Community-Care Part D Formulary Coverage Update | OpenPayer
CurrentCommunity-CarePolicy N/A
Senior Health Plan Part D Formulary (Drug List) - Coverage Criteria
This document is the plan formulary (Drug List) for CommunityCare Government Programs' Senior Health Plan Part D, describing covered drugs, restrictions (PA, QL, ST), tiers, member instructions, and how to request exceptions; it affects plan members and prescribing providers.
Policy Summary
PayerCommunity-Care
PolicySenior Health Plan Part D Formulary (Drug List) - Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material clinical or coverage changes in this revision.
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior authorization and provide supporting documentation when a drug is flagged with PA, PA_NSO, NDS or has a QL to avoid denial.
No material clinical or coverage changes in this revision.
05/22/2026formulary last updated
Monthlyupdate frequency
30 daysnotice period
72 hrsdecision time (exceptions)
MultiplePA/QL prevalence
Yes
specialty biologics listed
Coverage rules and formulary management
Formulary coverage and exception rules
Covered drugs are generally those listed on the plan formulary when medically necessary, filled at network pharmacies, and other plan rules are met.
General coverage conditions: Drug is on the formulary AND is medically necessary AND prescription is filled at a plan network pharmacy
See Evidence of Coverage for details on network pharmacy requirements and member responsibilities
Temporary coverage for new/transition members: Plan may provide a temporary supply for drugs not on the formulary or subject to restrictions during transitions: up to a 30‑day supply during the first 90 days of membership (or a 31‑day emergency supply for long‑term care residents) or a temporary supply when setting of care changes30-day or 31-day supply
Prescriber or pharmacy may request temporary supply while member pursues exception or treatment change
Exception approval standard: An exception (to cover a non‑formulary drug or waive a restriction) will generally be approved only if the formulary alternatives or applying the restriction would not be as effective for the member or would cause adverse effectsDecision within 72 hours (24 hours if expedited)
Prescriber supporting statement required for exception requests; expedited requests may be decided within 24 hours
Formulary tier and utilization management
Coverage and utilization management indications are listed per drug with DRUG TIER and REQUIREMENTS/LIMITS fields; tier assignment drives member cost‑sharing and utilization controls (PA, QL, ST) shown on each line.
Formulary assignment: Drugs are assigned to tiers (Tier 1–5) which determine member cost‑sharing; individual drug rows include REQUIREMENTS/LIMITS codes that impose utilization management (e.g., PA, PA_NSO, NDS, ST_NSO, QL)
See drug table entries for the specific tier and any listed REQUIREMENTS/LIMITS (examples include atomoxetine QL values and OLUMIANT/RINVOQ NDS PA QL entries)
Utilization management types: Requirements/Limits may include prior authorization (PA or PA variants), quantity limits (QL), step therapy (ST or ST_NSO), and non‑default/special distribution flags (NDS/PA_NSO)
Providers must follow the listed REQUIREMENTS/LIMITS when submitting claims or authorization requests
Formulary administrative coverage
Covered when listed on the formulary subject to the following administrative conditions:
Formulary administrative coverage: Drug is listed with a drug tier and is covered only if any stated REQUIREMENTS/LIMITS are satisfied (examples: PA_NSO, NDS, PA, QL)
Administrative conditions (PA, NDS, QL, ST) on the formulary line must be met for coverage; failure to obtain required authorization may result in denial
Prior authorization and specialty distribution: Many higher‑tier or specialty drugs carry PA_NSO or NDS PA flags indicating prior authorization and/or special ordering/dispensing requirements; claims submitted without required approvals or exceeding listed QL may be denied
Examples in the table: CAPLYTA, COBENFY, FANAPT, INVEGA SUSTENNA, and multiple oncology/specialty agents listed with PA_NSO and QL values
Quantity limits enforcement: Quantity limits (QL and NDS QL values) shown on formulary lines are enforced for the time period specified (e.g., per 28 or 30 days); documentation must support requests to exceed these limitsPer time period shown (e.g., QL=30 EA/30 Days)
If a prescribed drug is not listed on the plan formulary and an exception request is not approved, the plan will not cover the drug. Members and prescribers should contact the Pharmacy Helpdesk for alternatives or submit an exception request per the formulary procedures.
