Formulary and Prior Authorization Guidelines for Outpatient Drugs
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Governs the Denver Health Medical Plan Elevate outpatient pharmacy formulary, including tier definitions, prior authorization, generic substitution, exclusions, and medication request processes for members and providers.
No material clinical or coverage changes in this revision.
Formulary Coverage & Prior Authorization Rules
Formulary Coverage and Prior Authorization
Covered outpatient medications are listed on the formulary; use of FDA‑approved generics is required when available. Prior authorization (PA) applies where the formulary Notes indicate and requests are reviewed per P & T guidelines.
Member may be required to pay the cost difference if a brand is requested without documented medical need.
Fax PA requests to DHMP Pharmacy Department at (303) 602-2081 or contact (303) 602-2070; denied requests may be appealed with supporting medical necessity documentation.
Nasal antihistamine-steroid combination coverage
Nasal antihistamine–intranasal steroid combination products are covered when tiering, step therapy, and quantity limits shown on the formulary are satisfied.
Dymista status and tier vary by presentation; ST and QL noted on formulary.
See QNASL/XHANCE/ZETONNA entries for analogous ST and QL examples.
Dronabinol and related agents
Dronabinol and related cannabinoid antiemetics are subject to step therapy and quantity limits as specified on the formulary.
Syndros notes also reference prior generic dronabinol or megestrol when ST is indicated.
Inhaled bronchodilators and anticholinergics
Inhaled bronchodilators and anticholinergics are covered per formulary tiering; certain agents require step therapy or have quantity limits.
Tier assignment and QL vary by product; see product Notes for exact QL values.
Failure to meet ST or exceed QL may trigger denial or PA per formulary guidance.
Formulary listing with utilization controls
Formulary line items include tier placement and utilization controls (PA, ST, QL); providers must follow product‑specific Notes.
Examples: Brovana ST requiring prior Perforomist/Serevent/Striverdi within 120 days; many biologics and mAbs marked PA.
Coverage with utilization controls
Medications are assigned to tiers and may be subject to utilization controls as noted per product entry.
Examples include EMSAM (ST with prior MAOI), AUVELITY/VIIBRYD (ST with prior antidepressant trials), and multiple entries with QL values.
Formulary coverage with utilization management
Coverage is tiered and numerous agents are subject to step therapy, prior authorization, and quantity limits per product Notes.
Many sedative‑hypnotic entries also include QL (commonly 1 EA per day).
PA annotation appears in product Notes.
Formulary coverage rules (excerpt)
Formulary coverage by tier includes explicit utilization management flags (PA, ST) and quantity limits where specified.
Tier shown per product line.
PA requests reviewed according to P & T guidelines.
See individual product entries for required comparators and look‑back period.
Exact QL values are listed per product in the formulary.
Step Therapy / Prior prescription criteria
Step therapy requires prior trials of specified alternative therapies before coverage of higher‑tier or branded specialty agents.
Specialty biologics and PCSK9 inhibitors may have chained ST requirements.
Prior Authorization criteria
Prior authorization is required for many specialty, high‑cost, and select pulmonary agents as noted on the formulary.
PA annotation appears next to many specialty agents and formulations.
Quantity limits
Quantity limits (QL) are applied to many products and must be observed; some products have concurrent PA or ST requirements.
Prescribers/pharmacies must document and adhere to QL when dispensing; exceeding QL may require PA or be denied.
Formulary coverage entries
Selected formulary coverage entries (contraceptives, devices, dermatology, cough products) illustrate tier/status and product‑specific restrictions.
Status = PREV appears throughout contraceptive entries.
Age and QL must be documented at dispensing.
See ACANYA entry for explicit ST requirement.
The formulary identifies several over-the-counter (OTC) exclusions. Specifically, OTC medications or their equivalents are not covered unless listed on the formulary. Other general non‑covered categories include dietary supplements, drugs used for cosmetic purposes (e.g., anti‑wrinkle, hair removal/growth), blood or plasma products (except anti‑hemophilic factors), pigmenting/de‑pigmenting agents, infertility and weight‑loss drugs, most therapeutic devices or appliances (with the exception of formulary diabetic monitoring supplies), investigational/experimental treatments, drugs explicitly listed as not covered, and foreign‑sourced non‑FDA drugs except where permitted for shortages. Providers are encouraged to contact the plan for alternatives when a need is not met by the formulary.
