CurrentFidelis CarePolicy N/A

Ambetter from Fidelis Care Formulary (Drug List) — Coverage Criteria

Defines the plan's covered prescription drugs, formulary structure, utilization management (PA, QL, ST, age limits), specialty drug handling, and member/provider processes for Ambetter from Fidelis Care Qualified Health Plan members.

Policy Summary

PayerFidelis Care

PolicyAmbetter from Fidelis Care Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization (phone or fax) before dispensing drugs marked PA; complete and fax the Medication Request Form with clinical justification when requesting non-preferred exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AcariaHealthSpecialty pharmacy vendor named

7-dayNew opioid prescription limit for NY

P&T CommitteeClinical review governance

PA / QL / ST / ALUtilization management types described

MultipleTier 3 entries flagged

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Formulary Coverage Criteria and Controls

Non-preferred drug exception

Covered when ANY of the following exception criteria are met:

Non-preferred exception criteria: Documented allergic/adverse reaction to a preferred agent.

Non-preferred requests require prescriber justification and a completed Medication Request Form; decisions are reviewed per medical necessity/formulary exception process.

Non-preferred exception criteria: Documented failure of preferred agents despite adequate trial and adherence.

Prescriber must provide clinical rationale and prior therapy details on the request form.

Non-preferred exception criteria: Documented patient stability or control on the non-preferred drug, or contraindication to all preferred alternatives where a change is not advisable.

Documentation should show risk of destabilization or contraindication to switching therapies.

Formulary coverage controls

Coverage and utilization rules indicated in these chunks

PA required for listed Tier 3 products: Prior authorization is required for multiple Tier 3 drugs and certain formulations as indicated in the formulary entries.

Examples include SUNOSI, select dextroamphetamine and methylphenidate formulations, and biologics such as HUMIRA; providers must obtain PA before dispensing.

Quantity limits enforced: Quantity limits (QL) shown in formulary must be adhered to and requests exceeding QL require review or PA.QL values as listed per product

Examples include QL(2 EA daily), QL(0.143 ML daily), QL(0.072 EA daily).

Age limits enforced: Age limits (AL) specified for products must be met for coverage.AL as listed per product

Examples: many ADHD formulations require 'At least 6 yrs old'.

Formulary coverage constraints (partial)

Covered when listed with adherence to the following formulary constraints:

General formulary conditions: Drug coverage requires dispensing within the listed tier and compliance with any Quantity Limits (QL), Prior Authorization (PA), Age Limits (AL), Step Therapy (ST), or new-start supply limits shown for the product.see QL/PA/AL values per drug line

This segment includes NSAIDs, PDE4 inhibitors, and opioid analgesics with specific QL, PA, AL, and new-start supply limits that must be followed.

Formulary control rules (fragment)

Coverage and access are subject to the following formulary controls as listed per product/formulation in this fragment:

Formulary controls: Products are assigned tiers and may carry Quantity Limits (QL), Prior Authorization (PA), Specialty pharmacy (SP), or Step Therapy (ST) flags as specified for each formulation.

Providers must follow PA and QL requirements; tier placement impacts member cost share and access.

Antihyperlipidemic exception process

Coverage and utilization controls in this segment apply as follows

Antihyperlipidemics - exception process: Certain antihyperlipidemic products have an exception process that may permit a $0 copay for eligible members when medically necessary for primary prevention of cardiovascular disease.age 40 to 76

Applies to listed agents (e.g., icosapent ethyl, omega-3-acid ethyl esters, bile acid sequestrants, selected statins); providers must follow the exception process for $0 copay consideration.

Prior authorization

Products requiring prior authorization

PA required: Prior authorization is required for the products listed with ILimits = PA in the formulary extract.

Examples in this segment: QUZYTTIR SOLN IV and PRALUENT SOAJ; providers must obtain PA per payer process before dispensing.

