CurrentFidelis CarePolicy N/A

Formulary alternatives and restrictions — coverage criteria

Lists commonly used drugs that are not covered by the plan and suggests covered formulary alternatives, with any prior authorization (PA) or quantity limit (QL) restrictions; intended for providers, pharmacists, and members of Fidelis Care (Wellcare by Fidelis Care).

Policy Summary

PayerFidelis Care

PolicyFormulary alternatives and restrictions — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionConsult the plan formulary and submit prior authorization documentation when alternatives are subject to PA or QL.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrugs listed with suggested formulary alternatives

PA, QLexamples of formulary restrictions

** notedtherapeutic equivalence notation

listed in textdocument currency statement

Formulary Alternatives and Coverage Guidance

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.

Covered alternatives with possible restrictions

Covered when the following mapping and restriction statements apply:

Formulary alternative mapping: When a listed brand or discontinued drug is not covered, the document provides one or more covered formulary alternatives (examples: BASAGLAR KWIKPEN -> INSULIN GLARGINE-YFGN; BYDUREON BCISE -> MOUNJARO/OZEMPIC/RYBELSUS/TRULICITY).

See listed mappings in source chunks 1-9.

Restrictions may apply: Coverage of the alternative may be subject to formulary restrictions such as Prior Authorization (PA) and Quantity Limits (QL); specific alternatives list PA and/or QL where applicable (e.g., BYDUREON BCISE alternatives show PA, QL; many biologic/biosimilar alternatives show PA, QL).

PA/QL flags shown next to many alternatives in source chunks 1-9.

Provider Responsibilities and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) may be required for some formulary alternatives listed. Check the plan's drug list and prior authorization requirements before prescribing or dispensing an alternative drug to avoid claim delays or denials.

Examples in this document: several alternatives (e.g., BYDUREON BCISE, REPATHA, AJOVY, STELARA, HUMIRA) list PA as a formulary restriction.
When PA is required, obtain and submit the appropriate prior authorization documentation per Fidelis Care procedures.

Step Therapy

Therapeutic Substitution / Step Therapy

Therapeutic substitution or step therapy may apply when a listed brand product is not covered and a therapeutically equivalent generic, authorized generic, or biosimilar is available. Providers should consider formulary equivalents (marked ** in the source) and follow any step-therapy requirements noted on the drug list.

** indicates therapeutically equivalent generics, authorized generics, or biosimilars (same active ingredient).
If a member is already stabilized on a non-formulary drug, consult the formulary and prior authorization guidance before switching.

Documentation Required

Use Formulary and PA Documentation

Always consult the Fidelis Care drug list (formulary) and the plan's PA documentation for current coverage, restrictions, and required supporting information. The formulary is the definitive source for which alternative drugs are covered and any applicable quantity limits (QL) or prior authorization (PA) rules.

Use the plan formulary to verify covered alternatives (e.g., semglee**, lantus**, toujeo U-300, mirabegron, vascepa).
Formulary details (coverage, PA, QL) can change during the year; check the drug list for the most current information.

Denial Risk

Formulary Restriction Risks

Formulary restrictions such as prior authorization (PA) and quantity limits (QL) can result in delayed or denied coverage if not followed. Verify restrictions before prescribing and include required clinical documentation to reduce denial risk.

Several alternatives in this document show QL and/or PA (for example: BYDUREON BCISE = PA, QL; AJOVY = PA, QL; GEMTESA = QL).
Failure to obtain PA or to adhere to QL may lead to claim denial or member cost-sharing.

Prior Authorization

Specialty Drug PA/QL

Specialty drugs, biologics, and biosimilars may have specific PA or QL controls. Review specialty drug requirements and biosimilar interchangeability guidance on the formulary before initiating therapy.

Examples: biologic/biosimilar substitutions (e.g., STELARA, HUMIRA alternatives like CYLTEZO, YUFLYMA) frequently list PA and QL.
Follow Fidelis Care specialty drug submission procedures for coverage determinations.

