Gastrointestinal disorders — Ulcer disease drug formulary updates
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Formulary and utilization management changes for drugs used in upper gastrointestinal/ulcer disease (affecting pharmacy benefit coverage and management for Denver Health Medical Plan members). Applies to commercial clients as described in the document.
Omeprazole/sodium bicarbonate (generic) is listed with strengths 40-1680 mg in packet form, oral route, effective 01/01/2026.
Formulary/Access status and utilization management actions for upper gastrointestinal — ulcer disease were updated effective 01/01/2026.
ZEGALOGUE (dasiglucagon HCl) products (syringe and autoinjector) and GLUCAGON EMERGENCY KIT entries added with formulary/access designations.
Access status set to QL (quantity limit) for several hyperglycemics entries.
Client communication requirement: trial of BAQSIMI or GVOKE within past 120 days noted for Commercial/HIEX communications.
A quantity limit of 4 tablets per day was applied for commercial/HIEX.
Dextroamphetamine sulfate was added as a listed brand/generic with utilization management actions effective 01/01/2026.
Orphenadrine-aspirin-caffeine (25-385-30 tablet, oral) listed with utilization management and status indicators effective 01/01/2026.
Formulary/utilization status flags and action codes (e.g., 1, S=1, QL, PA) were applied to entries effective 01/01/2026.
Drug attributes were specified or updated for multiple hormone replacement products including estradiol patches and brand ALORA effective 01/01/2026.
Formulary actions and utilization management designations for pancreatic enzyme therapy (VIOKACE and alternatives) effective 01/01/2026; step trial of ZENPEP or CREON within 120 days noted.
Formulary utilization actions and status codes (QL, S=QL, NONE, A=ST, C=3, etc.) were assigned to multiple upper gastrointestinal disorder drug entries effective 01/01/2026.
Coverage Criteria and Access Designations
Formulary Access / Step Requirement
Covered when ALL of the following are met:
Effective 01/01/2026
Effective 01/01/2026
Formulary Utilization Actions
Formulary and utilization management designations (effective 01/01/2026):
Effective 01/01/2026
Specific clinical medical‑necessity criteria not provided in these chunks; follow UM flags for coverage determination.
Optional benefit and formulary exclusions are referenced in the rationale for upper gastrointestinal / ulcer disease entries and may affect coverage depending on client plan design. The document repeatedly shows fields for Optional Benefit Exclusion and Optional Formulary Exclusion (PFL/HIEX), but many of those fields are recorded as blank or as placeholders in the excerpt; where populated they reflect plan-level benefit designations rather than clinical medical-necessity determinations. Effective date for the listed entries is 01/01/2026.
The source text includes benefit exclusion flags for some gastrointestinal ulcer disease lines (noted as Benefit Exclusion = . in the rationale). This indicates an exclusion flag is present in the data export, but the excerpt does not provide product-level detail about which agents or member groups are specifically excluded.
Several entries show an access status of NONE for certain records in the rationale (for example, infectious-disease and miscellaneous drug lines). An access status of NONE indicates no formulary access is recorded for that channel and may prevent coverage unless otherwise overridden by plan policy.
The document lists Optional Formulary Exclusion (PFL/HIEX) categories in multiple therapeutic areas. One label used in the text is FDA Approved Non-Essential, and another optional benefit exclusion entry is recorded as Non‑Self Administered Drug (NSA) for some endocrine entries. These items reflect optional, plan-level exclusion categories rather than explicit clinical criteria.
The excerpt contains administrative and committee rationale (e.g., Clinical/Safety Strategy and P&T 3Q25) tied to formulary actions. Within this selection there are no explicit clinical exclusion statements; the content documents formulary action codes and committee decisions rather than detailed patient-level medical-necessity criteria.
Client communications include a quantity limit (QL) specification: the QL is recorded as limited to 4 tablets per day for affected entries. This quantity-limit instruction is part of the formulary actions effective 01/01/2026 and should be applied when evaluating dispensing or authorization requests.
