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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsEmblemHealth NYSHIP 2‑Tier Formulary Coverage | Op…
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    CurrentEmblemHealthPolicy NYS2

    EmblemHealth NYSHIP 2-Tier Prescription Drug Formulary (coverage criteria)

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    Defines the list of covered outpatient prescription drugs, tier placement, and common utilization controls (PA, QL, ST, LA) for EmblemHealth NYSHIP 2-Tier members; intended for members, providers, and pharmacies using the NYS2 formulary.

    Policy Summary
    PayerEmblemHealth
    PolicyEmblemHealth NYSHIP 2-Tier Prescription Drug Formulary (coverage criteria)
    Policy CodePolicy NYS2
    Change TypeNo material change
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and submit required documentation when a drug line lists PA, QL, SP, or LA to avoid claim denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2026Formulary version / update date listed
    2 tiersFormulary tiers
    PA, QL, ST, LAUtilization controls explained
    800-447-8255Customer service
    ~120Distinct drug entries (excerpt)

    Coverage Criteria and General Rules

    Authorization and quantity limit criteria (product-level)

    Products listed with flags are subject to the following controls where present.

    Authorization and quantity limits (product-level): When a formulary entry includes 'PA' the product requires prior authorization; when 'QL' is present coverage is limited to the specified quantity and time period; when 'SP' is present the product is managed through the specialty pharmacy program; when 'LA' is present limited-access program requirements apply.

    Examples from the formulary: abiraterone acetate entries show 'PA, QL (120 tablets/30 days), SP'; ALECENSA and many oncology agents list 'LA, PA, QL (specified quantity/period), SP'.

    Coverage conditioned on utilization controls

    Formulary coverage is conditional on drug-specific utilization controls listed in the Requirements/Limits field.

    Coverage conditioned on utilization controls: Drug is covered according to its tier when ALL specified requirements in the Requirements/Limits field are met (for example: prior authorization obtained when 'PA' is indicated; dispensing does not exceed any 'QL' quantities/periods; specialty pharmacy dispensing when 'SP' is required; limited-access program conditions when 'LA' is indicated).
    Policy Summary
    PayerEmblemHealth
    PolicyEmblemHealth NYSHIP 2-Tier Prescription Drug Formulary (coverage criteria)
    Policy CodePolicy NYS2
    Change TypeNo material change
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and submit required documentation when a drug line lists PA, QL, SP, or LA to avoid claim denial.
    SourceLink
    On This Page
    Coverage Criteria and General RulesCode Listings and Quantity ExamplesPrior Authorization, Step Therapy, Documentation RequirementsPolicy Background and ScopeAbbreviations and Term DefinitionsInitial Therapy and Clinical CriteriaStep Therapy / Limited Access IndicatorsQuantity Limits (Per-product Examples)Specialty Pharmacy and Site-of-Service RequirementsBiosimilars and Preference Notes

    Examples: XALKORI lines show 'LA, PA, QL (120 capsules/30 days), SP'; XPOVIO entries show 'LA, PA, QL (pack limits per 28 days), SP'; ZEJULA shows 'LA, PA, QL (30 tablets/30 days), SP'.

    No explicit exclusions are stated in this segment. The extract lists vaccines and other covered products with Requirements/Limits flags (for example, several vaccines are marked ACA), but it does not present any standalone exclusion language or an explicit list of items categorically excluded from coverage.

    Certain contraceptives and glucose products in the formulary are designated as ACA (Affordable Care Act preventive coverage) or OTC. Examples include levonorgestrel/ethinyl estradiol and related contraceptive regimens with Requirements/Limits = ACA, and multiple glucose chew tabs, gels and glucagon rescue products marked OTC. These ACA/OTC designations indicate such items may be subject to different benefit handling or coverage rules than prescription-tier drugs.

    The formulary lists several over-the-counter items (notably glucose chew tabs, gels and related rescue products) with Requirements/Limits = OTC and some contraceptive products marked ACA. When an entry is labeled ACA/OTC the item may be excluded from standard prescription coverage or applied under alternate benefit rules per formulary flags; providers should follow plan-specific billing and benefit instructions for these products.

    This segment does not include any statements declaring therapies or products to be not medically necessary. The entries shown are product listings with Requirements/Limits indicators (e.g., ACA) but do not contain 'not medically necessary' determinations in this excerpt.