No explicit formulary exclusions are shown in the excerpted pages of this document. The table uses symbols and abbreviations (defined at the start of the full formulary) to indicate coverage status and requirements; consult the full formulary introduction for any listed exclusions.
This excerpt does not include specific clinical exclusion criteria. Where clinical exclusions apply they would be presented in the complete formulary or policy sections not shown here.
No clinical exclusion lists are visible in the provided excerpt; the formulary entries shown focus on drug tiers and requirement/limit flags (e.g., PA_NSO, QL) rather than enumerated exclusions.
The excerpt does not state explicit coverage exclusions. Several rows refer readers back to the beginning of the table for symbol/abbreviation meanings, indicating that any exclusion language or special symbols would be defined in the table introduction.
The plan covers drugs listed on the formulary only when they are medically necessary, filled at a plan network pharmacy, and otherwise meet plan rules; drugs that are not medically necessary are not covered.
No discrete 'not medically necessary' policy statements are present in the visible excerpt. Determinations about medical necessity and Part B vs Part D applicability may require submission of supporting information as described elsewhere in the full formulary.
The provided pages do not include standalone 'not medically necessary' determinations or clinical criteria; entries show requirement/limit flags (e.g., PA, QL) but do not define medical‑necessity exclusions in this excerpt.
This excerpt does not define specific clinical criteria that would render a drug 'not medically necessary.' Such criteria, if applicable, would be found in the complete policy or in decision‑making guidance referenced elsewhere in the formulary.
Formulary codes, requirement codes and quantity limits examples
Formulary management codes and limitsmixed
QL=60 EA/30 Days
Quantity limit 60 each per 30 days (example shown in inhalants and anticoagulants)
QL=120 ML/30 Days
Quantity limit 120 mL per 30 days (example shown for inhaled/nebulizer solutions)
QL=13 GM/30 Days
Quantity limit example by grams per 30 days (examples in inhaler entries)
PA_BvD
Prior authorization flag (PA_BvD) shown for multiple inhalant and other products
PA_NSO
Prior authorization flag (PA_NSO) shown for certain anticonvulsants and specialty products
NDS
NDS indicator shown for some high-tier specialty drugs (e.g., DIACOMIT, EPIDIOLEX) combined with PA_NSO
Formulary management codesmixed
PA_NSO
Prior authorization / utilization management flag (as shown in Requirements/Limits column)
NDS
Non-default/special dispensing flag (as shown in Requirements/Limits column)
ST_NSO
Step therapy / utilization management flag (as shown in Requirements/Limits column)
QL
Quantity limit indicator with values provided per product (e.g., QL=360 EA/30 Days)
Formulary requirement codes and QL examplesmixed
QL=30 EA/30 Days
Quantity limit 30 each per 30 days (example shown on many entries)
PA_NSO
Prior authorization indicator (as listed)
PA QL=2 ML/28 Days
Prior authorization with quantity limit 2 mL per 28 days (example for injectables such as REPATHA)
ST_NSO
Step therapy indicator (as listed)
INS
Insulin coverage designation (INS) used in REQUIREMENTS/LIMITS column
INS PA_BvD
Insulin prior authorization / billing designation (INS PA_BvD) present on some insulin entries
NDS PA QL=120 EA/30 Days
Non-standard designation with prior authorization and QL (example patterns shown in table)
Formulary control codes and sample QL entriesmixed
QL=2 ML/28 Days
Quantity limit example for REPATHA 140MG/ML (2 mL per 28 days)
QL=30 EA/30 Days
Quantity limit example used across multiple products (e.g., dapagliflozin)
QL=84 EA/28 Days