QL and restriction rules

Quantity limits and product restrictions

Quantity limits: Products have specified quantity limits that must not be exceeded for coverage; QL values vary by product and formulation.see individual entries

Examples: levocetirizine SOLN QL(?? ML daily) / TABS QL(1 EA daily), promethazine SUPP QL(6 EA daily); QL values are product-specific.

Generic-only and age restrictions: Some agents are 'generic only' and have age-range restrictions that affect coverage and exceptions.age 40 to 76

Applies to multiple antihyperlipidemics where $0 copay exception and tiering reference 'generic only, age 40 to 76'.

Formulary coverage with utilization controls

Coverage and utilization rules shown as tier plus management codes

Formulary coverage entries: Medications are assigned a tier and may include QL, PA, and/or SP requirements as indicated; coverage is conditional on meeting those controls.

This excerpt lists agents with QL and PA flags (e.g., antiretrovirals, hepatitis C agents, pulmonary hypertension agents); full clinical PA criteria are not provided here.

General formulary coverage controls (partial)

Coverage with utilization controls as listed in formulary fragments

Formulary coverage conditions: Coverage is subject to the formulary tier, Quantity Limits (QL), Age Limits (AL), Prior Authorization (PA), and Step Therapy (ST) controls indicated for each product in these fragments.

Providers must follow the specific PA/QL/ST rules for each drug as listed in the full formulary; specialty-designated drugs (SP) may require specialty pharmacy dispensing.

Drugs, dosages, strengths, and formulations that are not listed in the formulary are considered non-formulary. The formulary document lists all covered dosages, strengths and formulations; items omitted from that list are outside the plan’s standard covered drug list and require an exception or prior authorization for coverage.

Within the provided formulary excerpts there are no standalone statements identifying additional explicit clinical exclusions. Coverage controls in these fragments focus on formulary tiering, quantity limits, age limits and prior authorization requirements rather than enumerated exclusion conditions.

The excerpts do not present explicit exclusionary clinical language; however, formulary age limits (AL) and prior authorization (PA) requirements shown (for example, PDE4 inhibitor and certain opioid entries) act as functional restrictions on coverage and must be met for a claim to be payable.

No explicit clinical coverage exclusions are stated in this segment. Instead, coverage and access are governed by product-specific controls such as tiers, quantity limits (QL), prior authorization (PA), specialty designation (SP) and step therapy (ST) flags shown in the formulary lines.

This fragment does not list discrete clinical exclusion conditions. It documents utilization controls (e.g., generic-only restrictions, age ranges for $0 copay exceptions, and QL values) that determine coverage terms for antihyperlipidemic and related agents.

No explicit clinical exclusions are described in this segment; instead, coverage is tied to the formulary tier and the presence of utilization management controls (such as QL, PA, or SP) for the listed drug entries.

This portion of the formulary does not provide explicit exclusionary clinical conditions. It does show entries with tier flags and management codes (for example, some topical products marked EX or Tier = 3) which indicate non-preferred or excluded status per tiering conventions rather than named clinical exclusions.

Some formulary entries are assigned a higher cost-share or explicit exclusion indicator — for example, several products in the excerpts are shown as Tier = 3 or marked EX, indicating a non-preferred or excluded status by tier. When Tier = 3 or EX is shown, prior authorization or step edits may apply and member cost share is typically higher.

These fragments do not include explicit statements labeling drugs as Not Medically Necessary. The document instead uses formulary controls (PA, QL, ST, AL) to manage coverage; absence of an NMN statement in the excerpt means denials would be driven by unmet PA/QL/AL/ST requirements rather than an explicit NMN policy in the shown text.

No explicit 'not medically necessary' findings are present in this segment. The listed opioid and analgesic entries note utilization rules (for example, new-start supply limits and QL values) and prior authorization that could lead to denial if not satisfied, but they are not framed as NMN statements in the excerpt.

The provided excerpt does not contain discrete 'not medically necessary' conditions. It documents formulary entries, new-start limits (commonly 7-day for opioids), and quantity/PA controls that determine coverage eligibility rather than explicit NMN declarations.

