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CurrentEmpire BluecrossPolicy N/A

Medicaid-Approved Preferred Drug List — Coverage Criteria

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A Medicaid preferred drug list (PDL) specifying covered outpatient prescription medications, program notes (PA, QL, SP, AL, DO, ST, OTC), and alphabetical drug listings that govern pharmacy benefit coverage for Empire Bluecross Medicaid members in the applicable state.

Policy Summary

PayerEmpire Bluecross

PolicyMedicaid-Approved Preferred Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for any medication or supply annotated 'PA' before the prescription is filled to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-08-01policy effective date

PA, QL, SP, AL, DO, ST, OTCcommon program notes

15+document chunks

NCapplicable state

Coverage Criteria / Formulary Notes

Products designated OTC in this PDL are listed for provider reference and may not require coverage under the outpatient prescription benefit when obtained over the counter; however, many OTC entries on the list also carry a QL (quantity limit) annotation. Where an OTC product is shown with QL, the payer has defined a quantity restriction that applies when the item is billed through the pharmacy benefit.

Individual product lines in the PDL include coverage-control flags in the Notes field: PA (prior authorization), QL (quantity limit), and OTC (over-the-counter). These annotations indicate that a listed item may require prior approval before a claim will be paid, may be subject to a specified dispensing limit, or is available OTC and should be documented accordingly on the prescription.

Many multivitamin and prenatal formulations are presented on the PDL as OTC entries but are also annotated with QL. That means although the product is available over the counter, the payer applies quantity limits when it is dispensed under the pharmacy benefit; providers should expect the QL annotation to govern allowable supply when billing.

What Providers Must Do / Authorization & Documentation

Prior Authorization

PA required — obtain prior authorization

Drugs annotated with 'PA' on the PDL require prior authorization before the prescription is filled (examples include armodafinil, modafinil, and multiple biologic/specialty products such as AMJEVITA).

Prior authorization must be obtained from the payer before dispensing PA‑designated drugs.

Prior Authorization

PA for select controlled substances

Several controlled substances and opioid products are marked 'PA' (e.g., morphine ER, oxycodone products, fentanyl patches), and require prior authorization for coverage.

Submit PA for coverage of listed controlled substances; failure to obtain PA may result in denial.

Prior Authorization

Legend / Definitions

Definition — PA (Prior Authorization)

PAPrior authorization is required — approval must be obtained before the prescription is filled; PA entries in the formulary indicate benefits must be authorized prior to dispensing.

Trigger examplesMany listed products are annotated 'PA' (e.g., armodafinil, INVEGA SUSTENNA/INVEGA TRINZA, numerous biologics and device kits) indicating PA applies.

ConsequenceFailure to obtain required PA may result in denial of coverage or claim payment.

Definition — QL (Quantity Limits)

QLQuantity limits — certain prescription medications and supplies have specified limits on the amount dispensed per prescription or per month as noted by 'QL' in the formulary legend.

ScopeQL applies across drug classes and supplies (examples include contraceptives, antivirals, topical products, insulin supplies and multivitamins).

Step Therapy / Preferred Product Notes

Drug	Notes
ALLI (orlistat) oral capsule	Notes = PA; OTC; QL (ST indicated in legend as a program note meaning step therapy may be required for ST‑marked drugs)

Drug / Class	DO / PA annotation and implication
Gabapentin (antiepileptic entries)	Notes = DO; QL — 'DO' (Dose Optimization) may reflect formulary preference or potential step/preference edits prior to coverage
Lamotrigine ER and other antiepileptics	Notes = DO; QL — 'DO' annotation indicates dose optimization/dispense preferences that may interact with step edits

Drug / Class	SP / PA / QL flags (step edit impact)
Antivirals (e.g., sofosbuvir‑velpatasvir, various HIV agents)	Notes include PA; SP; QL for some agents — no explicit step therapy sequences listed, but SP/PA may affect specialty routing or prior authorization steps
RUKOBIA; TROGARZO; SUNLENCA entries	Notes = PA; QL or PA; SP; QL — specialty and PA flags present; explicit ST sequences not provided

Reference / Preferred Agent	Implication for step therapy
Multiple contraceptives (Reference listed for many products e.g., AFIRMELLE, APRI, AUROVELA etc.)	Reference entries imply preferred agents which may be used before non‑reference products; explicit ST rules not provided in segment
Corticosteroid agents (class listing with References)	Reference indicated for several formulations — suggests preferred comparators though no explicit step sequence given

Annotation	Potential step implication
AL (Age Limit / administrative limitation) on topical and other entries	Entries with AL commonly paired with QL or PA; AL may indicate alternative or prerequisite requirements (suggesting trial of preferred agents first)
Pimecrolimus; Podofilox; Tretinoin entries	Notes include PA; AL; QL for some topical agents — AL annotation may imply step or alternative requirements before coverage

Quantity Limits (QL) — Items & Notes

Quantity Limit annotation — ALLI ORAL CAPSULE

ALLI ORAL CAPSULE QLALLI ORAL CAPSULE is annotated 'PA; OTC; QL' in the legend, indicating prior authorization, OTC designation and quantity limits apply.