Quantity limit pattern used for certain antidotes/opioid antagonists
PA_BvD
Prior authorization annotation (PA_BvD) as shown in table rows
PA
Prior authorization annotation (PA) as shown in table rows
INVEGA SUSTENNA 234MG/1.5ML syringe (repeat of specified NDS limits)
Aristada quantity codesmixed
QL=3.90 ML/56 Days
ARISTADA 1064MG/3.9ML syringe limit
NDS QL=1.60 ML/28 Days
ARISTADA 441MG/1.6ML syringe limit
NDS QL=2.40 ML/28 Days
ARISTADA 662MG/2.4ML syringe limit
QL=2.40 ML/42 Days
ARISTADA 675MG/2.4ML syringe limit
QL=3.20 ML/28 Days
ARISTADA 882MG/3.2ML syringe limit
Formulary requirement/limit codes (examples)mixed
QL=3.90 ML/56 Days
Quantity limit for ARISTADA 1064MG/3.9ML SYRINGE
QL=1.60 ML/28 Days
Quantity limit for ARISTADA 441MG/1.6ML SYRINGE
QL=2.40 ML/28 Days
Quantity limit for ARISTADA 662MG/2.4ML SYRINGE
QL=2.40 ML/42 Days
Quantity limit for ARISTADA 675MG/2.4ML SYRINGE
QL=3.20 ML/28 Days
Quantity limit for ARISTADA 882MG/3.2ML SYRINGE
PA_NSO QL=90 EA/30 Days
OPIPZA/OPIPZA-like oral film requirement/limit example (PA_NSO QL shown)
Examples of NDS/PA requirement codesmixed
NDS PA QL=84 EA/28 Days
Example NDS PA quantity limit pattern (used for certain antidotes/opioid antagonists)
NDS PA QL=28 EA/28 Days
Example NDS PA quantity limit (used for some PREVYMIS entries)
NDS PA QL=120 EA/30 Days
Example NDS PA quantity limit (used for LIVTENCITY)
NDS QL=2 ML/28 Days
Example NDS syringe quantity limit (pattern used for peginterferon/other injectables)
Not applicable — formulary drug list (no CPT/HCPCS/ICD-10 codes present)mixed
No codes listed
Quantity limits — inhaled tobramycin and oral agent examples
Tobramycin inhalation solutionQL=280 ML/28 Days
Amikacin (example inhaled)examples include inhaled aminoglycoside QLs such as 280 mL/28 Days
Oral atomoxetine examplesatomoxetine 10mg cap QL=60 EA/30 Days; atomoxetine 100mg cap QL=30 EA/30 Days
Prior authorization, step therapy, documentation and denial risks
Prior Authorization
Prior authorization, step therapy, documentation and denial risks
Many drugs on the formulary require prior authorization (PA) or are subject to step therapy (ST), quantity limits (QL), and specialty dispensing rules (NDS, PA_NSO, PA_BvD). Providers must obtain required authorizations before dispensing PA-marked agents (Tiers 2–5 and many specialty/brand products) to avoid claim denials. High-cost biologics, specialty injectables, oncology agents, and select oral brand products are frequently coded with PA, PA_NSO, NDS PA, or PA_BvD and have specific QL or NDS dispensing limits that must be followed.
Prior authorization is required for many Tier 2–5 agents and select Tier 1 items when annotated with PA, PA_NSO, PA_BvD, or NDS PA.
PA_NSO indicates prior authorization required for new starts only; PA_BvD indicates Part B vs Part D determination/authorization may be required.
High-tier specialty and oncology oral agents commonly carry NDS PA or PA_NSO codes (examples: many kinase inhibitors, XTANDI, ROZLYTREK, RETEVMO).
Selected injectables and biologics require PA and have per-claim or per-period QLs/NDS limits (examples: DUPIXENT, FASENRA, NUCALA, XOLAIR, REPATHA, SKYRIZI, TRULICITY, MOUNJARO, OZEMPIC).
Topical testosterone products and other androgen preparations are PA and have QLs (e.g., topical testosterone gel: PA QL=300 GM/30 Days).
Step therapy indicators and related utilization edits
Coverage label
Summary
ST / ST_NSO
Some drugs are subject to step therapy (ST) or step therapy for new starts (ST_NSO); members must try specified alternative drugs first before the plan will cover an alternate drug.
Coverage label
Example notes from formulary
PA QL
Stimulant agents such as armodafinil are listed with 'PA QL=30 EA/30 Days' indicating prior authorization and a quantity limit, but explicit multi‑step sequences are not shown in the excerpt.
