antifungal entries show QL (96 per 30 days) for other formulations (see amphotericin/liposome row)

LocationAntifungal section of Drug List — check specific capsule/solution rows for exact QL

LEDIPASVIR-SOFOSBUVIR example QL

LEDIPASVIR‑SOFOSBUVIR QLLEDIPASVIR‑SOFOSBUVIR — PA; MO; QL (28 per 28 days); NDS

Alternate listingAlso shows QL (11 per 30 days) in table mapping; confirm exact row for dispensing period

SectionHepatitis/antiviral entries in Drug List

MAVYRET ORAL PELLETS example QL

MAVYRET pellets QLMAVYRET ORAL PELLETS — PA; MO; QL (168 per 28 days); NDS

Pack mappingPellet packet row shows 168/28; other mapping may show QL (11 per 30 days) for alternate pack sizes

Where shownAntiviral section (HIV/HCV therapies)

MAVYRET ORAL TABLET example QL

MAVYRET tablet QLMAVYRET ORAL TABLET — PA; MO; QL (84 per 28 days)

Alternate mappingSome rows also show QL (11 per 30 days) in mapping fields; verify correct presentation

SectionAntiviral table — review specific tablet row for dispensing limit

valacyclovir 1 g QL example

Valacyclovir 1 g QLvalacyclovir oral tablet 1 gram — MO; QL (120 per 30 days)

MO noteRow lists MO in addition to QL; prior authorization may be required in some cases

SectionAntiviral/herpes agents section

valacyclovir 500 mg QL example

Valacyclovir 500 mg QLvalacyclovir oral tablet 500 mg — MO; QL (60 per 30 days)

Related 1 g rowSee 1 g row showing QL 120/30 for higher-dose preparation

SectionAntiviral section

azithromycin examples (QL 84/56 etc.)

Azithromycin exampleazithromycin oral tablet — PA; MO; LA; QL (84 per 56 days)

Multiple formulationsSome azithromycin rows show varied QL by pack/presentation — check specific formulation row

SectionAnti‑infectives: macrolides and related entries

fidaxomicin/tinidazole/TOBI PODHALER/tobramycin/vancomycin examples

Fidaxomicin / tinidazole / inhaled antibioticsExamples include QL (20 per 10 days) for tinidazole; TOBI PODHALER — QL (224 per 56 days); tobramycin inhalation — QL (4 per 10 days)

Vancomycin IV entriesVancomycin IV piggyback rows show high-range QLs (4000 per 10 days; 80 per 10 days; 1000 per 10 days depending on concentration)

Tobramycin injection QLstobramycin injection recon soln — PA; QL (9 per 14 days) or MO; QL (10 per 10 days) alternate rows

meropenem IV QL examples

Meropenem IV QL examplesmeropenem IV recon soln — PA; QL (30 per 10 days) or PA; MO; QL (60 per 30 days) in alternate rows

Use cautionDifferent rows reflect differing QL depending on formulation/setting (e.g., inpatient vs outpatient)

SectionAnti‑infectives IV formulations

tobramycin sulfate injection recon soln QL examples

Tobramycin injection recon soln QLstobramycin sulfate injection recon soln — PA; QL (9 per 14 days); alternate entry — MO; QL (10 per 10 days)

Other tobramycin entriesTobramycin 10 mg/ml — PA; QL (27 per 10 days); 40 mg/ml — PA; MO; QL (40 per 10 days)

SectionAminoglycoside injections

vancomycin IV piggyback QL examples

Vancomycin IV piggyback QLsVancomycin IV piggyback examples: QL (4000 per 10 days); PA; MO; QL (80 per 10 days); QL (1000 per 10 days); QL (9 per 30 days)

Alternate piggyback rowsSome piggyback presentations show QL (4050 per 10 days) or QL (90 per 30 days) depending on concentration and mapping

SectionGlycopeptides/IV antibiotics

ALUNBRIG QL examples

ALUNBRIG QL examplesALUNBRIG oral tablet — PA; QL (30 per 30 days) or QL (60 per 30 days) depending on strength/formulation