ImplicationProviders should mark OTC on prescriptions and verify QL/PA requirements for ALLI prior to dispensing.

Reference chunkChunk 2 contains the ALLI line with the PA; OTC; QL notes.

Quantity Limit annotation — AMJEVITA (all formulations)

AMJEVITA QLAMJEVITA (all formulations) lines are annotated 'PA; SP; QL' in the legend indicating prior authorization, specialty pharmacy routing and quantity limits apply.

Payer handlingAMJEVITA requires specialty pharmacy handling and PA documentation; quantity limits accompany the product lines.

Device & Code Identifiers

Device identifiers included inlinemixed

DEXG7G6

OMNIPOD 5 DEXG7G6 INTRO GEN 5 KIT (identifier shown in item line)

Site of Care / Dispensing Channel

Note

Background / Scope

This document is a formulary-style preferred drug list organized by therapeutic class and drug name. For each product the legend shows a preferred/reference designation plus Notes that encode utilization management controls such as PA (prior authorization), QL (quantity limits), SP (specialty pharmacy), AL (age limits), DO (dose/dispense indicators), ST (step therapy) and OTC (over-the-counter). These flags guide coverage, routing, and documentation requirements for outpatient pharmacy claims.

Policy Summary

PayerEmpire Bluecross

PolicyMedicaid-Approved Preferred Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for any medication or supply annotated 'PA' before the prescription is filled to avoid claim denial.

SourceLink

On This Page

PA required for long‑acting injectables, antivirals, specialty agents

Select products (including long‑acting injectable antipsychotics such as INVEGA SUSTENNA/TRINZA and risperidone microspheres, and multiple antiviral/specialty agents) are annotated 'PA' and require prior authorization prior to coverage.

Obtain PA for listed long‑acting injectables and specialty antiviral agents before dispensing.

Note

QL/AL annotations — expect limits and PA interplay

Entries with QL or AL notes indicate utilization controls that may interact with PA requirements; where QL/AL are present, providers should expect quantity or age limits and potential PA triggers.

When QL or AL appears alongside a product, include documentation supporting the requested quantity or member age as part of any PA submission.

Prior Authorization

Multiple PA‑annotated products — PA required

Multiple item lines in the PDL are marked 'PA' (numerous examples across therapeutic classes); prescriptions for these PA‑annotated products require prior authorization before fill.

Confirm PA status on the PDL for each product line and secure authorization prior to dispensing.

Prior Authorization

PA required for hematopoietic agents and IV iron

Several hematopoietic agents and IV iron products are annotated 'PA' (e.g., ARANESP, EPOGEN, ferumoxytol/Feraheme) and require prior authorization before coverage is approved.

Submit PA and specialty documentation for hematopoietic and IV iron products when indicated on the PDL.

Prior Authorization

PA for selected CGM devices (Dexcom, FreeStyle Libre)

Certain CGM components and related devices (DEXCOM G6 receiver/sensor/transmitter and FREESTYLE LIBRE sensors/readers) are marked 'PA' and require prior authorization for coverage.

Obtain PA for DEXCOM and FREESTYLE LIBRE devices/sensors prior to dispensing; include device specifics in the request.

Prior Authorization

PA required for selected supplies (Omnipod, meter kits)

Selected diabetes supplies and device kits (for example OMNIPOD introductory kits/pods and specific meter kits) are annotated 'PA' (often with QL) and require prior authorization before coverage.

Submit PA for Omnipod kits/pods and True Metrix/other meter kits as indicated; expect quantity limits (QL) on these lines.

Prior Authorization

PA required for riluzole and select ophthalmics

Specific agents in the ophthalmic and neurologic sections (for example riluzole noted as PA; SP; QL, and cyclosporine ophthalmic emulsion noted as PA; QL) require prior authorization and related documentation.

Include required PA documentation for riluzole and PA‑annotated ophthalmic agents; specialty routing applies where 'SP' is indicated.

Step Therapy

Step therapy (ST) — trial of prior medication required

Drugs marked 'ST' on the PDL require step therapy; a prior medication must be tried and documented before the listed medication can be authorized.

Verify required prior therapeutic trials and submit evidence of prior therapy when requesting coverage for ST‑designated drugs.

