EmblemHealth formulary Prior Auth & Coverage

General Coverage Conditions

Covered when ALL of the following are met:

Formulary coverage conditions: The drug is listed on the member's formulary for the applicable benefit plan.

Refer to the member's Certificate of Coverage for plan-specific applicability.

Utilization management requirements: Any listed utilization management requirements shown for the drug (Prior Authorization [PA], Quantity Limits [QL], Step Therapy [ST], or Limited Availability [LA]) are satisfied prior to coverage.

Providers must obtain required PA or follow QL/ST/LA processes; failure to meet these requirements may result in denial of payment.

Benefit design and exceptions: Use is consistent with the plan's benefit design (including tiering and ACA preventive drug rules) or an approved exception has been granted.

A drug being listed does not guarantee coverage for every plan; members/providers may request an exception per plan procedures.

Listing a drug in the formulary does not by itself guarantee payment. The formulary states that coverage depends on the member's specific Contract or Certificate of Coverage and that some drugs may require approval (prior authorization), be payable only for specific doses/strengths, or may not be covered under every benefit plan. Members and providers should check the plan benefit design and the member ID card for coverage details.

Within this extract there are no explicit coverage exclusion statements; the material shown is limited to drug entries with tier assignments and requirement/limit flags (e.g., PA, QL). The document directs readers to the start of the full table for definitions of symbols and abbreviations.

The supplied product listings in these chunks do not state any formal coverage exclusions. They present individual drugs with assigned Drug Tier values and Requirements/Limits flags (for example, PA) and advise consulting the beginning of the full table for symbol meanings.

No explicit exclusion conditions are listed in this portion of the formulary extract; the content is a catalog of products with associated tiers and requirement indicators rather than a set of named exclusion criteria.

The formulary clarifies that inclusion in the list does not guarantee coverage. Plan-specific rules — such as required prior authorization — may be necessary before the plan will pay for an indicated drug; members and providers should verify benefit details in the member's Certificate of Coverage.

No statements declaring specific products as not medically necessary are present in this excerpt. The material is limited to tier and requirement-limit annotations for drug entries.

This section of the extract does not include any not medically necessary determinations. It lists drug names with tier and requirements flags and refers readers to the table legend for definitions.

No explicit Not medically necessary statements appear in these chunks. The entries shown focus on drug listings with Requirements Limits like PA or LA rather than clinical coverage-denial language.

Authorization, Documentation & Denial Risks

Prior Authorization

Prior Authorization Required

Many drugs listed in the formulary are designated with utilization management flags. Prior Authorization (PA) is required for products labeled PA (or shown as “Requirements Limits = PA”) — providers must submit the plan’s prior authorization request and supporting clinical documentation before the prescription will be paid. Drugs with QL (quantity limits) are subject to maximum covered quantities; requests that exceed QL may be denied unless authorization or an exception is approved. Entries marked LA indicate limited availability (site or specialty channel) and may require additional steps or provider coordination.

Prior authorization is required for drugs shown with PA or with “Requirements Limits = PA”.
Providers must obtain PA prior to dispensing for PA‑flagged formulary agents (including many specialty, oncology, immunology, coagulation, and opioid/analgesic products listed).
When a product is labeled “PA; QL; LA” providers must supply clinical justification and follow PA submission instructions for both initial and continuation coverage.
Quantity limits (QL) are enforced; prescriptions exceeding QL may be denied unless prior authorization or an approved exception is in place.
Limited availability (LA) products may be restricted to certain pharmacies, sites of care, or specialty distribution — verify dispensing channel before submitting a claim.
Step therapy (ST) may apply where indicated by ST flags in the formulary; however, explicit step sequences are not included in this excerpt — contact the plan or consult the formulary legend for the applicable ST requirements.
Claims for PA/QL/LA products can be denied if requirements are not met or documentation is missing; obtain PA and provide required documentation to avoid denial.
Refer to the formulary legend and the List of Abbreviations at the start of the table for definitions of PA, QL, LA, ST, and ACA and for any plan-specific submission instructions.

Documentation Required

Required Documentation & Submission

What to submit: clinical rationale (diagnosis, relevant prior treatments and outcomes, dosing, and duration), supporting tests or notes when requested, and any evidence of failure/intolerance when step therapy or prior-line requirements apply. For products listed with LA or specialty-supply requirements, include proposed site-of-care or pharmacy details when known. Use the plan’s PA form or electronic prior authorization portal where available.