Within the provided extract there are no explicit blanket exclusions stated beyond the general exclusions section. The segment presents product listings, tier assignments, and utilization annotations (e.g., PA/ST/QL) but does not enumerate additional universal exclusion categories in this portion of the document.
This extract does not contain explicit therapeutic‑class exclusions. Drug entries include tiering, quantity limits, and utilization controls (for example, QL and PA flags) but no statements removing whole therapeutic classes from coverage are present in these chunks.
No explicit clinical exclusions (conditions or diagnoses for which drugs are categorically not covered) are documented in this portion of the formulary. The content focuses on product‑level status, tier placement, PA/ST/QL notes and related dispensing limits rather than clinical exclusion rules.
In the provided contraceptive and device listings there are no explicit exclusion conditions described. Entries instead emphasize product status flags (many showing Status = PREV) and associated quantity‑limit (QL) notes where applicable, rather than stating exclusion criteria.
These chunks do not contain explicit coverage exclusions. The material details specific contraceptive product listings, tier/status annotations and quantity‑limit examples (e.g., QL 91 EA per 84 days), but does not present additional exclusion language in this excerpt.
There are no explicit coverage exclusions in these contraceptive product listings. The entries predominantly show Status = PREV for many products and occasionally list QL notes (for example, 28‑ or 91‑day pack limits), but do not state that products are not covered on clinical or medical necessity grounds in this extract.
This portion of the formulary does not include explicit not medically necessary determinations. The emphasis in the extract is on tier assignments, utilization controls (Step Therapy/PA/QL) and product‑level notes rather than explicit statements that specific treatments are not medically necessary.
No explicit not medically necessary rules appear in this segment. Instead, the document lists product‑level utilization controls (e.g., step therapy prerequisites, quantity limits, and PA flags) and describes the documentation and prior‑therapy requirements used to adjudicate coverage.
These chunks do not state explicit not medically necessary policies. Coverage language in this portion centers on tiering, quantity limits (for example, QL = 1 EA per 1 day for some products), and PA/QL annotations rather than categorical noncoverage statements.
Formulary Items & Coding References
| NDC/HCPCS not listed | Formulary entries list product names and strengths; no explicit CPT/HCPCS/ICD codes provided in this segment |
| Formulary line items | Product names and tiers shown (e.g., GRASTEK, ODACTRA, ORALAIR, PALFORZIA) but no explicit billing codes provided in these chunks |
| NDC/Label-level not provided | Product-level entries listed with strengths and forms (e.g., INVEGA SUSTENNA, UZEDY, VERSACLOZ) but no explicit CPT/HCPCS/NDC values in these chunks |
| eprosartan 600 mg | eprosartan oral tablet 600 mg |
| irbesartan 150 mg, 300 mg, 75 mg | irbesartan oral tablet strengths listed |
| losartan 25 mg, 50 mg, 100 mg | losartan oral tablet strengths listed |
| olmesartan 5 mg, 20 mg, 40 mg | olmesartan oral tablet strengths listed |
| telmisartan 20 mg, 40 mg, 80 mg | telmisartan oral tablet strengths listed |
| valsartan 40 mg, 80 mg, 160 mg, 320 mg | valsartan oral tablet strengths listed |
| clonidine patch 0.1, 0.2, 0.3 mg/24 hr | clonidine transdermal patch strengths listed |
| clonidine oral 0.1 mg, 0.2 mg, 0.3 mg | clonidine oral tablet strengths listed |
| guanfacine 1 mg, 2 mg | guanfacine oral tablet strengths listed |
| methyldopa 250 mg, 500 mg | methyldopa oral tablet strengths listed |
| FUROSCIX SUBCUTANEOUS KIT 80 MG/10 ML | Furosemide subcutaneous kit |
| LASIX ORAL TABLET 20 MG, 40 MG, 80 MG | Furosemide oral tablet |
| ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG | Spironolactone oral tablet |
| REMODULIN INJECTION SOLUTION 0.4 MG/ML | Treprostinil injection solution |
| TYVASO DPI INHALATION CARTRIDGE 16 MCG | Inhaled treprostinil cartridge |
| PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML | Alirocumab (Praluent) |
| REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML | Evolocumab (Repatha) |
| QL (28 EA per 30 days) | Quantity limit example noted for methylergonovine and others |
| QL (30 ML per 1 day) | Quantity limit example for several syrups (e.g., promethazine-codeine) |
| Age (Min 18 Years) | Minimum age restriction for selected antitussive/narcotic products |
| QL (10 ML per 1 day) | Quantity limit example for hydrocodone-chlorpheniramine |
| FL: 10 DAYS' SUPPLY PER FILL | Florida-specific fill limit noted for TUXARIN ER |
Prior Authorization, Step Therapy & Documentation Requirements
Obtain Prior Authorization for PA‑flagged agents
Submit a Prior Authorization request when a drug line is marked “PA”; each request is reviewed against MedImpact P & T Committee guidelines and must meet those criteria for approval.
- PA requires a specific physician request process prior to dispensing.
- If the request does not meet P&T guidelines it will not be approved and an alternative may be recommended.
PA required for select allergen immunotherapy/specialty agents
Obtain Prior Authorization for listed allergen immunotherapy and specialty products (e.g., Grastek, Odactra, Oralaire, Palforzia) before dispensing—these products are designated Notes = PA.
- Examples: GRASTEK, ODACTRA, ORALAIR, multiple PALFORZIA levels are noted as PA in the formulary.
Follow PA/ST flags on specific products
When a product’s Notes show ST or PA (for example Brovana, Perforomist, Serevent, Striverdi), obtain prior authorization or document required step‑therapy evidence prior to filling.
- Brovana: ST requires prior prescription for Perforomist, Serevent, or Striverdi within past 120 days.
- Multiple inhaled/ICS products list ST or PA in Notes; follow the specific product note.
Do not dispense PA‑designated products without approval
Obtain prior authorization when Notes = PA on listed products such as EMSAM patch and other named agents; do not dispense without plan approval when PA is indicated.
- EMSAM patch: Notes = ST/PA as specified (example shows ST requirement for prior MAOI within 120 days).
- Products shown with Notes = PA must have PA submitted per plan process.
Meet ST/PA requirements for stimulant and antipsychotic products
For agents marked ST or PA (examples include certain stimulant and antipsychotic formulations), document prior comparator prescriptions or obtain PA before coverage.
- DYANAVEL XR / XELSTRYM: ST requires prior prescription for Azstarys or Jornay PM within 120 days.
- OPIPZA: ST requires prior generic aripiprazole within past 120 days.
Prior authorization required for listed CNS agents
Submit PA for agents explicitly noted as PA (examples: LYBALVI, HETLIOZ, SUNOSI, ADDYI) and await plan decision before dispensing.
- LYBALVI, HETLIOZ, SUNOSI, ADDYI are listed with Notes = PA in the formulary.
PA required for selected sleep/CNS products
Obtain prior authorization for products designated PA in Notes (for example IGALMI sublingual film, QUVIVIQ) before dispensing.
- IGALMI and QUVIVIQ are specifically annotated Notes = PA.
PA required for select cardiac/digitalis formulations
When digitalis/digoxin presentations list Notes = PA, submit prior authorization per plan requirements before dispensing those formulations.
- Digoxin tablets/solutions have Notes indicating PA for certain presentations.
Obtain PA for listed antihypertensive/alpha‑blocker agents
Submit prior authorization for products whose Notes = PA (examples: phenoxybenzamine/Dibenzyline, VECAMYL) as indicated in the formulary before coverage will be granted.
- DIBENZYLINE (phenoxybenzamine) and VECAMYL are listed with Notes = PA.