Note

DO/PA annotations — dispensing and PA implications

Some antiepileptic/anticonvulsant entries include 'DO' or 'PA' annotations, indicating dispensing or authorization preferences that may affect product selection or require PA.

For products annotated DO/PA, confirm dispensing expectations and obtain PA where required before dispensing.

Billing Rule

SP designation — specialty pharmacy handling plus PA

Many specialty antiviral and other PA‑designated products also carry 'SP' indicating specialty pharmacy handling; these items may require routing through specialty channels in addition to PA.

Route SP‑designated medications to the specialty pharmacy and include PA documentation as required.

Note

Reference products — preferred agents imply substitution/step expectations

Several entries reference 'Reference' products (preferred or reference agents), implying that non‑reference products may be subject to step or substitution expectations before coverage.

If a non‑reference product is requested, include rationale and prior therapy of reference/preferred agents in the PA submission.

Note

AL annotations — alternative/age‑based requirements possible

Entries annotated 'AL' are used alongside PA/QL in some listings and may indicate alternative or age‑based step requirements; providers should anticipate possible preconditions before coverage.

Where AL is present, document member age/eligibility and any required prior therapies when submitting PA requests.

Note

Follow Reference preferences — document exceptions for non‑reference agents

Reference listings repeatedly indicate preferred/reference agents; providers should follow reference preferences and document attempts or contraindications when requesting non‑reference products.

Document why a reference agent is not suitable if requesting a non‑reference product to support PA.

Note

Operational: confirm Notes flags and required routing

Operational notes: confirm each product's Notes field on the PDL for flags (PA, QL, SP, AL, ST, OTC) and follow the payer's required routing (e.g., specialty pharmacy for SP items).

Check the PDL Notes field on each item before prescribing or dispensing.
Route SP items to specialty pharmacy and submit PA where required.

Note

Operational: verify device/supply item‑level annotations

Operational note: for devices and supplies, verify item‑level annotations (PA, QL, OTC) — insulin syringes, pen needles, Omnipod kits, and meter kits may have differing PA/OTC/QL statuses affecting coverage and billing.

Confirm PA/QL status for the exact SKU being prescribed and include that detail in PA documentation.

Step Therapy

ST flagged but no sequences listed — provide prior trial documentation

No explicit step‑therapy sequences are listed in these segments; where ST is flagged, follow payer step requirements documented elsewhere and include prior trial evidence in PA submissions when applicable.

When ST appears without sequence details, provide documentation of prior medication trials and contact the payer for specific step rules if unclear.

Documentation Required

OTC notation — prescribers must indicate OTC on prescriptions

When prescribing an OTC‑designated product that appears on the PDL, prescribers should indicate 'OTC' on the prescription as directed in the legend.

Mark OTC on the prescription to align with PDL notation and payer processing.

Documentation Required

Documentation for PA/SP/QL specialty products — submit supporting PA materials

Specialty products and other PA/SP/QL‑annotated items (e.g., XOLAIR, TAKHZYRO, ARANESP) require submission of supporting prior authorization documentation and may be routed via specialty pharmacy.

Include clinical indication, prior therapies, and quantity justification with PA submissions for PA/SP/QL items.
Route SP items through specialty pharmacy as indicated.

Documentation Required

Documentation expectations for QL/AL items

Where QL or AL annotations appear, providers should be prepared to supply documentation supporting the requested quantity, dosing, or member age as part of the authorization process.

For QL items, document dosing schedule and medical necessity for quantities above standard limits.
For AL items, document member age or age‑based criteria.

Documentation Required

Follow PDL legend Notes — adhere to utilization controls

The PDL legend and item Notes fields encode utilization controls (PA, QL, AL, SP, OTC, DO, ST); providers must follow the coverage controls indicated in the Notes field for each product.

Check the Notes field for each product and adhere to the documented utilization controls when prescribing and submitting claims.

Documentation Required

Submit required documentation with PA/SP/QL requests

For PA, SP, or QL‑flagged products, submit the payer's required prior authorization forms and supporting clinical documentation (indication, prior therapies, dosing, and quantity justification) to avoid denial.

Include clinical rationale, prior treatment history, and specific product/sku information in PA submissions.
For SP items, ensure specialty pharmacy routing is used where indicated.

Prior Authorization

Item‑level PA/QL flags — obtain PA for flagged SKUs

Formulary lines explicitly mark PA and QL on certain item lines (e.g., insulin syringe sizes, OMNIPOD kits, True Metrix meter kits); providers must obtain PA for those specific SKUs prior to dispensing.

Verify exact SKU and its Notes flags on the PDL and secure PA when PA is present on the line item.

