Prior Authorization Requirement

Prior Authorization (PA) is required for many listed products. When a drug is marked with PA the plan requires approval before the prescription is filled; failure to obtain prior authorization may result in the claim being denied or not covered. Providers should verify PA requirements prior to dispensing and follow the plan's prior authorization process.

• PA = Prior Authorization required; obtain approval before dispensing or risk denial
• Failure to obtain PA may result in noncoverage or claim denial

Prior authorization required for select agents

Certain agents and product groups are explicitly designated as requiring prior authorization. Examples throughout the formulary include antifungals (CRESEMBA), hepatitis C agents (HARVONI, SOVALDI), specialty antivirals (GENVOYA with QL), and many oncology and high-cost drugs. Check the Requirements/Limits column for a PA flag on the specific product entry.

• Examples of common PA-marked products: CRESEMBA, HARVONI, SOVALDI, GENVOYA
• Check each formulary line item Requirements/Limits for the 'PA' flag

Prior Authorization and coverage flags

Products may carry one or more coverage flags that affect how they are managed: PA (Prior Authorization), QL (Quantity Limit), LA (Limited Availability), SP (Specialty), ACA (Affordable Care Act designation), ST (Step Therapy). These flags trigger specific administrative requirements — follow the indicated program/process for each flagged product.

• PA, QL, LA, SP, ACA, ST are common flags seen in the Requirements/Limits column
• Adhere to each flag's program requirements to avoid claim denials

Prior authorization required for select specialty drugs

Many specialty and oncology oral agents require PA and often additional handling (LA or SP). Examples noted in the formulary include ENSACOVE, KOSELUGO, VITRAKVI, and others. Specialty drugs may also have quantity limits and limited distribution requirements.

• Specialty agents frequently require PA + SP and may be limited to certain pharmacies
• Examples: KOSELUGO (LA, PA, QL, SP), VITRAKVI (LA, PA, QL, SP)

Prior authorization required for select specialty agents

Numerous specialty and high-cost endocrine/metabolic agents are subject to prior authorization (PA) and specialty pharmacy (SP) requirements (e.g., carglumic acid, cinacalcet, crinecerfont, GALAFOLD, Ravicti, IMCIVREE). Providers should prepare to submit supporting clinical documentation when requesting PA for these products.

• Endocrine/metabolic specialty examples: CARBAGLU (PA, SP), CINACALCET (PA, SP), GALAFOLD (LA, PA, QL, SP)
• Submit clinical justification and prior therapy history with PA requests

PA required for many PAH/specialty drugs

Many pulmonary arterial hypertension (PAH) and specialty drugs require PA and often LA/SP designations (e.g., UPTRAVI, ADEMPAS, bosentan products, TYVASO). These products commonly include quantity limits and may have staged dosing or titration packs that are separately flagged — obtain authorization for both starter/titration packs and maintenance supplies where applicable.

• PAH examples: UPTRAVI (LA, PA, QL, SP), TYVASO (PA, SP)
• Titration/starter packs (e.g., UPTRAVI TITRATION PACK) may have separate PA/QL requirements

PA required for select antihyperlipidemics

Some antihyperlipidemic agents (e.g., NEXLETOL, NEXLIZET) are subject to PA and quantity limits. Verify PA status and QL for newer or higher-tier lipid-lowering therapies before prescribing.

• NEXLETOL, NEXLIZET = PA, QL (typically 30 tablets/30 days)
• Check Requirements/Limits for coverage exceptions or ACA designations

Prior authorization required for listed specialty products

Many listed specialty products are marked with combinations of LA, PA, SP and QL — examples include TRIKAFTA, KALYDECO, OFEV, ALYFTREK, CHOLBAM, and others. These flags indicate restricted distribution, specialty pharmacy handling, prior authorization, and quantity controls that must all be satisfied.

• CF modulators and antifibrotics: TRIKAFTA, KALYDECO, OFEV = LA, PA, QL, SP
• Liver and rare disease agents such as CHOLBAM = LA, SP

Prior authorization required for selected agents

Several agents across the formulary are subject to PA along with other controls (LA, SP, QL). Examples include tasimelteon (PA, QL), orlistat/phentermine products (PA, QL), ZEPOSIA starter kits (PA, QL, SP), and many immunomodulators (OLYMPIANT-class entries). Confirm PA and plan-specific limits prior to dispensing.