Adhere to specified quantity limits (COREG CR example)
Observe quantity limits when dispensing (example: COREG CR ER capsule has QL = 1 EA per 1 day); obtain PA if dispensing would exceed QL.
- COREG CR (carvedilol phosphate ER) Notes = QL (1 EA per 1 day).
Obtain PA and satisfy ST prerequisites where indicated
When a drug line is marked PA or ST, submit PA and/or document prior therapy evidence per the Notes—providers must obtain PA when Notes indicate 'PA' and comply with ST when 'ST' is specified.
- Providers must obtain prior authorization when the formulary Notes designate 'PA'.
- Providers must document prior prescriptions when Notes designate 'ST'.
PA required for numerous listed drugs
Submit prior authorization for multiple drugs marked PA in the formulary; do not assume coverage without plan approval when Notes include PA.
- Numerous listed drugs are annotated with Notes = PA and require PA prior to coverage.
Submit PA for select high‑tier specialty agents
Prior authorization is required for high‑tier specialty agents (examples: CAMZYOS, ATTRUBY, VYNDAMAX, VYNDAQEL, VERQUVO); submit PA per plan process before dispensing.
- CAMZYOS, ATTRUBY, VYNDAMAX, VYNDAQEL, VERQUVO are each shown with Notes = PA.
Prior authorization required for NORTHERA (droxidopa)
NORTHERA (droxidopa) and listed formulations are designated Notes = PA—submit a prior authorization request before dispensing.
- Droxidopa (NORTHERA) entries include Notes = PA.
No explicit PA shown for listed contraceptives in this excerpt
This extract does not list explicit PA requirements in the shown contraceptive section; follow general PA/ST guidance elsewhere in the formulary when Notes indicate a restriction.
- Most contraceptive entries in this excerpt are marked Status = PREV; PA is not specified in these chunks.
Follow PA process when status/Notes elsewhere require it
Product statuses and quantity‑limit notes are shown in this excerpt without explicit PA for those specific NDCs—follow plan PA processes when PA is indicated elsewhere in the formulary.
- Where Notes do not explicitly state PA, use standard prior authorization channels if coverage requires PA per other sections.
Document prior generic clindamycin/BP gel for ACANYA
ACANYA topical gel requires evidence of prior prescription for a generic clindamycin/benzoyl peroxide gel within the past 120 days before coverage (ST requirement).
- ACANYA Notes = ST: Requires prior prescription for generic Clindamycin/Benzoyl Peroxide gel within past 120 days.
Confirm and document Step Therapy requirements
Step Therapy may apply when coverage depends on prior use of another drug; check the product Notes for ST and provide documentation of prior prescriptions where required.
- ST indicators are denoted throughout the formulary and commonly require prior prescriptions within past 120 days.
- If ST applies, prescribers must show prior trials of specified comparators per the Notes.
Document prior trials for nasal/antihistamine STs
Many nasal and antihistamine products carry ST requirements—document prior trials of the listed lower‑tier agents (commonly within 120 days) before requesting coverage for higher‑tier products.
- Dymista: ST requires prior prescription for Flunisolide or Fluticasone within past 120 days; QL 23 GM per 30 days.
- QNASL/XHANCE/ZETONNA list ST with specific intranasal corticosteroid comparators.
Document prior comparator prescriptions for Brovana/Perforomist
For products like Brovana and Perforomist, document a prior prescription for the specified comparator (Perforomist, Serevent, or Striverdi) within the past 120 days as required by ST notes.
- Brovana Notes = ST: Requires prior prescription for Perforomist, Serevent, or Striverdi within past 120 days; QL (120 ML per 30 days).
Support ST prerequisites with prior‑medication records (EMSAM example)
When EMSAM and similar entries list ST prerequisites, provide documentation of the required prior medications within 120 days to satisfy ST before coverage.
- EMSAM: ST requires prior prescription for Marplan, Phenelzine, or Tranylcypromine within past 120 days; QL (1 EA per 1 day).
- AUVELITY/VIIBRYD require prior antidepressant trials within 120 days.