Billing Rule

PA and QL noted on supply item lines — secure PA

The PDL marks many supplies (Omnipod kits/pods, True Metrix meter kits, insulin syringes, pen needles) with 'PA; QL' indicating prior authorization and quantity limits apply; failure to secure PA can result in claim denial.

Obtain PA and include quantity justification for these supplies; expect QL enforcement at claim adjudication.

Documentation Required

Documentation and routing required for PA/SP items (riluzole, cyclosporine)

For PA/SP products such as riluzole and cyclosporine ophthalmic emulsion, include required documentation and route to specialty pharmacy as indicated; missing PA or specialty routing may lead to denial.

Provide clinical indication, prior therapies, and quantity evidence in the PA submission; follow SP routing where flagged.

Denial Risk

Denial risk — fill only after PA approval

Prescriptions for drugs marked 'PA' must have prior authorization approved before the prescription is filled; failure to obtain PA can result in denial of benefits.

Do not dispense PA‑designated drugs without payer authorization to avoid claim denial.

Note

Utilization flags in legend — check before prescribing

Utilization control flags in the legend (PA, QL, AL, SP, OTC, DO, ST) signal requirements that affect coverage and billing; providers should review these flags for each product prior to prescribing.

Review the PDL legend and Notes field for each product to determine PA, QL, SP, AL, DO, ST, or OTC status before prescribing.

Denial Risk

PA/SP annotations — PA and specialty handling trigger

Products annotated with 'PA' (examples include long‑acting injectables, specialty agents, and selected supplies) trigger prior authorization requirements and specialty handling; these annotations indicate increased risk of denial without proper authorization.

Confirm PA/SP status and obtain required authorizations and specialty routing prior to dispensing to mitigate denial risk.

Denial Risk

Supply denial risk — PA required for certain diabetes supplies

Some supply items commonly used for diabetes care (insulin syringes, pen needles, CGM components) are marked 'PA' on specific lines; failure to obtain PA for those items may result in denial.

Verify PA status for the exact supply SKU and secure authorization before providing supplies to members.

Prior Authorization

PA‑annotated Omnipod and ophthalmics — obtain PA and document

OMNIPOD kits/pods and certain ophthalmic agents are explicitly annotated with PA on item lines (for example OMNIPOD 5 kits and cyclosporine ophthalmic emulsion); obtain PA and submit supporting documentation to avoid denial.

Include device SKU and clinical indication in PA requests for Omnipod kits and PA‑annotated ophthalmic agents.

Billing Rule

SP designation — route to specialty pharmacy and submit PA

Specialty products designated 'SP' on the PDL may require specialty pharmacy dispensing and additional PA documentation; route these products to the specialty channel and include required documentation.

Use specialty pharmacy channel for SP‑designated products and attach PA documentation per payer instructions.

ActionProviders should consult the formulary line item for the specific QL for each product when submitting claims or prior authorization requests.

Definition — SP (Specialty Pharmacy)

SPSpecialty Pharmacy — medication or product managed through a specialty pharmacy channel; 'SP' in the legend denotes specialty routing and handling requirements.

ExamplesBiologic and complex therapies (e.g., XOLAIR, AMJEVITA, TAKHZYRO, ARANESP) are annotated 'SP' indicating specialty management.

DocumentationProducts with 'SP' often also carry PA and QL notes; providers must follow specialty pharmacy routing and submit required documentation per payer rules.

Definition — AL (Age Limit)

ALAge Limit — annotation indicating age-based restrictions or administrative limits on coverage for the product as noted in the formulary legend.

UsageAL appears alongside many entries (e.g., contraceptives, antipsychotics) to signal age-specific coverage constraints.

Provider noteWhen AL is present, prescribers should ensure the member meets age criteria and include age documentation if required for authorization.

Definition — DO (Dose Optimization / Dispense Override)

DODO — Dose Optimization / Dispense-as-written indicator used to denote product-specific dispensing or formulary preference (Dose Optimization Program).

ImplicationEntries marked DO may reflect expectations for dosing forms, strengths, or controlled dispensing; check the formulary line for details.

Interaction with other flagsDO often appears with QL and AL and may influence step/preference edits or dispensing overrides.

Definition — OTC (Over the Counter)

OTCOver the Counter — product is available without a prescription; when listed as OTC on the PDL, prescribers should indicate 'OTC' on the prescription if coverage is sought.

ExamplesMany multivitamins, prenatal products and common OTC items (antacids, topical OTCs) are designated OTC; some OTC items still carry QL annotations.

Coverage noteOTC designation does not automatically exclude an item from the PDL; OTC items on the PDL may still be subject to quantity limits or other notes.

Definition — ST (Step Therapy)

STStep Therapy — 'ST' indicates a step therapy requirement: a specified prior medication or course must be tried and documented before benefits for the listed agent can be authorized.