Provide diagnosis, prior therapy history, and rationale for using the requested agent.
Include requested dose, duration, and relevant lab or imaging results if applicable.
For ST exceptions, document why preferred/step therapies were not appropriate or effective.
For LA/specialty products, indicate intended dispensing pharmacy or infusion/clinic site.

Denial Risk

Denial Triggers & Risks

Denial risks: claims for drugs marked with utilization management flags (PA, QL, LA, ST) are at risk for medical review denials or claim rejections if prior authorization is not obtained, required quantity limits are exceeded, or the drug is not dispensed via the permitted site. Providers should confirm coverage requirements before prescribing and should follow the plan’s PA appeal and exception processes if coverage is initially denied.

Failure to obtain PA for PA‑flagged drugs may result in claim denial or member financial liability.
Requests exceeding quantity limits (QL) may be denied unless a PA or exception is approved.
Limited availability (LA) drugs dispensed outside approved pharmacies or sites may be rejected.
If a PA is denied, follow the plan’s appeal and exception procedures; document clinical need thoroughly to support appeals.

Note

Formulary Flags & How to Interpret Them

Operational notes: consult the formulary legend at the beginning of the table for the exact meaning of each abbreviation and any plan-specific rules (for example, ACA preventive coverage exceptions). When the formulary shows PA/QL/LA together next to a drug, that product requires both authorization and adherence to the listed limits; check the plan portal for quantity-limit values and step-therapy algorithms.

Consult the table legend for symbol definitions and detailed rules.
When “Requirements Limits = PA” appears, submit the plan’s PA request prior to dispensing.
Check the plan portal or member benefit documents for quantity-limit values and step edits before prescribing.
For specialty or limited‑availability items, confirm approved dispensing sites and any additional site-of-care requirements.

Abbreviations & Legend

PA — Prior Authorization

DefinitionPrior Authorization (PA): The plan requires you or your physician to get approval before filling certain prescriptions; if approval is not obtained, the plan may not cover the drug.

PurposeUsed to manage utilization of specialty, high-cost, or clinically restricted medications listed in the formulary table.

Indicator locationPA appears in the Requirements/Limits column next to applicable drug entries. Consult the table legend for operational details.

QL — Quantity Limit

DefinitionQuantity Limit (QL): For certain drugs, the plan limits the amount of the drug that will be covered; the QL flag appears in the Requirements/Limits column and numeric limits are provided in the full table.

PurposeQLs control dispensing quantities and can trigger claim edits when exceeded.

Indicator locationQL is shown next to affected drug entries in the formulary table's Requirements/Limits column.

ST — Step Therapy

DefinitionStep Therapy (ST): In some cases, the plan requires you to try certain specified drugs first to treat a condition before the plan will cover another drug for that condition.

ExampleIf Drug A and Drug B both treat a condition, the plan may not cover Drug B unless Drug A is tried first; if Drug A fails, Drug B may then be covered.

Indicator locationST is referenced in the abbreviations/legend and may be indicated in the formulary table where applicable. Specific sequences are in the full table.

PA flag usage in table

UsageThe 'PA' flag is used in the Requirements/Limits column of the formulary table to denote drugs that require prior authorization before coverage.

PrevalencePA appears next to many specialty, oncology, and higher-tier drug entries throughout the table.

Provider actionProviders must submit PA requests per plan procedures for drugs marked with PA to avoid claim denials.

QL flag usage in table

UsageThe 'QL' flag is shown in the Requirements/Limits column to indicate drugs subject to quantity limits; numeric limits are specified in the full formulary entries.

PurposeQL restricts covered dispensing quantities and may cause claims to be limited or denied if exceeded.

ExamplesSeveral antifungal, cardiovascular, and CNS agents include QL in the Requirements/Limits notation.

ACA designation — presence and meaning

PresenceACA (Affordable Care Act) designation is used for some products in the table to denote services/drugs with no cost-sharing when criteria are met; its contextual meaning is described at the table start.

ExamplesCertain vaccines and preventive agents are labeled ACA in the abbreviations list.

ReferenceSee the table legend at the beginning of the formulary for exact ACA applicability and member cost-sharing implications.

PA flag shown next to drug entries

DisplayPA is displayed next to drug entries in the Requirements/Limits column to indicate prior authorization is required for those products.