Provide prior Azstarys/Jornay PM prescriptions for DYANAVEL/XELSTRYM
DYANAVEL XR and XELSTRYM require documentation of prior prescription for Azstarys or Jornay PM within the past 120 days before approval under ST.
- DYANAVEL XR / XELSTRYM Notes = ST: prior Azstarys or Jornay PM within 120 days; QL specified per product.
Document prior generic hypnotic trials for hypnotic STs
For hypnotics (e.g., Rozerem, tasimelteon), document required prior prescriptions (Eszopiclone, Zaleplon, or Zolpidem IR) within the past 120 days to meet ST.
- ROZEREM and related entries note ST: prior Eszopiclone, Zaleplon, or Zolpidem IR within past 120 days.
Supply prior‑use evidence for higher‑tier brand STs
Many higher‑tier brand agents require evidence of prior prescriptions for listed generics/alternatives within the past 120 days; provide prescription history or clinical rationale when submitting PA.
- ST entries commonly require prior use of specified alternatives within 120 days; prescribers must document those trials.
Document prior ACE inhibitor/ARB trials for ARB combos
For ARB combination products flagged with ST, document a prior prescription for an ACE inhibitor or ARB (or combination) within the past 120 days as required.
- EDARBI/EDARBYCLOR: ST requires prior ACE inhibitor/ARB prescription within past 120 days.
Include prior ACE/ARB prescriptions when required by ST
Some ARB entries require prior ACE inhibitor/ARB prescription within 120 days; include those prescriptions in the PA/ST submission to avoid denial.
- ST: prior ACE inhibitor/ARB within past 120 days is documented for specific ARB entries.
Document prior statin or biologic therapy for PCSK9/ST requirements
Specialty lipid agents (e.g., Repatha, Praluent) carry ST—document prior generic statin therapy (or prior biologic where specified) within the past 120 days before coverage.
- Repatha: ST requires prior generic statin within past 120 days; Praluent: ST requires prior Repatha within past 120 days.
Provide generic‑alternative trial records for Tier 4 STs
For Tier 4 products flagged with ST, document trials of generic alternatives within the past 120 days (trial evidence required to satisfy step therapy prior to brand coverage).
- Examples: Fenoglide/Lipofen require prior generic fenofibrate or gemfibrozil within past 120 days.
No ST specified in this extract
No step therapy rules are listed in the provided extract for these entries; follow other formulary Notes where ST or PA is indicated.
- When ST is not specified in the chunk, standard coverage rules apply unless noted elsewhere.
No ST specified in these contraceptive chunks
No step therapy requirements are specified in these chunks; follow product Notes in other sections for ST or PA requirements.
- These chunks focus on contraceptive status (PREV) and QL; ST is not listed here.
Provide prior‑prescription proof for ACANYA (clindamycin/BP)
ACANYA topical gel requires documentation of a prior prescription for generic clindamycin/benzoyl peroxide gel within 120 days before coverage; include those prior Rx records with any PA/ST submission.
- ACANYA Notes = ST: Requires prior prescription for generic Clindamycin/Benzoyl Peroxide gel within past 120 days.
How to submit a Prior Authorization to DHMP Pharmacy
Fax a completed Prior Authorization Request to DHMP Pharmacy Department at (303) 602‑2081 or contact DHMP Pharmacy Department at (303) 602‑2070 and provide all requested information.
- Use the DHMP Pharmacy Department fax number (303) 602‑2081 to submit PA requests.
- For questions or additional information call (303) 602‑2070.
Document prior prescriptions to satisfy ST flags
When a product is flagged ST, document prior prescriptions supporting the step‑therapy requirement (examples: desloratadine/levocetirizine trials for CLARINEX‑D ER and similar entries).
- CLARINEX‑D ER Notes = ST: Requires prior prescription for Desloratadine or Levocetirizine within past 120 days.
Submit PA for listed biologics and include clinical justification
PA is required for multiple biologics (e.g., DUPIXENT, FASENRA, XOLAIR, NUCALA, CINQAIR); submit PA and include clinical documentation supporting biologic use.