This fragment does not list specific not medically necessary (NMN) conditions. Coverage distinctions described here rely on quantity limits, age restrictions, prior authorization and tiering found on each product line.

No explicit 'not medically necessary' statements are present in these topical/dermatology fragments. The listings show quantity limits, max-fill windows, and PA/SP flags which control access and reimbursement rather than invoking NMN language.

Formulary Coding, Flags and Shorthand

Prior Authorization, Documentation and Prescriber Requirements

Prior Authorization

Prior Authorization Required / Action Required

Prior Authorization (PA) is required for many drugs listed on the formulary, including numerous specialty and Tier 3 agents. Providers must obtain PA from Ambetter from Fidelis Care before dispensing drugs marked PA; failure to obtain required PA may result in denial of coverage.

PA required for many specialty drugs — provider must contact Ambetter from Fidelis Care by phone 1-888-343-3547 or fax 1-844-235-4852 (pharmacy benefit) / 1-844-235-5090 (medical benefit) to request PA; obtain PA prior to contacting AcariaHealth Specialty Pharmacy (1-844-584-1072).
PA is indicated next to many Tier 3 products and selected formulations (examples: HUMIRA products, OTEZLA, PRALUENT SOAJ, QUZYTTIR SOLN IV, certain pulmonary hypertension agents).
Some entries explicitly state “PA” or show combined controls (SP; PA) — treat these as requiring PA and/or specialty dispensing per formulary.
New opioid prescriptions: Ambetter from Fidelis Care limits new opioid fills to a 7‑day supply per New York State law; new opioid prescriptions exceeding a 7‑day supply require PA.
Opioid supply and MME limits: Prescriptions exceeding 90 MME per 30‑day supply or otherwise exceeding stated quantity limits may trigger further review and require PA.
Claims exceeding quantity limits (QL), age limits (AL), or lacking required PA are at risk of denial — plan may not cover the drug if PA/QL/AL requirements are not met.

Initial Therapy and New-Start Limits

New start opioid limits

New start limitations for selected opioid products

New start opioid supply limits: New prescriptions (new starts) for many opioid formulations are limited to a maximum 7-day supply for initial fills.7 day supply

This new-start limit is applied across multiple opioid entries; exceeding the limit may require prior authorization per payer and state law.

Step Therapy Rules and Sequences

Policy requirement	Notes
Try preferred agent(s) before coverage of non-preferred alternatives	Requirement: Step Therapy — members must trial preferred first-line drugs (Drug A) before coverage of non-preferred alternatives (Drug B) unless an exception is granted.
Exception process	Non-preferred drug exception: prescriber must document medical justification and submit a Medication Request Form; decisions processed per plan procedure.

Agent / Class	ST flag present
Lisdexamfetamine dimesylate (caps)	ST (step therapy) indicated alongside QL and AL in formulary lines
Dextroamphetamine / dexmethylphenidate / methylphenidate formulations	Some listings include ST and QL/AL controls (see stimulant class entries)

Product / Group	ST / Controls
Gold Compounds (e.g., auranofin, flurbiprofen)	ST flags present; entries show QL (e.g., QL(4 EA daily)) and ST noted for multiple gold-compound lines

Agent example	Formulary note
Mefenamic acid (caps)	Formulary line includes language 'ST try' adjacent to QL entries indicating step therapy applies

Product examples	Tiering / Utilization controls
SUBLOCADE, ZUBSOLV and related high-cost or specialty agents	Listed with tier assignments and utilization limits (e.g., QL per fill; specialty or PA flags); specific site-of-care or PA may apply
Selected IV corticosteroids (e.g., SOLU-CORTEF, prednisolone solutions)	Entries include tiering and may carry ILimits (AL/QL/ST) as shown for some soln products