Coverage label
Formulary examples / implication
PA_NSO
Multiple anticonvulsant and specialty products (e.g., brivaracetam entries) are flagged 'PA_NSO' which implies prior authorization and/or step/authorization requirements for new starts prior to coverage.
Coverage label
Formulary entry / detail
ST_NSO
TRINTELLIX (5/10/20 mg) entries include 'ST_NSO QL=30 EA/30 Days', indicating step therapy for new starts may apply and a 30‑day quantity limit.
Coverage label
Implication for coverage
ST_NSO
TRINTELLIX lines repeat 'ST_NSO QL=30 EA/30 Days', signifying that step therapy for new starts may be required before coverage is approved.
Coverage label
Example
PA
REPATHA 140MG/ML auto‑injector and syringe are listed with 'PA QL=2 ML/28 Days', demonstrating a prior authorization requirement with a specified quantity limit as part of utilization management.
Coverage label
Formulary examples
PA_NSO / PA_BvD
Selected antineoplastic agents and related products include 'PA_NSO' or 'PA_BvD' annotations (for example, cyclophosphamide entries show PA_BvD), indicating prior authorization and program‑specific review before coverage.
Coverage label
Examples / implications
PA_NSO
Branded antipsychotic agents (e.g., COBENFY, CAPLYTA, INVEGA SUSTENNA, ARISTADA products) are designated with 'PA_NSO' and have QL/NDS values, indicating utilization management (prior authorization and quantity limits) for higher‑tier agents.
Coverage label
Formulary examples
PA_NSO
Higher‑tier transdermal patches and oral films (e.g., SECUADO patches and OPIPZA/OPIPZA films) are flagged with 'PA_NSO' and specific QL values, indicating step/authorization or other utilization controls apply.
Coverage label
Implication
PA / NDS
Some higher‑tier agents are listed with 'PA' or 'NDS' indicators requiring prior authorization or special dispensing before coverage; the excerpt does not detail explicit step sequences.
Coverage label
Note
ST implication
The document excerpt does not present explicit step‑therapy algorithms; tier assignments and flags (ST_NSO, PA, PA_NSO) imply preferred lower‑tier agents and utilization controls but specific step sequences are not shown in the provided text.
Itemized quantity limits by product (selected examples)
Simvastatin 80mg — prescription limit example
Simvastatin 80mg tablets per Rx30 tablets per prescription
ContextExample of a per-prescription/standard one-month supply limit shown in formulary overview
Follow-upCheck formulary row for additional PA/QL annotations when submitting claims
Atomoxetine quantity-limit examples
Atomoxetine caps (10–100 mg)QL=30–60 EA/30 Days depending on strength (e.g., 10mg QL=60; 100mg QL=30)
Reference examplesAtomoxetine 10mg cap QL=60 EA/30 Days; atomoxetine 100mg cap QL=30 EA/30 Days
Coverage setting and administration considerations
Documentation Required
Document setting/use (infusion center, outpatient, office, home) for Part B vs Part D decisions
For claims and PA submissions, providers must document site‑of‑care (infusion center, hospital outpatient, office, or home) and intended use when BvD or PA_BvD indicators are present so the plan can determine Part B vs Part D coverage.
Document the administration setting and clinical indication on the PA when BvD/PA_BvD appears.
This information is used to determine whether the drug is payable under Part B or Part D.
Documentation Required
Document intended administration setting for injectable biologics
Injectable products in the formulary are listed with dosing and QL values implying administration in appropriate settings (infusion center or similar); providers should document the intended administration setting when relevant to coverage determinations.
Abbreviations and formulary flags
Policy scope and purpose
Background: This formulary governs prescription coverage under the Senior Health Plan Part D. The document groups drugs by medical condition and lists each drug’s drug tier and any associated requirements or limits (for example PA and QL). It also describes exception and temporary coverage processes for members and notes that coverage is provided when a drug is on the formulary and is medically necessary and dispensed through network pharmacies.
Policy updates and review dates
2026-05-22last_reviewLatest
Document reviewed and last_review date recorded as 2026-05-22
2026version_year
Formulary identified as the 2026 Senior Health Plan Part D Prescription Drug Benefit
Policy Summary
PayerCommunity-Care
PolicySenior Health Plan Part D Formulary (Drug List) - Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material clinical or coverage changes in this revision.
