CurrentCareSourcePolicy 00026141

List of Covered Drugs (Drug List) — CareSource MyCare Ohio

CareSource MyCare Ohio formulary describing covered drugs, utilization controls (prior authorization, quantity limits, step therapy), and member/provider processes for exceptions and temporary supplies.

Policy Summary

PayerCareSource

PolicyList of Covered Drugs (Drug List) — CareSource MyCare Ohio

Policy CodePolicy 00026141

Change TypeAdministrative update — drug list refresh (no material clinical changes)

Effective Date05/01/2026

Next Review DateN/A

Key ActionObtain prior authorization when 'PA' is listed for a drug to avoid claim denial; contact Member Services for exception submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

V10formulary version

05/01/2026document update

1-855-475-3163member services

30 daysadvance notice

30-daytemporary supply (new members)

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.

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Coverage Criteria and General Rules

General coverage conditions

Covered when ALL of the following are met

Standard coverage conditions: Prescriber states the drug is medically necessary for the member

From Drug List coverage rules

Payer medical necessity agreement: CareSource MyCare Ohio agrees the drug is medically necessary for the member

From Drug List coverage rules

Network pharmacy dispensing: Prescription is filled at a CareSource MyCare Ohio network pharmacy

From Drug List coverage rules

Temporary and transition coverage

Temporary/transition supplies covered in specific scenarios

New member 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, plan rules limit the amount ordered, the drug requires prior authorization, or the drug is subject to step therapy30 days

From B9

One-time supply for unplanned transitions: In the event of an unplanned transition or level-of-care change, the plan may cover a one-time temporary supply up to 31 days31 days

From B9

Long-term care immediate supply: For members in a nursing home or long-term care facility who need a drug not on the Drug List, the plan will cover one 31-day supply (unless prescription is written for fewer days)31 days

From B9

Temporary Supply Coverage

Temporary supply coverage rules

Temporary supplies for new members or transitions: Cover temporary supply up to 30 days for new members within first 90 days if drug not on Drug List, plan rules limit amount, drug requires prior authorization, or drug is part of step therapy; allow multiple refills to provide up to 30 days if prescription written for fewer days30-day

From B9

Long-term care / unplanned transition temporary supply: If member has been in the plan >90 days and lives in long-term care facility or an unplanned transition occurs, cover one 31-day supply unless prescription specifies fewer days31-day

From B9

Exception Process and Timelines

Exception request and decision timelines

Exception submission: Member or prescriber may request an exception to cover a drug not on the Drug List or to change plan rules (for example, quantity limits, step therapy, or prior authorization); Member Services will assist with submitting the request

From B10 and B11

Decision timelines: Standard exception decision within 72 hours after receiving the prescriber's supporting statement; expedited exception decision within 24 hours if waiting may seriously harm the member; prescriber's supporting statement should be faxed to 1-877-328-966072 hours / 24 hours

From B12

Formulary Structure and Coverage

Formulary coverage and tiers

Copays and tiers: Members have no copays for Part D covered prescription and OTC drugs when following the plan's rules; drugs are grouped into tiers (Tier 1–5) with tiers reflecting generic/brand distinctions

From B19

Formulary rules and symbols: The List of Covered Drugs uses requirement/limit symbols such as PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), MO (Mail-Order), NDS (Non-Extended Days), and B/D PA (may be covered under Part B or D); these symbols indicate the actions or restrictions that apply to each drug

From C1

Coverage conditioned on listed requirements

Coverage and utilization management for listed drugs are governed by the Requirements/Limits column; coverage is conditional on meeting those controls

Formulary controls: Drug coverage depends on meeting Requirements/Limits entries such as PA (prior authorization), B/D PA (Part B/Part D determination), MO (mail-order/management indicator), LA (limited availability), ST (step therapy), NDS (non-extended days), and QL (quantity limit); failure to meet these requirements may result in noncoverage or denial

From formulary 'Requirements / Limits' definitions and antineoplastic/immunosuppressant entries

Drugs that are removed from the market or determined to be unsafe may be taken off the CareSource MyCare Ohio Drug List immediately and will not be covered.