Anticonvulsant / Related product	ST / PA annotation
APTIOM (eslicarbazepine) and other anticonvulsants	Entries show ST with QL limits (e.g., APTIOM: QL(2 EA daily); ST) and some formulations noted with PA
BRIVIACT solution and tablets; other anticonvulsant formulations	BRIVIACT SOLN PO noted with PA; tablets annotated with QL and PA; some anticonvulsants elsewhere are marked ST or PA

Antihyperlipidemic rule	Restriction before $0 copay exception
Selected statins and other antihyperlipidemics (generic-only)	Generic-only requirement and age range applied (age 40 to 76) before $0 copay exception process is available; QL values also listed per product

Step therapy sequences provided?	Implication
Explicit step sequences in excerpt	No full multi-step sequences are defined in this excerpt; PA, QL, AL and ST flags function as utilization controls. Providers should follow PA and ST flags when present.

Corticosteroid / IV or infusion product	ST presence
Prednisolone / prednisolone sodium phosphate solutions; other IV corticosteroids	Some entries include ST and age limits (e.g., AL(At least 12 yrs old)) and may carry QL/PA controls as listed for soln entries

Topical agent	ST / Notes
Clindamycin phosphate–tretinoin topical	Listed with AL(At least 12 yrs old) and ST — step therapy applies prior to coverage; some listings also reference PA or QL
DIFFERIN LOTN (adapalene) and sulfacetamide topical entries	DIFFERIN LOTN and sulfacetamide lines include AL(At least 12 yrs old) and ST; QL values shown for certain preparations (e.g., QL(6 GM daily))

Quantity Limits, Fill Windows and Examples

inv-142: Various (class-specific) — Maximum quantity per fill or daily as specified in formulary; example ADHD QL entries shown

Class-specific maximumsMaximum quantity per fill or per day is specified in formulary entries (examples shown for ADHD and biologic pens/syringes)

Example patternsBiologic pens show per-day fractional EA limits and per-28/180-day package limits; ADHD agents show EA/day QLs

EnforcementPharmacy claims must reflect the listed QL or may be denied or require PA

inv-143: New opioid prescriptions — 7-day supply for new fills

New opioid prescriptions — retail/initial fillsNew opioid prescriptions are limited to a 7-day supply for new fills

Definition of new

Specialty Pharmacy, Infusion and Dispensing Sites

Note

Policy Background and Scope

The formulary groups drugs by therapeutic class or indication and is intended to guide clinically appropriate, cost-effective prescribing. The document lists covered drugs and specifies utilization management controls; the Centene/P&T Committee reviews clinical evidence and cost when selecting formulary inclusions to support appropriate prescribing decisions.

Key Terms and Abbreviations

inv-102: biosimilar — definition entry

Biosimilar definitionBiosimilars are alternatives to original biologics; some interchangeable biosimilars may be substituted per state law

Substitution practiceInterchangeable biosimilars may be substituted without a new prescription depending on state laws

Cost implicationBiosimilars may cost less and are acceptable alternatives in the formulary

inv-103: generic substitution — definition entry

Generic substitution policyMandatory generic dispensing when an FDA-approved generic is available; some products exempt

Formulary notationBrand-name drugs capitalized; generics listed in lower-case italics in the document

Document Revision History

New-start opioid prescriptions in the formulary are limited by utilization rules. Per the formulary excerpts and applicable state law references, new starts are limited to a 7-day supply, and opioid prescribing may trigger review when thresholds are exceeded.

The formulary repeatedly documents new-start limits of 7 days for many opioid-containing products; this limit functions as a utilization control on initial opioid prescriptions and is enforced in conjunction with PA where indicated.

Biosimilar alternatives to original biologic products are recognized in the formulary. Where a biosimilar is designated as interchangeable under state law, it may be substituted for the reference biologic at the pharmacy without a new prescription in accordance with applicable state substitution rules.

Policy Summary

PayerFidelis Care

PolicyAmbetter from Fidelis Care Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Some products have combined rules: PA plus quantity limits (QL) and/or age limits (AL) — documentation must support the requested quantity, indication, and member age.