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior authorization and provide supporting documentation when a drug is flagged with PA, PA_NSO, NDS or has a QL to avoid denial.
Quantity limits — multiple QL values by drug/strength
Common 30-day tablet QLQL=60 EA/30 Days (e.g., many oral agents such as COBENFY)
PA with elevated QL examplePA QL=180 EA/30 Days (droxidopa example)
NDS PA high-volume ML exampleNDS PA QL=240 ML/30 Days (EVRYSDI oral solution)
Standard 30-day and high-volume oral solution examples
Standard 30-day quantity limitQL=30 EA/30 Days
High-volume oral solution standardQL=600 ML/30 Days (example common for some solutions)
Alternate phrase exampleUse QL unit and period shown (EA/30 Days, ML/30 Days, GM/30 Days)
Oseltamivir 30mg cap and related influenza-agent limits
Oseltamivir 30mg cap (180-day limit)QL=84 EA/180 Days
Oseltamivir oral suspensionQL=540 ML/180 Days (oseltamivir 6mg/mL oral suspension)
Oseltamivir 75mg capQL=42 EA/180 Days
Some oral branded agents are flagged PA_NSO (e.g., DRIZALMA, FETZIMA, CAPLYTA) and require PA for new starts plus QLs.
Step therapy may apply (ST, ST_NSO) for certain agents — where indicated, initial trials of preferred drugs are required before coverage of non-preferred options (example: TRINTELLIX entries show ST_NSO).
Quantity limits are enforced as shown (EA/30 Days, ML/28 Days, etc.); exceeding listed QL requires supporting documentation for exception.
Biologics and long-acting injectables often include NDS and specific ML/EA per 28/30/56/365 day limits — dispense quantities must follow these limits (examples: NUCALA, XOLAIR, INVEGA SUSTENNA, ARISTADA).
Providers must submit the prescriber’s supporting statement when requesting exceptions; expedited (24-hour) decisions require prompt prescriber documentation.
For Part B vs Part D (BvD) drugs, documentation about the drug’s use and setting may be required to determine coverage and obtain PA_BvD authorization.
Failure to obtain required prior authorization or to adhere to NDS/QL/PA codes on claims may result in denial of coverage.
When requesting PA for biologics or specialty drugs, include dosing, frequency, quantity, and clinical rationale to support the requested quantity or an exception to QL/NDS limits.
Follow the formulary requirement/limit codes exactly on authorization requests and claims (PA, PA_NSO, PA_BvD, NDS, QL, ST, ST_NSO).
If prescribing a drug with PA_NSO or NDS indicators, note whether the request is for a new start and provide any required justification or prior-treatment history.
Providers should consult the formulary table for the specific PA and QL values per formulation and use those values when submitting claims or prior authorization requests.
Common denial risks: missing PA, exceeding QL without documentation, not following NDS limits, or not providing Part B vs Part D use details when required.
ActionUse the strength-specific QL when authorizing or submitting claims
Tobramycin inhalation solution and related inhalant QLs
Tobramycin inhalation solutionQL=280 ML/28 Days
Arformoterol/nebulizer solution examplesPA_BvD QL=120 ML/30 Days for selected nebulizer solutions (BREO/BREYNA-related rows)
Use noteObserve ML vs EA units when dispensing inhalation solutions vs inhalers
OLUMIANT and RINVOQ — QL and NDS/PA notes
OLUMIANT and RINVOQ typical QLQL=30 EA/30 Days for tablets; RINVOQ oral solution QL=360 ML/30 Days
NDS PA annotationThese entries show NDS PA alongside QL indicating non-extended supply and prior authorization
ActionFollow NDS and PA requirements when submitting authorizations
XELJANZ QL range by formulation
XELJANZ formulation-dependent QLsQL=30–300 ML/30 Days for oral solution or QL=60 EA/30 Days for tablets (varies by formulation)
NDS PA notedEntries include NDS PA alongside QL for several XELJANZ formulations
Claim guidanceSubmit QL and PA values exactly as listed for each formulation
Fentanyl patches and opioid QL examples
Fentanyl patchesQL=10 EA/30 Days (all listed strengths share same QL)