- DUPIXENT and related IL‑4/IL‑5 biologics list Notes = PA and require PA submission.
Include 120‑day prior prescription history when ST applies
When ST is indicated, documentation must support prior prescriptions within the past 120 days (e.g., prior antidepressant or comparator drug prescriptions) to satisfy step therapy.
- Examples include prior antidepressant prescriptions for AUVELITY/VIIBRYD and other ST entries requiring 120‑day look‑back.
Document prior medication history for ST examples (DYANAVEL/XELSTRYM)
Provide prior medication history when ST is required (e.g., Azstarys/Jornay PM evidence for DYANAVEL XR/XELSTRYM) and include those records with PA or claims.
- DYANAVEL XR/XELSTRYM: ST requires prior Azstarys or Jornay PM within 120 days.
- OPIPZA: ST requires prior generic aripiprazole within 120 days.
Respect QL restrictions for long‑acting injectables
Observe quantity limits for long‑acting injectables and other products (e.g., Invega Sustenna, Perseris, Invega Trinza have explicit QL per dosing interval) when submitting claims.
- INVEGA SUSTENNA Notes = QL (0.75 mL per 21 days) for 117 mg/0.75 mL syringe example.
- PERSERIS Notes = QL (1 EA per 28 days).
Document prior therapies per ST Notes
When a product's Notes specify 'ST', prescribers must show evidence of prior prescriptions for the listed alternatives (commonly within 120 days); include those prescriptions in the PA/claim.
- ST notes frequently state 'Requires prior prescription for [listed alternatives] within the past 120 days'—provide supporting prescriptions.
Provide prior prescription evidence for specialty oral solutions
For specialty oral solutions and other oral solution entries that include ST/QL notes, include supporting prescriptions and observe the stated QL (e.g., EPANED/QBRELIS require prior enalapril tablet Rx if patient ≥12 years).
- EPANED/QBRELIS Notes = ST: prior Enalapril tablets within past 120 days if ≥12 years; QL (1200 mL per 30 days).
Provide proof of prior therapy when ST/PA indicated
When ST or PA notes are listed, prescriptions supporting prior therapy or prior prescription history may be required; include those prescriptions or clinical rationale to avoid denial.
- Example: SOTYLIZE requires prior sotalol tablets within 120 days; other entries require ACE inhibitor/ARB or beta‑blocker trials.
Support QL/ST with documentation to avoid denial
When QL or ST is specified, include documentation supporting prior prescriptions or clinical rationale with the PA to reduce denial risk (e.g., QL = 1 EA per 1 day requires appropriate claim documentation).
- Claims exceeding QL or missing ST evidence may be denied or require PA; support QL/ST with documentation.
Document prior beta‑blocker trial for ivabradine (Corlanor)
For ivabradine (Corlanor), document a prior prescription for Bisoprolol, Carvedilol, or Metoprolol Succinate within the past 120 days (ST requirement) and observe the QL (2 tablets per day).
- Corlanor Notes = ST: Requires prior Bisoprolol, Carvedilol, or Metoprolol Succinate within past 120 days; QL (2 EA per 1 day).
Adhere to explicit QL values on dispensing claims
Observe specified quantity limits when dispensing (examples shown include 91 EA per 84 days; 28 EA per 28 days; 1 EA per 1 day) and document adherence to QL on claims.
- Common QL examples: 91 EA per 84 days (3‑month packs), 28 EA per 28 days (monthly packs), 1 EA per 1 day for many tablets.
Risk of denial if PA criteria are unmet
Denials will occur for PA requests that do not meet MedImpact P & T Committee guidelines; alternative therapy may be recommended if PA criteria are not satisfied.
- Requests failing to meet P&T guidelines will not be approved.
- Providers may appeal non‑approved requests with supporting medical necessity information.
Denial risk when ST prior agents not documented
Failure to document prior trials required by step therapy (e.g., missing required 120‑day prior prescriptions) may result in utilization management denials.