When a formulary entry lists PA (Prior Authorization), the plan requires approval before the prescription can be filled; if prior authorization is not obtained, CareSource MyCare Ohio may not cover the drug.

Within the excerpted formulary segments provided here there are no standalone explicit exclusion statements; the drug listings instead use requirement and limits codes (e.g., PA, QL, MO, NDS, LA, B/D) and refer readers to the table legend at the start of the full Drug List for symbol meanings that may imply coverage constraints.

The partial drug table shown in this excerpt does not include explicit exclusion conditions for specific products; coverage language is conveyed via the Requirements/Limits column entries rather than separate exclusion statements in these chunks.

This segment of the Drug List does not list explicit exclusions; instead, the table uses symbols and abbreviations in the Requirements/Limits column. Users should consult the formulary legend at the beginning of the full table to interpret symbol meanings that drive coverage decisions.

The provided extract includes many requirement flags (e.g., PA, MO, QL, NDS, LA, B/D) and quantity limits but does not contain standalone exclusion language; coverage conditions for each line are determined by the Requirements/Limits entries and the table legend.

CareSource MyCare Ohio will cover drugs listed on the Drug List when the prescriber determines the drug is medically necessary, CareSource MyCare Ohio agrees the drug is medically necessary, and the prescription is filled at a CareSource MyCare Ohio network pharmacy.

No explicit 'Not Medically Necessary' (NMN) statements appear in the excerpted sections; coverage determinations in this extract are expressed through the Drug List entries and the Requirements/Limits codes rather than by separate NMN declarations.

This partial section does not include explicit statements labeling drugs as 'Not Medically Necessary.' Instead, access is controlled through the Requirements/Limits codes (e.g., PA, MO, QL, NDS) applied to individual formulary entries.

Within the provided excerpt there are no line‑level declarations that a drug is 'not medically necessary.' The plan communicates coverage conditions via the Drug List and the associated requirement/limit codes; for full NMN determinations refer to the complete policy and PA criteria.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required — Some drugs listed on this Drug List require prior authorization (PA) from CareSource MyCare Ohio before the prescription can be filled. If prior authorization is not obtained when required, the Plan may not cover the drug and the claim may be denied.

PA = Prior Authorization — approval required before dispensing
Many antineoplastic and immunosuppressant drugs and select high-tier or specialty products frequently require PA or B/D PA (benefit/setting determination) as shown in the Requirements/Limits column

Documentation Required

Prior authorization and requirement codes

Prior authorization and requirement codes — The formulary uses requirement codes in the 'Requirements/Limits' column that may affect coverage. These include PA (Prior Authorization), B/D PA (may be covered under Medicare Part B or D depending on use/setting), MO (Mail-Order availability), LA (Limited Availability), QL (Quantity Limit), NDS (Non‑Extended Days' Supply), and ST (Step Therapy). Failure to meet the indicated requirement(s) may result in denial or reduced coverage.

Formulary Codes, Requirement Flags, and Quantity Limit Examples

Selected Formulary Products (neutral)mixed

AIMOVIG	AIMOVIG AUTOINJECTOR — Requirements /Limits = PA; MO; QL (1 per 30 days).
EMGALITY	EMGALITY PEN / SUBCUTANEOUS SYRINGE 120 — Requirements /Limits = PA; MO; QL (2 per 30 days).
XCOPRI	XCOPRI TITRATION PACK / ORAL TABLETS — referenced as drug name for topiramate products; QL (28 per 180 days) for some formulations.
VALTOCO	VALTOCO — Requirements /Limits = PA; MO; QL (10 per 30 days).
INBRIJA	INBRIJA — referenced in antineoplastic/neurology lists (ensure present in formulary mapping).
NEUPRO	NEUPRO — referenced in neurology / movement disorder product group; ensure availability and any QL or MO flags.