ApplicationST is applied to select drugs and requires following the documented step sequence or referencing preferred products prior to authorization.

Provider actionSubmit evidence of prior therapy failure or intolerance per payer step therapy requirements when requesting authorization for ST agents.

Legend — PA flag

Legend flag: PAIndicates the product requires prior authorization before dispensing; present on many formulary line items.

ImplicationPA flags trigger the payer's prior authorization process and may lead to claim denial if authorization is not obtained.

Where seenPA appears across drug classes including controlled substances, biologics, devices, and ophthalmics in the formulary extract.

Legend — QL flag

Legend flag: QLDenotes that the item is subject to a quantity limit (per prescription or per month); consult line-item QL for specifics.

ScopeApplies to drugs, OTC items, and supplies (e.g., insulin syringes, lancets, test strips) as shown throughout the formulary.

Provider actionWhen prescribing or dispensing, verify the allowed quantity and frequency to avoid coverage or claim issues.

Legend — OTC flag (example)

OTC exampleEntries such as childrens ibuprofen, many prenatal multivitamins and antacids are labeled OTC; providers should mark OTC on prescriptions when applicable.

QL coexistenceSome OTC products on the PDL (e.g., prenatal gummies, multivitamins) also include QL annotations indicating quantity limits apply.

Coverage implicationOTC designation on the PDL signals different coverage handling; check the line for QL or PA notes before submitting claims.

Legend — SP flag (example)

SP exampleSpecialty products such as XOLAIR and numerous hematopoietic agents (e.g., ARANESP, TAKHZYRO) are annotated 'SP' indicating specialty pharmacy processing.

Associated controlsSP items frequently also carry PA and QL flags; specialty routing and required documentation are indicated on the formulary lines.

Provider actionFollow specialty pharmacy referral/routing instructions and include required supporting documentation for SP-designated products.

Legend — DO flag (example)

DO exampleDO appears on multiple central nervous system agents and antipsychotics (e.g., lamotrigine formulations, haloperidol), indicating dosing/dispense optimization expectations.

ImplicationDO may be used to enforce dispensing of specific formulations or to indicate preferred dosing approaches; check line-item notes for details.

InteractionDO commonly appears alongside QL and AL and can influence prior authorization or step edits.

Legend — AL flag (example)

AL exampleAL is shown on many antipsychotic and contraceptive entries (e.g., INVEGA SUSTENNA, various contraceptives) to denote age-based or administrative limits.

Provider checkWhen AL is present, verify the patient's age and include appropriate documentation when requesting authorization if required.

Common pairingAL often appears with QL and PA annotations on the same line, indicating combined utilization controls.

Legend — PA flag (examples across document)

PA exampleNumerous topical, systemic and specialty products in the extract are annotated 'PA' (e.g., TRIDERM, CREON, SELARSDI), signifying prior authorization requirements.

DocumentationPA examples across chunks demonstrate the need to submit prior authorization documentation per payer instructions for covered agents.

RiskClaims for PA-flagged items may be denied without completed authorization; refer to the formulary line and payer prior authorization process.

Legend — QL flag (examples in other chunks)

QL exampleTopical OTC and prescription products (e.g., hydrocortisone creams, lidocaine patches) are frequently marked 'QL' indicating quantity limits apply.

Provider actionCheck each line for the specific QL; OTC status does not negate QL applicability for many products.

ScopeQL annotations appear across dermatologic, analgesic and other product lines in the PDL extract.

Legend — AL flag (examples in other chunks)

AL exampleAL appears with OTC and QL on numerous topical and dermatologic entries (e.g., hydrocortisone products) indicating age-based restrictions may apply.

CheckConfirm member age against AL restrictions when prescribing or authorizing such products.

Combined flagsAL is often listed together with QL and occasionally PA, reflecting multiple utilization controls.

Legend — DO flag (examples in other chunks)

DO exampleDO annotations are present on anticonvulsants and antipsychotics (e.g., lamotrigine ER, haloperidol) indicating dispense/dose optimization rules.

Operational impactPharmacies may need to follow DO-related dispensing instructions or override rules per payer guidance.

Often pairedDO commonly appears with QL and AL flags, affecting authorization and dispensing processes.

Legend — SP flag (examples in other chunks)

SP exampleSP flag is used for specialty biologics and hematopoietic agents (e.g., XOLAIR, TAKHZYRO, ARANESP) which require specialty pharmacy handling.

Associated notesSP items are frequently annotated with PA and QL as well; specialty routing and documentation are required for coverage.

Provider stepArrange specialty pharmacy fulfillment and include required prior authorization and clinical documentation as indicated.

