Senior Health Plan Part D Formulary (abridged) — Prescription Drug Coverage Criteria
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Defines the plan's prescription drug formulary, coverage rules (prior authorization, step therapy, quantity limits), and cost-sharing for Senior Health Plan members (Medicare Advantage plans listed) and network pharmacy use.
No material clinical or coverage changes in this revision.
Formulary Coverage Rules
General coverage conditions
Covered when ALL of the following are met:
See Evidence of Coverage for details.
Temporary supply and exception handling
Temporary and exception coverage provided in specific situations:
New or continuing members: up to a 30‑day temporary supply; long‑term care residents may receive a 31‑day emergency supply; temporary supply during setting‑of‑care changes also available.
Standard decision within 72 hours; expedited decision within 24 hours when clinically necessary.
Prescribers should follow PA procedures in the formulary listing.
Formulary inclusion with tiering and restrictions
Drugs listed on the Part D formulary are included with an assigned tier and, where shown, may have requirement/limit annotations:
Examples from table: REPATHA (PA QL=2 ML/28 Days); ondansetron oral solution (PA_BvD QL=900 ML/30 Days); dapagliflozin (QL=30 EA/30 Days).
Formulary line-item coverage
Per‑line coverage and constraints apply to each strength/formulation listed:
Examples: PA_NSO flags for antipsychotics and PA_NSO/NDS rules for injectables with mL‑based QLs; see table lines for specific QL/NDS values.
Formulary coverage (table-based)
Formulary coverage and dispensing limits — drugs are covered subject to tier placement and the Requirements/Limits shown in the table:
Quantity limits (QL) are expressed as units per period (e.g., QL=30 EA/30 Days) and numeric dose supply (NDS) values are used for injectables (e.g., NDS QL=.75 ML/28 Days).
Formulary coverage with utilization controls
Coverage follows the formulary listing and the utilization controls shown for each product:
Prescribers should obtain PA where indicated and ensure dispensed quantity complies with the listed QL/NDS to avoid claim denial or adjustment.
The formulary may be changed when a drug is withdrawn from the market. Per the formulary: when a drug is withdrawn from sale by the manufacturer or the FDA determines it should be withdrawn for safety or effectiveness reasons, the plan may immediately remove the drug from the formulary and it will not be covered. The plan will later provide notice to affected members and describe exception rights and transition options.
This excerpt is an abridged segment of the full Part D formulary. It does not reproduce the complete legend or the start-of-table explanations that define the abbreviations and symbols used in the Requirements/Limits column. For definitions of flags such as PA, PA_NSO, NDS, QL and other table abbreviations, refer to the beginning of the full formulary table and the formulary legend.
Within these chunks there are no standalone plan-level exclusions listed. Many line items show only drug, strength/form, tier and, where applicable, Requirements/Limits; entries that do not include a Requirements/Limits value appear here without additional restrictions and therefore are not shown as excluded in this excerpt.
This excerpt of the formulary does not identify any drugs as explicitly excluded from coverage. The pages shown are a listing of formulary lines and, where present, their Requirements/Limits; explicit exclusions are not present in these chunks.
The segment provided is a formulary listing of topical antibiotic products and related entries and does not contain explicit medical-exclusion conditions. It lists drug line items and tiers rather than medical exclusion criteria.
Some drugs listed on the formulary require prior authorization. The formulary warns that if prior authorization is required and is not obtained, the plan may not cover the drug. When a Requirements/Limits field contains PA, PA_NSO, PA_BvD, NDS PA or similar flags, prescribers must submit the required prior authorization and supporting documentation per the plan’s processes.
This excerpt does not include any explicit statements declaring products or uses as 'not medically necessary.' The document directs readers to the full formulary legend and related sections for complete coverage determinations.
The pages in this extract do not contain explicit 'not medically necessary' determinations. The content here is a formulary table showing drug names, tiers and, where applicable, Requirements/Limits; clinical medical-necessity findings are not stated in these chunks.