• Sleep, weight-loss, and MS starter kits often require PA and have QL limits
• Starter kits and therapy packs (e.g., ZEPOSIA, MAVENCLAD, MAYZENT) commonly flagged LA/PA/QL/SP

Authorization flags present

Authorization flags (PA, LA, SP, QL) shown in the formulary are active triggers for coverage review. Claims for products marked with these flags may be denied without prior approval or if quantity limits are exceeded. Providers must follow PA procedures and document adherence to quantity limits.

• Claims may be denied for missing PA or exceeding QL
• LA/SP designations may restrict dispensing to specific pharmacies

Authorization/denial triggers

PA, LA, SP, and QL are common denial triggers when requests lack required information or when the requested quantity exceeds plan limits. Extended-release and high-strength formulations frequently have PA/QL rules (e.g., NUCYNTA ER, XTAMPZA ER). Ensure PA is submitted and QL is respected to reduce denial risk.

• ER formulations often require PA and have QL — obtain authorization prior to dispensing
• Provide full dosing and prior therapy history to minimize denials

Prior authorization/quantity limit risk

Not meeting PA or quantity limit (QL) requirements risks claim denial or nonpayment. Requests for products flagged PA/QL/LA/SP must include required documentation and be submitted per the plan's prior authorization process. Review the Requirements/Limits column for each drug to confirm applicable controls.

• Noncompliance with PA/QL/LA/SP may result in claim denial
• Verify plan-specific submission steps and required clinical information

PA/LA/SP requirements

When a product is labeled LA, PA, SP or QL, there are program requirements to meet. Limited Availability (LA) may restrict the number of dispensing sites; Specialty (SP) often requires use of a designated specialty pharmacy; Quantity Limits (QL) cap the reimbursable amount; PA requires clinical justification and approval.

• LA: limited dispensing locations
• SP: specialty pharmacy distribution and monitoring
• QL: precise day/quantity limits listed per product

Quantity and program flag triggers

Quantity limits and other program flags shown in the Requirements/Limits column (e.g., QL 30 tablets/30 days, QL 28 packets/28 days) are enforced at claim adjudication. Prescribers should prescribe within these limits or provide justification when requesting exceptions via PA.

• Adhere to QL values as listed (examples: GENVOYA QL 30/30, HARVONI QL 28/28)
• Request QL overrides only with supporting clinical documentation

Prior authorization required for listed PA/LA drugs

Products marked PA, LA, or SP in the Requirements/Limits column require prior authorization and may have limited distribution or specialty pharmacy requirements. Examples include many cystic fibrosis, rare disease, and oncology therapies. Confirm whether dispensing must occur through a specialty vendor and include that information in the PA request.

• PA/LA drugs often restricted to specialty pharmacy dispensing
• Check product line-item notes for pharmacy/channel restrictions

PA/QL noncompliance

Noncompliance with PA, LA, SP or QL (for example, failing to obtain approval or exceeding a quantity limit) may result in claim denial or member financial liability. Always confirm coverage details in the Certificate of Coverage and the member's specific plan before dispensing.

• PA/QL/LA/SP noncompliance can trigger denials and member cost-sharing
• Review member's Certificate of Coverage for plan-specific rules

ER formulation controls

Extended-release (ER) formulations and certain high-risk analgesics often have special controls: PA and QL are commonly applied (e.g., NUCYNTA ER, other ER opioid products). If prescribing ER formulations, include prior authorization and rationale to support necessity over alternatives.

• ER formulations commonly require PA and have QL (quantity/30 days)
• Provide justification for ER use versus immediate-release alternatives

PA/QL/LA/SP may trigger denial

PA, LA, SP and QL flags across the formulary may lead to coverage denial if requirements are not met. Providers should proactively identify flagged products, obtain necessary approvals, and ensure dispensing occurs through authorized channels to avoid interruptions in therapy.