Legend — QL example (chunk 91)

QL (chunk 91)Contraceptive products and related entries show QL and AL annotations in chunk 91 indicating quantity and age limits apply to many contraceptives.

ImplicationProviders should confirm QL for specific contraceptive products when prescribing or dispensing.

Reference fieldChunk 91 also demonstrates the 'Reference' field concept used to show preferred or comparator products alongside QL/AL flags.

Legend — AL flag example (chunk 91)

AL (chunk 91)Chunk 91 shows AL applied to multiple contraceptive entries (e.g., AFIRMELLE, AUROVELA variants) indicating age-based restrictions on those products.

Provider checkVerify member age and include age documentation where required for authorization of AL-flagged contraceptives.

Combined flagsAL frequently appears with QL on contraceptive lines in chunk 91.

Legend — OTC flag example (chunk group)

OTC (chunk 91/216)Chunks 2 and 216/219 show many OTC-designated items (e.g., ALLI, prenatal vitamins, antacids); prescribers should indicate 'OTC' on prescriptions for OTC PDL items.

QL coexistenceEven when OTC, products may carry QL (e.g., prenatal multivitamins), so check the line for quantity limits.

Coverage noteOTC designation on the PDL signals alternative coverage handling; review the PDL line before submitting claims or authorizations.

Legend — OTC flag examples (chunks 127,133,134)

OTC examplesMultiple topical and OTC items (e.g., gnp lidocaine patches, hydrocortisone preparations, various OTC antifungals) are labeled OTC in chunks 127,133,134.

QL pairingThese OTC items frequently include QL annotations indicating quantity limits apply despite OTC status.

Provider actionWhen prescribing an OTC PDL item, mark 'OTC' on the prescription and verify any QL that may apply.

Legend — QL flag examples (chunks 131,133,144)

QL examplesMany dermatologic and topical products (hydrocortisone, lidocaine patches) are annotated with QL in chunks 126,128,130 indicating quantity limits.

OTC overlapSome of these products are OTC and QL concurrently; verify both when prescribing.

Provider guidanceConsult the PDL line-item to determine permitted quantities and any age or PA restrictions before dispensing.

Legend — SP flag examples (chunks 131,133,144)

SP examplesChunks 131,133 and 144 show SP annotations on specialized products (e.g., SELARSDI, TAKHZYRO, ARANESP) indicating specialty pharmacy routing.

Associated PA/QLSP items commonly carry PA and QL flags as shown in these chunks; follow specialty routing and PA processes.

Practical noteSpecialty-designated products may require coordination with the payer's specialty pharmacy vendor for fulfillment and authorization.

Legend — AL flag examples (chunks 131,133)

AL examplesChunks 131 and 133 include AL on topical and pediatric products (e.g., pimecrolimus, podofilox) indicating age-based limitations.

ActionConfirm age eligibility and provide age-related documentation when requesting authorization for AL-flagged items.

Combined flagsAL often co-occurs with PA and QL on the same line, requiring combined checks before dispensing.

Legend — PA flag example (chunk 144)

PA example (chunk 144)Chunk 144 lists hematopoietic and other agents (e.g., TAKHZYRO, ARANESP, EPOGEN) annotated 'PA; SP; QL', illustrating PA requirements for these high-cost agents.

Provider actionSubmit prior authorization and specialty documentation per payer instructions for these agents to avoid denial.

RoutingThese products are typically routed via specialty pharmacy and subject to quantity limits.

Legend — QL flag example (chunk 144)

QL example (chunk 144)Chunk 144 shows QL applied to hematopoietic agents and specialty products (ARANESP, EPOGEN) indicating quantity restrictions accompany PA/SP annotations.

ImpactRequests for these agents should document required dose and quantity to align with QL expectations.

Combined controlsPA; SP; QL are frequently applied together to manage utilization of high-cost specialty medications.

Legend — SP flag example (chunk 144)

SP example (chunk 144)SP is used with PA and QL on hematopoietic and specialty injectable agents in chunk 144 (e.g., ARANESP, TAKHZYRO), indicating specialty pharmacy handling.

Provider stepCoordinate with specialty pharmacy partners and include required clinical documentation to obtain authorization and fulfillment.

Utilization controlSP designation often implies additional utilization management steps such as PA and QL enforcement.

Legend — OTC flag example (chunk 148)

OTC example (chunk 148)Chunk 148 demonstrates OTC labeling for multiple items in the hypnotic/sedative and laxative classes (e.g., bisacodyl, CLEARLAX) marked OTC; QL may still apply.

ImplicationEven when OTC, these products can carry QL annotations and require checking the line-item notes prior to coverage decisions.

Provider noteIndicate OTC on prescriptions when the product is listed OTC on the PDL to ensure correct processing.

