CurrentCentenePolicy N/A

Health Net Essential Drug List (Formulary) and Utilization Management Coverage Criteria

Defines the Health Net Essential List (formulary) structure, tiers, utilization management (prior authorization, step therapy, quantity limits, specialty requirements), member cost-sharing rules for oral cancer drugs and contraceptives, and how members/providers request exceptions. Applies to members of Ambetter by Health Net and California Individual & Family Plans.

Policy Summary

PayerCentene

PolicyHealth Net Essential Drug List (Formulary) and Utilization Management Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests with required supporting documentation when a drug is marked PA; specialty drugs must be routed through the specified in-network specialty pharmacy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyformulary update frequency

$250oral cancer max copay (30d)

$600specialty drug threshold (1mo)

72/24hPA response time

90 days

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.

mail-order max supply

7 daysopioid first-fill limit

Coverage Criteria and Formulary Controls

Prior Authorization and Exception Processing

Coverage and exception processing

Prior Authorization and Exception Approval: Health Net will cover medically necessary drugs when a prior authorization or exception request is submitted with the required supporting statement from the prescriber; if the plan fails to respond to a completed prior authorization or step therapy exception within 72 hours for non-urgent requests or 24 hours for expedited (exigent) requests, the request is deemed approved.

If approved, the exception continues until the end of the plan year provided the member remains enrolled and any continuation requirements are met.

Step Therapy

Step therapy coverage rules

Step Therapy: Coverage for a drug subject to step therapy is allowed when one or more required preferred agent(s) have been tried and failed or when an approved step therapy exception condition is met.

Acceptable exceptions include: contraindication or likely adverse reaction, expected ineffectiveness, documented prior trial and failure while covered, clinical inappropriateness (e.g., would worsen comorbidity or impair function), stability on the requested therapy under prior coverage, or significant barriers to adherence; exception requests are processed the same way as prior authorization requests.

Preventive and contraceptive coverage

Covered outpatient pharmacy items and preventive medications

Contraceptives and preventive drugs: FDA‑approved prescription contraceptives and preventive drugs with USPSTF A or B recommendations (including contraceptives, male condoms, and HIV PrEP) are covered; OTC oral contraceptives or condoms may be obtained through pharmacy claims with no member copay.

Members obtaining OTC oral contraceptives should inform their physician; office‑administered injectable medications are provided under the medical benefit.

Medical vs Pharmacy benefit

Distinguishing pharmacy vs medical benefit

Medical vs Pharmacy benefit: Drugs that are administered by a provider (non‑self‑injectable) are covered under the medical benefit and the provider will instruct where to receive them; self‑administered drugs are generally covered under the pharmacy benefit per plan documentation and Evidence of Coverage.

Prescriptions are required for blood glucose supplies and pharmacy‑covered drugs; refer to plan documents for specific routing.

Specialty drugs and hemophilia agents

Specialty drug dispensing requirements

Specialty pharmacy requirement: Certain injectable and high‑cost drugs (including many hemophilia drugs and blood factors) are designated specialty drugs and must be filled and dispensed by an in‑network specialty pharmacy; these products require prior authorization and are routed through the contracted specialty pharmacy (e.g., Acaria Health).

Specialty drug routing and any vendor instructions are shown in the Requirements/Limits column of the drug list (e.g., 'Must use AcariaHealth').

Mail order pharmacy

Mail order and maintenance drugs

Mail order program: Maintenance prescription drugs can be obtained via the contracted Mail Order Pharmacy for up to a 90‑day supply; Tier 4 and Specialty drugs are not available through mail order and a new prescription permitting a 90‑day supply is required to use mail order.90-day supply

Provider must supply a prescription written for up to a 90‑day supply and mail order forms are available from the plan.

Anti-obesity medications

Weight loss medication coverage conditions

Anti‑obesity medication coverage: Most plans cover weight‑loss medications only when prior authorization is approved and the member is enrolled in and actively participates in a behavior modification program (diet, exercise, behavior modification) for 6 months prior to and during treatment; the member must meet plan BMI requirements.6 months

Covered weight‑loss medications are identified on the drug list (examples: Contrave, Wegovy, Qsymia, Saxenda, Zepbound, Xenical).

Formulary coverage attributes and limits

Formulary coverage is expressed per product as a tier with associated limits and occasional prior authorization; opioid first‑fill limits are a common control.

Fentanyl transdermal patches are covered per their tier but are limited to 15 patches per month (QL = 0.5 EA daily) and include multiple mcg strengths in the formulary listing.15 patches/month

Some fentanyl strengths are noted as not available through mail order.

Opioid oral and liquid formulations: Oral and liquid opioid products carry tier assignments and ILimits; a repeated formulary control limits first fills of opioids to 7 days and applicable quantity limits vary by product.First fill limited to 7 days

Applies broadly across opioid entries (e.g., oxycodone, hydromorphone, morphine).

Buprenorphine‑naloxone products (e.g., SUBOXONE): Buprenorphine‑naloxone formulations are listed with quantity limits (e.g., QL(2 EA daily)) and may require prior authorization; tiering varies by presentation.