No explicit 'not medically necessary' language appears in this segment. The lines shown list propranolol and related agents by strength and tier with blank Requirements/Limits fields where no additional restrictions are recorded in this excerpt.
Formulary Line Coding & Flags
| ATROVENT 17MCG HFA INHALER | REQUIREMENTS/LIMITS = QL=25.80 GM/30 Days |
| INCRUSE ELLIPTA 62.5MCG/INH POWDER INHALER | DRUG TIER = 3; REQUIREMENTS/LIMITS = QL=30 EA/30 Days |
| ipratropium bromide 0.02% inh soln | DRUG TIER = 2; REQUIREMENTS/LIMITS = PA_BvD |
| SPIRIVA RESPIMAT 1.25MCG/ACT INHALER | DRUG TIER = 3; REQUIREMENTS/LIMITS = QL=4 GM/30 Days |
| montelukast 10mg tab | DRUG TIER = 1; REQUIREMENTS/LIMITS = . |
| QL=60 EA/30 Days | common anticoagulant quantity limit (examples: dabigatran, rivaroxaban) |
| QL=620 ML/30 Days | rivaroxaban 1mg/ml oral suspension quantity limit |
| PA_NSO | prior authorization notation applied to certain anticonvulsant products (e.g., brivaracetam) |
| NDS | notation appearing with DIACOMIT indicating specialty distribution/refill rules |
| QL=30 EA/30 Days | quantity limit example (e.g., dapagliflozin, FARXIGA, JARDIANCE) |
| PA_BvD | prior authorization with business validation (appears for ondansetron and related entries) |
| NDS PA | non-standard distribution / specialty prior authorization (appears for CRESEMBA) |
| QL=900 ML/30 Days | quantity limit for ondansetron 0.8mg/ml oral solution |
| QL=2 ML/28 Days | quantity limit example for REPATHA 140MG/ML |
| QL=84 EA/28 Days | quantity limit for XERMELO 250MG TAB |
| NOVOLIN MIX (70/30) 100UNIT/ML FLEXPEN (3ML) | listed product and form; REQUIREMENTS/LIMITS = INS |
| TOUJEO 300UNIT/ML PEN INJ (1.5ML) | listed product and form; REQUIREMENTS/LIMITS = INS |
| TRESIBA 100UNIT/ML PEN INJ (3ML) | listed product and form; REQUIREMENTS/LIMITS = INS |
| DAPAGLIFLOZIN 10MG TAB | listed product and form; REQUIREMENTS/LIMITS = QL=30 EA/30 Days |
| REPATHA 140MG/ML AUTO-INJECTOR | listed product and form; REQUIREMENTS/LIMITS = PA QL=2 ML/28 Days |
| CRESEMBA 186MG CAP | listed product and form; REQUIREMENTS/LIMITS = NDS PA |
| PA_NSO | Prior authorization / non-standard override flag as shown in table |
| QL | Quantity limit (units per period) as shown in Requirements/Limits |
| EA | Each (unit) used in quantity limit expressions |
| TAFINLAR 10MG TAB | TAFINLAR 10MG TAB FOR ORAL SUSP, REQUIREMENTS/LIMITS = NDS PA_NSO QL=120 EA/30 Days = NDS PA_NSO QL=840 EA/28 Days |
| TAFINLAR 50MG CAP | REQUIREMENTS/LIMITS = NDS PA_NSO QL=120 EA/30 Days |
| TAFINLAR 75MG CAP | REQUIREMENTS/LIMITS = NDS PA_NSO QL=120 EA/30 Days |
| TALZENNA 0.1MG CAP | REQUIREMENTS/LIMITS = NDS PA_NSO QL=120 EA/30 Days = NDS PA_NSO QL=30 EA/30 Days |
| TAZVERIK 200MG TAB | DRUG TIER = 5; REQUIREMENTS/LIMITS = NDS PA_NSO QL=240 EA/30 Days |
| TEPMETKO 225MG TAB | DRUG TIER = 5; REQUIREMENTS/LIMITS = NDS PA_NSO QL=60 EA/30 Days |
| TIBSOVO 250MG TAB | DRUG TIER = 5; REQUIREMENTS/LIMITS = NDS PA_NSO QL=60 EA/30 Days |