Quantity Limit Examples (neutral)mixed

QL_120_30	Example: QL (120 per 30 days) — e.g., itraconazole, famciclovir, EVOTAZ/ETRAVIRINE entries.
QL_28_28	Example: QL (28 per 28 days) — e.g., some PAXLOVID/SOFOSBUVIR/VALTOCO related entries.
QL_84_28	Example: QL (84 per 28 days) — e.g., MAVYRET oral tablet.
QL_4000_10	Example: QL (4000 per 10 days) — vancomycin IV piggyback examples.
QL_40_10	Example: QL (40 per 10 days) — vancomycin oral capsule.
QL_240_30	Example: QL (240 per 30 days) — AUGTYRO.
QL_66_28	Example: QL (66 per 28 days) — AVMAPKI-FAKZYNJA.
QL_30_30	Example: QL (30 per 30 days) — many oncology oral products.
QL_180_30	Example: QL (180 per 30 days) — multiple antineoplastics (e.g., abiraterone).
QL_60_30	Example: QL (60 per 30 days) — various products.

1–10 of 18

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Requirement/Management Codes (neutral)mixed

PA	Prior Authorization required for listed products (PA).
MO	Mail-Order availability flag (MO).
LA	Limited Availability (LA) — specialty or limited pharmacies.
NDS	Non-Extended Days' Supply (NDS) — limited to 30-day supply at retail/mail-order.
B/D PA	May require Part B vs Part D determination (B/D PA).

Step Therapy Rules and Indicators

Requirement	Summary / Plan action
Step therapy (ST)	Members must try specified prior agent(s) before the plan will cover a next‑line drug; prescriber may document failure or contraindication to the prior agent to allow coverage of the alternative.
Temporary supply during step review	Drugs subject to step therapy may be eligible for a temporary 30‑day supply for new members while exception or transition requests are processed.

Step Therapy Indicator	Meaning / Plan action
ST (Step Therapy)	Plan requires specified first‑line drugs to be tried for the medical condition before covering alternative drugs; if first drug fails or is not tolerated, second drug may be covered upon documentation.
Table legend reference	See the formulary table legend at the beginning for specific drug‑level step therapy details and required sequence; providers may call Member Services for clarification.

Flags present	Interpretation
PA; MO; LA	Entries showing combinations such as PA; MO; LA indicate prior authorization and management/limited‑access routing may apply and can reflect step or specialty requirements; specific step algorithms are not provided in these excerpts.
NDS	Non‑drug‑specific (NDS) appears alongside other flags and may affect how step/management rules are applied per the formulary legend.

Agent / Flag examples	Implication for step or authorization
ADCETRIS; many antineoplastic agents (e.g., ALECENSA, azacitidine)	Marked B/D PA; MO; NDS or PA; LA indicating layered authorization (benefit/diagnosis PA, medical override, limited access) — may require multiple authorization pathways before coverage.
AUGTYRO; AYVAKIT; BALVERSA	Examples show PA with LA or B/D PA flags — plan applies prior authorization and may route approvals through specialty/benefit review consistent with step/managed processes.

Flags	Practical effect
MO; LA	MO (medical/management override) and LA (limited access) flags indicate utilization management or step‑edit controls may apply to the listed product; exact step criteria are defined in the full formulary legend or PA criteria.
B/D PA	B/D PA denotes benefit/diagnosis or billing/documentation prior authorization which may functionally operate like a step/managed edit for coverage determinations.

Drug	Step-like controls / Limits
AIMOVIG (autoinjector)	Requirements/Limits = PA; MO; QL (1 per 30 days) — prior authorization plus a quantity limit of 1 per 30 days restricts access and functions similarly to step management.

Product / Entry	Step Therapy note
EXXUA (extended release formulations)	Requirements/Limits include ST and QL (e.g., ST; QL (30 per 30 days)) indicating step therapy is required for specific formulations.
FANAPT titration packs	Entries list ST; MO; QL (varies) for FANAPT titration packs — step therapy applies to these formulations per the Requirements/Limits column.