Formulary coverage designations and access controls (excerpt)

Coverage and access for formulary drugs are governed by tier plus utilization controls shown on each product line.

Formulary controls apply: Drug coverage is determined by the assigned formulary Tier AND any attached utilization controls (Prior Authorization, Quantity Limits, Specialty designation, Anti‑Cancer designation, Age Limits) and any specified vendor routing (for example, AcariaHealth) must be satisfied for coverage.

This block reflects administrative controls shown beside each product; clinical criteria may be specified on individual PA forms.

Formulary placement with utilization controls

Tier plus utilization controls: Drugs are covered according to their formulary tier PROVIDED any listed utilization controls (PA, QL, SP, AC, AL) are met; failure to satisfy those controls may result in noncoverage or denial.

Examples in the formulary include MONUROL (flagged PA/SP), rifabutin (AC/PA), and many antineoplastic entries requiring specialty vendor routing and PA.

The presence of a drug on the formulary does not guarantee it is appropriate for a patient’s specific medical condition. Review the drug listing as informational only and confirm the prescribed therapy is clinically appropriate for the patient. If a generic equivalent is available or covered differently, that will be reflected on the list and may affect prescribing. Always check member plan documents, prior authorization (PA) status, quantity limits (QL), step therapy (ST) and specialty routing instructions before dispensing or scheduling therapy.

Infertility drugs are excluded from coverage under this drug list. Do not submit prior authorization requests for infertility medications; coverage determinations for reproductive services are governed by separate plan documents.

Certain specialty biologic entries are conditioned on plan-specific terms — for example, some HUMIRA presentations include the instruction to "Check Plan Documents for coverage". Providers must verify the member’s benefit documents for any plan-level coverage limits or additional requirements before initiating therapy.

Some fentanyl transdermal patch strengths are marked as "Not available through mail order". Confirm that these strengths must be dispensed at retail or via specialty channels as indicated on the formulary entry rather than processed through mail-order pharmacy.

This excerpt does not contain explicit clinical exclusion criteria. The section focuses on formulary tiering, utilization controls (PA, QL, ST), and specialty routing rather than listing clinical contraindications or disease-specific exclusions.

Drugs dispensed by non‑network pharmacies are not covered except in emergency or urgent situations. Specialty and many high‑cost injectable drugs must be filled at an in‑network specialty pharmacy; claims from non‑contracted pharmacies may be denied outside of exigent circumstances.

Products flagged as SP (specialty) or NF (non‑formulary) may require alternate handling: specialty agents often must be dispensed through a contracted specialty pharmacy and some NF items (or specific presentations) are instead covered under the medical benefit with prior authorization. For example, certain opioid and analgesic entries reference medical‑benefit coverage or specialty routing; check the line‑item ILimits for PA, SP, or statements such as "Covered under Medical Benefit; PA."

Coding, Codes & Cost Thresholds

Formulary stimulant/ADHD product entriesmixed

ADDERALL XR CP24	adderall xr product entries and related tier/limits info
DESOXYN	DESOXYN (methamphetamine hcl) entries with tier and prior auth / quantity limits
PROCENTRA SOLN	dextroamphetamine sulfate solution entries
DEXEDRINE	dextroamphetamine sulfate product entries

No explicit billing codes in this excerptmixed

No codes listed

Formulary internal product codes / shorthandmixed

PT72	fentanyl transdermal patch reference in listing (multiple mcg strengths shown)
TB24	tablet 24-hour extended release reference (e.g., hydromorphone TB24 strengths)
CP24	capsule 24-hour reference (e.g., amphetamine/ methylphenidate CP24 entries)

NDC / CPT / HCPCS not provided in excerptmixed

No codes listed

Formulary entries (no procedure/diagnosis codes provided) - placeholdermixed

No codes listed

Quantity limit expression examplesmixed

QL(2 EA daily)	Quantity limit example for MACRODANTIN / related entries
QL(210 ML per 90 day(s) retail)	Quantity limit example for linezolid suspension
QL(20 EA per [90 day] retail)	Quantity limit example for linezolid tablets

Specialty pharmacy routingmixed

Specialty Rx at 1-844-538-4661

Designated specialty pharmacy routing (AcariaHealth) for many antineoplastic and specialty agents

inv-25: Specialty drug cost threshold

Specialty drug cost threshold$600 per one-month supply (net of rebates)

Tier placement for specialty/high-cost drugsDrugs that cost the plan >$600/month net of rebates are placed at Tier 4 (Specialty/High Cost)

Specialty distribution noteDrugs requiring specialty distribution (per Tier 4) may have additional routing and prior authorization requirements

inv-26: Oral cancer drug maximum cost share

Oral cancer drug max cost share$250 maximum copayment per individual prescription of up to a 30-day supply

Provider Requirements, Prior Authorization & Exceptions

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed on the formulary. Prescribers must obtain approval from the plan before dispensing PA-designated products; failure to obtain PA may result in non-coverage or claim denial. PA requests may be submitted electronically (CoverMyMeds), by phone, or by fax and must include supporting clinical documentation explaining medical necessity.