For Commercial/HIEX channels the rationale explicitly documents a quantity restriction of 4 tablets per day. Requests for quantities exceeding this per-day limit are subject to utilization management and may be denied or require prior authorization per plan processes.
Optional benefit and formulary exclusion flags are present in the rationale and include categories such as FDA Approved Non-Essential. These flags are administrative indicators that certain products or therapeutic classes may be treated as optional exclusions under some client benefit designs; the excerpt does not map these flags to specific clinical scenarios.
Multiple entries include the optional exclusion fields (Optional Benefit Exclusion / Optional Formulary Exclusion), but many of those fields are left blank in the excerpt. The presence of blank fields indicates the template supports optional exclusions even when none are applied for the listed item.
Optional benefit or formulary exclusion fields are referenced throughout the rationale but in these chunks no explicit exclusion conditions (e.g., patient populations or diagnosis limits) are provided. That means an exclusion flag may be present administratively without accompanying clinical exclusion text in this excerpt.
Several rationale lines show optional exclusion fields as blank for upper gastrointestinal disorder entries. Where blanks appear, no optional benefit/formulary exclusion was recorded in the source fragment for that product entry.
Some formulary action entries within the GI sections are set to NONE, indicating that no specific formulary action (for example, substitution, step, or other managed action) is recorded for those entries in the excerpt. This is an administrative status rather than a clinical exclusion statement.
In the provided fragments, multiple optional exclusion fields remain empty (recorded as blank). The absence of values means no optional benefit exclusion or optional formulary exclusion was applied in those particular entries.
Optional benefit/formulary exclusions are shown in the data structure and one recurring category is labeled FDA Approved Non-Essential. This label signals an optional exclusion classification used by the formulary team; application depends on client benefit design and is administrative in nature.
Optional Benefit Exclusion entries in the rationale include entries such as Non‑Self Administered Drug (NSA). These denote categories by which a plan may optionally exclude coverage for certain administrations or product types; specifics about affected products or members are not provided in the excerpt.
The excerpt does not include explicit not medically necessary (NMN) language for the GI / ulcer disease entries. Where utilization actions are recorded (e.g., NONE or QL), they are administrative formulary designations and the text does not state a medical‑necessity determination in these chunks.
Across the provided chunks there are no statements explicitly phrasing coverage as not medically necessary. The rationale focuses on formulary status, optional exclusion flags, and utilization actions without NMN language in these fragments.
Some entries indicate actions as NONE or leave action fields blank; however, the source fragments do not provide explicit not medically necessary statements tied to those entries. The administrative status may reflect no specific action rather than a clinical denial rationale.
Drug Attributes, Codes, and Limits
| N/A | Oral tablet route; strengths listed 10.4-39.2K and 20.9-78.3K (units as in document) |
| Status=2 | Formulary status code referenced for certain dermatology items |
| QL | Quantity limit flag |
| S=QL | Site-specific quantity limit or special quantity limit |
| Q L ST / S=ST | Quantity limit with step therapy / special step therapy indicators |
| C=3 | Formulary classification code C=3 |
| 3 | Formulary Current Status = 3 (status code referenced in document) |
| C=E | Action shorthand 'C=E' referenced as a formulary/utilization action |
| PAG | Action shorthand 'PA' or 'PAG' referenced as utilization action (shorthand present) |
Provider-Facing Utilization Management and Documentation Guidance
PA/UM referenced
Prior authorization (PA) and other utilization management actions are referenced in the UM legend and throughout the formulary changes; providers should anticipate PA, ST, QL, and AGE controls may apply even though specific PA code lists are not shown in this excerpt.
- UM legend defines PA, ST, QL, AGE and related action codes.
- Rationale notes reference PA/PAG and other UM actions across formulary entries.