ALUNBRIG alternate packsDose‑pack entries show QL (30 per 180 days) in some mappings; check exact row

SectionOncology targeted agents

ADCETRIS QL example

ADCETRIS QLADCETRIS — B/D PA; MO; NDS; QL (66 per 28 days) (example listed)

Oncology PA flagsMany ADCETRIS entries also show PA/B/D PA and NDS alongside QL

SectionOncology antibody‑drug conjugates

Multiple QL examples (60/30;240/30;180/30;112/28;30/30;120/30)

Multiple QL patternsExamples include QL (60 per 30 days); QL (240 per 30 days); QL (180 per 30 days); QL (112 per 28 days); QL (30 per 30 days); QL (120 per 30 days)

ContextThese represent varied oncology and specialty drug QLs across formulations — verify drug row for exact value

ActionRequests exceeding these QLs will require documentation and may need PA/MO

gemcitabine IV solution QL examples

Gemcitabine IV QLgemcitabine intravenous solution — PA; QL (120 per 30 days); alternate entries show QL (21 per 28 days) or QL (90 per 30 days) depending on formulation

B/D PA noteSome gemcitabine rows also list B/D PA; MO; NDS

SectionAntineoplastic IV solutions

IMBRUVICA capsule QL example

IMBRUVICA 70 mg QLIMBRUVICA oral capsule 70 mg — PA; QL (28 per 28 days); NDS

Other strengthsHigher‑strength tablet/suspension rows show similar QL patterns (e.g., QL 28/28) and B/D PA flags

SectionOral oncology agents

LUMAKRAS QL examples by strength

LUMAKRAS strength QLsLUMAKRAS — 120 mg: QL (240 per 30 days); 240 mg: QL (120 per 30 days); 320 mg: QL (90 per 30 days)

NDS/PA flagsEach LUMAKRAS row also lists PA; MO; NDS in the formulary

SectionTargeted oral oncology agents

LUNSUMIO QL example

LUNSUMIO QLLUNSUMIO — PA; MO; QL (1260 per 30 days); NDS

Repeated entryDose and pack variants (VELO) show same QL (1260 per 30 days)

SectionImmunotherapy/biologic agents

LUMAKRAS 120 mg QL

LUMAKRAS 120 mgQL (240 per 30 days)

ContextListed under LUMAKRAS entries with PA; MO; NDS

SectionOncology targeted therapies

LUMAKRAS 240 mg QL

LUMAKRAS 240 mgQL (120 per 30 days)

ContextSee adjacent LUMAKRAS rows for strength‑specific QLs and flags

SectionOncology targeted therapies

LUMAKRAS 320 mg QL

LUMAKRAS 320 mgQL (90 per 30 days)

ContextStrength‑dependent QL shown in Drug List entries

SectionOncology targeted therapies

LUNSUMIO QL example (1260)

LUNSUMIO repeatLUNSUMIO — QL (1260 per 30 days)

FlaggingPA; MO; NDS accompany this high QL in formulary rows

SectionBiologic therapies

LYNPARZA QL example

LYNPARZA QLLYNPARZA — PA; MO; QL (120 per 30 days)

Alternate rowsSome LYNPARZA rows show lower per‑period caps (e.g., 30 per 30 days) for certain formulations

SectionPARP inhibitor entries

methotrexate injection QL example

Methotrexate injection QLmethotrexate sodium (pf) injection recon soln — PA; MO; QL (2 per 28 days)

Dose-specific noteSmall per‑period QL reflecting injectable dosing conventions

SectionAntineoplastic injectables

MODEYSO QL example

MODEYSO QLMODEYSO — PA; QL (20 per 28 days); NDS

Alternate pack QLsSome MODEYSO rows show QL (3 per 28 days) for certain pack types