| TRUQAP 200MG TAB | DRUG TIER = 5; REQUIREMENTS/LIMITS = NDS PA_NSO QL=64 EA/28 Days |
| TURALIO 125MG CAP | DRUG TIER = 5; REQUIREMENTS/LIMITS = NDS PA_NSO QL=120 EA/30 Days |
| VITRAKVI 20MG/ML ORAL SOLN | DRUG TIER = 5; REQUIREMENTS/LIMITS = NDS PA_NSO QL=300 ML/30 Days |
| QL=30 EA/30 Days | Quantity limit: 30 each per 30 days |
| QL=60 EA/30 Days | Quantity limit: 60 each per 30 days |
| QL=240 ML/30 Days | Quantity limit: 240 mL per 30 days (oral solution example) |
| NDS QL=.75 ML/28 Days | Numeric dose supply limit: 0.75 mL per 28 days (INVEGA SUSTENNA example) |
| NDS QL=1 ML/28 Days | Numeric dose supply limit: 1 mL per 28 days |
| NDS QL=1.50 ML/28 Days | Numeric dose supply limit: 1.50 mL per 28 days |
| NDS QL=.25 ML/28 Days | Numeric dose supply limit: 0.25 mL per 28 days |
| DRUG TIER = 1 | Tier 1 preferred generic / lower cost sharing |
| DRUG TIER = 2 | Tier 2 |
| DRUG TIER = 4 | Tier 4 |
| DRUG TIER = 5 | Tier 5 (specialty / high cost) |
| QL=240 EA/30 Days | quantity limit example for ENTRESTO oral pellets |
| PA QL=90 EA/30 Days | droxidopa 100mg cap prior authorization and quantity limit |
| PA QL=180 EA/30 Days | droxidopa 200mg and 300mg caps prior authorization and quantity limit |
| PA QL=60 EA/30 Days | ivabradine strengths prior authorization and quantity limit |
| QL=60 EA/30 Days | ranolazine formulations quantity limit |
| PA QL=30 EA/30 Days | VERQUVO strengths prior authorization and quantity limit |
| NDS PA QL=240 ML/30 Days | EVRYSDI oral solution non-standard dose prior auth and quantity limit |
| NDS PA QL=30 EA/30 Days | EVRYSDI tablet NDS prior auth and quantity limit |
| NDS PA QL=70 ML/28 Days | RADICAVA oral suspension NDS prior auth and quantity limit |
| QL=60 EA/30 Days | sacubitril/valsartan strengths quantity limit |
Prior Authorization, Step Therapy, and Documentation
Obtain prior authorization per PA/PA_NSO/PA_BvD flags
Prescribers must obtain prior authorization when the formulary lists PA, PA_NSO, or PA_BvD for a product; PA_NSO applies to new starts and PA_BvD is used when a Part B vs Part D determination is required. Follow the plan's prior authorization pathways (including non-standard/NDS routes) before dispensing.
- PA_NSO = prior authorization restriction for new starts only
- PA_BvD = prior authorization to determine Part B vs Part D payment responsibility
- NDS PA indicates non-standard distribution with PA requirements
PA required for many specialty/high-cost agents
Numerous specialty and high-cost agents are marked NDS PA or PA in the Requirements/Limits and require prescribers to submit prior authorization before the plan will cover them.
- Examples: OLUMIANT, RINVOQ, XELJANZ, and anti‑TNF agents are listed with NDS PA QL entries
PA plus quantity limits for stimulants/wakefulness agents
Selected stimulants and wakefulness agents show both prior authorization (PA) and quantity limits (QL); prescribers must request PA and ensure prescriptions conform to the listed QL.