- Dymista and other ST entries require prior comparator prescriptions within 120 days; absence of these records can trigger denial.
Initial Therapy & Prior-Prescription Requirements
| Product | Step therapy requirement |
|---|---|
| CLARINEX-D 12 HOUR ORAL TABLET (desloratadine-chlorpheniramine) — ER multiphase 2.5–120 mg | ST: Requires prior prescription for Desloratadine or Levocetirizine tablets within the past 120 days |
| Example product / class | Required prior trial(s) (look‑back period) |
|---|---|
| Desloratadine / Levocetirizine products (oral disintegrating tablets, solutions) | ST: Requires prior prescription for Desloratadine or Levocetirizine tablets within the past 120 days |
| DYMISTA (azelastine–fluticasone nasal spray) | ST: Requires prior prescription for Flunisolide (nasal) or Fluticasone within the past 120 days; QL (23 GM per 30 days) |
| QNASL / XHANCE / ZETONNA (intranasal corticosteroid/unique delivery) | ST: Requires prior prescription for Flunisolide, Fluticasone, or Mometasone within the past 120 days; product‑specific QL applies |
| Dronabinol (Marinol) / Syndros | ST: Requires prior prescription for a 5HT3 antagonist, corticosteroid, Emend (aprepitant), or Megestrol suspension within the past 120 days; QL noted per product |
| Various branded higher‑tier agents (general) | ST: Requires trial of listed lower‑tier or specified comparator agents within the past 120 days before coverage of branded/higher‑tier products |
| Product | Step therapy requirement |
|---|---|
| BROVANA inhalation solution for nebulization (arformoterol) 15 mcg/2 mL | ST: Requires prior prescription for Perforomist (formoterol), Serevent (salmeterol), or Striverdi within the past 120 days; QL (120 ML per 30 days) |
| Product / class | Step therapy requirement |
|---|---|
| Combination inhalers and inhaled corticosteroid (e.g., ADVAIR, BREO ELLIPTA, WIXELA, SYMBICORT, BREYNA) | ST: Some combination inhalers require prior prescription for Advair HFA or BreoEllipta within the past 120 days; product‑specific QL applies (e.g., 60 EA per 30 days) |
| Arnuity Ellipta / related ICS products (e.g., ALVESCO, ASMANEX) | ST: Certain ICS products list ST: Requires prior prescription for Arnuity Ellipta within the past 120 days (product QL where noted) |
| Product | Step therapy requirement |
|---|---|
| ARNUITY ELLIPTA (fluticasone furoate) and some ICS entries | ST: Requires prior prescription for Arnuity Ellipta within the past 120 days; QL noted per product (example: Arnuity QL 30 EA per 30 days) |
| Product / example | Step therapy requirement |
|---|---|
| EMSAM transdermal patch (selegiline) and other MAOI entries | ST: Requires prior prescription for Marplan, Phenelzine, or Tranylcypromine within the past 120 days; QL where noted (e.g., 1 EA per 1 day) |
| AUVELITY / VIIBRYD and selected antidepressants | ST: Requires prior prescriptions for listed antidepressants (examples include bupropion, citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, etc.) within the past 120 days |
| Product | Step therapy requirement |
|---|---|
| DYANAVEL XR (oral suspension) and XELSTRYM (transdermal patch) | ST: Requires prior prescription for Azstarys or Jornay PM within the past 120 days; product‑specific QL applies (e.g., DYANAVEL XR QL 240 mL per 30 days for suspension) |
| XELSTRYM transdermal patch | ST: Requires prior prescription for Azstarys or Jornay PM within the past 120 days; QL (1 EA per 1 day) |
| Product / group | Step therapy requirement |
|---|---|
| Hypnotics and related agents (e.g., Rozerem, tasimelteon, Belsomra, Dayvigo, doxepin entries) | ST: Requires prior prescription for Eszopiclone, Zaleplon, or Zolpidem IR (or other specified generics per entry) within the past 120 days; QL commonly 1 EA per day where noted |
| ZENZEDI (dextroamphetamine) examples | ST: For specific stimulant/hypnotic cross‑references entries may require prior dextroamphetamine IR tablets or solutions within past 120 days (as listed) |
