Obtain prior authorization for PA‑flagged drugs

Certain drugs listed on the formulary are designated "PA" (Prior Authorization) in the Requirements/Limits column and require prior authorization before coverage will be provided; example: ARIKAYCE is listed with Requirements/Limits = LA, PA, QL (28 vials/28 days), SP.

• Submit a prior authorization request for any drug shown with "PA" in Requirements/Limits.
• Example drug entry: ARIKAYCE — Requirements/Limits = LA, PA, QL (28 vials/28 days), SP.

Follow PA and limited‑access/specialty requirements

Some products are marked LA (Limited Availability) or LA plus PA/SP and must follow limited‑access or specialty distribution processes in addition to prior authorization when shown in Requirements/Limits; example: CRESEMBA is listed with Requirements/Limits = PA and SIRTURO with LA, SP.

• Follow limited‑access (LA) distribution and specialty pharmacy (SP) routing where indicated.
• Submit PA when LA or SP annotations accompany the drug entry (e.g., CRESEMBA = PA; SIRTURO = LA, SP).

Submit PA where the Requirements/Limits show "PA"

Prior authorization is required for any product where the formulary's Requirements/Limits column includes the "PA" flag; providers must submit the authorization request prior to dispensing.

• Check each formulary line for a "PA" annotation and submit the corresponding PA request.
• Examples in this section include ISTURISA and JYNARQUE entries that list LA, PA, QL and require PA.

Prior authorization for specialty agents and higher‑tier products

Many specialty or higher‑cost products are subject to prior authorization and additional controls (quantity limits, specialty routing); follow the PA and SP processes when prescribing these agents.

• Examples include ATTRUBY (LA, PA, QL 112 tablets/28 days, SP) and ADEMPAS (LA, PA, QL 90 tablets/30 days, SP).
• Confirm PA and any QL before authorizing or dispensing specialty drugs.

PA required for PA‑marked formulary entries

Drugs explicitly marked "PA" in the Requirements/Limits column require prior authorization before coverage; examples in the formulary include ALYFTREK, BRINSUPRI, TRIKAFTA and other PA‑marked entries.

• Do not assume coverage without an approved PA for PA‑marked medications.
• Refer to each drug line for accompanying QL/LA/SP flags that may affect the PA process.

Submit PA for specified formulary entries with flags

The formulary denotes PA, LA, QL, and SP next to products that are subject to administrative controls; providers must submit prior authorization requests for those entries as indicated.

• Review the Requirements/Limits column on the formulary entry and submit PA/LA/SP/QL documentation as applicable.
• Some products also list exact QL values that must be observed when requesting PA.

PA required for annotated products

Several products listed in the formulary require prior authorization per their annotation (PA); examples include tasimelteon, SUNOSI, WAKIX, AUSTEDO and cladribine therapy packs where PA is shown.

• Ensure PA requests reference the specific formulary product and pack size when applicable.
• Cladribine (MAVENCLAD) therapy packs list PA and QL and must follow PA procedures.

Obtain PA for many branded/specialty drugs

Prior authorization is required for many branded and specialty medications listed with PA and may be combined with LA, QL, or SP restrictions; check each line item and secure PA as needed.

• Examples: INGREZZA (LA, PA, QL), MAVENCLAD (LA, PA, QL), VUMERITY (LA, PA, QL).
• PA must be obtained prior to coverage to avoid claim denials.

Check PA on individual product lines

Certain individual products show the "PA" flag in their line entry and therefore require prior authorization before coverage (e.g., ELYXYB, NURTEC, QULIPTA, and topiramate ER sprinkle formulations are noted with PA/QL where applicable).

• Verify PA requirements for oral solution or specialty formulations that may have separate PA/QL designations.
• Topiramate ER sprinkle formulations list PA and QL in the formulary extract.

Obtain PA for listed PA drugs (oral/liquid/ophthalmic)

Many specialty, branded oral, liquid, and ophthalmic products include a "PA" annotation in Requirements/Limits and require prior authorization prior to coverage; review each entry and submit PA as applicable.

• The Requirements/Limits column is the authoritative source for whether PA applies to a specific formulation.
• If PA is indicated, do not dispense expecting coverage without approval.

PA required for select listed agents

Some select agents in the formulary are annotated with "PA" and require prior authorization (examples include AKLIEF, ANZUPGO, CIBINQO, FILSUVEZ, HYFTOR, OPZELURA); submit PA requests for these agents when prescribing.

• Confirm whether the entry also lists QL, LA, or SP and include that information in the PA submission.
• Follow specialty distribution instructions (SP/LA) when present.