    Code Listings and Quantity Examples

    Vaccines listedmixedCovered
    ROTATEQrotavirus vaccine, live oral pentavalent soln
    SHINGRIXzoster vaccine recombinant adjuvanted for IM injection
    SPIKEVAXCOVID-19 vaccine mRNA (Moderna) 50 mcg prefilled syringe
    TRUMENBAmeningococcal group B vaccine (recombinant) IM prefilled syringe
    TWINRIXhepatitis A and B vaccine suspension
    VAQTAhepatitis A vaccine injection
    VARIVAXvaricella virus vaccine live for injection
    VAXNEUVANCEpneumococcal 15-valent conjugate vaccine
    Biologicals / allergen immunotherapy productsmixedCovered
    PALFORZIA LEVEL 11peanut allergen powder maintenance packet 300 mg
    PALFORZIA LEVEL 1peanut powder 3 mg dose
    GRASTEKtimothy grass pollen sublingual tablet 2800 BAU
    Antineoplastic / specialty oral agents (examples)mixed
    abiraterone acetate 250 mgZytiga
    ALECENSA 150 mgalectinib HCl capsule
    ALUNBRIG 90/180/30 mgbrigatinib tablets (various strengths)
    IBRANCE 75/100/125 mgpalbociclib
    IMBRUVICA 140/280/420 mgibrutinib
    Drugs (no billing codes in extract)mixed
    NDC/HCPCS not listedDocument lists drug names and strengths but does not provide NDC/HCPCS codes in this extract.
    Quantity limits — product examples
    PREVYMIS (tablets)QL = 200 tablets per 365 days
    PREVYMIS (pellet pack)QL = 800 packets per 365 days
    PREZCOBIX (darunavir‑cobicistat)QL = 30 tablets per 30 days
    PREZISTA (oral suspension)QL = 400 mLs per 30 days
    Selected HIV/antiviral agents (examples)Product-specific QLs commonly 30 or 60 tablets per 30 days (see individual entries)
    Quantity limit format — typical examples
    Common tablet QL (30/30)Example: many oral antivirals and HIV agents listed with QL = 30 tablets per 30 days
    Common tablet QL (60/30)Example: darunavir 600 mg and other agents listed with QL = 60 tablets per 30 days
    Capsule/pack QL (56/28)Example: some therapy packs/pellet packs and specific product packs shown as QL = 56 capsules/28 days (see CF modulators and therapy packs)

    Prior Authorization, Step Therapy, Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Many drugs listed on the formulary require prior authorization (PA) before the plan will cover them. This includes numerous antiviral, antifungal, specialty, oncology, biologic, lipid‑lowering, endocrine/metabolic, and other high‑cost agents. Prescribers should obtain PA when an item is marked with PA to avoid claim denial.

    • PA required for many antiviral/antifungal agents (examples: EPCLUSA, SOVALDI, CRESEMBA, SIRTURO)
    • PA required for numerous PA‑designated drugs across therapeutic classes
    • PA required for specialty and oncolytic agents (examples: XALKORI, XPOVIO, XTANDI, ZEJULA, WELIREG)
    • PA required for select GLP‑1 receptor agonists and tirzepatide (examples: MOUNJARO, OZEMPIC, TRULICITY, TRULICITY, WEGOVY, WEGOVY, ZEPBOUND)
    • PA required for specified formulations (examples: nimodipine oral solution, certain liquid suspensions)
    • PA required for many specialty/high‑tier drugs — oncology, cystic fibrosis modulators, pulmonary arterial hypertension, and others show LA/PA/QL/SP
    • PA required for biologics and specialty injectables (examples: REPATHA, CIMZIA, ENTYVIO PEN)
    • PA and specialty pharmacy (SP) routing required when SP is indicated
    • PA often accompanies quantity limits (QL) and limited availability (LA) flags — adherence to QL is required
    • Failure to obtain required PA may result in non‑coverage or claim denial
    Step Therapy

    Step Therapy / Program Controls

    Step therapy (ST) and program‑based controls may apply to selected agents. Where a drug is flagged ST or part of a program, the plan may require trial of specified first‑line therapies or routing through a specialty/limited access program before approving an alternate agent.