Quantity limit (QL) / formulary access
Several hyperglycemic/rescue product entries are assigned a Current Status = QL and client communications specify QL-based access effective 01/01/2026; providers must follow quantity-limit controls for these products.
- Multiple hyperglycemics entries list Current Status = QL (effective 01/01/2026).
- Client communication: QL limited to 4 tablets per day (Commercial/HIEX) where specified.
Utilization management for select antihypertensives
Selected antihypertensive agents are assigned utilization management statuses (QL and ST) indicating quantity limits and/or step requirements may apply beginning 01/01/2026.
- Entries for cardiovascular — hypertension show Status = QL ST and action codes including D=QL/D=ST/A=PA.
- P&T committee rationale (3Q25) accompanies these UM changes.
Prior authorization/quantity limit designation
Endocrine-category drug entries include QL status and action flags such as D=QL and A=PA, indicating quantity limits and possible prior authorization requirements effective 01/01/2026.
- Current Status = QL recorded for endocrine disorder entries.
- Action flags include D=QL and A=PA (implying QL with associated PA actions).
Prior authorization and committee action (no codes listed)
Committee (P&T) actions and commercial clinical/safety strategy are cited as the rationale for changes, but this excerpt does not provide a specific list of drugs tied to explicit PA codes — providers should check the plan formulary for PA code details.
- Rationale references P&T committee actions (2Q25 / Ad-Hoc Formulary Maintenance) driving formulary decisions.
- No explicit PA code list is provided in the cited chunks.
Formulary utilization management
Formulary status and utilization management action codes (QL, S=QL, PA, ST) are applied across entries effective 01/01/2026; providers must follow the effective date when submitting requests.
- Formulary actions show effective date 01/01/2026 for UM changes.
- Action codes (e.g., QL, S=QL, PA, ST) are present and govern coverage rules.
Prior authorization / quantity limits
Some formulary entries explicitly show prior authorization (PA) or quantity limit (QL) actions effective 01/01/2026; where an action code indicates PA or A=QL/D=PA, prior authorization may be required.
- ActionGLYPH entries include D=PA, A=QL and related flags.
- Effective date for these PA/QL designations is 01/01/2026.
Formulary status implies utilization management
Hormone deficiency products include formulary status values (e.g., status = 2 or C=3) and QL/S=QL action flags effective 01/01/2026; these status codes imply utilization management controls that providers must observe.
- Current Status values shown (2, C=3) for hormonal deficiency category.
- ActionGLYPH entries include QL and S=QL applied to these products.
Utilization management may require prior authorization
Quantity limits (QL) and site-special quantity limits (S=QL) are applied to products effective 01/01/2026 and may be enforced at pharmacy dispensing or via prior authorization processes.
- UM actions such as QL and S=QL are recorded for multiple entries.
- These controls may require PA or limit dispensing quantities at the pharmacy.
Formulary utilization actions (possible PA/limits)
Pancreatic enzyme (upper GI) entries are assigned utilization actions including QL, S=QL, NONE, or A=ST effective 01/01/2026; providers should follow these actions when seeking coverage.
- Entries list possible actions: QL, S=QL, NONE, A=ST for pancreatic enzyme products.
- Effective date for these UM designations is 01/01/2026.
Utilization management status codes
Utilization management flags such as QL and ST are repeatedly used across the formulary; expect quantity limits and step edits to be enforced for affected products effective 01/01/2026.
- Entries include combinations like QL ST, S=QL S=ST and status C=3.
- These flags are effective 01/01/2026 and indicate UM enforcement.
Prior authorization / utilization status
Some entries show Current Status = 2 with Action = NONE for lower GI (e.g., mesalamine/PENTASA), indicating managed status but no specific UM action recorded in the snippet — check the full formulary for PA requirements.
- Mesalamine 250 mg ER oral: route and strength recorded; Current Status = 2.
- ActionGLYPH = NONE appears for some lower GI entries despite managed status.