Product	ST flag
RALDESY	Requirements/Limits = ST; MO; NDS — 'ST' present indicates step therapy applies to RALDESY per the formulary entry.

General observation	Supporting detail
Step therapy not fully enumerated	This segment does not provide full step therapy algorithms for most agents; several agents are listed with PA requirements indicating prior authorization is required before coverage.

Flag examples	Possible meaning re: step edits
B/D PA	Benefit/diagnosis or billing/documentation PA entries (B/D PA) may reflect step therapy or benefit‑based edits requiring additional review prior to coverage.
Managed (MO) entries	MO combined with PA/QL flags indicates utilization management; when present these may function as step‑like edits though specific sequences are not shown here.

Requirement / Flag	Operational effect (provider action)
PA (Prior Authorization)	Many listed products require prior authorization before the prescription will be covered; failure to obtain PA may result in noncoverage — follow the Requirements/Limits field for each product and submit supporting documentation as required.
QL (Quantity Limit) / NDC restrictions	Adhere to quantity limits (QL) shown per time period and any NDC‑specific restrictions noted (e.g., 'ONLY NDCS STARTING WITH ...'); claims exceeding QL or using non‑allowed NDCs may be denied or require override.
ST / MO / LA / B/D PA	Step therapy (ST) and management flags (MO, LA) and billing/benefit PA (B/D PA) indicate additional utilization management controls — providers should consult the formulary legend and submit PA or exception requests as applicable.

Quantity Limits (Examples and Per-Drug Values)

inv-135: plan may impose quantity limits — overview

Plan policyPlan may impose quantity limits on drugs (see Requirements/Limits column)

Provider contactCall CareSource MyCare Ohio at 1-855-475-3163 for questions

Formulary legendSymbols/abbreviations are defined at the beginning of the full table

inv-136: itraconazole oral capsule — 120

Productitraconazole oral capsule

Quantity limit (numeric)120

Time period

Site-of-Care Notes and Infusion Requirements

Note

Definitions and Abbreviations

Background and Document Purpose

This document is the CareSource MyCare Ohio formulary (the List of Covered Drugs) that sets out which drugs the plan covers and identifies utilization management controls (such as PA, QL, ST, and other requirement codes). It explains coverage conditions, how temporary supplies and transitions are handled, and provides contact information for members and providers to request exceptions or clarification.

Biosimilar and Biological Product Substitution

Note

Policy Summary

PayerCareSource

PolicyList of Covered Drugs (Drug List) — CareSource MyCare Ohio

Policy CodePolicy 00026141

Change TypeAdministrative update — drug list refresh (no material clinical changes)

Effective Date05/01/2026

Next Review DateN/A

Key ActionObtain prior authorization when 'PA' is listed for a drug to avoid claim denial; contact Member Services for exception submission.

SourceLink

On This Page

B/D PA: may require documentation to determine Part B vs Part D coverage
MO: mail-order designation — may be required or preferred for maintenance meds
LA: limited to certain pharmacies; call Customer Service for details
QL and NDS: quantity and days' supply limits applied as indicated
ST: step therapy — prescriber must try required agent(s) first

Prior Authorization

Prior authorization required for many listed drugs

Prior authorization required for many listed drugs — Numerous drugs across therapeutic categories (including many antineoplastic and immunosuppressant agents, specialty drugs, and certain formulations) list PA, B/D PA, or other requirement codes in the Requirements/Limits column. Examples include oral, IV, and injectable formulations where PA and site/setting documentation is commonly required.

Many entries include PA or B/D PA and may also carry MO, LA, QL, NDS, or ST flags
Site-of-care or formulation-specific PA may apply (e.g., certain IV or infusion products)

Documentation Required

Prior authorization and requirement summary

Prior authorization and requirement summary — To receive coverage, providers must follow the Requirements/Limits for each formulary entry. Requirements may include submitting clinical documentation, fulfilling step therapy, adhering to quantity limits, or confirming the benefit/setting. Requests that require B/D PA need supporting documentation describing use and setting to determine Part B vs Part D coverage.