ExamplesEntries such as BARACLUDE, COMPLERA and other antiviral agents show PA or PA; QL in their Requirements/Limits fields.

ImplicationPharmacies should screen for PA at point of sale and obtain authorization when PA is present to prevent denials.

QL flag shown next to drug entries

DisplayQL is shown next to affected drug entries in the Requirements/Limits column to indicate quantity-based coverage limits.

ExamplesBIKTARVY and EPCLUSA (among others) include QL in their Requirements/Limits notation.

Operational notePharmacies and prescribers should check the specific QL numeric limits in the full table when QL is present.

LA — Limited Availability / Limited Access

Probable meaningLA (Limited Availability/Limited Access) denotes restricted availability or site-of-care limitations (for example, certain pharmacies or administration sites).

UsageLA appears in the Requirements/Limits column for some inhalation, infusion, or specialty agents to indicate site-specific dispensing or administration.

Provider actionWhen LA is listed, providers may need to use designated pharmacies or sites for dispensing/administration. Contact Customer Service for details.

PA (Requirements/Limits column)

ExamplesPA appears within the Requirements/Limits column for multiple entries (e.g., FIRVANQ, VANCOCIN) indicating prior authorization is required as listed.

FunctionThe Requirements/Limits column is the authoritative location for PA flags tied to each drug entry.

ReferenceConsult the table legend and specific drug row for PA operational details.

LA (Requirements/Limits column)

ExamplesLA appears in the Requirements/Limits column for agents such as AFINITOR DISPERZ and BORTEZOMIB (some presentations) to denote limited access/site or administration restrictions.

Co-occurrenceLA is frequently listed alongside PA and/or QL in the Requirements/Limits column for specialty agents.

ImplicationLA may require use of specialty distribution channels or specific administration settings; follow plan procedures.

QL (Requirements/Limits column)

ExamplesQL is indicated in the Requirements/Limits column for many products (e.g., antifungals, LYRICA entries) to denote quantity limits.

Operational impactWhere QL is shown, dispensing is limited to the covered quantity unless exception or PA is granted.

DocumentationClaims exceeding QL may require documentation or PA for coverage.

Formulary requirement abbreviations

AbbreviationsPA = Prior Authorization; LA = Limited Access (Limited Availability); QL = Quantity Limits — as used in the Requirements/Limits column and defined at the start of the table.

Reference locationDefinitions and exact meanings of these abbreviations are provided at the beginning of the formulary table (see abbreviations/legend).

UseThese abbreviations are used consistently across drug listing rows to indicate utilization management controls.

PA flag usage (reference)

Usage notePA flag usage is reinforced in the table legend and appears repeatedly next to drugs that require prior authorization.

Provider guidanceRefer to the table legend for PA process details and contact Customer Service or PA resources to submit requests.

Claim riskClaims for PA-marked drugs may be denied if PA is not obtained.

QL flag usage (reference)

Usage noteQL flag is used throughout the table to indicate quantity-based coverage limits; where present, numeric QL values are in the full table.

ExamplesFluconazole 150 mg and other antivirals/antifungals show QL in the Requirements/Limits column.

ImplicationExceeding QL may trigger claim edits or require PA.

LA flag usage (reference)

Usage noteLA is applied to products with distribution or administration limitations (e.g., inhalation solutions, specialty injectables) and is shown in the Requirements/Limits column.

ExamplesAgents such as TOBI inhalation solution and AFINITOR DISPERZ include LA in their Requirements/Limits listing.

ActionWhen LA is listed, follow designated dispensing/administration channels indicated by the plan. Contact Customer Service for details.

PA listed next to many products

PrevalencePA is listed next to many products across therapeutic sections (e.g., NSAIDs, topical agents) as a requirements flag.

ExamplesANAPROX DS, ARTHROTEC and other entries include 'Requirements Limits = PA' in these chunks.

Provider actionObtain PA per plan procedures for products marked PA to avoid coverage denial.

QL listed for many products

PrevalenceQL is listed for many products indicating restricted dispensing quantities (e.g., opioid and analgesic entries).

ExamplesMorphine and oxycodone listings include 'Requirements Limits = PA; QL' across entries.

Operational notePharmacies should verify QL numeric values in the full table when processing claims for QL-marked products.