High‑tier and specialty agents (e.g., QUZYTTIR SOLN IV, PRALUENT SOAJ, select biologics and pulmonary hypertension therapies) explicitly require PA and often specialty pharmacy (SP) handling.

PA is required when noted in the formulary; entries that list PA, SP; PA, or ILimits = PA should trigger submission of a prior authorization request.

Step therapy (ST) edits may also apply — many agents list ST or require trying preferred first‑line drugs before alternatives are covered; lack of prior step completion may result in denial.

Documentation Required

Documentation and Exception Process

Provide clinical documentation with PA requests and quantity exceptions. Use the Medication Request Form for non‑preferred drug exception requests; the prescriber must fax the completed form to Ambetter from Fidelis Care. Decisions on exceptions are made after receipt of necessary information (typically within 24 hours for urgent requests per the formulary process).

For non‑preferred drug exceptions: prescribers must complete and fax the Medication Request Form (obtain via 1-888-343-3547 or from Fidelis Care website) and provide medical justification (allergy, intolerance, documented failure of preferred agents, or clinical stability on current therapy).
Documentation should include diagnosis/indication, prior therapies tried and response, dosage and quantity requested, and member age when age limits (AL) apply.
Quantity limits (QL) and fill limits (e.g., retail/mail max fills per X days) must be documented; requests exceeding QL require supporting rationale.
For specialty drug PA, include indication, package/quantity requested consistent with product rules (starter kits, per‑period fill limits), and any age criteria.
Exception process for certain $0 copay scenarios (eg. some antihyperlipidemic combinations) requires medical necessity documentation when applicable.

Denial Risk

Denial Risk: PA, QL, AL, and ST Enforcement

Claims may be denied if PA, QL, ST, or AL requirements are not satisfied. Watch for combined denial triggers: missing PA, exceeding quantity limits, and age noncompliance.

Denial triggers include: no prior authorization when required; requested quantity exceeding the formulary quantity limit; member not within specified age range; step therapy requirements not met.
Opioid-specific denials: New opioid prescriptions exceeding the 7‑day new‑start limit or fills exceeding MME or quantity limits without PA may be denied.
Requests that exceed retail/mail fill limits (for example, starter kits or max fills per 180/365 days) require PA or will be subject to denial.
Specialty and high‑cost drugs with PA/SP flags are high risk for denials if documentation is incomplete or PA not obtained (examples: biologics, PCSK9 agents, pulmonary hypertension therapies).
If a request is denied, follow the plan’s exception and appeals processes; prescribers should supply additional clinical information as requested to support coverage.

Step Therapy

Step Therapy Requirements

Step Therapy (ST) is enforced for selected agents — the formulary flags ST where a preferred agent must be tried before covering an alternative.

ST applies to multiple drug classes and specific products (look for the ST flag on formulary entries).
When ST is present, submit documentation of trials of required preferred agents and clinical rationale for bypassing ST if clinically necessary.
Some entries show ST without an explicit sequence in the fragment — consult the full plan formulary or PA criteria for the required step sequence and acceptable exceptions.

A 'new' opioid = no opioid filled under the plan in the prior 90 days

PA triggerNew fills >7 days require Prior Authorization per NY requirements

inv-144: Examples of stimulants and formulations — QL(1 EA daily), QL(2 EA daily), QL(3 EA daily), QL(4 EA daily)

Stimulant QL examplesQL(1 EA daily); QL(2 EA daily); QL(3 EA daily); QL(4 EA daily)

Formulations coveredApplies to various stimulant formulations including tabs, patches, and CP24 products

Associated flagsSome stimulant entries also include AL (age) and ST (step therapy) flags

inv-145: Biologic pens/syringes examples (HUMIRA) — QL examples and per-period limits

Biologic pen/syringe examples (HUMIRA, etc.)Examples include per-day EA fractional QLs (e.g., QL(0.072 EA daily); QL(0.143 EA daily)) and per-period package limits (per 28 day or per 180 day retail/mail)