Follow the exact codes shown in the 'Requirements/Limits' column for each drug
B/D PA entries generally require additional clinical documentation to determine coverage pathway

Prior Authorization

PA required for specific formulations

PA required for specific formulations — Some formulations (for example, certain intravenous, injectable, or high-cost specialty formulations) specifically include 'PA' or 'B/D PA' in their Requirements/Limits. Check the formulation-level line in the table for PA, MO, LA, QL, or NDS flags before dispensing.

Formulation-specific entries may carry different requirements than other formulations of the same active ingredient
If Requirements/Limits lists PA for a given formulation, obtain PA prior to dispensing

Denial Risk

Prior authorization required where noted

Prior authorization required where noted — Certain products and dose forms list 'PA' in the Requirements/Limits (for example, many oncology, infusion, and specialty products). Claims for these items may be denied if PA or B/D PA (when applicable) is not obtained.

Examples across therapeutic classes — review the Requirements/Limits column on the drug line
Denial is possible if PA or B/D PA is not in place

Denial Risk

Prior Authorization Denial Risk

Prior Authorization Denial Risk — Failure to obtain required prior authorization, to satisfy step therapy (ST), to comply with quantity limits (QL/NDS), or to submit required B/D PA documentation may result in claim denial or noncoverage.

PA, B/D PA, ST, MO, LA, QL, and NDS are actionable requirements — not meeting them can trigger denial
For B/D PA, lack of setting/use documentation may prevent correct Part B vs Part D adjudication

Denial Risk

Requirement codes may trigger denial or restriction

Requirement codes may trigger denial or restriction — The codes shown in the Requirements/Limits column indicate utilization management controls that must be satisfied for coverage. Examples include PA (prior authorization), ST (step therapy), QL (quantity limits), NDS (non‑extended days' supply), MO (mail-order), LA (limited availability), and B/D PA (benefit/setting review).

Claims not meeting the listed Requirements/Limits may be denied or require additional follow-up
Consult the specific drug line to determine which controls apply

Note

Member document access and Exception Supporting Statement

Member document access and exception support — Members may request this Drug List or other plan documents in alternate formats (large print, braille, audio) or other languages by calling Member Services. For exception requests that need prescriber supporting statements, fax the prescriber's statement to the number provided.

Member Services: 1-855-475-3163 (TTY: 1-833-711-4711 or 711), Mon–Fri 8 a.m.–8 p.m. ET (extended availability Oct 1–Mar 31)
Exception prescriber supporting statement fax: 1-877-328-9660 — standard decision within 72 hours; expedited within 24 hours if prescriber certifies harm from delay

Documentation Required

Definitions and support contact; Submission guidance

Definitions, provider support contact, and submission guidance — The formulary defines the codes and abbreviations at the start of the drug table. Providers should consult that legend and follow the Requirements/Limits when submitting authorization requests. Documentation requirements vary by requirement code (B/D PA often requires setting/use documentation; PA may require clinical justification).

Consult the formulary legend for meanings of PA, B/D PA, MO, LA, QL, NDS, ST
Submit required clinical documentation as specified for B/D PA or PA requests
For questions or to submit requests, call CareSource MyCare Ohio Provider Services at 1-855-475-3163 (TTY details as above)

Step Therapy

Step therapy / specialty requirements

Step therapy and specialty requirements — Some drugs are subject to step therapy (ST) or other program-specific requirements. When ST applies, required prior agents must be tried and documented before the requested drug will be covered. Certain specialty products may carry LA, MO, or B/D PA flags reflecting benefit, site, or distribution controls.