Drug Tier — definition

DefinitionDrug Tier: Plan-specific formulary tier assignment (e.g., 1, 2, 3, ACA) that influences member cost-share and may interact with utilization controls.

UsageTiers are shown per drug row; higher tiers often correspond with greater utilization controls and member cost.

ReferenceSee plan Certificate of Coverage for tier-specific cost-sharing details.

PA/QL/LA — abbreviations used

ObservationThe table consistently uses PA, QL, and LA abbreviations in the Requirements/Limits column to denote utilization management controls.

ReferenceFull table legend at the start of the formulary provides exact definitions and operational instructions for these abbreviations.

Provider actionFollow the specific PA/QL/LA processes when submitting coverage requests for flagged drugs.

PA / QL / LA — definitions

Definitions summaryPA = Prior Authorization required; QL = Quantity Limit; LA = Limited Access or site-specific administration requirement. These meanings are defined in the table legend.

LocationDefinitions are presented at the beginning of the formulary table and used throughout the drug listings.

ImplicationProviders should consult the legend to interpret flags and complete any necessary authorization steps.

Formulary requirement abbreviations (reference)

Abbreviation setFormulary requirement abbreviations include PA (Prior Authorization), LA (Limited Access/Limited Availability), and QL (Quantity Limit).

UsageThese abbreviations are annotated in the Requirements/Limits column for each drug as applicable.

ReferenceConsult the table start legend for full operational definitions and exception procedures.

PA — table abbreviation reference

PAPA in the table abbreviations denotes Prior Authorization required for coverage of the drug as indicated in the Requirements/Limits column.

Where shownPA appears across cardiovascular, hemostasis, and other therapeutic sections in this excerpt.

ActionProviders must obtain PA before dispensing PA-marked drugs to avoid claim denial.

LA — table abbreviation reference

LALA in table abbreviations denotes Limited Access/Limited Availability, often indicating site-of-care, restricted pharmacy distribution, or special handling requirements.

ExamplesLA is used for products like BORTEZOMIB (some presentations) and specialty inhalation solutions.

Provider actionFollow plan instructions for designated dispensing sites or administration settings when LA is present. Contact Customer Service for details.

QL — table abbreviation reference

QLQL in the table abbreviations denotes that a Quantity Limit applies to the drug; the specific numeric limits are detailed in the full formulary rows.

ExamplesFLUCONAZOLE 150 mg and other agents show 'Requirements Limits = QL' in the antifungal section.

Operational effectClaims exceeding QL are subject to denial or require prior authorization/exception.

Step Therapy Indicators & Tables

Step therapy (ST) — policy summary	Notes / excerpt evidence
Formulary indicates Step Therapy (ST) is used where applicable and defines the concept in the abbreviations section (ST: plan may require trying specified drugs first before covering another drug).
Source shows ST definition and that the table marks agents with ST where applicable; no specific step sequences are provided in this excerpt (see abbreviations).

Drug / Group	Step therapy entries present?
Various antiviral and hepatitis agents (e.g., HARVONI, GENVOYA, EVOTAZ) shown in the table excerpt
No explicit step therapy entries or sequences are specified for these listed drugs in the provided excerpt; only requirement flags (PA/QL/LA) are shown.

Table-level observation	Implication for Step Therapy
Formulary tables in this extract present Drug Tier and Requirements/Limits flags (PA, QL, LA) for each product.
Step therapy is not explicitly detailed here; the table shows tier and PA/LA/QL flags only, so ST sequences are not available from the excerpt.

Explicit ST sequences	Available detail in excerpt
Explicit step-therapy sequences (e.g., required first-line agent then next-line agent) are not listed in these chunks.
Excerpt contains ST definition and many PA/QL/LA flags but no step sequence rules; consult full formulary legend for operational ST rules.

LA / other restriction flags noted	Guidance
Some products include 'LA' (Limited Availability / Limited Access) alongside PA and QL in the Requirements/Limits field (examples: MEKINIST entries; VIVITROL listed with LA).
LA may indicate site-of-care or restricted distribution and can imply step/line restrictions; refer to the beginning of the full formulary table/legend for exact operational meaning of LA and any ST interaction.

Class / examples	Step therapy / edits present in excerpt?
Selected oral anticoagulants and lipid-lowering agents (e.g., XARELTO starter packs, ALTOPREV, LIPITOR, NEXLETOL) are assigned tiers and Requirements/Limits flags (PA; QL).
These tier and QL/PA assignments may be used operationally as part of step edits by the plan, but explicit step-therapy sequences are not provided in this extract.