    • ST present for select agents (example: KERENDIA shows ST; certain hypnotics and other classes show ST flags)
    • Program indicators (LA, SP) may include embedded step or sequencing requirements
    • Step therapy specifics are not listed for every flagged drug in this extract — check the full formulary or contact Member Services for details
    Denial Risk

    Utilization Management Flags

    Many formulary entries include utilization‑management flags (PA, QL, SP, LA). When these flags are present prescribers and pharmacies must follow the plan’s operational rules: obtain prior authorization, adhere to quantity limits, and, when required, route dispensing through the indicated specialty or limited‑access channels.

    • PA — obtain approval prior to dispensing when listed
    • QL — ensure the dispensed quantity does not exceed the listed limit (per days/period)
    • SP — specialty pharmacy dispensing required when indicated
    • LA — limited availability may restrict where the drug can be obtained
    • Claims may be denied or reduced if PA is not obtained or QLs are exceeded
    Documentation Required

    Documentation and Supporting Information

    When PA, QL, LA, or SP is indicated the plan expects supporting documentation to justify medical necessity, dosing, and quantity. For specialty and oncology drugs, include diagnosis, prior treatment history (including failures/intolerance), and regimen details. For QL exceptions, document the clinical rationale for quantities above the limit.

    • Required documentation: clinical indication, prior therapies and outcomes, dosing plan, expected duration
    • Oncology/specialty PA often requires treatment plan, chart notes, and supporting labs or genetic test results
    • For biologics and specialty injectables, include dosing interval and previous biologic exposure
    • Quantity justification must align with dose and duration; exceedance may require additional clinical rationale
    Note

    Member & Provider Support

    Member and provider support is available for PA, formulary interpretation, language assistance, and to request exceptions. Contact EmblemHealth Member Services for help with PA submission requirements and to locate full coverage criteria.

    • Member Services: Call 800‑447‑8255 (TTY: 711), hours 8 a.m.–6 p.m., Monday–Friday
    • Language assistance and auxiliary aids: Call 877‑411‑3625 (TTY: 711) for free services in multiple languages
    • Providers may request formulary exception or obtain a list of therapeutically equivalent alternatives through the plan

    Policy Background and Scope

    This document is a drug formulary that lists covered outpatient prescription drugs organized by therapeutic section and product presentation. Each line shows the drug name, dosage form, formulary tier and any Requirements/Limits flags (for example, ACA for preventive vaccines). The listing is intended to indicate coverage status, tier placement and whether utilization controls such as PA, QL, ST or SP/LA apply.