Legend — QL flag example (chunk 162)

QL example (chunk 162)Chunk 162 shows insulin syringes and related supplies annotated 'QL' indicating quantity limits apply to many syringe SKUs.

Provider actionVerify permitted quantities for specific syringe models and gauges before dispensing to avoid claim issues.

Supply scopeQL covers both consumable supplies and devices (syringes, pen needles, lancets) across the PDL extract.

Legend — PA flag example (chunk 166)

PA example (chunk 166)Chunk 166 includes items (e.g., certain lancet kits and comfort devices) with PA annotations, indicating prior authorization is required for some supply items.

Provider stepObtain PA for PA-flagged supplies (e.g., Comfort Choice kits) before dispensing to prevent denials.

Combined flagsPA on supplies commonly coexists with OTC and QL annotations in the formulary lines.

Legend — OTC flag example (chunk 163)

OTC example (chunk 163)Chunk 163 lists BD insulin syringe SKUs with OTC and QL annotations for some items, illustrating OTC plus QL status for diabetic supplies.

CheckConfirm OTC/QL status per SKU when prescribing or dispensing insulin syringes and pen needles.

DocumentationEven OTC-designated supply SKUs may require documentation of medical necessity for larger quantities.

Legend — OTC flag examples (chunks 180-199)

OTC examples (chunks 180-199)Chunks 180–199 include numerous supply items (sterile lancets, TRUEPLUS lancets and related consumables) labeled OTC; many are also QL-restricted.

QL interactionOTC supplies frequently carry accompanying QL annotations, requiring quantity verification at dispensing.

Provider actionConfirm both OTC designation and any QL or PA flags on the specific SKU to ensure correct processing.

Legend — PA flag examples (chunks 180-199)

PA examples (chunks 180-199)Within chunks 180–199 and elsewhere, select supplies and specialty products (e.g., Omnipod kits, ULTICARE syringes) are annotated 'PA; QL', indicating PA is required for these items.

ImpactClaims for PA-flagged supplies will require prior authorization submission to avoid denial; follow payer PA process for supplies and devices.

ReferenceFormulary lines often show combined PA and QL controls for devices and specialty supplies.

Legend — QL flag examples (chunks 180-199)

QL examples (chunks 180-199)Chunks 180–199 list many supplies (sterile lancets, inhaler training devices, etc.) with QL annotations indicating quantity restrictions for these items.

Provider checkConfirm the allowed quantity per interval for each supply SKU before authorizing or dispensing.

Coverage noteSupplies may be OTC yet still subject to QL as shown across supply entries.

Legend — QL flag examples (chunks 216,231,233)

QL examples (chunks 216,231,233)Multivitamins, prenatal products and many ophthalmic agents are annotated 'QL' in these chunks indicating quantity limits apply.

OTC overlapMany multivitamin/prenatal entries are OTC and also carry QL annotations (chunks 216–219), requiring quantity verification.

ActionCheck the PDL line-item QL and any accompanying flags (OTC, PA) when prescribing multivitamins or ophthalmic agents.

Legend — PA flag examples (chunks 231,233)

PA examples (chunks 231,233)Ophthalmic specialty agents and select neurologic agents (e.g., riluzole, cyclosporine ophthalmic emulsion) are marked 'PA' requiring prior authorization.

Provider actionObtain PA and include clinical justification for PA-flagged ophthalmic and neurologic agents to ensure coverage.

Associated flagsThese PA items commonly also carry SP and QL annotations (e.g., riluzole: PA; SP; QL; cyclosporine: PA; QL).

Legend — SP flag example (chunk 231)

SP example (chunk 231)Chunk 231 includes riluzole annotated 'PA; SP; QL', illustrating specialty handling (SP) for certain neurologic agents.

DocumentationSpecialty routing for neurologic agents means providers must follow PA and specialty fulfillment procedures for these items.

Practical noteConfirm specialty pharmacy vendor and submission requirements for SP-designated neurologic agents.

Reference (preferred) product	Notes / Coverage implication
TAKHZYRO (prefilled syringe) and other hematopoietic agents (ARANESP, EPOGEN) listed with Reference entries	Notes = PA; SP; QL for many — Reference entries indicate preferred agents which may be preferred in utilization management prior to non‑reference agents

Supply / SKU	PA / OTC / QL / Preference note
[{"text":"Insulin syringe 28g x 1/2" 0.5 ml","status":""},{"text":"Notes = PA; QL (reference = BD Insulin Syringe MicroFine) — PA and QL may affect coverage and preferred OTC alternatives may be available for some sizes","status":""}]
BD Insulin Syringes / Pen needles / Lancets (various SKUs)	Notes = QL or OTC; some SKUs noted PA; QL — designation indicates quantity limits and prior authorization for certain items and reference preferred SKUs

Drug	Coverage flags
Riluzole oral tablet	Notes = PA; SP; QL — no explicit step therapy sequence listed in the document extract

ReferenceChunk 8 lists multiple AMJEVITA formulations with PA; SP; QL notes.

