Submit PA form for non‑formulary drugs

Prior authorization for non-formulary drugs: provider must complete and submit the Prior Authorization form; urgent requests will be answered within 24 hours and non‑urgent requests within 72 hours. If the request is disapproved, the denial notice will explain specific reasons or identify missing information needed to complete the request.

• Complete and submit the payer's Prior Authorization form
• Expect urgent response within 24 hours and non‑urgent within 72 hours
• Denial notices will state specific reasons or missing information

Obtain PA when 'PA' is listed on formulary row

Prior authorization is required for numerous formulary entries that are annotated with 'PA' — providers must obtain PA before coverage for those products.

• Check the formulary row for 'PA' and obtain prior authorization prior to dispensing
• Examples include certain methylphenidate formulations, CYLTEZO/HUMIRA starter kits, and ACTEMRA entries

Request PA for PA‑marked opioid formulations

Certain opioid products include 'PA' in their formulary lines; providers must request prior authorization for those opioid formulations before coverage will be approved.

• Review opioid product row for 'PA' and new‑start limits
• Submit PA when PA is indicated for morphine, oxycodone, or other listed opioid presentations

Obtain PA for listed biologics and anticoagulants

Select biologic and anticoagulant injectables (e.g., FASENRA, NUCALA, XOLAIR; enoxaparin/fondaparinux formulations) list 'PA' and QL — providers must obtain prior authorization and document quantity/administration as required.

• Obtain PA for listed biologic/specialty injectables before coverage
• Provide documentation to support requested per‑day or per‑period quantities (QL)

Secure PA for PA‑flagged agents

Many agents in the formulary include a 'PA' flag; prescribers must obtain prior authorization when that flag appears to avoid coverage denial.

• Check each product line for 'PA' or 'SP; PA' flags
• Submit required PA documentation before claim submission

Obtain PA for products annotated 'PA'

Multiple product lines are explicitly labeled 'PA' — providers must request prior authorization for those specific products prior to dispensing to secure coverage.

• Confirm PA requirement on formulary row
• Submit PA request with supporting documentation when PA is listed

Submit PA for selected PA‑marked agents

Numerous listed agents are marked 'PA' indicating prior authorization is required before coverage; providers must submit PA requests for those selections.

• Identify PA‑marked entries in the formulary and obtain authorization in advance
• Examples include SIVEXTRO and other select agents

Obtain PA for oncology and specialty drugs

Many oncology and specialty antineoplastic agents are designated 'SP' and/or 'PA'; providers must submit prior authorization (and follow specialty program requirements) prior to coverage.

• Submit PA for antineoplastic/specialty agents marked 'PA' or 'SP; PA'
• Comply with any specialty program routing or documentation requirements

Prior authorization required for PA‑marked drugs

Entries marked 'PA' require prior authorization before coverage (examples include SELZENTRY, VOSEVI, and pulmonary hypertension agents); providers must request PA for those products.

• Confirm 'PA' on the formulary line before prescribing
• Submit PA for PA‑marked antiviral and pulmonary hypertension products

Obtain PA for PA‑noted product lines

Several product lines (e.g., UPTRAVI, tadalafil entries) note 'PA' — prescribers must obtain prior authorization where PA is indicated to avoid claim denial.

• Check UPTRAVI and related product rows for PA and submit authorization requests as required
• Document indication and dosing when submitting PA

Secure PA for PA‑annotated products

The formulary shows 'PA' annotations across multiple product categories; providers must obtain prior authorization for any drug line that lists 'PA' or 'SP; PA' before coverage.

• Identify 'PA' on topical or biologic product rows and submit PA requests
• Include age/indication/quantity documentation when applicable

Request PA for select topical/flagged products

Selected topical and biologic products are listed with 'PA' — providers must obtain prior authorization for those entries prior to dispensing.