- Examples: atomoxetine entries include QL values; methylphenidate oral solutions list QL=1800 ML/30 Days
PA required for annotated inhaled and anticonvulsant products
Several inhaled and anticonvulsant products are annotated with PA_BvD or PA_NSO in the Requirements/Limits; prescribers must obtain the indicated prior authorization before coverage.
- Examples: ipratropium inhalation solution marked PA_BvD; multiple anticonvulsants (brivaracetam, DIACOMIT, EPIDIOLEX) show PA_NSO/NDS PA_NSO
PA required for formulary entries flagged PA_NSO / NDS PA_NSO
Drugs flagged with PA_NSO or NDS PA_NSO in the Requirements/Limits require prior authorization or non-standard review; prescribers must secure authorization and observe any quantity constraints.
- PA_NSO and NDS PA_NSO appear across many line items and trigger PA requirements
Submit PA for listed products with PA or specialty PA flags
Many listed drugs include PA or specialty PA flags in their Requirements/Limits; providers must submit prior authorization per the plan when those flags are present.
- Examples in the table include EXXUA formulations (PA_NSO), RALDESY (PA_NSO QL), and several GLP‑1/insulin products showing PA/QL
PA (and QL) required for select specialty/high‑cost drugs
Select specialty/high‑cost drugs are listed with PA and QL entries; prescribers must obtain prior authorization and adhere to the quantity limits shown for coverage.
- Example: REPATHA requires PA with QL=2 ML/28 Days; CRESEMBA is listed as NDS PA
Obtain PA when PA_NSO is listed
Numerous agents in the antineoplastic and other specialty sections are marked PA_NSO; prescribers must obtain prior authorization when PA_NSO appears in Requirements/Limits and provide supporting documentation.
- PA_NSO appears on many oncology/specialty entries and often is paired with NDS or QL values
PA required for entries marked NDS PA_NSO or PA_NSO
Several drugs are listed with 'NDS PA_NSO' or 'PA_NSO' indicating prior authorization or non‑standard prior authorization is required prior to coverage; prescribers must secure authorization before dispensing.
- NDS PA_NSO entries include numeric dose‑supply quantity limits for injectables and specialty items
PA required for PA_NSO‑listed psychotropic agents
Multiple psychotropic agents include PA_NSO in their Requirements/Limits; prescribers should submit prior authorization for these drugs before the plan will cover them.
- Examples: NUPLAZID, VRAYLAR, and long‑acting injectable antipsychotics show PA_NSO QL entries
PA required for select high‑cost antivirals (NDS PA)
High‑cost antiviral and hepatitis C direct‑acting agents are listed with NDS PA or PA flags; prescribers must obtain prior authorization before coverage and comply with the listed quantity limits.
- Examples: MAVYRET and SOFOSBUVIR/VELPATASVIR are listed with NDS PA QL values
PA required for select listed drugs with PA/QL
Certain listed drugs (e.g., droxidopa, ivabradine, VERQUVO, EVRYSDI, RADICAVA) have PA and QL annotations; prescribers must request prior authorization and ensure prescriptions meet the quantity limits shown.
- Example: droxidopa 100 mg cap = PA QL=90 EA/30 Days; EVRYSDI oral solution = NDS PA QL=240 ML/30 Days
PA required for flagged topical and related agents
Topical and other products marked 'PA' or 'NDS PA' in Requirements/Limits require prior authorization before coverage; prescribers must submit PA to avoid denial.
- Examples: multiple tretinoin formulations show PA QL=45 GM/30 Days; OTEZLA and SKYRIZI are listed with NDS PA/PA and QL values
Follow step therapy (ST / ST_NSO) when flagged
Step therapy may apply when ST or ST_NSO appears; ST_NSO indicates step edits apply to new starts only — prescribers should follow the plan's step sequence where specified.