Submit PA via CoverMyMeds, phone, or fax with a supporting statement from the prescribing provider.
If the plan fails to respond to a completed non-urgent PA or step therapy exception within 72 hours (24 hours for exigent/expedited requests), the request is deemed approved.
Expedited requests require a clinician statement that waiting could seriously harm the member; decision timeframe = 24 hours.

Prior Authorization

Prior authorization for PA-designated products

Drugs marked with ILimits = PA or with 'PA' in the Limits column require prior authorization before coverage. Use the ILimits field on the drug list to determine whether PA, quantity limits (QL), step therapy (ST), age limits (AL), or specialty routing (SP / 'Must use AcariaHealth Specialty Rx') apply when submitting claims.

Legend, Tiers & Abbreviations

inv-99: Formulary / Drug List — definition of formulary and committee selection

Formulary / Drug List definitionA complete list of covered drugs selected by a committee of physicians and pharmacists who evaluate drugs for safety, effectiveness, side effects, and value

Committee rolePharmacy & therapeutics committee meets regularly to review new and existing drugs and recommend inclusion

PurposeTier placement and formulary choices reflect safety, efficacy, and value — lower-cost equally effective drugs preferred

inv-100: PA (Prior Authorization) definition

Prior Authorization (PA) definitionPrior Authorization requires prescriber approval from the plan before a prescription will be covered; providers must obtain approval prior to filling when PA is indicated

Consequences

Quantity Limits by Product / Examples

inv-147: self-administered hormonal contraceptives — 12-month supply

12-month supply for contraceptivesHealth Net covers a 12-month supply when dispensed at one time of all self-administered hormonal contraceptives on the Formulary

Coverage mechanismOTC contraceptives require a prescription to be covered under the pharmacy benefit

Preventive benefit noteSome contraceptives may be covered under preventive benefits with $0 copay per ACA rules (see plan-specific Evidence of Coverage)

inv-148: Various stimulant products — QL examples

Various stimulant QL examplesFormulary entries for stimulants include QL(2 EA daily), QL(90 EA per fill retail), QL(1 EA daily), QL(4 EA daily) depending on product and strength

Retail vs mail-fill limits

Initial Access Controls and Limits

Initial opioid fill restriction

Initial therapy criteria (first‑fill limits)

First‑fill opioid restriction: Initial opioid fills are limited to a 7‑day supply on first fill as noted in multiple opioid formulary entries.7 days

This first‑fill limitation is repeatedly referenced across opioid product lines and applies unless an exception is approved.

Specialty vendor and PA requirements

Initial access controls for specialty products

Specialty vendor and PA: Certain specialty products require prior authorization and must be obtained via the specified specialty vendor (for example, JADENU Sprinkle Pack and JADENU Tabs require AcariaHealth and PA as indicated on the formulary line).

Failure to route specialty drugs through the required vendor or obtain PA may result in denial.

Site of Care Requirements

Note

Formulary Governance & Selection

The formulary is selected and maintained by a multidisciplinary committee of physicians and pharmacists who evaluate drugs for safety, effectiveness, side effects, and value. Tier placement and utilization controls (PA, ST, QL, SP) are applied to align clinical appropriateness with cost‑management and member benefit design.

Policy Summary

PayerCentene

PolicyHealth Net Essential Drug List (Formulary) and Utilization Management Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests with required supporting documentation when a drug is marked PA; specialty drugs must be routed through the specified in-network specialty pharmacy.

SourceLink

On This Page

Provider should check ILimits for PA and QL.

Testosterone and androgen products: Androgen/testosterone formulations have product‑specific quantity limits (examples include QL(10 GM daily), limited to 300 g/month for some gels) and some preparations are flagged with PA or specialty assignment.varies by product

Some products are designated NF or SP; consult the formulary line for ILimits.

Days' supply for oral cancer drugs30 days (maximum cost-share applies per 30-day supply)

State law noteTotal copayment/coinsurance for an oral chemotherapy prescription up to 30 days shall not exceed $250 notwithstanding deductible

inv-27: Quantity limits examples — stimulant QL examples

ADDERALL XR CP24 (stimulant) limitsQL(2 EA daily); 90-day fill limits referenced for some formulations

CONCERTA and methylphenidate examplesQL entries include QL(1 EA daily), QL(2 EA daily), and 90 EA per fill retail for certain strengths

DESOXYN and other stimulant examplesDESOXYN entries show QL(1 EA daily) or QL(2 EA daily); some stimulant tablets limited to 90 EA per fill retail

inv-28: Quantity limits examples — assorted QL examples

CONCERTA TBCR examplesCONCERTA TBCR entries include QL(1 EA daily), QL(2 EA daily), and per-fill limits (e.g., 90 or 180 EA per fill depending on strength)