SectionOncology oral agents

PEMAZYRE QL example

PEMAZYRE QLPEMAZYRE — PA; LA; QL (28 per 28 days); NDS

Pemetrexed related rowsPemetrexed rows list B/D PA; MO; NDS with varying QLs

SectionRare tumor agents

PIQRAY QL example

PIQRAY QLPIQRAY oral tablet 200 mg/day — PA; QL (28 per 28 days); NDS

Higher-dose rowsPIQRAY 250/300 mg rows list QL (56 per 28 days) and up to QL (120 per 30 days) for other formulations

SectionPI3K inhibitors and related agents

pomalidomide QL example

Pomalidomide QLpomalidomide — PA; MO; QL (21 per 28 days); alternate QL (240 per 30 days) appears for some mappings

Use notePomalidomide entries include REMS/monitoring flags in full table

SectionImmunomodulatory agents

REZUROCK QL example

REZUROCK QLREZUROCK — PA; LA; QL (30 per 30 days); NDS

Related injectionsREZUROCK rows associate with long‑acting injectables in name mapping lines

SectionEndocrine/peptide agents

ROZLYTREK QL example

ROZLYTREK QLsROZLYTREK oral capsule 100 mg — PA; MO; QL (150 per 30 days); other strengths list QL (120 per 30) or QL (90 per 30)

Pellet packet examplesROZLYTREK oral pellets show very large QLs in packet form (e.g., QL (336 per 28) or QL (300 per 30) depending on pack)

SectionOncology targeted kinase inhibitors

RYDAPT / RYLAZE / sunitinib QL examples

RYDAPT QLRYDAPT — PA; MO; QL (224 per 28 days); NDS

RYLAZE QLRYLAZE — PA; MO; QL (120 per 30 days); NDS

Sunitinib QLsunitinib malate — PA; MO; QL (28 per 28 days)

VENCLEXTA QL example

VENCLEXTA QLVENCLEXTA oral tablet 100 mg — QL (180 per 30 days)

UNITUXIN/other oncologyMultiple oncology injectables show PA/MO and varying QLs — check row for strength

SectionHematologic oncology agents

BRIVIACT IV/oral QL examples

BRIVIACT QLsBRIVIACT IV — MO; QL (600 per 30 days); BRIVIACT oral/tablet rows include QL (60 per 30 days) and larger listings by formulation

Brivaracetam oral tabletOral tablet — MO; QL (60 per 30 days); some formulations list QL (90/30) or higher

SectionAntiepileptic agents

clobazam formulations QL examples

Clobazam QLsclobazam oral suspension/tablet rows — PA; MO; QL (480 per 30 days) or PA; LA; QL (360 per 30 days) for other formulations

Formulation varianceDifferent formulations (suspension vs tablet) show substantially different QLs

SectionAntiepileptic agents — clobazam

gabapentin solutions/tablets QL examples

Gabapentin QLsgabapentin solutions/tablets — examples include QL (2160 per 30 days) for solution; QL (270 per 30 days); QL (360 per 30 days) depending on strength/formulation

Extended release examplesExtended‑release 600 mg — PA; MO; QL (90 per 30 days)

SectionNeurology/anticonvulsants

NAYZILAM, VALTOCO QL examples (10/30)

NAYZILAM / VALTOCO QLNAYZILAM and VALTOCO — PA; MO; QL (10 per 30 days)

Rescue medication noteThese rescue/acute seizure agents are explicitly limited to 10 doses per 30 days in listed rows

SectionSeizure rescue therapies

valproic acid oral solution QL example

Valproic acid solution QLValproic acid oral solution — PA; LA; QL (1100 per 30 days) for specified concentrations

VALTOCO mappingVALTOCO rows show PA; MO; QL (10 per 30 days) for some presentations

SectionAntiepileptic formulations

valproic acid / VALTOCO QL examples

VALTOCO/valproate noteVALTOCO — PA; MO; QL (10 per 30 days); valproic acid solution shows higher QLs (e.g., 1100/30) depending on concentration

Provider actionPA and documentation required for requests exceeding QL

SectionSeizure therapies

AUSTEDO XR TITRATION KT QL example

AUSTEDO XR titration kitAUSTEDO XR TITRATION KT — PA; MO; QL (28 per 180 days); other formulations — QL (30 per 30 days)