- ST_NSO = step therapy for new starts only; TRINTELLIX entries show ST_NSO QL=30 EA/30 Days
No explicit step‑therapy sequences in this excerpt — consult full guidance
The formulary excerpt includes category‑level Requirements/Limits for some classes but does not provide explicit step‑therapy sequences in this segment; prescribers should consult the plan's full PA/ST guidance when a step edit is indicated.
- Category‑level flags are present (e.g., ADHD class), but explicit prior step drugs or sequences are not listed here
Step/UM indicators present (e.g., TRINTELLIX ST_NSO)
Some tiered products (for example TRINTELLIX) include ST_NSO indicating that step therapy or utilization management may apply; prescribers must meet step criteria where required.
- TRINTELLIX 5/10/20 mg tabs list ST_NSO QL=30 EA/30 Days
TRINTELLIX requires ST_NSO for new starts
TRINTELLIX products are assigned ST_NSO in Requirements/Limits, meaning step edits for new starts must be satisfied per plan rules before coverage.
- TRINTELLIX 5/10/20 mg tabs — ST_NSO QL=30 EA/30 Days
No explicit step sequences shown — follow full plan step/ST guidance
This formulary excerpt does not list explicit multi‑step sequences; when step therapy is required the prescriber must follow the plan's documented step requirements found in the full formulary or PA guidance.
- Plan-level step sequences and prior authorization criteria are published in detailed PA/ST documents referenced in the formulary
Hepatitis C antivirals flagged for utilization management (NDS PA)
Hepatitis C DAAs and other specialty antivirals are flagged NDS PA, indicating utilization management applies; prescribers must obtain PA though specific step sequences are not shown here.
- Examples include SOFOSBUVIR/VELPATASVIR and VOSEVI listed with NDS PA QL values
Provide a medical statement for formulary exception requests (72 / 24 hr timelines)
When requesting a formulary exception, the prescriber must provide a supporting medical statement explaining the medical necessity; standard decision timelines are 72 hours and expedited decisions 24 hours upon receipt of the prescriber's statement.
- Prescriber must state medical reasons supporting the exception
- Decision timelines: standard 72 hours; expedited 24 hours
Submit clinical context for PA_BvD (Part B vs Part D) determinations
For drugs annotated PA_BvD, prescribers should submit clinical information describing the drug's use and setting to allow the plan to determine whether Medicare Part B or Part D is the payment responsibility.
- PA_BvD = prior authorization to determine Part B vs Part D coverage
Ensure dispensing complies with listed quantity limits (QL)
Quantity limits (QL) are specified per product (e.g., QL=30 EA/30 Days); prescribers and pharmacists must ensure prescriptions do not exceed the listed QL unless prior authorization or an approved exception is obtained.
- Examples: DAPAGLIFLOZIN 10MG TAB = QL=30 EA/30 Days; methylphenidate oral solutions list ML QLs
Provide medical necessity documentation for PA_NSO / NDS PA_NSO drugs
When a formulary line shows PA_NSO or NDS PA_NSO, providers must supply documentation supporting medical necessity and demonstrate adherence to the listed quantity limits as part of the prior authorization submission.
- PA_NSO/NDS PA_NSO entries commonly require medical necessity documentation with PA submission
Document PA and ML for injectable GLP‑1 agents (MOUNJARO, OZEMPIC, TRULICITY)
Injectable GLP‑1 agents and pen products in the formulary list PA and ML/QL requirements; prescribers must include documentation consistent with prior authorization rules when requesting coverage.
- Examples: MOUNJARO entries show PA QL=2 ML/28 Days; OZEMPIC entries show PA QL=3 ML/28 Days; TRULICITY entries show PA QL=2 ML/28 Days
Match prescription/claim data to formulary line‑item (name, strength, tier, Requirements/Limits)
Formulary entries use annotations such as PA_BvD, PA, NDS PA, PA_NSO, ST_NSO and QL per strength/formulation; ensure prescription and claim data match the listed name, strength/formulation, tier, and Requirements/Limits when submitting a PA or claim.