Specialty handlingMany biologics include PA and SP flags and may require specialty pharmacy dispensing

Starter kitsStarter/ pediatric kits may be limited to package(s) per 180 day(s) retail/mail

inv-146: AURANOFIN 3 MG / Gold Compounds entries — QL(4 EA daily) or QL( EA daily)

AURANOFIN / Gold Compounds QL formsListed as QL(4 EA daily) or abbreviated QL( EA daily) in the document

Step therapy flagGold compound entries also include ST (step therapy) in many lines

Coverage implicationQL and ST must be met for coverage of these products

inv-147: etodolac TABS / etodolac TB24 — max fill(s) per 180

Etodolac fill limitsRetail 'max fill(s) per 180' is documented for etodolac TB24/TABS

Common window180 day(s) retail; max fill(s) per 180 appears repeatedly for starter/packaged items

PA associationSome entries show PA in conjunction with these fill limits

inv-148: OTEZLA TABS — QL(2 EA daily)

OTEZLA TABS quantity limitQL(2 EA daily)

PA flagOTEZLA entries also list Prior Authorization (PA) where indicated

Age/packagingOTEZLA TBPK shows 180 day retail with 1 max fill per 180 where listed

inv-149: fentanyl PT72 examples — multiple QL values per formulation

Fentanyl PT72 / formulations — multiple QLsFormulary shows several QL values per fentanyl formulation (e.g., QL(0.34 EA daily); QL(0.143 ML daily))

PA and SP flagsSome fentanyl entries include PA or specialty (SP) flags depending on formulation

New-start limitsMany fentanyl lines include 'New starts limited to 7 day' language where opioid rule applies

inv-150: tramadol hcl TB24 200 MG — QL(12 EA daily)

Tramadol 200 mg (TB24) quantity limitQL(12 EA daily) shown for tramadol hcl TB24 200 MG

New-start languageTramadol TB24 entries include 'New starts limited to 7 day supply' elsewhere in opioid section

Formulary groupingListed under Opioid Combinations / Opioid entries with QL specifics

inv-151: meloxicam TABS 7.5/15 MG — QL(2 EA daily) / QL(6 EA daily) as shown for strengths

Meloxicam tablet QLs by strengthQL(2 EA daily) for 7.5 mg; QL(6 EA daily) for 15 mg (strength-dependent)

Unit of measureEA (each) per day

ImplicationStrength-specific QLs must be honored on claims

inv-152: oxymorphone HCl — QL(2 EA daily)

Oxymorphone HCl QLQL(2 EA daily)

PA flagOxymorphone lines also list PA in some formulations

New-start limitNew starts limited to 7 day supply noted for several oxymorphone entries

inv-153: SUBSYS LIQD 800 MCG — QL(8 EA daily)

SUBSYS LIQD 800 MCG QLQL(8 EA daily)

PA requirementSUBSYS entries include PA where indicated

New-start noteNew starts limited to 7 day supply for many liquid opioid formulations

inv-154: selected buprenorphine and related products — QL and per-fill limits documented

Selected buprenorphine-related QLs and per-fill limitsExamples include QL(2 EA daily); 6 EA per fill retail; 6 per fill mail; max fills per X days (varies)

ProductsApplies to SUBLOCADE, ZUBSOLV and other buprenorphine formulations listed

Specialty/retail distinctionsPer-fill limits differ between retail and mail as shown in formulary entries

inv-155: budesonide (intrarectal) — QL(3.2 GM)

Budesonide (intrarectal) QLQL(3.2 GM)

Formulary placementListed under intrarectal/rectal steroids with tiering as shown

Age/PA notesSome rectal steroid entries include age or PA restrictions elsewhere

inv-156: BREZTRI AEROSPHERE — QL(0.38 GM daily)

BREZTRI AEROSPHERE QLQL(0.38 GM daily)

Package/dispense noteAlso documented with package per 30 day retail and 3 packages per X in some lines