DAYTRANA and dexmethylphenidate examplesPatches/tablet forms include QL per day and 90-day retail fill limits (e.g., QL(1 EA daily); 90 EA per fill)

Focalin and related methylphenidate formsExamples list QL(1 EA daily) to QL(2 EA daily) with 90/180 EA per fill limits noted for some products

inv-29: Quantity limits examples — celecoxib, ENBREL, fentanyl examples

Celecoxib (CELEBREX) limitsCELEBREX 50/100/200 mg and 400 mg entries show QL(2 EA daily) (400 mg also flagged with PA in some entries)

ENBREL examplesENBREL SOLN: QL(0.143 ML daily); ENBREL SOSY 50 MG/ML: QL(0.286 ML daily) and specialty routing required via AcariaHealth

Fentanyl patch exampleFentanyl PT72 patches: Limit 15 patches per month; QL(0.5 EA daily)

inv-30: Fentanyl patch monthly limit — 15 patches/month; QL(0.5 EA daily)

Fentanyl patch monthly limitLimit 15 patches per month; QL(0.5 EA daily)

First-fill opioid restrictionFirst fill opioids limited to 7 days (applies to many opioid entries including fentanyl patch statements)

Mail-order note for some fentanyl strengthsCertain fentanyl strengths are noted as not available through mail order in the formulary entries

inv-31: Hydromorphone TB24 quantity examples

Hydromorphone TB24 8/12/16 mgQL(4 EA daily) for hydromorphone TB24 8/12/16 mg formulations

Hydromorphone TB24 32 mgQL(2 EA daily) for hydromorphone TB24 32 mg strength

First-fill opioid rule appliesMany hydromorphone entries reiterate 'First fill opioids limited to 7 days' in ILimits

Check each drug's ILimits entry for PA, QL, ST, AL, and SP flags before prescribing or dispensing.
When ILimits indicates PA, attach product strength, quantity, and clinical rationale to the PA submission.

Prior Authorization

Specialty biologics PA & routing

Many specialty biologics and hemophilia products require PA and must be dispensed through the plan's contracted specialty vendor (AcariaHealth). Prescribers must follow specialty routing instructions; failure to use the specified specialty pharmacy may result in denial.

Examples: HUMIRA starter kits, ENBREL products, hemophilia drugs and other specialty biologics list 'Must use AcariaHealth Specialty Rx at 1-844-538-4661'.
Specialty products flagged SP often also include PA, QL, and AC (anti-cancer) flags — verify all ILimits before ordering.

Prior Authorization

Products requiring prior authorization

A broad set of products require prior authorization — examples in the formulary include SUBOXONE films, select androgen/testosterone agents, EPIDIOLEX, SPRAVATO doses, VIIBRYD starter packs, ANDEXXA, JADENU, FERRIPROX, TRICOR (selected formulations), and many oncology agents. Always confirm PA requirements on the drug list.

Behavioral health and addiction treatments (e.g., SUBOXONE) may have QL and PA requirements.
Selected anticonvulsants and specialty psychiatric agents (e.g., EPIDIOLEX, SPRAVATO) are PA-listed.

Prior Authorization

Specialty routing and PA

Specialty routing and PA often go together: many oncology, hematology, and other specialty therapies require PA and must be obtained via AcariaHealth Specialty Rx prior to dispensing. Confirm both the PA and the specialty pharmacy requirement on the formulary entry.

Oncology examples: melphalan, lenvatinib, abiraterone and multiple Antineoplastics show 'Must use AcariaHealth Specialty Rx' plus 'PA' and 'AC'.
Hemophilia products and certain injectables are shipped via the contracted specialty pharmacy and require prior approval.

Prior Authorization

Prior authorization for anticoagulants and limited-duration injectables

Some anticoagulants and limited-duration injectables are limited to short supplies without prior authorization (commonly 7 days) — larger quantities or ongoing therapy require PA. Quantity limits and limited-supply rules are enforced and documented in ILimits.

Examples: enoxaparin and other low-molecular-weight heparins limited to 7 days without authorization; larger fills require PA.
Fondaparinux and related agents may carry QL and PA entries — include indication and duration in PA requests.

Prior Authorization

PA required for select agents and additional PA flags

Select high-cost or specialty agents require PA (e.g., EPIDIOLEX, ANDEXXA, JADENU, FERRIPROX, SPRAVATO, various oncology drugs). The formulary entries identify these agents with PA flags; prescribers must submit sufficient clinical information to support medical necessity.

High-cost specialty tabs often include PA plus additional distribution requirements (e.g., AcariaHealth).
Include prior treatment history, diagnosis, and supporting labs or documentation when requesting PA for these agents.

Documentation Required

Missing information and notification

When required information is missing from a PA or step therapy exception request, the plan will notify the prescribing provider within 72 hours (24 hours if exigent). The decision clock pauses until requested information is received; failure to notify within the applicable time results in deemed approval for the duration of the prescription.

The plan will advise which additional documentation is needed; once received the standard decision timelines restart.
If the plan does not request missing info within the timeframes, the request may be deemed approved including refills.