- Provide exact drug name, strength/form, intended days' supply, and any clinical justification requested
Ensure prescription matches formulary strength/form and PA_NSO/QL codes
Pharmacies must present a prescription that matches the listed strength and formulation and adhere to PA_NSO and quantity‑limit codes shown in the formulary; dispensing beyond QL or without PA may lead to claim adjustments or denials.
- Pharmacy should confirm QL (EA/30 Days, ML/28 Days, etc.) and PA flags prior to dispensing
Adhere to table QL periods and units when dispensing
Follow the exact quantity limits shown in the table for dispensing (examples include EA/30 Days, EA/28 Days, ML/30 Days); prescriptions exceeding these limits require justification or prior authorization.
- Examples: REPATHA QL=2 ML/28 Days; many injectables list NDS mL limits per 28 days
Conform to NDS (mL) quantity limits for injectables
Long‑acting injectables and NDS items show numeric dose supply (mL) limits (e.g., .75 mL/28 Days, 1 mL/28 Days); prescribers and pharmacies must conform dispensing and PA requests to these NDS QL values.
- INVEGA SUSTENNA examples show NDS QL values (e.g., .25 mL/28 Days, .50 mL/28 Days, 1.50 mL/28 Days)
Include exact formulary details on PA/claim submissions
When submitting PA or claims, include drug name, strength/formulation, tier, and Requirements/Limits (QL/PA flags) so the plan can match the request to the formulary entry and avoid processing delays.
- Provide intended days' supply and quantity to align with QL values
Provide PA documentation when table shows PA or QL
If a formulary table line indicates PA and/or QL, prescribers should provide the required prior authorization documentation to the Part D PA process to support coverage.
- PA and QL annotations on entries (e.g., droxidopa PA QL=90 EA/30 Days) require PA documentation
Justify or obtain PA for prescriptions exceeding QL
Prescriptions exceeding listed quantity limits per the specified period (QL=...) may require clinical justification or prior authorization before the plan will cover the excess amount.
- Providers should document the medical necessity for quantities above the listed QL when requesting overrides
Risk of denial if required PA is not obtained
Failure to obtain required prior authorization where indicated may result in the plan denying coverage for the drug at the point of sale.
- The formulary warns that lack of PA may lead to non‑coverage
Denial risk for NDS/PA‑flagged drugs without PA
Drugs flagged with 'NDS PA' or general 'PA' entries indicate claims may be denied without prior authorization or required documentation; prescribers must secure PA to avoid claim denial.
- High‑cost and non‑standard distribution items commonly carry this denial risk
PA required for some stimulants/wakefulness agents — denial risk if not obtained
Selected stimulants and wakefulness agents include 'PA' in their Requirements/Limits, so prescribers must obtain prior authorization for these agents to prevent claim denial.
- Examples include atomoxetine and methylphenidate formulations with QL and PA annotations
Claims may be denied for PA_BvD / PA_NSO items without PA
Products marked PA_BvD or PA_NSO require prior authorization per the formulary; claims submitted without the required PA may be denied or require manual review.
- PA_BvD entries (e.g., ondansetron oral solution) and PA_NSO entries (multiple line items) trigger PA pathways
PA_NSO / NDS PA_NSO drugs carry denial risk if requirements unmet
Claims for drugs flagged with PA_NSO or NDS PA_NSO may be denied or require non‑standard review when quantity limits are exceeded or criteria are not met; prescribers should secure PA and document necessity.
- Examples: DIACOMIT and EPIDIOLEX entries show NDS PA_NSO flags with QL values
PA/QL/ST flags can trigger coverage denial if not met
Coverage may be denied or limited if PA or QL specified for a product (PA_NSO, PA, ST_NSO, NDS PA) are not satisfied per the formulary listing; prescribers must follow these controls to obtain coverage.
- Formulary flags indicate PA/QL/ST controls that determine coverage
PA/QL/NDS flags trigger coverage controls
Drugs marked with PA, PA_BvD, NDS, or QL may trigger coverage limits or prior authorization requirements per the formulary; prescribers should verify and comply with the listed controls.