• Confirm PA requirement for topical/scabicide/pediculicide and biologic lines
• Submit supporting clinical documentation when requesting PA

Obtain PA (and use SP) for specified products

Multiple listed products and classes require prior authorization and/or specialty pharmacy handling as indicated on each line; providers must obtain PA (and route via SP if required) before coverage.

• Obtain PA where formulation lists 'PA' and arrange specialty pharmacy fulfillment where 'SP' appears
• Provide required documentation with the PA request

Comply with step therapy trial requirements

Some formulary entries indicate step therapy (ST) — providers must ensure required trial(s) of preferred agent(s) have been attempted before requesting coverage for the subsequent drug.

• Confirm 'ST' notation on formulary rows and document prior trials of preferred agents
• Request PA with documentation of step‑therapy failure or contraindication if seeking exception

Route SP products to specialty pharmacy and obtain PA

Certain entries include 'SP' (specialty) markers alongside PA and QL — providers should route specialty drugs through the appropriate specialty pharmacy channel and obtain PA when required.

• Use participating specialty/hemophilia network pharmacies for SP‑designated products
• Obtain PA when 'SP; PA' is shown on the formulary row

Opioid entries: follow PA/QL (no ST specified)

The opioid sections do not specify step‑therapy algorithms; providers should follow PA/QL controls shown on the product row rather than expecting a step sequence for opioids.

• For opioid entries, follow 'New starts' and QL/PA requirements listed on the formulary row
• No opioid step therapy sequence is defined in the excerpt

Document prior trials for ST‑flagged anticonvulsants

Some anticonvulsant entries include 'ST' (step therapy) flags (e.g., APTIOM shows ST) — providers must document trial of required alternatives before coverage of the ST‑flagged agent.

• Document trials of preferred anticonvulsants when 'ST' appears
• Include failure or intolerance rationale when submitting PA for ST agents

Meet step therapy requirements where 'ST' is listed

Certain products include 'ST' indicating step therapy applies (example: eslicarbazepine acetate shows 'ST'); providers must meet the step requirement before coverage.

• Confirm ST on the formulary line and document prior therapy steps
• Provide supporting clinical rationale if requesting an exception

When ST not specified, follow PA/QL controls

Some entries reference tiering without explicit step therapy rules — providers should follow listed PA and QL controls and consult the formulary row for any step requirements.

• If 'ST' is not present, rely on PA/QL noted on the product row
• Contact payer for clarification when step therapy status is unclear

Route 'SP' drugs through specialty programs and obtain PA

Agents marked 'SP' or 'SP; PA' are specialty‑designated — providers must route dispensing through specialty channels and obtain PA and any specialty program approvals required.

• Arrange specialty pharmacy fulfillment for 'SP' products
• Submit PA and specialty program documentation when 'SP; PA' is indicated

No unified step‑therapy algorithm — follow row flags

This section contains no explicit step therapy algorithm text; providers must rely on the individual formulary row flags ('ST', 'PA', 'QL') to determine requirements.

• Review individual product lines for ST/PA/QL notations
• Submit PA or document QL/AL compliance as required

Follow SP/PA routing for pulmonary hypertension agents

Step edits (SP) are applied for some pulmonary hypertension agents (e.g., tadalafil shows 'SP'); providers must follow step‑edit routing and obtain PA as indicated for these agents.

• For pulmonary hypertension agents check for 'SP' and 'PA'
• Submit PA and route via specialty pathway if 'SP' is listed

Arrange specialty pharmacy routing when 'SP' listed

Where 'SP' appears on a product row, dispensing via specialty pharmacy may be required — providers should arrange specialty fulfillment and obtain any required PA.

• Confirm specialty pharmacy routing for 'SP' products
• Obtain PA and coordinate specialty fulfillment to avoid denial

Document ST/AL compliance for ST‑marked dermatologic products

Step edits and 'ST' appear for some products (e.g., clindamycin phosphate–tretinoin entries show 'ST') — providers must document compliance with step requirements for those age‑limited or ST entries.