Formulary utilization actions
Action flags across the formulary include QL, S=QL, and S=ST (effective 01/01/2026); these indicate quantity limits and step therapy mechanisms that may affect coverage.
- Multiple entries use S=QL and S=ST shorthand.
- Providers should anticipate these as enforcement mechanisms tied to formulary status.
Prior authorization may be required
Formulary entries with status codes (e.g., status '3' and actions like C=E) are assigned utilization actions that may require prior authorization depending on the assigned action; providers should verify PA requirements for status '3' items.
- Current Status = 3 and action C=E are used in rationale entries.
- PA may be required where the assigned action indicates a change/exclusion.
Formulary actions / utilization management
Endocrinology-related formulary flags include PAG/C=PA style shorthand and other UM statuses effective 01/01/2026, suggesting prior authorization or other utilization controls may apply to endocrine drugs.
- Action flags include PAG, C=PA and PAGLYPH-related entries.
- Effective date for these flags is 01/01/2026.
Step therapy referenced
Step therapy (ST/HST) is defined in the UM legend and included in the utilization management legend; providers should expect step edits may apply to affected agents.
- UM legend explicitly defines ST (Step Therapy) and HST (Hard Step).
- Step therapy is included among UM actions that govern coverage.
Step/Trial requirement
Client communications for Commercial/HIEX lines specify a required trial of BAQSIMI or GVOKE within the past 120 days for certain hyperglycemics/rescue products; providers must document that trial in submission materials.
- ST: TRIAL OF BAQSIMI OR GVOKE IN THE PAST 120 DAYS (effective 01/01/2026).
- Applies to hyperglycemics entries per client communication notes.
Step/clinical strategy referenced
P&T and committee rationale entries reference clinical/safety strategy and placement decisions that may include step edits; providers should be aware these committee decisions informed the UM changes.
- Rationale cites Clinical/Safety/Trade strategy and P&T actions (2Q25/3Q25).
- Committee decisions drove formulary placement and potential step edits.
Step therapy (none stated)
This excerpt contains no explicit universal step therapy rules beyond the specific trial requirements noted; providers must rely on product-level formulary details for step edits.
- Multiple chunks state 'no explicit step therapy requirements' in this excerpt.
- Product-level client communications are the authoritative source for any step edits.
Clinical/Safety Strategy and P&T decisions imply formulary management; no concrete step rules present
Committee clinical/safety strategy and P&T decisions imply formulary management changes, but the excerpt does not list concrete step-therapy rules for providers to follow; check the full formulary guidance.
- Ad-Hoc Formulary Maintenance and P&T rationale noted as drivers of changes.
- No concrete step-therapy rules are provided in the snippet.
P&T committee decisions
P&T committee actions (noted as 3Q25) are recorded as the rationale for some formulary updates; providers should treat these committee decisions as the basis for UM changes effective 01/01/2026.
- Committee actions referenced include P&T 2Q25 and 3Q25 in the rationale.
- These actions support the effective-date UM assignments.
Step therapy
This section does not include explicit step therapy language for the majority of items; product-specific client communications must be consulted for any step requirements.
- Multiple indications that no explicit step therapy requirements are present in these chunks.
- Check product-level formulary entries for exceptions.
Formulary committee actions
Formulary committee actions note ad-hoc maintenance and commercial strategy as drivers of updates; clinicians should anticipate formulary placement or managed-entry decisions may change coverage mechanics.
- Rationale cites Ad-Hoc Formulary Maintenance and trade relations strategy.
- These committee actions underlie UM and placement decisions.
Step trial of Zenpep/Creon
Client communications for pancreatic enzyme products require a trial of ZENPEP or CREON in the past 120 days for Commercial/HIEX coverage considerations; providers must document that prior trial when requesting coverage.
- ST: TRIAL OF ZENPEP OR CREON IN THE PAST 120 DAYS (applies to upper GI / pancreatic enzyme entries).