Documentation Required

Quantity limits, first-fill rules, age limits and required documentation

Quantity limits (QL), first-fill limits (for opioids), age limits (AL), and step therapy (ST) are enforced per the ILimits field. Documentation supporting requested frequency, dose, or exceptions must be provided with PA submissions.

Opioid first-fill quantity limits commonly restrict initial fills to 7 days; exceeding QL may prompt denial or require retrospective PA.
When a QL is specified, include product strength and quantity on the prescription and PA to support approval.

Step Therapy

Step Therapy Requirement and Exceptions

Step therapy (ST) rules require trying preferred drugs before advancing to non-preferred therapies. Providers may request step therapy exceptions if clinical criteria are met. Step therapy requests follow the same submission and review timelines as PAs.

Step therapy exceptions can be granted if the required agent is contraindicated, previously failed, likely to be ineffective, or would harm the member.
If the member is stable on a drug subject to ST from prior coverage, the step requirement may be waived.

Denial Risk

Denial Risk: QL, PA, specialty routing and step therapy violations

Denials can be triggered when PA, QL, ST, specialty routing, or age restrictions are not met. Providers should verify ILimits and follow specialty vendor routing instructions to avoid coverage denial.

Denial triggers include: missing PA for PA-designated products, exceeding QL or first-fill limits, failure to use required specialty pharmacy (AcariaHealth), and unmet step therapy requirements.
If denied, the prescriber or member can appeal; denial notices include appeal rights and instructions.

If approval is not obtained, the plan may not cover the drug

Submission methodsPA requests may be submitted electronically (CoverMyMeds), phone, or fax as described in the plan materials

inv-101: ST (Step Therapy) definition

Step Therapy (ST) definitionStep therapy requires trying one or more preferred drugs before covering another drug in a stepwise sequence unless an approved exception applies

ExceptionsExceptions granted for contraindication, likely ineffectiveness, prior intolerance/failure, clinical inappropriateness, stability on current therapy, or adherence barriers

Provider actionProviders may request a step therapy exception with supporting documentation

inv-102: SP (Specialty Drug) definition

Specialty Drug (SP) definitionSpecialty drugs are those distributed through a contracted specialty pharmacy, often requiring special handling or monitoring and frequently costing >$600/month (net of rebates)

Distribution requirementSpecialty drugs are required to be provided through a Health Net contracted Specialty Pharmacy once approved

Implication for coverageSP designation may trigger PA and specific vendor routing (e.g., AcariaHealth) noted on formulary line items

inv-103: Brand drug definition

Brand drugA brand drug is marketed under a proprietary, trademark-protected name and is listed in the formulary in all capital letters

Listing conventionBrand drugs appear in uppercase on the formulary for identification

ImplicationBrand designation often corresponds to tiering and cost-share differences versus generics

inv-104: Coinsurance definition

Coinsurance definitionCoinsurance is the percentage of the cost of a covered benefit you pay after meeting any applicable deductible

Applies after deductibleCoinsurance applies after the deductible has been satisfied if a deductible applies to the benefit

Includes in out-of-pocket costsCoinsurance contributes to member out-of-pocket costs alongside copayments and deductibles

inv-105: Copayment definition

Copayment definitionCopayment is a fixed dollar amount you pay for a covered health care benefit (often after deductible if applicable)

Plan specificsCopayment amounts depend on plan tier and benefit design; see Evidence of Coverage for exact cost-share details

Relation to deductibleCopayment may apply after deductible is met depending on plan rules

inv-106: Exigent circumstances definition

Exigent circumstances definitionExigent circumstances are situations where a medical condition may seriously jeopardize life, health, or function, or when undergoing a current course of treatment using a non-formulary drug

Exception handlingStep therapy or PA timelines may be expedited under exigent circumstances

Provider documentationProviders should indicate exigent status when requesting expedited review or exception

inv-107: Medically Necessary definition

Medically Necessary definitionMedically necessary means a benefit needed to diagnose, treat, or prevent a condition that meets accepted standards of medicine

Coverage implicationThe plan covers drugs determined medically necessary through PA/exception processes as required

Standard appliedDetermination follows accepted standards of medicine and documented clinical need

inv-108: Prior Authorization / Step Therapy combined definition

Prior Authorization / Step Therapy combinedPA is a plan decision that a drug is medically necessary and requires approval before fill; Step Therapy specifies a sequence of drugs to try prior to covering a prescribed drug — both are utilization controls enforced via the formulary

InteractionDrugs may be subject to both PA and ST as indicated in ILimits; providers must satisfy both where applicable

Exception mechanismProviders may request exceptions to step therapy or PA with supporting documentation; timelines for plan response apply

inv-109: Tier definition — categories 1-4 etc.