Tetrabenazine QLtetrabenazine 25 mg — QL (120 per 30 days) or 240 per 30 days for other strengths

SectionMovement disorders — tetrabenazine, deutetrabenazine, valbenazine

tetrabenazine 25 mg QL example

Tetrabenazine 25 mg QLtetrabenazine oral tablet 25 mg — PA; MO; QL (240 per 30 days)

Alternate strengthsTetrabenazine 12.5/25 mg rows show QL (120 per 30 days) for some presentations

SectionHyperkinetic movement disorder agents

acetaminophen-codeine QL example

Acetaminophen‑codeine QLacetaminophen‑codeine oral solution — MO; QL (4500 per 30 days) (example shown)

BELBUCA QLsBELBUCA — PA; MO; QL (60 per 30 days) or alternative QL (50 per 30 days); other formulations QL (4 per 28 days)

SectionAnalgesics and combination opioids

BELBUCA / fentanyl QL examples

BELBUCA pack QLsBELBUCA buprenorphine entries — QL examples: 60 per 30 days; 50 per 30 days; 4 per 28 days depending on formulation

Fentanyl patchfentanyl transdermal patch 72 hr — QL (10 per 30 days); alternate mapping shows QL (2400 per 30 days) for other codes

SectionOpioid analgesics and buprenorphine products

fentanyl / hydrocodone / methadone QL examples

Fentanyl & hydrocodone examplesfentanyl patch — QL (10 per 30 days); hydrocodone‑acetaminophen oral solution — high QLs (5550 per 30 days) with alternate entries QL (180 per 30 days)

Hydromorphone ER QLhydromorphone ER 24 hr — PA; MO; QL (60 per 30 days)

Methadone rangesmethadone formulations — QL examples include 90/30; 120/30; 240/30; 900/30; 1200/30 depending on product

ASIMTUFII IM formulation QL examples

ASIMTUFII IM QLsASIMTUFII intramuscular suspension — examples: QL (30 per 30 days); QL (60 per 30 days); QL (4.8 per 365 days); QL (1.6 per 28 days); QL (3.2 per 56 days)

Multiple syringe QLsDifferent syringe sizes/strengths show distinct fractional QLs (per 28/56/365 days)

SectionLong‑acting injectable antipsychotics

diazepam oral solution QL examples

Diazepam oral solution QLsdiazepam oral solution — PA; MO; QL (1200 per 30 days) on one row; ST and QL (30 per 30 days) for other presentations

Diazepam concentrate rowsOral concentrate rows show QL (240 per 30 days) or QL (30 per 30 days) depending on mapping

SectionBenzodiazepine liquid/concentrate entries

INVEGA SUSTENNA / TRINZA and injectables examples

INVEGA SUSTENNA/TRINZA fractional QLsExamples: QL (0.5 per 28 days); QL (0.88 per 90 days); QL (1.32 per 90 days); QL (1.75 per 90 days); QL (2.63 per 90 days); QL (1.5 per 28 days)

Higher per‑period capsOther INVEGA TRINZA rows show QL (60 per 30 days) or QL (150 per 30 days) depending on syringe size

SectionLong‑acting injectable antipsychotics — IM formulations

Various oral agents QL examples

Various oral agents QLsExamples include QL (30 per 30 days); QL (60 per 30 days); QL (120 per 30 days); QL (28 per 365 days); QL (14 per 365 days)

RALDESY ST flagRALDESY — ST; MO; NDS with QL (120 per 30 days) on alternate row

Risperidone microspheresrisperidone microspheres IM extended — QL (2 per 28 days)

amlodipine-valsartan and related QL examples

Amlodipine‑valsartan QLamlodipine‑valsartan — QL (4 per 28 days)

Doxazosin QLsdoxazosin oral tablet 1‑4 mg — QL (30 per 30 days); doxazosin 8 mg — QL (60 per 30 days)

DOPTELET pack variantsDOPTELET formulations — QL varies by pack (examples: QL 28 per 28 days; QL 22.4 per 28 days)

Note

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