• Document prior therapy trials and patient age where AL/ST apply
• Provide supporting documentation with PA if seeking an exception

Use therapeutic alternatives / preferred agents first

Formulary rows list therapeutic alternatives and preferred products; providers should consider preferred/alternative agents first to comply with step or tiering expectations.

• Check the 'prug Name' or preferred alternatives listed next to non‑preferred drugs
• Use preferred agents to meet step/tiering expectations where applicable

Verify PA/SP for high‑tier biologic products

Some biologic and specialty products appear in higher tiers which may imply managed step or specialty processes; providers should verify PA/SP requirements on the product row before prescribing.

• Verify PA/SP and tier status for biologic/specialty products
• Obtain PA and arrange specialty fulfillment when indicated

Complete PA form and expect 24/72‑hour response

Providers must complete the payer's Prior Authorization form and submit necessary supporting information; urgent PA requests are answered within 24 hours and non‑urgent within 72 hours.

• Complete and submit the Prior Authorization form with supporting clinical documentation
• Expect 24‑hour response for urgent requests and 72‑hour for non‑urgent requests

Document and PA starter‑kit limits (package per 180 days)

Certain biologic 'starter' kits (e.g., CYLTEZO, HUMIRA starter kits) have limits (package(s) per 180 days) and may require prior authorization; providers should document kit use and follow pack‑per‑180‑day limits.

• Document starter kit dispensing and adhere to package(s) per 180 day(s) limits
• Obtain PA when the starter kit line lists 'PA'

Document indication when requesting >7‑day opioid starts

For new starts on many opioid products, coverage is limited to a 7‑day supply; prescribers must document indication and intended duration when requesting fills beyond the new‑start limit.

• New starts limited to 7‑day supply for many opioid formulations
• Document indication and duration intent when requesting fills beyond 7 days

Provide clinical documentation with PA requests

When a formulary line lists 'PA' the prescriber must supply documentation to support the PA request (clinical rationale, dosing, quantity, age where applicable) to demonstrate medical necessity.

• Provide clinical rationale, dosing and quantity details when submitting PA
• Include age or indication documentation if AL is present on the row

Expect to submit medical necessity documentation for PA/SP

When PA or SP appears on a formulary line, prescribers should expect to provide documentation that demonstrates medical necessity and meets the payer's prior authorization requirements.

• Expect to supply clinical notes, prior therapy trials, and dosing/quantity information
• Specialty (SP) lines may also require specialty program documentation

Document and adhere to QL/PA/max‑fill limits

Formulary entries include QL, PA, and max fill limits; providers must document and adhere to those limits when submitting claims to avoid denials.

• Follow QL (quantity limits) and max‑fill day restrictions listed on the product row
• Document any requested quantity/period exceptions in the PA submission

Supply indication‑specific documentation for indication‑limited drugs

Products limited to specific indications (e.g., antimalarials 'Covered for malaria treatment only' with 'Limit 1 fill every 180 days') require documentation supporting the indicated use when requesting coverage.

• Provide indication‑specific documentation for agents limited to particular uses (for example malaria treatment)
• Adhere to fill frequency limits (e.g., 1 fill per 180 days) unless PA granted

Document dose/frequency to support QL exceptions

Quantity limits (QL) specified on formulary rows determine maximum dispensed amounts; providers must document dose/frequency to support exceptions or larger quantities.

• QL examples include QL(2 EA daily), QL(4 EA daily) etc.; adhere to these limits
• Document dose and frequency when requesting exceptions to QL

Include dosing justification when requesting >QL

Quantity‑limit notes (e.g., QL values shown on product lines) indicate dispensing caps; providers must include documentation of dose and frequency when seeking approval beyond the listed QL.