Quantity Limits & Pack/Starter References

Antifungal agents — QL notes

Antifungals and othersSeveral antifungal and other drug classes list QL in their Requirements/Limits column; numeric QL values are provided per drug in the full table (not shown here).

ExamplesEntries in the antifungal section include CRESEMBA, DIFLUCAN (some presentations), SPORANOX, and TOLSURA with PA/QL annotations.

Provider actionWhen QL is indicated, verify the allowed quantity in the formulary row and seek PA or exception if the prescribed quantity exceeds the limit.

BIKTARVY — QL flag

DrugBIKTARVY ORAL TABLET is listed with Requirements/Limits = QL in the formulary.

TierDrug Tier = 2 (BIKTARVY).

NoteNumeric QL value is not shown in this excerpt and must be referenced in the full formulary entry.

EPCLUSA — PA; LA; QL

DrugEPCLUSA ORAL TABLET is listed with Requirements/Limits = PA; LA; QL in the formulary.

TierDrug Tier = 2 (EPCLUSA).

NoteSpecific numeric QL values are not provided in this excerpt; consult the full table for exact limits.

ALINIA (nitazoxanide) — QL

DrugALINIA (nitazoxanide) entries show Requirements/Limits = QL in the table.

TierDrug Tier = 3 for ALINIA oral suspension/tablet entries in this excerpt.

NoteNumeric QL values are not present here; check the full formulary row for the specific quantity limit.

AFINITOR — PA; LA; QL

DrugAFINITOR (everolimus) is listed with Requirements/Limits = PA; LA; QL.

PresentationsAFINITOR and AFINITOR DISPERZ presentations are separately listed and both carry PA/LA/QL annotations where applicable.

ActionSpecialty oncology agents like AFINITOR frequently require PA and may have QL/LA restrictions; follow document legend and PA processes.

AFINITOR DISPERZ — PA; LA; QL

DrugAFINITOR DISPERZ ORAL TABLET FOR SUSPENSION is listed with Requirements/Limits = PA; LA; QL.

TierDrug Tier = 2 for the Disperz presentation in this excerpt.

NoteNumeric QL specifics are in the full formulary; providers should reference the detailed row for dispensing limits.

BORTEZOMIB injection — LA; QL

DrugBORTEZOMIB INJECTION RECON SOLN (1 mg, 2.5 mg) entries include 'LA; QL' in Requirements/Limits for certain presentations.

ContextSome BORTEZOMIB presentations also list PA in addition to LA and QL depending on strength/form.

ImplicationAdministration and dispensing of BORTEZOMIB may be restricted by site and quantity limits; follow plan processes.

Multiple entries — QL where indicated

GeneralMultiple listed products across oncology and specialty sections show QL where indicated in the Requirements/Limits column; specific numeric limits are provided per drug in the full table.

ExamplesMEKINIST, MEKTOVI, and other agents display PA/LA/QL notations in the abbreviated listings.

ActionConsult the full formulary row for exact QL values and any associated PA/LA requirements.

Diazepam rectal kit — QL indicated

DrugDiazepam rectal kit is listed with Requirements/Limits = QL (unspecified numeric limit in this excerpt).

TierDrug Tier = 1 for the diazepam rectal kit in this excerpt.

NoteCheck the detailed formulary row for the specific QL numeric limit.

LYRICA — PA; QL

DrugLYRICA oral capsule entries are annotated with 'PA; QL' in the Requirements/Limits column.

TierDrug Tier = 3 for LYRICA presentations in this excerpt.

ImplicationDispensing LYRICA may require prior authorization and be subject to quantity limits; follow PA and QL procedures.

Multiple products — QL indicated

GeneralMultiple opioid and analgesic products list 'Requirements Limits = PA; QL' indicating both prior authorization and quantity limits apply.

ExamplesMorphine, oxycodone, oxymorphone and combination products are annotated with PA and QL in the opioid section.

Operational notePharmacies should verify both PA and QL requirements when processing opioid prescriptions to avoid denials.

Multiple listed products — QL where indicated

GeneralAcross psychotherapeutic and CNS listings, Quantity Limits are indicated where 'Requirements/Limits = QL' appears; numeric limits are in full entries.