- Effective date for this client communication is 01/01/2026.
Step therapy: trial required
Commercial communications require prior trial of alternative pancreatic enzyme products (ZENPEP or CREON) within 120 days for certain entries; failure to document this trial may lead to non-preferred coverage or UM action.
- Client communication: ST = trial of Zenpep or Creon within 120 days.
- Applies to upper GI pancreatic enzyme formulary actions effective 01/01/2026.
Formulary action notes
Some formulary action entries are set to 'NONE', indicating no substitution or UM action recorded for those items in the excerpt; providers should not assume absence of restrictions without checking the full formulary.
- ActionGLYPH = NONE recorded for certain lower GI entries.
- Absence of an action in this excerpt does not guarantee lack of coverage controls.
Step therapy indicators
Status code C=3 and ST qualifiers are referenced for some items, suggesting staged step therapy or step-staging rules may exist; providers should verify item-level requirements before prescribing.
- Current Status = C=3 and Action = QL ST appear in rationale entries.
- ST qualifiers indicate possible staged step edits tied to status C=3.
Potential age/quantity limits
Some action descriptors include 'AGE QL', implying age or quantity restrictions may apply; providers should confirm age-based limits when submitting requests for affected drugs.
- ActionGLYPH = AGE QL recorded for select entries (effective 01/01/2026).
- Indicates age-based quantity limit control may be enforced.
Quantity limits and step therapy flags
Combined action codes (e.g., QL ST; S=QL S=ST) indicate both quantity limits and step therapy controls are applied to certain diabetes-related entries effective 01/01/2026; providers must meet both constraints as applicable.
- Entries show Current Status = S=3 and actions = QL ST or S=QL C=ST.
- These combined flags indicate concurrent QL and step therapy enforcement.
UM documentation expectations
Providers should submit documentation consistent with formulary/UM actions (age limits, quantity limits, step therapy trials, prior authorization) as defined in the UM legend and client communications.
- UM legend defines AGE, QL, ST, PA and related actions — documentation should reflect applicable controls.
- Client communications set effective date 01/01/2026 for these requirements.
Required documentation elements
When prior trial requirements apply (e.g., BAQSIMI/GVOKE or ZENPEP/CREON), document the brand/generic product, formulation, and the prior trial date/window (120 days) in authorization requests.
- Client communications require a trial within the past 120 days where noted.
- Include product name, formulation, and trial evidence when submitting requests.
Client communication / trial history
Commercial/HIEX client communications explicitly require evidence of a trial of BAQSIMI or GVOKE within the prior 120 days for affected hyperglycemics entries; providers must include this trial history for coverage consideration.
- ST: TRIAL OF BAQSIMI OR GVOKE IN THE PAST 120 DAYS is specified for hyperglycemics (effective 01/01/2026).
- Documented trial evidence should be submitted with requests.
Committee actions and clinical/safety strategy (informational)
Committee rationale (P&T 3Q25) and clinical/safety strategy are noted as supporting the formulary changes, but these chunks do not specify additional provider submission steps beyond standard UM documentation.
- P&T committee rationale recorded as the basis for changes.
- No extra provider-facing submission requirements specified in these chunks.
Formulary utilization management — status and actions effective date
Administrative notes repeatedly state the effective date of 01/01/2026 for the listed formulary and UM changes; providers should reference this date when preparing PA requests or documentation.
- Multiple chunks indicate Effective: 01/01/2026 for UM and formulary actions.
- Use the effective date when determining which rules apply to a request.
Quantity limit documentation
Document the prescribed quantity to respect QL controls — client communications indicate a quantity limit of 4 tablets per day for specified entries; exceeding this limit may prompt UM review or denial.
- QL: LIMITED TO 4 TABLETS PER DAY (Commercial/HIEX) noted in client communications.
- Requests over the stated QL are subject to utilization management enforcement.
