Prior Authorization and Utilization Controls

Prior authorization (PA) and other utilization controls apply to many drugs listed in this formulary. When a drug is annotated with PA, LA (limited access), QL (quantity limit), SP (specialty), or ST (step therapy), prescribers and pharmacies must obtain the required approvals and submit supporting documentation prior to dispensing. Failure to obtain required authorizations or to follow site-of-service/specialty pharmacy routing may result in denial of coverage or claim payment.

• PA = Prior Authorization — plan requires approval before fill; lack of PA may cause noncoverage.
• LA = Limited Availability — product may be restricted to certain pharmacies or sites of service.
• SP = Specialty — may require dispensing via the plan’s specialty pharmacy and additional monitoring.
• QL = Quantity Limit — plan limits the amount covered per time period; claims exceeding QL may be denied.
• ST = Step Therapy — some drugs require trials of preferred agents first; ST is indicated where applicable (e.g., select CNS and specialty agents).

Interpretation of Requirement Codes and How to Comply

Interpretation of requirement codes: PA, LA, QL, SP, and ST indicate utilization management controls. Providers must review these flags on the drug listing and follow the plan’s operational rules when submitting prescriptions and claims.

• Confirm the specific code(s) shown next to each drug on the formulary entry prior to prescribing.
• When PA is indicated, submit a prior authorization request and include all required clinical documentation.
• For LA/SP drugs, follow the plan’s specialty pharmacy or site-of-service requirements.
• Match the requested quantity on the claim to the stated QL to avoid denial.

Long‑Acting and Specialty Product Authorization (including SUNLENCA/YEZTUGO)

Certain long-acting and specialty products (for example, lenacapavir products SUNLENCA/YEZTUGO and other LA/SP agents) require additional handling: limited authorization (LA), prior authorization (PA), specialty pharmacy (SP), and specific quantity limitations. These products commonly have low annual or per‑period QL values and may be limited to specialty dispensing only.

• SUNLENCA / YEZTUGO (lenacapavir) — flagged LA, QL (annual limits shown), SP; prior authorization required before coverage.
• Long-acting agents and injectables labeled LA/SP often require documentation of clinical rationale and may be dispensed only through network specialty pharmacies.
• Claims for LA/SP products submitted without the required PA and correct site-of-service may be denied.

Required Documentation and Claim Matching

Documentation expectations: when PA, LA, QL, or SP is indicated, providers must submit supporting clinical documentation with the authorization request and ensure claim-level data match the approved authorization (drug, strength, days’ supply, quantity).

• Include diagnosis, relevant prior treatments (for ST where applicable), and clinical rationale demonstrating medical necessity.
• For LA/SP drugs, provide site-of-care information and any required monitoring plans.
• Ensure the NDC/pack size and quantity on the claim match the PA/QL parameters (mismatch can trigger denial).
• Formulation-specific documentation (e.g., oral solutions, suspensions, injectables) may be required for certain products.

Denial Risk for Unmet Utilization Controls

Denial risk and enforcement: claims that do not meet utilization controls (missing PA, exceeded QL, incorrect site-of-service, or unmet ST requirements) are at risk for denial. Prior authorization approval must be obtained and in effect at the time of dispensing.

• Requests exceeding stated QLs (examples in formulary: many insulins, oral solids, and specialty injectables) may be denied.
• Failure to follow ST where indicated (e.g., certain CNS and specialty agents) may result in noncoverage.
• Specialty/LA/PA requirements are strictly enforced for many oncology, biologic, and rare-disease therapies; confirm PA and specialty routing before dispensing.

Provider Operational Steps and Member Resources

Operational notes and provider actions: check member’s Certificate of Coverage and contact Customer Service for plan‑specific rules, request forms, or help with reasonable modifications and language assistance. Use the plan’s PA submission process and specialty pharmacy channels as required.

• Members and providers should verify coverage and cost-sharing via the member portal or ID‑card phone number prior to initiating therapy.
• If assistance is needed (language access, disability accommodations), contact Customer Service at the number on the member ID card.
• Follow the payer’s PA form instructions and include all requested supportive documentation to avoid delays.

Step Therapy (ST) — Presence and Documentation

Step therapy (ST): where ST is indicated on the formulary, the plan may require trial and failure of specified first‑line agents before approving non‑preferred drugs. Some entries in the formulary indicate ST; where ST is not shown, no explicit step requirement is provided in that listing — always verify for the specific product.

• When ST is shown (drug annotated with ST), document prior trials and outcomes as part of the PA.
• If ST is not specified in the formulary excerpt, do not assume there are no step requirements — confirm via the PA policy or member plan documents.
• Examples: KERENDIA and selected CNS agents show ST notation; other agents may require step therapy per plan rules.