Tier 1-4 and 7 overviewTier 1: Preferred Generics; Tier 2: Preferred Brand/High Cost Generics; Tier 3: Non-Preferred Brand; Tier 4: High Cost/Specialty; Tier 7: Brand Reference Only

Tier 4 specificsTier 4 includes drugs requiring specialty pharmacy distribution, special handling, or costing >$600 net of rebates per month

Preventive tierCertain preventive drugs are covered as Tier 5 (preventive/ACA) and may have $0 copay per plan rules

inv-110: Abbreviations list — PV, AL, PA, QL, sT, SP etc.

Common abbreviationsPV=Preventive Drugs; AL=Age Limit; PA=Prior Authorization; QL=Quantity Limit; sT=Step Therapy; SP=Specialty Drug

Additional legend codesAC=Anti-Cancer; LA=Limited Access; RXIOTC=Prescription & OTC

UsageAbbreviations appear in formulary ILimits and legend to indicate utilization controls and special statuses

inv-111: Tier and abbreviations — legend entries

Tier legend entriesLegend explains tiers and abbreviations: 1=Preferred Generics; 2=Preferred Brand/High Cost Generics; 3=Non-Preferred Brand; 4=High Cost Drugs; 7=Brand Reference Only; PV, AL, PA, QL, sT, AC, LA, SP, RXIOTC

Where shownLegend appears at top of formulary and is referenced throughout product line items

InterpretationProviders should consult legend to interpret ILimits and tier assignments on each drug line

inv-112: Legend terms — tier definitions

Legend term: Tier categories1 Preferred Generics; 2 Preferred Brand/High Cost Generics; 3 Non-Preferred Brand Drugs; 4 High Cost Drugs; 7 Brand Reference Only

Legend term: Utilization abbreviationsPV, PA, QL, sT, AC, LA, SP, RXIOTC, AL are defined in the legend

Reference for members/providersSee legend for interpreting formulary columns and ILimits flags

inv-113: PA abbreviation

PA abbreviationPA = Prior Authorization (authorization required before coverage)

Where usedAppears in ILimits next to products that require plan approval before dispensing

ImpactFailure to obtain PA may result in the drug not being covered

inv-114: QL abbreviation

QL abbreviationQL = Quantity Limit (maximum quantity allowed per day/fill/timeframe as specified)

ExamplesQL expressions include per day (e.g., QL(2 EA daily)), per fill (e.g., 90 EA per fill), or per month/90 days as listed

Provider actionPrescribers should include strength and quantity to ensure QL compliance or request PA for higher quantities

inv-115: AL abbreviation

AL abbreviationAL = Age Limit (age-based restriction for coverage)

Use in formularyAL flags indicate age restrictions in ILimits for specific formulations or patient groups

Example implicationProducts with AL may require verification of member age to authorize coverage

inv-116: SP abbreviation

SP abbreviationSP = Specialty Drug (requires specialty distribution and may require PA)

DistributionSP items often must be dispensed via contracted specialty pharmacy (e.g., AcariaHealth) and may have vendor routing noted

Cost implicationSP designation frequently aligns with Tier 4/high-cost placement

inv-117: Tier / Legend reiteration

Tier / Legend reiterationNumeric tiers and abbreviations are defined in the formulary legend and apply across drug line entries

GuidanceConsult legend for interpreting ILimits (PA, QL, ST, SP, AC, LA, PV, AL, RXIOTC)

ApplicabilityLegend applies to all products in the formulary excerpt; specific controls shown per product line

inv-118: PA (restate)

PA (restate)PA — Prior Authorization required prior to coverage as indicated in the formulary legend and ILimits

Provider obligationProviders must request PA when ILimits indicate PA to avoid denial

Deemed approval timelinesPlan must respond within statutory timelines; see PA rules for deemed approval conditions

inv-119: QL (restate)

QL (restate)QL — Quantity Limit specifying maximum units per day/30 days/other timeframe as listed on each drug line

ExpressionsQL examples include QL(1 EA daily), QL(90 EA per fill retail), QL(210 ML per 90 days), etc.

Claim impactClaims exceeding QL may be denied or require PA/exception request

inv-120: ST (restate)

ST (restate)ST (sT) — Step Therapy: required sequence of drugs to try before coverage of a prescribed drug unless exception is approved

Appears in legendsT is defined in the formulary legend and appears on product ILimits where applicable

Exception processProviders can request step therapy exceptions with supporting clinical documentation

inv-121: SP (restate)

SP (restate)SP = Specialty Drug designation indicating specialty distribution requirements and potential PA

Routing detailProduct lines may instruct 'Must use AcariaHealth Specialty Rx at 1-844-538-4661' for dispensing

Coverage implicationSP items often require specialty pharmacy handling and may be denied if not routed correctly

inv-122: Formulary abbreviations — SP/PA/QL/ST/NF

Formulary abbreviations listCommon abbreviations used on the formulary include SP, PA, QL, ST, NF — see legend for full definitions

Where to findAbbreviations appear in the legend and at top of formulary pages (Updated January 2026)

Interpretation tipUse legend to interpret per-drug ILimits and tier codes when reviewing coverage controls

inv-123: PA (definition reiteration)

PA (definition reiteration)PA = Prior Authorization; requires plan approval before covering the prescription listed with PA in ILimits

Provider stepsSubmit PA with supporting documentation; failure to obtain PA may result in noncoverage or denial

Appeal and timelinesPA decisions follow plan timelines and may be subject to deemed approval rules if timelines not met

inv-124: QL (definition reiteration)

QL (definition reiteration)QL = Quantity Limit indicating maximum allowed quantity in a specified timeframe (per day, per fill, per 30/90 days) as shown on product lines

Examples in documentExamples include QL(2 EA daily), QL(210 ML per 90 days), QL(90 EA per fill retail), etc.