Document status/action codes
When submitting authorization requests, include any applicable formulary status and utilization action codes (e.g., 1, S=1, QL, PA, C=QL) as shown on the formulary entries to support processing.
- Formulary status/action codes are recorded in the rationale and should be referenced on requests.
- Including these codes helps align requests with the formulary's UM logic.
Documentation / committee rationale
The P&T rationale and committee notes are included for context but do not list explicit provider documentation requirements beyond recording product attributes and prior trials where indicated.
- Rationale entries reference P&T and committee decisions as justification.
- Providers should follow product-specific documentation expectations rather than the committee text itself.
Required product identification
Include brand and generic product identifiers (e.g., ALORA / Estradiol) plus route and strength when submitting claims or prior authorization requests so the formulary entry can be matched accurately.
- Client communications record brand/generic identifiers for clarity in submissions.
- Provide product name, route, and strength to align with formulary records.
Drug strength and route documentation
Record tablet strength and route for prescriptions where strength ranges are listed (examples: 10.4-39.2K and 20.9-78.3K tablets, oral); include these details in UM/PA submissions.
- Strength/dosage ranges are documented in the rationale for upper GI entries.
- Route indicated as oral tablet — include this on requests.
Prior trial documentation
Document prior trial of ZENPEP or CREON within the prior 120 days for Commercial/HIEX members where the client communication specifies this requirement; absence of this documentation may result in adverse formulary action.
- Client communication: ST = trial of Zenpep or Creon in past 120 days (effective 01/01/2026).
- Submit trial evidence with authorization requests for affected pancreatic enzyme products.
Required drug attribute documentation
Include formulation, strength, and route for mesalamine (PENTASA 250 mg ER oral) in documentation used for benefit determination and any UM/PA requests.
- Mesalamine 250 mg ER capsule, route = oral is recorded in the rationale.
- Provide these drug attributes when requesting coverage or PA.
Drug attribute documentation
Drug attribute details (e.g., KLISYRI / tirbanibulin 1% ointment topical) are captured in the formulary rationale; include these attributes in claims or prior authorization submissions for accurate processing.
- KLISYRI (tirbanibulin) 1% ointment topical recorded with effective date 01/01/2026.
- Include strength and route in submission materials.
Formulary actions / utilization management — effective date
Multiple chunks reiterate the effective date 01/01/2026 for the formulary and UM changes; ensure documentation and prior authorization submissions reference the effective-date rules.
- Effective: 01/01/2026 noted throughout the rationale.
- Use the effective date to determine applicable UM and coverage rules.
Formulary status documentation
Formulary status entries (e.g., Current Status = 4; S=4) are recorded and may affect documentation requirements — providers should verify formulary rules for the specific status code before submitting a request.
- Current Status values (e.g., 4, S=4) appear in endocrine-related entries.
- Confirm status-driven documentation expectations on the full formulary.
UM enforcement implied
Formulary and UM legend changes indicate UM enforcement is implied (PA/ST/QL); failure to obtain required prior authorization or to follow step/quantity limits may lead to coverage denial.
- Legend and rationale reference PA, ST, QL as enforceable UM actions.
- Lack of required PA or failure to meet step/QL conditions risks denial.
Prior trial requirement
Failure to document a trial of BAQSIMI or GVOKE in the past 120 days, when required by client communication for hyperglycemics entries, may result in denial for Commercial/HIEX members.
- ST: TRIAL OF BAQSIMI OR GVOKE IN THE PAST 120 DAYS specified for certain entries.
- Document prior trial evidence to avoid denial risk.
Access status may block coverage
Access status entries show some items as 'NONE'; if an item has Access = NONE for a given channel, coverage requests for that item may be denied.
- Current Status = NONE is used for some infectious disease and miscellaneous drug entries.
- Access = NONE indicates lack of formulary access in the cited channel and may block coverage.
Formulary access restrictions (informational)
Several entries indicate Access = NONE or NONE/HIEX for Commercial/HIEX channels, implying lack of formulary access in those channels; providers should verify channel-specific access before prescribing.