    Abbreviations and Term Definitions

    PA — Prior Authorization
    DefinitionPrior Authorization (PA): the plan requires approval from the payer before the drug will be covered
    When shownPA is displayed on formulary lines where clinical/administrative review is required prior to coverage
    ConsequenceFailure to obtain PA may result in the plan not covering the drug
    QL — Quantity Limit
    DefinitionQuantity Limit (QL): a plan-imposed maximum quantity of a drug covered for a specified time period
    ExpressionShown as number + unit + time period (e.g., 30 tablets/30 days; 100 mL/30 days; 200 tablets/365 days)
    Operational noteDispensing must not exceed the specified QL without appropriate authorization or exception
    ST — Step Therapy
    DefinitionStep Therapy (ST): a requirement to try one or more specified drugs first before coverage of an alternate agent is allowed
    Formulary useEntries annotated 'ST' indicate step requirements apply; specific step sequences are referenced on individual lines or PA process
    Provider actionPrescribers should document prior trials per ST requirements when requesting coverage for a non-preferred agent
    LA — Limited Availability
    DefinitionLimited Availability (LA): indicates the drug may have restricted distribution or be available only at select pharmacies or channels
    Formulary implicationLA often accompanies PA, QL, or SP flags and signals additional access controls (see individual Requirements/Limits)
    Operational detailOperational meaning and procedures for LA are defined in the payer's master policy or PA instructions
    Abbreviations used in formulary entries
    PAPrior Authorization — approval required before coverage
    QLQuantity Limit — maximum permitted quantity per time period (e.g., 30 tablets/30 days)
    SPSpecialty Pharmacy — indicates specialty dispensing/handling
    LALimited Availability — restricted distribution/limited pharmacies
    ACAAffordable Care Act — preventative/vaccine items that may be covered under ACA rules
    Prior Authorization indicator
    IndicatorPA shown on formulary line when clinical review or approval is required prior to coverage
    Action for providerSubmit PA documentation per the plan's prior authorization process to avoid coverage denial
    Typical pairingPA frequently appears with QL and/or SP for specialty or high-cost products
    Quantity Limit (QL) indicator
    MeaningQL indicates the allowed quantity and associated time period (e.g., 60 tablets/30 days; 100 mLs/30 days)
    ExamplesInsulins: QL = 100 mL/30 days; FARXIGA: QL = 30 tablets/30 days; REPATHA SureClick: QL = 6 pens/28 days
    Claims impactClaims exceeding QL may deny unless PA or exception is obtained
    SP — Specialty drug designation
    DesignationSP = Specialty Pharmacy designation — medication requires dispensing via specialty pharmacy or program
    Typical useSP commonly applied to biologics, injectables, cystic fibrosis modulators, and other high-cost specialty agents
    Associated controlsSP entries often include PA, QL, and LA flags requiring specialty routing and documentation
    Formulary abbreviations — mapping
    PA = Prior AuthorizationCoverage is contingent on payer approval when PA is shown
    QL = Quantity LimitSpecifies maximum units per timeframe (e.g., tablets/30 days, mLs/30 days)
    SP = Specialty PharmacyRequires specialty dispensing channel for the product
    LA = Limited AvailabilityIndicates restricted distribution or limited pharmacies for dispensing
    PA — coverage contingent on approval
    Where shownPA appears on product lines that require clinical or administrative review before the plan will cover the drug
    Provider requirementObtain and submit PA per plan instructions to avoid claim denial
    Common pairingPA is frequently listed alongside QL and SP on specialty or oncology agents
    QL — Quantity Limit (adjudication)
    DefinitionQL = maximum permitted quantity per specified period (e.g., 30 tablets/30 days; 6 pens/28 days)
    ExamplesTRIJARDY XR / JANUVIA / JARDIANCE entries: QL 30 tablets/30 days; Insulin pens: QL 100 mL/30 days
    Adjudication noteClaims exceeding QL require PA or may be rejected at claim adjudication
    SP — Specialty Pharmacy
    DefinitionSP indicates the drug is managed through the specialty pharmacy program and typically requires specialty dispensing
    ExamplesREPATHA, NUCALA, KESIMPTA, many oncology biologics and CF modulators are flagged SP
    Provider impactPrescribers should route prescriptions to the specialty pharmacy specified by the plan and include required documentation
    LA — Limited Access (operational note)
    LA meaningLA (Limited Access) flag denotes restricted availability or distribution — operational rules defined in the master policy
    Typical pairingLA often accompanies PA, QL, and SP on high‑cost or limited‑distribution products
    Where to find detailsRefer to the payer's master policy or PA instructions for operational LA procedures and site-of-care requirements
    OTC designation examples