- Examples: REPATHA (PA QL), CRESEMBA (NDS PA) — coverage tied to listed requirements
Denial risk when formulary requirements/QL not met
Claims for listed drugs may be denied or require review if prescribers or pharmacies do not meet the listed requirements (e.g., PA_NSO) or exceed specified quantity limits; obtain PA and document as required.
- Ensure PA submissions reference the formulary line's Requirements/Limits to avoid denials
PA_NSO entries require prior authorization — risk of denial if not obtained
When a formulary entry shows 'PA_NSO' or 'NDS PA_NSO', prior authorization is indicated; prescribers must request PA for these items to prevent claim denial at point of sale.
- PA_NSO commonly appears across specialty and oncology entries
Submit PA for PA_NSO‑listed drugs with clinical support
PA_NSO‑listed drugs are subject to prior authorization review; prescribers should submit PA requests with supporting clinical information to secure coverage.
- Examples include NUPLAZID and many VRAYLAR strengths showing PA_NSO QL=30 EA/30 Days
Obtain PA for select high‑cost antiviral agents (NDS PA indicated)
Certain high‑cost agents (e.g., MAVYRET, SOFOSBUVIR/VELPATASVIR, VOSEVI, LIVTENCITY, PREVYMIS) list NDS PA or similar flags; prescribers must obtain PA to satisfy non‑standard distribution requirements before coverage.
- NDS PA entries include specific QL values that must be followed
Exceeding QL or lacking PA may trigger denial for listed products
Claims exceeding specified quantity limits or lacking required prior authorization for products such as droxidopa, ENTRESTO oral pellets, ivabradine, VERQUVO, EVRYSDI, and RADICAVA may be denied; prescribers must secure PA or justification.
- Examples: droxidopa PA QL=90/180 EA/30 Days; EVRYSDI NDS PA QL=240 ML/30 Days; RADICAVA NDS PA QL=70 ML/28 Days
PA required for flagged topical agents — obtain PA to avoid denial
Topical agents flagged with 'PA' or 'NDS PA_NSO' require prior authorization or non‑standard dispensing authorization before coverage; prescribers should request PA to avoid denials.
- Examples: multiple tretinoin formulations show PA QL=45 GM/30 Days; lidocaine topical entries show PA QL values
NDS PA required for select specialty agents (OTEZLA, SKYRIZI) — secure PA
Entries showing 'NDS PA' for specialty agents such as OTEZLA and SKYRIZI indicate non‑standard distribution and prior authorization requirements; prescribers must obtain NDS/PA to ensure coverage.
- OTEZLA entries list NDS PA QL values (e.g., QL=60 EA/30 Days); SKYRIZI lists PA QL=7 ML/365 Days
Formulary Flags and Legend
Initial Coverage & Step Examples
Step therapy for TRINTELLIX
Step therapy applies as indicated for specific products (new‑start only where shown):
ST_NSO indicates step therapy applies to new starts per formulary flags; prescriber must meet step criteria or request an exception.
Initial therapy prior authorization
Initial dispensing for listed agents may require prior authorization before coverage:
See respective formulary line items for associated QL/NDS values that also apply.