QL annotation present — various products

Various products — QL presentMultiple product lines across chunks (e.g., opioids, anticoagulants, XOLAIR) include QL annotations as part of their legend notes.

ScopeQL appears broadly across therapeutic classes and product types in the extract, from analgesics to specialty biologics.

ActionCheck each product's line-item notes for QL specifics when prescribing or dispensing.

QL annotations across product groups (antivirals, specialty, etc.)

QL annotations across classesChunks 126,133 and 144 show QL annotations on dermatologic, genetic/metabolic and hematologic products (e.g., CREON, SELARSDI, TAKHZYRO), indicating quantity limits extend to these classes.

Paired flagsThese QL annotations frequently coexist with PA and SP notes for high-cost or specialty therapies.

Provider guidanceRefer to the specific line-item QL and accompanying PA/SP indicators for authorization and dispensing requirements.

QL annotation — contraceptives and other products

Contraceptives and others — QLMultiple contraceptive products and common OTC/prescription items (chunks 91,126,127) include QL flags indicating quantity limits apply to these product lines.

OTC overlapSome contraceptives and OTC items carry both OTC and QL flags; verify both when prescribing.

ActionCheck the PDL legend and reference field for specific QL values on contraceptives and related products.

QL annotation — Prednisolone sodium phosphate (Orapred ODT)

Orapred ODT — QLPrednisolone sodium phosphate oral tablet dispersible (Orapred ODT) is annotated 'QL' in the legend, indicating a quantity limit applies.

ImplicationRefer to the line-item QL when prescribing Orapred ODT to ensure authorized quantity is not exceeded.

Reference chunkChunk 108 lists Orapred ODT with Notes = QL.

QL annotation — multiple product lines

Multiple product lines — QL presentA broad set of topical, dermatologic and other OTC/prescription items in chunks 126–131 are annotated with QL, demonstrating widespread quantity controls across product lines.

ExamplesHydrocortisone preparations, lidocaine patches, terbinafine, mupirocin and others include QL notes in these chunks.

Provider actionConsult each line for the precise QL; OTC status may not exempt an item from quantity limits.

QL annotation — OTC and prescription entries

OTC and prescription entries — QL notedChunks 127,130 and 133 show many OTC and prescription items that carry QL designations, including pain patches, creams and diagnostic strips.

ImplicationProviders must check both OTC and QL status for these items before prescribing or dispensing.

ReferenceSee the specific line-item entries in the cited chunks for product-level QL details.

QL annotation — many supplies (insulin syringes, lancets, CGM components)

Supplies — QL annotatedMany supplies (insulin syringes, lancets, CGM components, pen needles) are subject to QL as indicated in chunks 162–166.

SKU-level limitsSpecific syringe gauges and pen needle SKUs list QL; verify SKU-specific quantity limits when ordering or dispensing supplies.

Provider actionConfirm allowed quantities per interval for diabetic supplies to avoid denials or excess dispensing.

QL annotation — multiple listed supply items

Supply items — QL indicatedChunks 180 and 199 list multiple supply items (lancets, syringes, test strips) with QL annotations on individual lines.

OTC/PA overlapSome supply SKUs are OTC while others require PA; many have QL in addition to OTC/PA flags.

Provider guidanceReview each supply SKU line for combined OTC, PA and QL flags prior to fulfillment.

QL annotation — multiple OTC multivitamin/prenatal products

OTC multivitamins/prenatals — QLChunks 216–219 show many multivitamin and prenatal products labeled OTC with accompanying QL flags, indicating quantity limits apply to these OTC products.

ExamplesCentrum Specialist Prenatal, CVS prenatal gummies and multiple branded prenatal/multivitamin SKUs are annotated OTC; QL applies.

Provider actionWhen prescribing prenatal/multivitamin products from the PDL, verify the QL and mark OTC on the prescription if required.

PA & QL annotations — cyclosporine ophthalmic emulsion; LASTACAFT

PA; QL on ophthalmic agentsCyclosporine ophthalmic emulsion (Restasis) and LASTACAFT OPHTHALMIC SOLUTION are annotated 'PA; QL' (and LASTACAFT also 'OTC' in one line) indicating PA and quantity limits apply.

ImplicationProviders must obtain prior authorization and adhere to quantity limits for these specialty ophthalmic agents to secure coverage.

ReferenceChunk 233 lists Restasis as PA; QL and chunk 235 shows LASTACAFT with PA; OTC; QL.