• Multiple flags on a product increase the administrative steps required
• Coordinate with the member and specialty pharmacy early for high-cost therapies

Failure to meet product Requirements/Limits

Failure to meet the listed Requirements/Limits (PA, LA, SP, QL, ST, ACA) for a product may result in the claim not being processed or being denied. Always consult the Requirements/Limits column on the formulary page for the product and confirm member eligibility and plan-specific exceptions.

• Requirements/Limits column is the authoritative source for program flags
• Confirm member plan coverage and any group-specific notations (e.g., '*' next to tier)

Quantity-limit documentation

Quantity-limit documentation must be available for products showing QL (e.g., GENVOYA QL 30 tablets/30 days, ISENTRESS QL 60 tablets/30 days). When requesting a QL override, submit the clinical rationale and specify the requested quantity and duration.

• List QL value in the PA request and include clinical justification for higher quantities
• Examples: QL (30 tablets/30 days), QL (28 packets/28 days), QL (60 capsules/30 days)

Required documentation when flags present

When flags such as PA, LA, SP or QL are present, include required supporting documentation with the prior authorization submission: diagnosis, prior therapy trials, dosing/titration schedule, pharmacy preference (if SP/LA), and expected duration of therapy.

• Essential PA documents: diagnosis, previous treatments, clinical notes, labs/imaging where applicable
• For LA/SP products, include preferred specialty pharmacy or acknowledgement of limited dispensing

Documentation of applicable requirements

Providers must document applicable requirements when submitting PA — include clinical rationale, prior treatment history, dosing/titration details, and any monitoring plans required for safe use. Specialty therapies often require additional documentation such as genetic testing results or REMS enrollment.

• Include genetic test results, REMS enrollment, or specialty monitoring plans when relevant
• Staged dosing/titration packs should be documented separately in the PA

Documentation for restricted products

Restricted products (LA, SP) and PA/QL-labeled products require detailed documentation to support coverage. For specialty agents, include product-specific materials (e.g., therapy pack details, titration schedule, prior authorization forms from specialty pharmacy) with the PA request.

• Provide therapy pack/titration details for products like UPTRAVI, TRIKAFTA, ZEPOSIA starter kits
• Attach specialty pharmacy plan-of-care or enrollment documentation when requested

Supporting documentation for PA

PA requests should include supporting documentation for PA and limit exceptions (e.g., reason for quantity above QL, clinical failure of preferred agents, contraindications). Timely and complete documentation reduces review time and denial likelihood.

• Supporting documents: clinician notes, prior medications tried, laboratory results, imaging
• Document why preferred or lower-cost alternatives are inappropriate or contraindicated

Specialty/PA documentation

Specialty products require specialty/PA documentation: prescriber's specialty credentialing, treatment plan, expected duration, infusion or administration site, and monitoring requirements. Many specialty products in the formulary (e.g., hemophilia factors, high-cost biologics) are PA and SP flagged.

• Include prescriber specialty and treatment site information for SP products
• Examples: coagulation factors, hemophilia products, biologic immunomodulators

Step therapy applies to select agents

Step therapy (ST) applies to select agents. Products marked with ST require trying specified first-line drugs before higher-tier treatments will be approved. Examples include KERENDIA and some behavioral health and neurologic agents. Follow the plan's step edits when submitting PA to document failed trials of required agents if applicable.

• ST = Step Therapy; evidence of trial(s) of first-line agent(s) may be required
• Examples: KERENDIA (ST), AUVELITY (ST), FANAPT titration packs (ST)

Step therapy / Specialty program requirements

Step therapy and specialty program indicators (ST, SP) are present for multiple drugs. When ST is indicated, PA submissions should include documentation of trials and failures of the required step agents or justification for bypassing step therapy (e.g., intolerance, contraindication).

• Document prior medication trials and reasons for failure when requesting exceptions to ST
• SP programs may include additional enrollment steps or monitoring

Formulary Lookup & Coverage Documentation

Use the formulary index and the Requirements/Limits column to identify program flags and required documentation. Refer to the member's Certificate of Coverage and the member portal for plan-specific details. Contact the plan using the number on the member ID card for questions about PA submission processes.

• Formulary index locates drugs and shows Requirements/Limits flags
• Contact payer via the member ID card phone number for plan-specific PA procedures