ExamplesSome stimulant and sleep agent entries show PA; QL annotations (e.g., RELEXXII, QUVIVIQ).

ActionCheck the detailed formulary rows for exact QL amounts and PA requirements.

QUILLIVANT XR — PA; QL

DrugQUILLIVANT XR oral suspension (ext rel 24 hr, recon) is listed with Requirements/Limits = PA; QL (PA and QL indicated).

TierDrug Tier = 3 for QUILLIVANT XR in this excerpt.

NoteNumeric quantity limits are not shown in this excerpt; consult the full table for specifics.

WAKIX / WELLBUTRIN / XYREM entries — PA; LA; QL

ExamplesWAKIX, WELLBUTRIN SR/XL, XYREM/XYWAV entries include PA; LA; QL annotations where applicable.

ImplicationThese CNS agents may require prior authorization, have limited access designations, and be subject to quantity limits.

ActionConsult the specific formulary rows for numeric QL values and PA/LA procedures.

CARDIZEM CD — PA; QL

DrugCARDIZEM CD oral capsule, extended release 24 hr is listed with Requirements/Limits = PA; QL in the table.

TierDrug Tier = 3 for CARDIZEM CD in this excerpt.

NoteNumeric QL specifics should be referenced in the full formulary row.

FUROSCIX — PA; QL

ProductFUROSCIX subcutaneous kit is listed with Requirements/Limits = PA; QL.

ContextFUROSCIX is a specialty kit with both prior authorization and quantity-limit annotations in the listing.

ActionFollow PA and QL procedures for dispensing FUROSCIX; consult plan resources for specifics.

DOPTELET — 15 TAB PACK (pack-specific QL)

DrugDOPTELET is referenced with a '15 TAB PACK' pack-specific notation in the Requirements/Limits column (pack-specific QL).

UnitSpecified pack: 15-tablet pack (pack-specific coverage noted).

ImplicationCoverage and dispensing may be limited to the specified pack; check full entry for authorization or dispensing rules.

ELIQUIS — 30D START (starter pack reference)

ProductELIQUIS DVT-PE TREAT 30D START is referenced as a 30-day starter pack in the Requirements/Limits column.

Unit30-day starter pack referenced for initial DVT-PE treatment.

Operational noteStarter-pack references indicate the covered initial dispensing quantity; subsequent supplies may follow different QL or PA rules.

Clindamycin-benzoyl peroxide topicals — QL for pump formulations

Product groupClindamycin-benzoyl peroxide topical products: some pump formulations are indicated with Requirements/Limits = QL in the table.

ExamplesClindamycin-benzoyl peroxide topical with pump formulations show QL in the excerpt.

ImplicationPump-format topical products may have monthly QL restrictions; consult full formulary rows for exact limits.

Acyclovir topical products — PA; QL noted

Product groupAcyclovir topical products include Requirements/Limits = PA; QL for some formulations in the table.

ExamplesZOVIRAX topical ointment is shown with PA; QL in the Requirements/Limits column.

ActionFor PA/QL-marked topical antivirals, providers should obtain required authorization or document justification per plan guidance.

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION	Drug Tier = 2; Requirements/Limits = .
ABILIFY ORAL TABLET	Drug Tier = 3; Requirements/Limits = PA; QL

DOPTELET (15 TAB PACK) ORAL TABLET	Requirements/Limits = PA; LA; QL
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK	Dose pack listing — see formulary for limits

OpenPayer

Large Group Legacy Prescription Drug Formulary (2025)

Coverage Conditions & Scope

Formulary Listings & Code References

Authorization, Documentation & Denial Risks

Formulary Organization & Purpose

Abbreviations & Legend

Step Therapy Indicators & Tables

Quantity Limits & Pack/Starter References

Administration & Site Restrictions

QL	Quantity Limits flag present (numeric limits specified elsewhere)
PA	Prior Authorization required

MORPHINE ORAL TABLET	Requirements/Limits = PA; QL
OXYCODONE ORAL TABLET	Requirements/Limits = PA; QL

EUFLEXXA INTRA-ARTICULAR SYRINGE	Requirements/Limits = PA; LA
MONOVISC INTRA-ARTICULAR SYRINGE	Requirements/Limits = PA; LA

15 TAB PACK	Pack-size threshold referenced in formulary
30D START	30-day starter pack referenced in formulary