Secure PA for listed dermatology and specialty products

Certain products in the dermatology and related segments are shown with "PA" in their Requirements/Limits and require prior authorization (examples: tazarotene cream/gel entries, ZELSUVMI, LUPKYNIS); obtain PA before dispensing.

• When PA is indicated, submit supporting clinical documentation per payer instructions.
• Check for accompanying QL, LA, or SP requirements on the same line.

Index is a reference — check product entries for PA

This index segment is a product index only and does not enumerate prior authorization rules; providers must refer to the specific formulary line or policy section referenced by the index to determine PA requirements.

• Index entries list product name and references — they do not replace per‑product Requirements/Limits.
• Consult the main formulary listings for PA/QL/LA/SP details.

Index does not list PA requirements

The index pages shown do not include prior authorization requirements themselves; no PA rules are listed in this index excerpt — consult the full formulary entry for authorization details.

• Do not rely on the index alone to determine PA — the Requirements/Limits field on the product line is authoritative.
• If unsure, contact Member Services for guidance.

Follow step therapy for ST‑annotated drugs

Drugs annotated with "ST" (Step Therapy) require members to try specified first‑line agents before later‑step drugs will be covered; where "ST" appears, follow the step‑therapy requirements before requesting coverage.

• If a product is marked "ST", submit documentation of tried and failed first‑line agents as part of the authorization.
• Example: ST is defined in the abbreviations list as requiring trial of earlier agents before coverage of later‑step drugs.

No step‑therapy sequence listed here — verify before assuming

No explicit step‑therapy pathways are provided in this extract for many products; where the formulary does not show a specific ST sequence, follow the line‑item flags (PA/QL/LA/SP) and consult full policy or prior‑authorization resources for step details.

• When ST is not detailed on the line, do not assume a specific step sequence—request PA guidance from the payer or Member Services.
• Tiering and access flags alone do not define step‑therapy sequences.

Adhere to step therapy where the 'ST' flag appears

Some products in the formulary are explicitly marked with 'ST' and require adherence to step therapy where shown; for example, KERENDIA is listed with Requirements/Limits = QL (30 tablets/30 days), ST and requires step‑therapy compliance.

• Include evidence of prior therapy trials when submitting authorization for ST‑flagged agents.
• KERENDIA (finerenone) is an example of a product with ST annotation.

Submit step‑therapy documentation for ST‑flagged drugs

Step therapy is indicated for select agents in the formulary (examples include AUVELITY QL/ST, FETZIMA ST, FLUOXETINE DR ST, TRINTELLIX ST); when ST is annotated, providers must document prior trials per the step requirement.

• Submit documentation of failure, intolerance, or contraindication to first‑line agents to support PA for a later‑step drug.
• Follow the plan's ST instructions where an ST flag is shown on the product line.

Contact Member Services for PA/coverage questions

Members and providers may contact Member Services for coverage questions and next steps; the formulary indicates which drugs require PA, QL, ST, SP or LA and those annotations guide documentation and authorization workflows.

• Member Services phone: 877-793-6253 (TTY: 711).
• Use Member Services to clarify PA, QL, LA, SP and step‑therapy requirements before submitting prescriptions.

Document indication and quantity when QL applies

When quantity limits (QL) apply, providers should document the indication and the quantity requested; the formulary lists precise QL values (e.g., abacavir solution QL 960 mls/30 days, BIKTARVY QL 30 tablets/30 days).

• Include clinical justification when requesting quantities above the listed QL.
• Reference the exact QL value from the formulary in the PA or exception request.

Meet PA/QL/LA/SP designations listed per drug

Prior authorization (PA), quantity limits (QL), limited access (LA), and specialty pharmacy (SP) designations are applied to listed products and must be met per the drug-specific Requirements/Limits.

• Use the Requirements/Limits annotations on each line as the basis for authorization and dispensing actions.
• Do not dispense assuming coverage if PA or other flags are present without prior approval.

Provide required documentation with PA requests

Prescribers should supply supporting documentation required for prior authorization where indicated; the formulary entries show 'Requirements/Limits = PA, QL, LA, SP' for specific products and that documentation must accompany PA submissions.

• Include clinical notes, prior treatment history, and quantity rationale as applicable.
• For LA/SP drugs, coordinate with the specialty pharmacy and include any distributor‑specific paperwork.

Follow PA/LA/SP and QL requirements on the formulary

Prescribers must follow payer requirements for drugs flagged with PA, LA, SP and adhere to specified quantity limits (examples include ALYFTREK QL 84 tablets/28 days and TRIKAFTA QL 56 packets/28 days); follow the formulary instructions when requesting coverage.

• When a drug lists QL, ensure the prescribed quantity does not exceed the QL unless a PA justification is submitted.
• For LA and SP entries, use the designated distribution channel and include necessary documentation in the PA.