ST indicates a required trial of specified agents before coverage of an alternative
Temporary 30‑day supply may be available for new members during transition (chunk 18)
LA and MO flags indicate limited pharmacy availability or mail‑order pathways for specialty agents

inv-137: Examples: PAXLOVID; valacyclovir; MAVYRET; fidaxomicin — varies by drug entry

Example drugsPAXLOVID; valacyclovir; MAVYRET; fidaxomicin

VariationQuantity limits vary by drug entry (examples shown in table)

See entriesRefer to specific product lines for exact QL and time period

inv-138: amikacin injection solution — (14 per 14 days)

amikacin injection solution(14 per 14 days)

Requirements notedPA; MO in formulary entry

Formulary contextListed under miscellaneous antiinfectives

inv-139: CAYSTON — QL (84 per 56 days)

CAYSTONQL (84 per 56 days)

RequirementsPA; MO; LA; NDS (per entry)

Drug classPseudomonas antiinfective (formulary listing)

inv-140: VANCOMYCIN IV PIGGYBACK — QL (4000 per 10 days)

VANCOMYCIN IV PIGGYBACKQL (4000 per 10 days)

Other limitsVariants show PA; MO; QL with differing numeric values per formulation

ContextIV piggyback entries imply infusion setting

inv-141: vancomycin oral capsule 125 mg — QL (40 per 10 days)

Productvancomycin oral capsule 125 mg

Quantity limitQL (40 per 10 days)

RequirementsPA; MO; QL (per formulary)

inv-142: abiraterone oral tablet 250 mg — QL (120 per 30 days)

abiraterone oral tablet 250 mgQL (120 per 30 days)

RequirementsPA; MO; QL (60 per 30 days shown for other strength entries)

Therapeutic classAntineoplastic / immunosuppressant

inv-143: AUGTYRO ORAL CAPSULE 40 MG — 240

AUGTYRO ORAL CAPSULE 40 MG240 per 30 days

TierTier 5 (per entry)

RequirementsPA; QL (240 per 30 days); NDS

inv-144: AVMAPKI- FAKZYNJA — 66

AVMAPKI- FAKZYNJA66 per 28 days

RequirementsPA; QL (66 per 28 days); NDS

Formulary noteListed under antineoplastic agents

inv-145: COMETRIQ ORAL CAPSULE 100 MG/DAY — 56

COMETRIQ ORAL CAPSULE 100 MG/DAY56 per 28 days

RequirementsPer formulary entry

Therapeutic classAntineoplastic

inv-146: ERLEADA ORAL TABLET 60 MG — 120

ERLEADA ORAL TABLET 60 MG120 per 30 days

RequirementsPA; MO; QL (per entry)

Therapeutic areaOncology

inv-147: FYARRO — 126

FYARRO126 per 28 days

RequirementsPA; QL (126 per 28 days); NDS

MappingMapped to GOMEKLI entries in table

inv-148: gemcitabine intravenous solution — 120

gemcitabine intravenous solution120 per 30 days

RequirementsPA; QL (120 per 30 days) for certain formulations

NotesVarious strengths/formulations have differing QLs in table

inv-149: GOMEKLI ORAL CAPSULE examples — 126 per 28 days; 84 per 28 days; 30 per 30 days

GOMEKLI oral capsule examples126 per 28 days; 84 per 28 days; 30 per 30 days (varies by entry)

RequirementsPA; QL per specific entry

ContextMultiple line items show different QLs for GOMEKLI variants

inv-150: gemcitabine various formulations — 90 per 30 days; 120 per 30 days; 21 per 28 days

Gemcitabine formulationsExamples: 90 per 30 days; 120 per 30 days; 21 per 28 days (varies by formulation)

RequirementsPA; MO; QL for specific formulations

TieringEntries span tiers 2–5 depending on formulation

inv-151: JAYPIRCA; KEYTRUDA; KISQALI — 30 per 30 days; 60 per 30 days; 28 per 28 days; 21 per 28 days

JAYPIRCA / KEYTRUDA / KISQALI examples30 per 30 days; 60 per 30 days; 28 per 28 days; 21 per 28 days

Requirement flagsPA; MO; QL present for many strengths

TieringTypically Tier 5 for many strengths but varies

inv-152: LUMAKRAS; LORBRENA; LUNSUMIO — 240 per 30 days; 90 per 30 days; 140 per 28 days