Action when exceededPrescribers must request PA or exception to exceed QL limits; claims may be denied if QL exceeded

inv-125: SP (definition reiteration)

SP (definition reiteration)SP = Specialty Drug; requires specialty pharmacy dispensing and may have PA and vendor routing requirements

Vendor routingMany SP products instruct use of AcariaHealth Specialty Rx (phone number provided) for dispensing

Coverage checkpointEnsure specialty vendor routing and PA are followed to avoid denial

inv-126: Legend abbreviations block

Legend abbreviations blockThe formulary legend defines numeric tiers and abbreviations used across the drug list (PV, AL, PA, QL, sT, AC, LA, SP, RXIOTC)

LocationLegend appears prominently on formulary pages marked 'Updated January 2026'

Use caseReference legend when interpreting each drug line's ILimits and tier assignment

inv-127: Formulary tier codes (legend)

Formulary tier codes (legend)1=Preferred Generics; 2=Preferred Brand/High Cost Generics; 3=Non-Preferred Brand Drugs; 4=High Cost Drugs; 7=Brand Reference Only

Additional codingPV=Preventive Drugs; AC=Anti-Cancer; SP=Specialty Drug; PA=Prior Authorization; QL=Quantity Limit; sT=Step Therapy

Guide for cost shareTier dictates member cost-share; refer to Evidence of Coverage for plan-specific amounts

inv-128: PA (legend restatement)

PA (legend restatement)PA indicates prior authorization required before coverage for that product

Seen in ILimitsPA flags appear in ILimits column next to specific drug entries (e.g., EPIDIOLEX, SPRAVATO, many specialty agents)

Provider impactObtain PA prior to dispensing to reduce risk of denial

inv-129: QL (legend restatement)

QL (legend restatement)QL indicates a quantity limit and the allowable units/timeframe (per day, per fill, per month, per 90 days) for the product

ExamplesDocument includes multiple QL formats (e.g., QL(2 EA daily), QL(210 ML per 90 days), QL(6 EA per fill))

Claims handlingClaims exceeding QL may require PA or be denied

inv-130: SP (legend restatement)

SP (legend restatement)SP designates a specialty drug and usually signals specialty pharmacy handling and potential PA

Vendor requirementSP items often include explicit 'Must use AcariaHealth Specialty Rx' instructions on the product line

Coverage consequenceFailure to route SP products through required specialty vendor may lead to denial

inv-131: AC (Anti-Cancer) abbreviation

AC abbreviation (Anti-Cancer)AC = Anti-Cancer designation used for oncology agents and dose-level entries that may require AC/PA/SP controls

Usage exampleMany antineoplastic agents are marked AC and also require PA and specialty routing (e.g., LENVIMA, KISQALI)

ImplicationAC flag signals oncology-specific controls in addition to usual formulary limits

Some products note 90-day retail fill limits or specific per-fill caps (e.g., 90 EA per fill)

PA flags for stimulantsCertain stimulant entries are also flagged with PA or NF depending on formulation and tier

inv-149: Methylphenidate & CONCERTA entries — QL examples

CONCERTA TBCR and methylphenidate QLsCONCERTA TBCR entries list QL(1 EA daily), QL(2 EA daily) and per-fill limits such as 90 or 180 EA per fill depending on strength

DAYTRANA and dexmethylphenidate examplesDAYTRANA PTCH and dexmethylphenidate entries include daily QL and 90-day per-fill limits for some formulations

Clinical noteProviders should verify the specific QL for the product/strength being prescribed to ensure correct days' supply

inv-150: HUMIRA presentations — QL examples

HUMIRA presentations — QL examplesHUMIRA entries include QL(0.143 EA daily) and package limits (e.g., 1 package per 180 days) and note 'Check Plan Documents for coverage' on some lines

Specialty routingMany HUMIRA presentations are Tier = SP and may require specialty pharmacy routing and PA

Coverage verificationPlan document checks are required for some HUMIRA entries to determine coverage specifics

inv-151: CELEBREX 50/100/200 mg — QL(2 EA daily)

CELEBREX 50/100/200 mg QLQL(2 EA daily)

CELEBREX clinical noteSome CELEBREX strengths may also be flagged with PA depending on formulation

InterpretationQL(2 EA daily) indicates maximum 2 units per day for listed strengths

inv-152: CELEBREX 400 mg — QL(2 EA daily)

CELEBREX 400 mg QLQL(2 EA daily)