PA/tiersListed with Tier = 2 and QL per daily weight

inv-158: enoxaparin sodium SOLN IJ 300 MG/3ML — QL(6 ML daily)

Enoxaparin 300 mg/3 mL QLQL(6 ML daily)

Other strengths exampleSOSY pen formats show QL in mL (e.g., QL(0.8 ML daily) for 40 mg/0.4 mL)

Specialty flagSome enoxaparin SOSY strengths include SP and PA flags

inv-159: levocetirizine dihydrochloride SOLN — QL(TO ML daily)

Levocetirizine solution QLQL(TO ML daily)

Levocetirizine tabs QL variantsQL(1 EA daily) or QL(7 EA daily) depending on listing

PA and OTC notesSome levocetirizine lines include PA or RX/OTC distinctions

inv-160: levocetirizine dihydrochloride TABS — QL(1 EA daily) or QL(7 EA daily)

Levocetirizine tabs examplesQL(1 EA daily) or QL(7 EA daily) depending on listing

Coverage nuanceDifferent tab listings have distinct QLs and OTC/Rx flags

Claim enforcementPharmacy claims must reflect the specific QL for the listed tablet formulation

inv-161: promethazine hcl SUPP — QL(6 EA daily) or QL(2 EA daily) depending on strength

Promethazine suppository QLsQL(6 EA daily) or QL(2 EA daily) depending on strength/listing

Promethazine solution/tabsSolution and tab forms have separate QL/age/copay notes in formulary

ContextQL varies by formulation and strength as indicated in the document

inv-162: cholestyramine PACK/POWD — QL values depending on formulation

Cholestyramine pack/powd QLsQL(6 EA daily) for PACK; QL(24 GM daily) or QL(25.2 GM daily) for POWD depending on formulation

Exception processException process for $0 copay noted elsewhere for select antihyperlipidemics

Formulary noteQL varies by physical form (pack vs powder) as listed

inv-163: fluvastatin sodium CAPS — QL(1 EA daily) or QL(2 EA daily) depending on strength

Fluvastatin capsule QLs and copay exceptionQL(1 EA daily) or QL(2 EA daily) depending on strength; included in $0 copay generic-only age 40–76 exception process

Class applicationApplies to multiple generic statins with age-based $0 copay exception process

DocumentationException requests require documentation per formulary process

inv-164: emtricitabine-tenofovir example — QL(2 EA daily)

Emtricitabine-tenofovir QL exampleQL(2 EA daily)

Antiretroviral class noteMultiple antiretroviral agents list per-day EA QLs (varies by product)

Coverage implicationQL values must be followed for antiviral dispensing and PA where indicated

inv-165: SOFOSBUVIR-VELPATASVIR TABS (example) — QL(1 EA daily)

Sofosbuvir-velpatasvir QLQL(1 EA daily); SP; PA for certain hepatitis C agents

Specialty/PASome hepatitis C products are SP and require PA

Formulary tieringListed with Tier = 3 for certain HCV agents (e.g., SOVALDI)

inv-166: Epoprostenol / OPSUMIT / TRACLEER examples — various QL values

Epoprostenol / OPSUMIT / TRACLEER QLsVarious QL values listed (e.g., QL(3 EA daily); QL(1 EA daily); QL(2 EA daily))

PA/SP flagsMany pulmonary hypertension agents include PA and SP flags in formulary entries

Coverage noteProviders must submit PA when indicated and adhere to QL for coverage

inv-167: sildenafil citrate (pulmonary hypertension) TABS — QL(3 EA daily)

Sildenafil (PH) tablet QLQL(3 EA daily)

Tadalafil (PH) tablet QLQL(2 EA daily)

UPTRAVI QLQL(2 EA daily) for selexipag (UPTRAVI)

inv-168: tadalafil (pulmonary hypertension) TABS — QL(2 EA daily)

Tadalafil (PH) QL exampleQL(2 EA daily)