LUMAKRAS / LORBRENA / LUNSUMIO240 per 30 days; 90 per 30 days; 140 per 28 days (examples)

RequirementsPA; MO; QL as listed per strength

NotesMultiple strengths show different QLs and tiers

inv-153: octreotide micropheres IM suspension ER — QL (14 per 28 days)

Octreotide microspheres IM ERQL (14 per 28 days)

RequirementsPA; MO; QL; NDS on formulary

Therapeutic areaAntineoplastic/immunosuppressant listings include this formulation

inv-154: PEMAZYRE — QL (28 per 28 days)

PEMAZYREQL (28 per 28 days)

RequirementsPA; LA; QL; NDS (per entry)

Drug mappingMapped to PRALATREXATE IV solution in table

inv-155: TAFINLAR oral tablet — QL (840 per 28 days)

TAFINLAR oral tablet for suspensionQL (840 per 28 days)

RequirementsPA; MO; QL; NDS

Therapeutic useAntineoplastic listing

inv-156: VENCLEXTA tablets — examples include QL (60 per 30 days), QL (180 per 30 days), QL (30 per 30 days)

VENCLEXTA (various strengths)Examples include QL (60 per 30 days); QL (180 per 30 days); QL (30 per 30 days)

RequirementsPA; LA; QL; NDS depending on strength

NotesStarting packs and strengths have distinct QL patterns

inv-157: VENCLEXTA various strengths — QL examples: 60/30; 30/30; 180/30

VENCLEXTA QL patternsQL examples: 60 per 30 days; 30 per 30 days; 180 per 30 days

TieringTiers vary by strength (3 or 5)

Requirement flagsPA; LA; NDS noted

inv-158: VITRAKVI — QL examples: 60 per 30 days; 90 per 30 days; 180 per 30 days; 300 per 30 days

VITRAKVIQL examples: 60 per 30 days; 90 per 30 days; 180 per 30 days; 300 per 30 days

RequirementsPA; MO; LA; QL; NDS

FormulationsCapsules and solutions with differing QLs

inv-159: ZEJULA / ZELBORAF / other — QL examples: 30 per 30; 224 per 28; 600 per 30

ZEJULA / ZELBORAF / otherQL examples: 30 per 30; 224 per 28; 600 per 30

RequirementsPA; MO; LA; QL depending on strength

NotesMultiple QL patterns appear across these agents in table

inv-160: Antiepileptic agents — multiple QL entries including 60/30, 90/30, 120/30, 360/30, 480/30, 720/30, 2160/30, 1200/30

Antiepileptic agents QLsMultiple QL entries including 60/30, 90/30, 120/30, 360/30, 480/30, 720/30, 2160/30, 1200/30

gabapentin 600 mg180 per 30 days

gabapentin 800 mg120 per 30 days

inv-161: gabapentin 600 mg — 180

gabapentin 600 mg (oral)180 per 30 days

gabapentin 800 mg (oral)120 per 30 days

Formulary flagsMO; QL (per entry)

inv-162: gabapentin 800 mg — 120

gabapentin 800 mg (oral)120 per 30 days

RequirementsMO; QL (per formulary)

ContextListed among antiepileptic entries

inv-163: levetiracetam IV piggyback 1000/500 mg/100 ml — 30

levetiracetam IV piggyback 1000/500 mg/100 ml30 per 30 days

RequirementsMO; QL (per entry)

MappingAssociated with oral levetiracetam entries

inv-164: XCOPRI tablets — 30

XCOPRI tablets (100 mg, 25 mg, 50 mg)30 per 30 days

Maintenance packQL (56 per 28 days) for maintenance pack variant

RequirementsMO; QL per entry

inv-165: glatiramer 40 mg/ml example — 12

glatiramer 40 mg/ml (example)12 per 28 days

RequirementsPA; MO; QL (per entry)

UseMultiple MS therapy entries reference this QL

inv-166: dalfampridine — 60

dalfampridine60 per 30 days

RequirementsPA; MO; QL (per formulary)

