Prior Authorization Required — Certain drugs require prior authorization before dispensing; high‑strength formulations require PA

Prior Authorization Required — CommunityCare requires prior authorization (PA) for many drugs and high‑strength formulations. Failure to obtain PA may result in denial of coverage.

• High‑strength opioid formulations (e.g., select fentanyl, hydrocodone, oxycodone, oxymorphone, morphine beads/tbcr, tramadol high‑strength, XTAMPZA ER 36mg, NUCYNTA ER high strengths) require PA.
• Many morphine high‑strength products (e.g., morphine sulfate beads 120mg, tbcr high strengths) are PA‑required; select oral/liquid morphine products have quantity limits and initial 7‑day limits.
• Some hydrocodone and fentanyl high‑strength patches/lozenges denote: “High Strength Requires PA.”

Prior authorization for high‑strength opioids — Certain high‑strength opioid formulations require prior authorization

Prior authorization is required for some high‑strength opioid formulations and many opioid products are also subject to step therapy (ST) and quantity limits (QL). Document the indication and strength when submitting PA.

• Opioid analgesics often have ST and QL (initial 7‑day limits for many immediate‑release opioids).
• High‑strength entries explicitly state “High Strength Requires PA” — prescribers must document medical necessity and strength.
• Examples: fentanyl high‑strength patches and lozenges; hydrocodone t24a 100/120mg; oxycodone/oxymorphone high‑strength formulations; morphine beads/tbcr 120mg.

CABENUVA PA & QL — CABENUVA injection kits require PA and have quantity limits

CABENUVA injection kits require prior authorization and are subject to quantity limits. Initial loading dose rules apply per formulary.

• CABENUVA SUS 400‑600: PA; QL (1 kit every 30 days).
• CABENUVA SUS 600‑900: PA; QL (1 kit every 60 days). Loading dose of 1 kit in 30 days allowed for initial fill.
• Prescribers must document indication and request PA prior to administration or dispensing.

Hepatitis C agents PA & QL — EPCLUSA and HARVONI products require PA and have specific QL

Hepatitis C direct‑acting antivirals commonly require prior authorization and have specific quantity limits; some products also require step therapy.

• EPCLUSA (tablets/paks): PA; QL (28 tabs/pellets every 28 days).
• HARVONI (tabs/paks): PA; QL (28 tabs/pellets every 28 days).
• SOVALDI and related sofosbuvir products: ST; PA; QL (28 or 56 pellets/tabs as listed).
• VOSEVI: PA; QL (28 tabs every 28 days).
• PA/QL documentation and indication must be submitted with requests.

Prior authorization required for many specialty agents — Prior authorization is required for many listed high‑cost or specialty agents

Prior authorization is required for many specialty, high‑cost, oncology, hematologic, immunologic, and physician‑administered agents. Quantity limits and step therapy requirements frequently apply.

• Many oral antineoplastics (e.g., venetoclax, dasatinib, erlotinib, imatinib, everolimus, axitinib, ribociclib) require PA and have QLs (tab count or dosing packs).
• Physician‑administered biologics and immunologic agents (e.g., ACTEMRA, INFLIXIMAB, SIMPONI ARIA, SKYRIZI, STELARA) require PA and have QLs (vials/syringes per dosing interval).
• Hematologic agents (e.g., VENCLEXTA, KADCYLA, pegfilgrastim products) are PA and QL controlled.
• Prescribers must document diagnosis, dosing schedule, quantity, and rationale when requesting PA for these agents.

PA required for select migraine agents — Migraine agents listed with 'PA**' require prior authorization per formulary notes

Select migraine therapies are subject to step therapy and prior authorization per formulary notes; many monoclonal antibody migraine preventives require PA and QL.

• Acute and preventive migraine agents such as QULIPTA and UBRELVY show ST and PA** designations.
• Monoclonal antibodies (AIMOVIG, EMGALITY, etc.) show ST, QL (injections per 30 days) and PA** — loading‑dose exceptions noted (e.g., EMGALITY).
• Submit prior authorization with prior trial history to satisfy ST where applicable.

PA for endocrine and metabolic specialty agents — PA required for many endocrine/somatostatin and somatropin‑related products

Many endocrine, metabolic and specialty hormone agents require prior authorization and have quantity limits; some agents also invoke step therapy.

• Somatostatin analogs and growth modulators (octreotide, lanreotide, pegvisomant) — PA and QL specified (ml/vials or injections per period).
• GLP‑1 and incretin agents (liraglutide, MOUNJARO, OZEMPIC, TRULICITY) — PA and QL applied (pens per 28/30 days).
• Combination and select oral antidiabetics (JANUMET, SYNJARDY, GLYXAMBI) show ST; PA**.
• Prescribers must document prior treatments when PA or ST is indicated and include quantity and intended dosing frequency.