| Higher‑tier product example | Required alternative(s) tried within look‑back |
|---|---|
| BELSOMRA, DAYVIGO, other higher‑tier sleep agents | ST: Requires prior prescription for Eszopiclone, Zaleplon, or Zolpidem within the past 120 days; QL typically 1 EA per day |
| OPIPZA (oral film) and certain antipsychotic/brand formulations | ST: Requires prior prescription for generic aripiprazole tablets within the past 120 days before coverage |
| ADHD branded products (examples: Cotempla, Aptensio, Qullichew) | ST: Requires prior prescription for methylphenidate ER/LA/CD or listed comparators (e.g., Azstarys, Jornay PM, generic lisdexamfetamine) within the past 120 days |
| Product / class | Step therapy requirement |
|---|---|
| EDARBI and other ARB combination products | ST: Requires prior prescription for an ACE inhibitor, ACE inhibitor combination, ARB, or ARB combination within the past 120 days |
| Select combination ARB products (EDARBYCLOR, EDARBI examples) | ST: Prior ACE inhibitor/ARB therapy within 120 days is required before coverage |
| Product | Required prior prescription |
|---|---|
| Hemangeol oral solution (propranolol 4.28 mg/mL) | ST: Requires prior prescription for generic propranolol oral solution within the past 120 days if patient is ≥1 year of age; QL (360 mL per 30 days) |
| SOTYLIZE oral solution 5 mg/mL | ST: Requires prior prescription for sotalol tablets within the past 120 days; QL: 8 bottles in 30 days |
| ARB product example | Step therapy requirement |
|---|---|
| EDARBI (azilsartan) and selected ARB entries | ST: Requires prior prescription for an ACE inhibitor, ACE inhibitor combination, ARB, or ARB combination within the past 120 days |
| Specialty biologic example | Prior therapy required |
|---|---|
| REPATHA (evolocumab) products | ST: Requires prior prescription for a generic statin within the past 120 days before Repatha coverage (product‑specific QL may apply) |
| PRALUENT (alirocumab) pen | ST: Requires prior prescription for Repatha within the past 120 days before Praluent coverage |
| Product / class | Step therapy requirement |
|---|---|
| FENOGLIDE / Lipofen / other branded fenofibrate products | ST: Requires prior prescription for generic fenofibrate or gemfibrozil within the past 120 days before coverage |
| Product | Step therapy requirement |
|---|---|
| CORLANOR (ivabradine) oral tablet / solution | ST: Requires prior prescription for Bisoprolol, Carvedilol, or Metoprolol Succinate within the past 120 days; QL (2 EA per 1 day for tablets; solution QL as noted) |
| Scope / general rule | Typical requirement |
|---|---|
| Generics and lower‑tier comparator requirement (general ST rule) | ST: Many branded/higher‑tier products require documented prior prescription(s) for specified generic or comparator agents within the past 120 days before coverage; documentation of prior prescriptions must be provided to satisfy ST |
| When no ST is specified | Some products in the formulary do not list step therapy requirements — coverage follows tier and PA rules where applicable |
| Note | Content |
|---|---|
| Step therapy rules absent (example chunk) | No step therapy requirements are specified in these chunks |
| Product | Step therapy requirement |
|---|---|
| ACANYA topical gel with pump (clindamycin–benzoyl peroxide) 1.2–2.5% | ST: Requires prior prescription for generic clindamycin/benzoyl peroxide gel within the past 120 days; QL (30 mL per 1 day) and age minimums where noted |
Quantity Limits & Supply Restrictions
Policy Governance & Rationale
The formulary and therapeutic review are overseen by the plan’s pharmacy and therapeutics process. The MedImpact P & T and Formulary Committees evaluate drugs for safety, efficacy, therapeutic benefit relative to formulary agents, and cost‑effectiveness to maintain access to clinically appropriate therapies and to inform utilization controls such as PA, ST, and QL.
Key Terms & Abbreviations
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.