• Provide clinical justification and dosing details when requesting quantities exceeding QL
• Examples: QL(8 EA daily) shown for some agents

When QL+PA/SP apply, include both QL and PA documentation

Examples of products carrying both QL and PA/SP designations (e.g., sildenafil solution QL(7.5 ML daily); UPTRAVI tabs QL and PA) require providers to include both quantity and PA documentation when requesting coverage.

• When QL and PA/SP apply, include quantity justification and standard PA clinical documentation
• Check UPTRAVI titration pack limits (max fill(s) per 180 days) and submit PA accordingly

Adhere to specified QL for 91‑day contraceptives

Levonorgestrel‑ethinyl estradiol 91‑day formulations have specified QL allowances (QL(3 EA per 28 days retail; 9 EA per 84 days mail)); providers must follow these quantity rules or document justification for exceptions.

• Adhere to QL(3 EA per 28 days retail; 9 EA per 84 days mail) for 91‑day combination contraceptives
• Provide documentation if requesting quantities beyond these limits

Document patient age where AL applies

Age limits (AL) appear on many entries (e.g., AL(At least 12 yrs old) for topical acne agents); providers must document patient age to meet AL requirements when seeking coverage.

• Document patient age when AL is listed on the product row
• Examples include topical acne and retinoid formulations

Provide supporting documentation for PA/QL requests

When a formulary row lists PA or QL, prescribers must provide supporting documentation to meet the PA requirement and demonstrate adherence to QL thresholds to secure approval.

• Submit clinical justification and dosing/quantity details with PA requests
• Confirm QL limits and provide rationale for any requested exceedance

Submit PA documentation for PA/SP‑listed lines

Formulary lines that list 'PA' or 'SP' require prescribers to submit prior authorization documentation when requesting coverage for those products.

• Submit PA documentation for any line listing 'PA' or 'SP'
• Coordinate specialty program documentation when 'SP' is indicated

Denial notices will explain specific reasons or missing information

If a PA request is disapproved, the notice will include a clear explanation of the specific reasons for denial or identify missing material information required to complete the request; providers should use that information to correct and resubmit.

• Review denial notice for specific reasons or missing information
• Provide requested material information and resubmit the PA as appropriate

Adhere to 7‑day new‑start supply limits to avoid denial

New‑start supply limits exist for certain products (many analgesics and opioids are limited to a 7‑day supply); exceeding these new‑start limits may trigger denial.

• New starts limited to 7‑day supply for many opioid/analgesic formulations
• Requests exceeding the new‑start limit risk denial without PA

Avoid denials by meeting QL and PA requirements

Requests that exceed specified quantity limits (QL) or lack required prior authorization (PA) are subject to denial; providers must ensure QL/PA compliance before claim submission.

• Verify requested quantity does not exceed the formulary QL
• Obtain PA if the product line requires it to prevent denial

Noncompliance with QL/PA for biologics risks denial

Requests that exceed stated quantity limits or that lack required prior authorization for PA‑flagged products (e.g., certain biologics) risk denial — providers must ensure both QL and PA compliance.

• Confirm per‑day or per‑period QL adherence for biologic/anticoagulant entries
• Obtain PA where 'PA' is listed to prevent denials

PA/SP flags can trigger denial if not addressed

Products flagged with 'PA' or 'SP' may be denied or require prior authorization — providers must obtain PA and comply with special program requirements to avoid coverage denial.

• Identify 'PA'/'SP' flags and obtain PA before dispensing
• Follow any special program routing or documentation instructions

Claims for PA‑annotated products may be denied without PA

Some products are explicitly annotated 'PA' — coverage may be denied if prior authorization is not obtained for those items.

• Do not dispense PA‑annotated products without prior authorization
• Examples include multiple combination and specialty product rows

Naloxone QL exceedance can cause denial

Naloxone liquid has specific fill limits (QL(2 EA per retail); 2 max fills per 30 days retail) — requests exceeding these quantity limits can trigger denial.