PA required for select drugs/devices — Prior authorization (PA) is required for certain medications/devices noted as 'PA'

Certain drugs and devices across the formulary require PA; this includes some pumps, specialty devices, and vaccine age‑based limitations.

• Insulin infusion pumps and refill kits (TWIIST, V‑GO) are listed with coverage entries — confirm PA if indicated by plan.
• VOWST CAPS (fecal microbiota spores) — PA; QL (12 caps every 30 days).
• Some vaccines and devices may have age‑based coverage limits — check formulary entries and submit PA when required.

VIBERZI (eluxadoline) PA — VIBERZI requires prior authorization

VIBERZI (eluxadoline) is subject to prior authorization per formulary requirements.

• VIBERZI TABS 75mg, 100mg — Requirements/Limits indicate PA.

Hematologic/selected GI agents PA — Selected agents require prior authorization; see formulary entries

Hematologic agents and selected GI therapies (including many physician‑administered biologics) require PA and often have QLs documented in the formulary.

• Hematopoietic growth factors (e.g., ARANESP, pegfilgrastim biosimilars) — PA; QL per dosing interval.
• Multiple biologic agents for autoimmune and GI indications (e.g., STELARA, SKYRIZI, TREMFYA) — PA and QL (vials/syringes per days/weeks/months).
• Submit dosing schedule and indication with PA requests for these agents.

Prior authorization/tier notes — Listing assigns tiers and 'Requirements/Limits' but specific prior‑authorization criteria not present here

Formulary entries list tiers and Requirements/Limits (PA, ST, QL). Where PA is indicated, follow the plan's prior authorization process and include complete documentation to avoid delays or denials.

• Requirements/Limits column indicates applicable PA, ST, and QL details — review for each product prior to prescribing.
• Some entries use PA** to denote additional PA/step‑therapy requirements — follow the plan’s defined PA criteria.
• Prior Authorization Risk: Failure to obtain required PA may result in noncoverage.

Prior Authorization Risk — Failure to obtain prior authorization may result in the drug not being covered

Failure to obtain prior authorization when required may result in the drug not being covered. Providers should obtain PA before dispensing and include supporting documentation to avoid member financial liability.

• If an exception is requested, submit the prescriber's supporting statement. Expedited exceptions: decision within 24 hours after receiving prescriber support.
• Decisions for standard exceptions will be made within 72 hours of receipt of necessary information.

Exception Request Documentation — Submit prescriber's supporting statement for exceptions; expedited requests require prescriber support

When requesting an exception or a PA, submit clinical documentation that justifies medical necessity, specifies the indication, dose/strength, and the requested quantity and duration.

• Exception Request Documentation: include prescriber's supporting statement; expedited requests require prescriber support for faster review.
• Document indication, strength, dose, and quantity for PA requests — especially important for high‑strength opioids, CABENUVA, hepatitis C agents, and oncology agents.
• CABENUVA documentation: include intended kit (loading vs maintenance), dosing interval, and rationale for PA.
• Hepatitis C DAAs (EPCLUSA, HARVONI, SOVALDI, VOSEVI): include genotype/indication, prior treatment history, and quantity requested (28‑ or 56‑day packs).
• Documentation to support PA/QL: supply diagnosis, prior therapies tried (for ST), dosing schedule, planned monitoring, and expected duration of therapy.
• Quantity limit documentation: when requesting override of a QL, provide clinical justification and planned duration.
• Folic acid and specific PPI formulations, bowel preps, PEG products, and select oral agents may have QLs — document why a different quantity or formulation is needed.
• VOWST CAPS: PA and QL (12 caps every 30 days) — include indication and prior therapies tried.
• Provide all supporting clinical records with the PA submission to avoid delays.

Step Therapy Requirement — Step therapy is required for some drugs—members must try preferred first‑line drugs before alternatives are covered

Step therapy (ST) is common across many therapeutic classes. Where ST is required, prescribers must document trials of preferred agents before a nonpreferred drug will be approved.

• ST applies to many analgesics and select hepatitis C entries (SOVALDI PACK entries include ST).
• ST/PA triggers are noted for migraine agents, certain psychiatric and endocrine combination products (e.g., VRAYLAR, JANUMET, SOLIQUA, XULTOPHY, SYNJARDY).
• For physician‑administered immunologic agents, ST plus PA and QL often apply before coverage is authorized.