PA flagCELEBREX 400 mg may be accompanied by PA on some listings

Limit meaning2 units per day maximum as listed in ILimits

inv-153: ENBREL SOLN — QL(0.143 ML daily)

ENBREL SOLN QLQL(0.143 ML daily); product designated SP and requires specialty vendor routing (AcariaHealth)

ENBREL SURECLICK and MINIOther ENBREL presentations include QL values and SP designation; many require use of AcariaHealth Specialty Rx

ENBREL SOSY 50 MG/MLQL(0.286 ML daily); some SOSY entries include PA in ILimits

inv-154: ENBREL SOSY 50 MG/ML — QL(0.286 ML daily)

ENBREL SOLN QLQL(0.143 ML daily); SP; must use AcariaHealth Specialty Rx

ENBREL SOSY 50 MG/ML QLQL(0.286 ML daily); SP; some entries include PA

Vendor routingENBREL listings consistently instruct use of AcariaHealth Specialty Rx at 1-844-538-4661 for dispensing

inv-155: fentanyl PT72 patches — Limit 15 patches per month; QL(0.5 EA daily)

Fentanyl PT72 patch limitLimit 15 patches per month; QL(0.5 EA daily)

First-fill opioid ruleFirst fill opioids limited to 7 days; applies to many opioid product lines including fentanyl patches

Mail-order availabilitySome fentanyl strengths are noted as not available through mail order

inv-156: hydromorphone TB24 8/12/16 mg — QL(4 EA daily)

Hydromorphone TB24 8/12/16 mg QLQL(4 EA daily)

Hydromorphone TB24 32 mg QLQL(2 EA daily) for 32 mg strength

First-fill opioid statementHydromorphone tablet and liquid lines reiterate first-fill opioid limit of 7 days in ILimits

Billing Rule

Use Health Net contracted specialty pharmacy for specialty drugs

Prescribers must use the Health Net contracted specialty pharmacy for specialty drugs when the formulary specifies a contracted vendor; once approved, the contracted specialty pharmacy will arrange delivery.

Specialty drugs are required to be provided through a Health Net contracted Specialty Pharmacy.
After PA approval, contracted specialty pharmacy will contact patient to arrange delivery.

Billing Rule

In‑network specialty pharmacy required for high‑cost injectables

Specialty and certain high‑cost injectable drugs must be dispensed and delivered by an in‑network specialty pharmacy; check ILimits for vendor instructions and PA requirements before ordering.

In‑network specialty pharmacy dispensing is required for many high‑cost injectables.
Confirm PA and QL prior to authorizing specialty injectable fills.

Billing Rule

AcariaHealth required for specified specialty biologics and agents

AcariaHealth Specialty Rx is the designated vendor for many listed specialty biologics and specialty agents; the formulary repeatedly states 'Must use AcariaHealth Specialty Rx at 1‑844‑538‑4661' for these products.

Contact AcariaHealth at 1‑844‑538‑4661 to arrange specialty fills.
Follow PA and QL instructions alongside the vendor routing requirement.

Billing Rule

Route listed specialty biologics to AcariaHealth with PA as required

For the specialty biologics and agents listed, AcariaHealth is the required dispenser (phone number provided on the formulary); providers must route prescriptions accordingly and secure PA when ILimits indicates it.

Use AcariaHealth Specialty Rx at 1‑844‑538‑4661 for dispensing where noted.
Obtain PA as indicated on the product line prior to specialty pharmacy dispensing.

Billing Rule

Coordinate PA and dispensing through AcariaHealth for specified specialty agents

AcariaHealth is the required specialty pharmacy for many specified specialty products; prescribers should coordinate PA and shipping through AcariaHealth for those drugs.

Confirm PA and vendor routing on the formulary line for each specialty product.
Coordinate patient delivery through AcariaHealth after PA approval.

Note

SPRAVATO: AcariaHealth/SP designation and PA; administered in controlled setting

SPRAVATO is designated SP with ILimits = PA and must be administered in a controlled clinical setting per standard of care; providers must secure PA before scheduling and ensure administration occurs in the appropriate site of care.

Obtain PA for SPRAVATO dosing prior to administration.
Arrange controlled‑setting administration consistent with standard of care.

Billing Rule

Use specified specialty pharmacy for SP‑designated products

Many specialty products listed as SP must be dispensed via the specified specialty pharmacy; providers should check product lines for 'Must use AcariaHealth Specialty Rx at 1‑844‑538‑4661' and follow those routing instructions.

Use AcariaHealth at 1‑844‑538‑4661 for SP products when indicated.
Verify QL and PA requirements before referring to specialty pharmacy.

Billing Rule

Confirm and follow specialty pharmacy routing for SP‑designated drugs

Multiple SP‑designated products require routing through a specified specialty pharmacy (often AcariaHealth); confirm the formulary line's vendor instructions and obtain PA before ordering.

Check each SP line for the designated specialty vendor and phone number.
Ensure PA and QL compliance prior to specialty pharmacist fulfillment.