| Category / Product group | Requirements / Limits |
|---|---|
| ADHD / Anti-Narcolepsy / Anti-Obesity / Anorexiants (category-level) | REQUIREMENTS/LIMITS: Category-level REQUIREMENTS/LIMITS entry present; explicit step sequences not shown in excerpt |
| Amphetamines (examples: amphetamine/dextroamphetamine, lisdexamfetamine) | REQUIREMENTS/LIMITS: Category-level entry present; individual strengths show QL where specified (see line items). No explicit step sequence listed |
| Atomoxetine | REQUIREMENTS/LIMITS = QL=30 EA/30 Days or QL=60 EA/30 Days depending on strength (per line items) — category-level sequencing not specified |
| Product / Example | Requirements / Limits (flag) |
|---|---|
| Brivaracetam (tabs, oral solution) | REQUIREMENTS/LIMITS = PA_NSO QL=60 EA/30 Days (tabs); PA_NSO QL=600 ML/30 Days (oral solution) — PA_NSO flag shown |
| DIACOMIT (carbamazepine formulations) | REQUIREMENTS/LIMITS include NDS / QL annotations for certain formulations; some anticonvulsant items show PA_NSO/NDS flags (specialty PA) — sequence not provided |
| Other anticonvulsants (selected examples) | REQUIREMENTS/LIMITS: Several anticonvulsant entries annotated with PA_NSO indicating prior authorization/new-start-only handling at PA review |
| Product | Step therapy / Requirement |
|---|---|
| TRINTELLIX (5 mg, 10 mg, 20 mg tabs) | REQUIREMENTS/LIMITS = ST_NSO QL=30 EA/30 Days — ST_NSO (step therapy new-start only) applies |
| Product | Step therapy flag |
|---|---|
| TRINTELLIX (all listed strengths) | ST_NSO indicated for TRINTELLIX products (ST_NSO QL=30 EA/30 Days) — step edits apply to new starts |
| Scope | Coverage note / Prior authorization |
|---|---|
| General step therapy sequences in excerpt | No explicit step therapy sequences shown in the provided excerpt; several specialty/high-cost drugs require prior authorization (PA) or NDS PA before coverage |
| Specialty / oncology entries (example) | REQUIREMENTS/LIMITS frequently include NDS PA_NSO or NDS PA flags; PA is required prior to coverage though step order is not detailed in excerpt |
| Step | Description |
|---|---|
| Step 1 | (Placeholder) — no explicit step content shown in the excerpt; category-level flags present but sequences not detailed |
| Agent / Group | Notes on PA_NSO and step edits |
|---|---|
| VRAYLAR, REXULTI and similar antipsychotics | Some agents flagged PA_NSO (e.g., VRAYLAR, REXULTI) — PA_NSO may indicate step edits or requirements evaluated at PA review rather than an explicit prior step sequence |
| Other antipsychotic class entries | REQUIREMENTS/LIMITS commonly include PA_NSO QL=30 EA/30 Days for many strengths; PA_NSO may trigger step-related review at prior authorization |
| Excerpt scope | Step therapy sequences present? |
|---|---|
| Table excerpt covering multiple classes | No explicit step therapy sequences shown in these chunks; entries display tiering and REQUIREMENTS/LIMITS flags only |
| Product / Class | Requirement prior to coverage |
|---|---|
| Hepatitis C direct-acting antivirals (e.g., MAVYRET, SOFOSBUVIR/VELPATASVIR, VOSEVI) | REQUIREMENTS/LIMITS = NDS PA QL=... — NDS PA or PA required prior to coverage; specific step sequence is not detailed in excerpt |
| PAXLOVID / PREVYMIS (examples) | REQUIREMENTS/LIMITS include QL and NDS PA flags for specialty antivirals; prior authorization or non-standard dispensing required before coverage |
| Table region | Step therapy sequencing shown? |
|---|---|
| Cardiovascular / CNS / specialty entries in excerpt | No explicit step therapy sequences are defined in these chunks; entries list drug tier plus PA and/or QL controls only |
| Selected specialty entries with NDS PA | Where NDS PA or PA are shown (e.g., VERQUVO, EVRYSDI, RADICAVA), prior authorization and quantity limits govern coverage; step sequencing not provided in excerpt |
Per-Product Quantity Limits (Selected Examples)
Document Context
This extract is a segment of the Part D formulary table listing multiple therapeutic classes (for example respiratory inhalers, anticoagulants and anticonvulsants), each drug’s strength/formulation, assigned drug tier, and, where applicable, utilization controls such as PA (prior authorization) and QL (quantity limits). The listing is a benefit-administration artifact and does not provide clinical prescribing guidance; coverage is governed by the tier and any Requirements/Limits shown on each line.
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