Therapeutic classNeurology agents

inv-167: dimethyl fumarate 120 mg — 56

dimethyl fumarate 120 mg (delayed release)56 per 28 days

Alternative QLsAlso appears with 12 per 28 days and 120 per 180 days in other entries

RequirementsPA; MO; QL noted

inv-168: teriflunomide — 30

teriflunomide30 per 30 days

RequirementsPA; MO; QL per entry

Therapeutic areaNeurology / MS agents

inv-169: endocet example — 360

endocet example360 per 30 days

RequirementsQL (per entry)

NotesOpioid/combination analgesic listing

inv-170: fentanyl transdermal patch — 10

fentanyl transdermal patch10 per 30 days

RequirementsPA; MO; QL in some strengths

Form72-hour transdermal patches (various mcg/hr)

inv-171: hydrocodone-acetaminophen formulations — 5550

hydrocodone-acetaminophen formulations5550 per 30 days (example entry)

RequirementsMO; QL patterns vary by formulation

NotesMultiple QL levels shown across opioid entries

inv-172: methadone 5 mg — 240

methadone 5 mg240 per 30 days

RequirementsPA; MO; QL (per entry)

ContextUsed in opioid therapy management listings

inv-173: morphine oral solution — 900

morphine oral solution900 per 30 days

RequirementsMO; QL per formulary

NotesConcentrates and solutions have large numeric QLs

inv-174: ibuprofen example — 240

ibuprofen examples240 per 30 days

RequirementsMO; QL per entry

FormOral suspension/tablet entries

inv-175: lurbiro example — 2.4

lurbiro example2.4 per 56 days

RequirementsMO; QL recorded in table

NotesUncommon numeric formats (decimal) appear in some QLs

inv-176: naloxone injection solution — 3.2

naloxone injection solution3.2 per 56 days

RequirementsMO; QL per formulary entry

UseNaloxone rescue therapy listing

inv-177: aripiprazole tablet — 30

aripiprazole oral tablet30 per 30 days

RequirementsMO; QL per entry

Therapeutic areaPsychiatric agents listing

inv-178: ARISTADA INITIO — 4.8

ARISTADA INITIO4.8 per 365 days

RequirementsMO; QL (per entry)

NotesLong-acting injectable with annual QL metric

inv-179: ARISTADA (441 mg) — 1.6

ARISTADA (441 mg)1.6 per 28 days

RequirementsMO; QL noted

ContextMultiple ARISTADA strengths with differing QLs

inv-180: INVEGA SUSTENNA (various strengths) — 0.75-1.5 (per listing)

INVEGA SUSTENNA (various strengths)0.75-1.5 per listing (examples: 0.75 per 28 days; 2.63 per 90 days; 1 per 28 days)

RequirementsMO; QL; NDS across listings

MappingEntries map to INVEGA TRINZA for longer-interval dosing

inv-181: INVEGA SUSTENNA / TRINZA entries — e.g., QL (0.75 per 28 days); QL (2.63 per 90 days); QL (1 per 28 days)

INVEGA SUSTENNA / TRINZA entriesExamples: QL (0.75 per 28 days); QL (2.63 per 90 days); QL (1 per 28 days)

RequirementsMO; QL; NDS; some PA flags

UseLong-acting injectable antipsychotics with dosing-interval QLs

inv-182: sodium oxybate preferred NDCs starting with 00054 — QL (540 per 30 days) and alternate QL (60 per 30 days)

sodium oxybate (preferred NDCs starting with 00054)QL (540 per 30 days) and alternate QL (60 per 30 days)

RequirementsPA; MO; LA; QL; NDS depending on NDC grouping

NotePreferred NDC grouping affects applicable QL

inv-183: quetiapine formulations — QL (examples present)

quetiapine formulationsQL values present (e.g., 90 per 30 days; 60 per 30 days; 120 per 30 days)

RequirementsMO; QL per strength/formulation

TieringTiers vary across formulations