    OTC designationSome glucose rescue products and selected contraceptives are designated OTC (over‑the‑counter) in Requirements/Limits
    ExamplesCVS SOFT GLUCOSE, DEX4 GLUCOSE and similar glucose chew tabs marked OTC
    ImplicationOTC-designated items may be handled differently for coverage and member cost sharing per plan rules
    LA / PA / QL / SP — shorthand mapping
    LA/PA/QL/SP mappingLA = Limited Access; PA = Prior Authorization; QL = Quantity Limit; SP = Specialty Pharmacy — these shorthand flags appear next to product lines
    UsageFlags denote utilization management controls that must be met for coverage (e.g., PA must be obtained, QL not exceeded, SP dispensed via specialty channel)
    Provider actionFollow Requirements/Limits shown on each formulary line when prescribing or dispensing
    PA — (repeat definition)
    PA (repeat definition)Prior Authorization: plan approval required prior to coverage
    ImplicationPA shown on formulary lines indicates prescriber must request approval per plan process
    Denial riskLack of PA may result in claim denial
    QL — (repeat definition)
    QL (repeat)Quantity Limit: maximum quantity allowed per specified time period (e.g., tablets/30 days)
    Common formatsExpressed as units/timeframe such as '30 tablets/30 days' or '100 mL/30 days'
    Claims noteExceeding QL without PA may lead to denial
    SP — (repeat definition)
    SP (repeat)Specialty Pharmacy — medication managed via specialty channel; often requires PA and QL
    ExamplesMany biologics, injectables and specialty oncology agents are SP-designated
    Operational impactSpecialty drugs may have limited network pharmacies and additional documentation requirements
    LA — (repeat definition)
    LA (repeat)Limited Access — indicates restricted availability; see master policy for operational details
    Common pairingLA frequently appears with PA and QL on high‑cost specialty products
    Provider notePrescribers should consult PA/LA instructions for required documentation or site‑of‑care stipulations
    PA — (repeat)
    PA (repeat)Prior Authorization — approval required before plan covers the drug
    Where listedShown in Requirements/Limits on product lines that need prior review
    ActionSubmit clinical justification per PA form/process
    QL — (repeat)
    QL (repeat)Quantity Limit — maximum allowed quantity per specified period (example: 100 mL/30 days for many insulins)
    ExamplesInsulins: QL 100 mL/30 days; JANUVIA/JARDIANCE: QL 30 tablets/30 days
    Operational notePharmacy claims subject to QL at adjudication; exceeding QL may require PA
    SP — (repeat)
    SP (repeat)Specialty Pharmacy designation — medication managed under specialty program
    EffectMay require dispensing through designated specialty pharmacies and additional documentation
    Common co-flagsSP lines commonly include PA, QL, LA
    PA — (repeat)
    PA (repeat)Prior Authorization — coverage contingent on plan approval
    Provider stepInitiate PA request when PA flag appears on formulary line
    Denial riskClaims with no PA when required may be denied
    QL — (repeat)
    QL (repeat)Quantity Limit — maximum units per timeframe (e.g., tablets/30 days) enforced at claim adjudication
    ExamplesFARXIGA: 30 tablets/30 days; JANUMET XR: 30–60 tablets/30 days depending on strength
    Provider actionRequest PA if intended dispensing exceeds QL
    SP — (repeat)
    SP (repeat)Specialty Pharmacy — requires specialty dispensing and program management
    ImplicationSP products often have QL and PA requirements and may be limited to select dispensing channels
    ExamplesREPATHA, NUCALA, ATTRUBY, many oncology biologics listed as SP
    QL — (repeat)
    QL (repeat)Quantity Limit — expresses a cap (units/timeframe) enforced by the plan
    AdjudicationClaims beyond QL require PA or may be rejected
    DocumentationProvide quantity justification when requesting exceptions or PA
    PA — (repeat)
    PA (repeat)Prior Authorization — approval required for coverage when shown
    Provider instructionFollow the payer's PA submission process and include required clinical documentation
    RiskNo PA when required can lead to claim denial
    LA — (repeat)
    LA (repeat)Limited Access — indicates restricted distribution or availability; see master policy for details
    Common pairingLA commonly appears with PA, QL, SP for specialty or limited-distribution drugs
    Operational noteRefer to plan operational guidance for LA dispensing and exception processes
    SP — (repeat)
    SP (repeat)Specialty Pharmacy — medication managed through specialty program; often requires PA/QL
    Provider actionRoute prescriptions to designated specialty pharmacies and submit documentation per PA requirements
    ExamplesMany injectables and biologics in the formulary are SP-designated
    ST — (repeat)
    ST (repeat)Step Therapy — requires trial of specified drugs before coverage of others; 'ST' flag appears on select lines
    ActionDocument prior trials as required when seeking coverage for step‑protected agents
    NoteExplicit step sequences are provided via PA guidance or individual product entries when applicable