Specialty flagsPH agents commonly show SP and PA flags

Formulary implicationCoverage dependent on meeting QL and PA/SP requirements

inv-169: UPTRAVI TABS — QL(2 EA daily)

UPTRAVI (selexipag) QLQL(2 EA daily)

Therapeutic classListed under Prostacyclin Receptor agents

Coverage requirementAdhere to QL for coverage; PA where indicated

inv-170: SOLU-CORTEF 250 MG — QL(2 GM daily) shown for some solution entries

SOLU-CORTEF solution QLQL(2 GM daily) shown for some solution entries

Multiple strengthsSOLU-CORTEF available in 100 mg, 250 mg, 500 mg, 1000 mg with per-period notes

ImplicationQL listed in grams for solution formulations; adhere on claims

inv-171: sodium chloride (inhalant) NEBU — QL(8 ML daily)

Sodium chloride (nebulized) QLQL(8 ML daily)

Concentration variantsApplies to 0.9%, 3%, 7%, 10% nebulized saline formulations

Age/AL notesSome inhalant entries include AL(At least 12 yrs old) where applicable

inv-172: IUD products — max fill(s) per 365 day(s); typically 1 per 365

IUD product fill frequencyMax fill(s) per 365 day(s); typically 1 per 365

ProductsKYLEENA, LILETTA, MIRENA, PARAGARD listed with 1 per 365 retail/mail limits

Coverage implicationPer-year max fill enforced for IUD products as shown

inv-173: sodium chloride (inhalant) NEBU variants — QL(8 ML daily)

Sodium chloride NEBU variants QLQL(8 ML daily) for 0.9%, 3%, 7%, 10% formulations

UsageListed under Misc. Respiratory Inhalants with per-day mL QL

Claim handlingClaims must reflect QL per formulation strength

inv-174: isotretinoin (10/30/40 mg) — QL(3.35 GM daily)

Isotretinoin QLQL(3.35 GM daily)

Age/PA pairingIsotretinoin entries include AL(At least 12 yrs old) and PA for some strengths

Per-fill noteHigher-strength isotretinoin (25/35 mg) may require PA

inv-175: clobetasol propionate (0.05%) — QL(6 GM daily)

Clobetasol propionate QLQL(6 GM daily) (examples show 6 GM / 3 GM / 4 GM for various forms)

Formulation varianceDifferent formulations (ointment, cream, foam, gel) list distinct QLs and some list ST/PA

Coverage implicationAdhere to listed QL to avoid denial or PA requirement

inv-176: Biologic pen/syringe products (e.g., STELARA, SKYRIZI, TREMFYA) — various QL values listed

Biologic pen/syringe QL patternsVarious QLs shown (e.g., QL(0.012 ML daily), QL(0.025 ML), QL(0.018 ML daily), QL(60 GM per fill retail))

Products includedExamples include STELARA, SKYRIZI, TREMFYA and associated pen/syringe or SOSY presentations

Per-period limitsSome products list per-fill GM limits and max fills per 30 days retail/mail

ImpactIf a generic is available it must be dispensed under the plan's mandatory generic pharmacy benefit

inv-104: QL — Quantity Limit definition

QL definitionQuantity Limit — maximum units allowed in the specified time period (e.g., QL(2 EA daily))

Forms of QLCan be per day, per fill, per 28/30/180/365 day period depending on item listing

EnforcementClaims exceeding QL may be denied or require PA

inv-105: AL — Age Limit definition

AL definitionAge Limit — minimum (and/or maximum) age required for coverage (e.g., AL(At least 6 yrs old))

ExamplesUsed across pediatric and dermatologic entries (At least 6 yrs old; At least 12 yrs old; Up to 30 yrs)

DocumentationAge must be documented on PA or claim when AL applies

inv-106: PA — Prior Authorization definition

PA definitionPrior Authorization — prior approval required for coverage of certain drugs

Provider actionProviders must obtain PA before dispensing when PA is indicated in formulary entries

Denial riskFailure to obtain required PA may result in the plan not covering the drug