- Chunks record Current Status = NONE for cardiovascular and miscellaneous categories.
- NONE/HIEX access status suggests unavailability for certain client channels.
Quantity limit
A communicated quantity limit of 4 tablets per day applies to specified entries; exceeding this QL risks denial or will trigger utilization management review.
- Client Communication: QL limited to 4 tablets per day (Commercial/HIEX).
- Submitting requests above this limit may be denied or subject to UM.
Quantity limit enforcement
Requests that exceed documented quantity limits (e.g., 4 tablets/day for affected entries) risk denial or will be subject to utilization management enforcement per the formulary action codes.
- Explicit QL = 4 tablets/day recorded in client communications.
- Exceeding the QL may necessitate PA or lead to noncoverage.
Utilization management triggers
Presence of utilization management actions such as QL, S=QL, and status codes (C=E, C=3) indicates claims may be managed or denied if utilization limits or status conditions are not met; providers should ensure submissions address these controls.
- UM flags (QL, S=QL, C=3, C=E) appear across multiple entries.
- Claims not meeting UM conditions may be denied or require PA.
Utilization management enforcement
Prescriptions subject to utilization management actions (QL, S=QL) may face coverage limits or prior authorization enforcement; providers should document justification and prior trials where applicable to reduce denial risk.
- Action flags S=QL and QL ST indicate both quantity and step controls.
- Documenting adherence to these controls supports coverage determination.
Prior trial requirement noted
Failure to document a trial of Zenpep or Creon within the past 120 days for applicable pancreatic enzyme entries may trigger UM communication or denial for Commercial/HIEX members.
- Client communication: ST = trial of Zenpep or Creon in past 120 days.
- Lack of trial evidence may result in adverse formulary action.
Prior trial communication
If a required trial of ZENPEP or CREON within 120 days is not documented for Commercial/HIEX members, the member may receive non-preferred coverage or the request may be denied per formulary rules.
- Client communications explicitly set ST: TRIAL OF ZENPEP OR CREON IN THE PAST 120 DAYS.
- Document trial history to avoid adverse formulary decisions.
Managed status indicator
A Current Status = 2 for bowel inflammatory disorder entries indicates a managed status that may require UM controls; providers should verify whether PA or other controls apply for these items.
- Mesalamine/bowel inflammatory disorders list Current Status = 2.
- Managed status commonly triggers UM review per formulary processes.
Potential denial triggers from formulary status
Formulary utilization management statuses (for example status = 2) may trigger standard prior authorization or coverage rules according to plan processes; providers should confirm applicable plan-level PA rules.
- Multiple entries cite status values (2, 3, C=3) tied to UM actions.
- Verify plan-specific PA/coverage rules for items with these statuses.
Formulary exclusion risk
An optional formulary exclusion labeled 'FDA Approved Non-Essential' is recorded in the rationale; if applied, this optional exclusion can result in exclusion-based denial if the client benefit excludes that category.
- Optional Formulary Exclusion = FDA Approved Non-Essential noted in rationale.
- Coverage depends on client benefit design; exclusions may lead to denial.
Optional benefit exclusion noted
Certain endocrinology entries list Optional Benefit Exclusion = Non-Self Administered Drug (NSA); where the client benefit applies this exclusion, claims may be denied for benefit reasons.
- Optional Benefit Exclusion = Non-Self Administered Drug (NSA) recorded for endocrine category.
- Apply plan benefit verification to determine whether exclusion leads to denial.
Policy Background and Scope
Background: this section documents formulary and utilization management updates for drugs used in upper gastrointestinal / ulcer disease and related categories. Changes were reviewed and recorded with an effective date of 01/01/2026; the rationale entries include formulary status flags (e.g., QL) and client communications that may impose step or trial requirements for certain products.
Definitions, Drug Attributes, and Administrative Notes
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