    Initial Therapy and Clinical Criteria

    Initial therapy requirements for selected biologics

    Prescribing rules for selected biologic or specialty injectable products where provided.

    Initial therapy requirements for selected biologics: Prescriptions for certain biologic or specialty injectable products require prior authorization and adherence to listed quantity limits at initiation. For example, the formulary shows ENTYVIO and similar biologics flagged with PA and QL; prescribers must request PA and prescribe within the stated QL for initial supply.2 pens/28 days (example for some prefilled products)

    Refer to the product-specific Requirements/Limits field for the exact QL and any LA/SP program requirements when initiating therapy.

    Step Therapy / Limited Access Indicators

    Coverage noteImplication for provider
    Utilization management flags (LA, PA, SP) present for select agents; explicit multi-step therapy sequences are not included in this excerpt.
    When an entry shows LA, PA, or SP providers should follow the plan's authorization, limited‑access and specialty pharmacy processes (obtain PA, adhere to QL and route to SP as required).
    Coverage noteImplication for provider
    Some agents have 'LA' (likely limited access) flags; step therapy specifics are not provided in this segment.
    Providers should verify limited‑access requirements and submit required documentation/PA per the formulary entry before dispensing.
    Coverage noteImplication for provider
    Some agents are marked LA which may imply additional routing or requirements; explicit step therapy steps are not provided.
    Confirm LA routing and program enrollment (if applicable) and obtain PA/meet QL as specified on the formulary line prior to dispensing.
    Coverage noteImplication for provider
    Certain entries list 'LA' indicating limited access/step requirements before coverage; prescriber must meet LA‑defined criteria.
    Prescribers should review the formulary Requirements/Limits field for LA criteria and submit supporting clinical documentation with PA requests as needed.
    Coverage noteImplication for provider
    Some products require prior authorization (PA) before coverage; step therapy specifics not detailed in these chunks.
    Obtain PA following the plan's process and include required documentation; check the formulary line for any accompanying QL or SP routing.
    Coverage noteImplication for provider
    KERENDIA is noted with 'ST' indicating a step therapy requirement may apply prior to coverage.
    If prescribing KERENDIA, confirm step‑therapy requirements in the formulary and document prior trial of required agents or obtain PA per step rules.
    Coverage noteImplication for provider
    Some specialty and high‑cost agents are flagged with program indicators (LA, PA, SP) which imply prior steps or program enrollment may be required.
    Providers should verify specialty program enrollment, obtain PA, and comply with QL and specialty dispensing requirements before initiating therapy.
    Coverage noteImplication for provider
    Although many products are PA/LA/QL/SP flagged, explicit step therapy sequences are not specified in these chunks; providers should refer to the master formulary for step sequences.
    For step order and required prior trials consult the payer's full formulary or PA guidance and include documentation when submitting PA requests.
    Coverage noteImplication for provider
    LA and PA indicators suggest managed access and potential step requirements though explicit step rules are not included in this excerpt.
    Confirm specific access controls and step edits by reviewing the formulary Requirements/Limits field or contacting member services prior to dispensing.
    Coverage noteImplication for provider
    Designated agents annotated 'ST' require step therapy per formulary rules before covering certain products.
    When 'ST' appears on a formulary line, follow the formulary's step‑therapy algorithm and provide documentation of failed/contraindicated prior therapies or request PA per step policy.
    Coverage noteImplication for provider
    Some starter packs or step‑designated products require PA and limited quantities before full supply (e.g., ZEPOSIA starter kits list PA and QL).
    If prescribing a starter kit or step‑designated product, obtain PA and ensure dispensing does not exceed the starter/QL limits shown on the formulary line.
    Coverage noteImplication for provider
    Some biologics and JAK inhibitors are designated LA, PA, and SP; step edits may apply though explicit sequences are not included in this extract.
    Confirm biologic/JAK inhibitor program requirements (PA, QL, SP) and any step edits via the master formulary or PA documentation before initiating therapy.

    Quantity Limits (Per-product Examples)

    abacavir — quantity limits
    abacavir sulfate soln 20 mg/mLQL = 960 mLs per 30 days
    abacavir sulfate tab 300 mgQL = 60 tablets per 30 days
    abacavir sulfate-lamivudine 600-300 mgQL = 30 tablets per 30 days
    abacavir / zidovudine QLs (examples)
    abacavir sulfate tab 300 mgQL = 60 tablets per 30 days
    zidovudine tab 300 mgQL = 60 tablets per 30 days
    zidovudine capsules (Retrovir)QL = 180 capsules per 30 days
    darunavir — quantity limits
    darunavir tab 600 mgQL = 60 tablets per 30 days
    PREZISTA darunavir tab 75 mgQL = 300 tablets per 30 days
    PREZISTA oral suspensionQL = 400 mLs per 30 days
    Hepatitis C product QLs (examples)
    EPCLUSA (sofosbuvir‑velpatasvir)QL = 28 tablets per 28 days; PA and SP where shown
    HARVONI (ledipasvir‑sofosbuvir)QL = 28 tablets per 28 days; may show PA/SP
    SOVALDI (sofosbuvir)QL = 28 tablets per 28 days; PA, QL, SP noted

    Specialty Pharmacy and Site-of-Service Requirements

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    Biosimilars and Preference Notes

    Note