• Adhere to naloxone QL(2 EA per retail) and 2 max fills per 30 days retail
• Obtain PA or justification if requesting more than allowed

PA/SP/QL flags are triggers for utilization management

Claims may be denied or restricted when a drug is labeled with 'PA', 'SP', or exceeds specified QL — providers should verify those flags and limits before submitting requests.

• Check for PA/SP/QL labels on the formulary row before prescribing
• Submit PA and documentation addressing QL to avoid utilization management denials

PA/SP flags on oncology drugs may trigger denial

PA or SP flags on antineoplastic and specialty agent rows may trigger denial if the authorization requirements are not satisfied; providers must obtain PA and follow SP routing where indicated.

• Obtain PA for antineoplastic products marked 'PA' or 'SP; PA'
• Coordinate specialty pharmacy or program requirements to avoid denials

Obtain PA for SP; PA entries to avoid denial

Drugs listed with 'PA' or 'SP; PA' indicate prior authorization and/or specialty prior authorization may be required and claims may be denied if not obtained; providers should secure required authorization.

• Secure PA (and specialty PA where 'SP; PA' is shown) prior to dispensing
• Include supporting documentation to meet authorization criteria

PA/SP flags require submission of PA and documentation

PA or SP flags indicate the product is subject to prior authorization and may be denied if PA requirements are not met; providers must submit required documentation for PA.

• Submit PA and required documentation when 'PA' or 'SP' appears
• Review product row for QL/AL details that must be met

Claims without required PA risk denial

Claims lacking prior authorization where PA is specified (for example UPTRAVI and other listed drugs) may be denied; providers must obtain PA before claim submission.

• Obtain PA for UPTRAVI and other PA‑listed drugs prior to dispensing
• Retain PA documentation to support the claim

Obtain PA for PA‑listed topical agents

Prior authorization is required for certain topical agents (e.g., clindamycin phosphate–benzoyl peroxide) as indicated by 'PA' — providers must obtain PA for those topical products.

• Check topical product rows for 'PA' and obtain authorization when present
• Provide age and indication documentation as required

Get PA for high‑potency topical corticosteroids when listed

Some high‑potency topical corticosteroid formulations list 'PA' (e.g., clobetasol propionate cream/ointment/solution rows) — providers must obtain prior authorization for those formulations.

• Obtain PA for clobetasol propionate formulations when 'PA' is listed
• Document clinical rationale and quantity when submitting PA

Request PA for non‑FDA uses

Non‑FDA approved uses (e.g., certain scabicide/pediculicide entries like permethrin LIQD EX, spinosad) require Prior Authorization; providers must request PA for non‑FDA uses to secure coverage.

• Submit PA for non‑FDA uses of products listed as requiring PA
• Provide clinical justification for off‑label indications

Submit PA and arrange SP fulfillment for specialty products

Formulary lines indicate PA or SP for many specialty products; prescribers must submit prior authorization documentation (and arrange specialty fulfillment if 'SP' is present) when requesting coverage.

• Submit PA documentation for lines listing 'PA' or 'SP'
• Coordinate specialty pharmacy fulfillment for 'SP' products to meet program requirements

Use participating specialty pharmacies for SP drugs

Specialty drugs may require fulfillment at participating specialty or hemophilia network pharmacies; providers should route prescriptions to those pharmacies when 'SP' is indicated on the formulary.

• Use participating specialty/hemophilia network pharmacies for SP‑designated products
• Confirm network specialty pharmacy details on Ambetter's pharmacy information resources

Coordinate site‑of‑care and PA for SP/PA products

Some inhaled/infused or specialty products are marked 'SP'/'PA' indicating specialty pharmacy or site restrictions; where present, providers should coordinate site‑of‑care (infusion center or specialty pharmacy) and obtain PA as required.

• Coordinate infusion center scheduling or specialty pharmacy dispensing for SP/PA products
• Obtain PA and ensure site‑of‑care arrangements align with payer requirements