Key Terms and Notation

inv-09: ** — therapeutically equivalent notation (generics, authorized generics, biosimilars)

Notation meaningThe document uses '**' to mark therapeutically equivalent products (generics, authorized generics, and biosimilars).

Example - inhaled productADVAIR DISKUS** and wixela inhub** are marked as therapeutically equivalent to fluticasone-salmeterol diskus**.

Example - insulinSEMGLEE (insulin glargine-yfgn)** is listed as therapeutically equivalent to LANTUS (insulin glargine)** in the formulary mappings.

Actionable noteWhen '**' appears next to a listed alternative, it indicates the alternative has the same active ingredient or therapeutic equivalence — prescribers and pharmacists may substitute accordingly per formulary and state substitution rules.

inv-10: PA — Prior authorization definition

DefinitionPrior authorization (PA) is a formulary restriction that may require approval before coverage.

Where indicatedPA flags are shown next to many alternatives in the formulary mappings (e.g., BYDUREON BCISE alternatives, AJOVY alternatives, REPAT H A mapping).

Provider actionProviders should submit PA requests with supporting documentation when alternatives list 'FORMULARY RESTRICTIONS = PA' to avoid claim denial or step edits.

Examples from documentBYDUREON BCISE — FORMULARY RESTRICTIONS = PA, QL; AJOVY — FORMULARY RESTRICTIONS = PA, QL; REPATHA — FORMULARY RESTRICTIONS = PA.

inv-11: QL — Quantity limit definition

DefinitionQuantity limit (QL) is a formulary restriction that limits the quantity of a drug covered (typically noted per month in the document).

Where indicatedQL flags are shown next to many alternatives in the formulary mappings (examples: XULTOPHY -> SOLIQUA = QL; GEMTESA alternatives = QL).

Provider implicationClaims exceeding the listed QL may be denied or require prior authorization or step edits at point of sale.

Examples from documentXULTOPHY — FORMULARY RESTRICTIONS = QL; GEMTESA — FORMULARY RESTRICTIONS = QL; TRULANCE — FORMULARY RESTRICTIONS = QL.

Step Therapy / Mapping of Discontinued Brands to Alternatives

Discontinued / Non‑covered brand	Covered formulary alternative(s)	Formulary restrictions
BASAGLAR KWIKPEN (insulin glargine)	SEMGLEE (insulin glargine‑yfgn); LANTUS (insulin glargine)	None
BYDUREON BCISE [DISCONTINUED]	MOUNJARO; OZEMPIC; RYBELSUS; TRULICITY	PA, QL
XULTOPHY	SOLIQUA	QL
ADVAIR DISKUS / wixela inhub	fluticasone‑salmeterol diskus**; breyna hfa; BREO ELLIPTA; ADVAIR HFA	QL
AJOVY	AIMOVIG; EMGALITY 120mg/mL	PA, QL
QULIPTA / UBRELVY / ZAVZPRET	NURTEC	PA, QL
STELARA (ustekinumab)** / ACTEMRA (tocilizumab)	STEQEYMA (ustekinumab‑stba)**; TYENNE (tocilizumab‑aazg); CYLTEZO; YUFLYMA; COSENTYX	PA, QL

Quantity Limits Noted for Alternatives

inv-13: Many listed alternatives — notes where QL applies

ScopeMany listed formulary alternatives include QL and/or PA flags; the document highlights these restrictions alongside each alternative mapping.

Common QL examplesXULTOPHY -> SOLIQUA (FORMULARY RESTRICTIONS = QL); GEMTESA -> mirabegron/tolterodine/solifenacin/oxybutynin (FORMULARY RESTRICTIONS = QL); TRULANCE -> LINZESS/lubiprostone (FORMULARY RESTRICTIONS = QL).

Combined PA/QL examplesBYDUREON BCISE alternatives and AJOVY alternatives are shown with both PA and QL restrictions (FORMULARY RESTRICTIONS = PA, QL).

Actionable itemCheck the specific alternative entry for a QL flag before dispensing; if QL is listed, confirm covered quantity limits or submit authorization as needed to avoid claim denial.

Biosimilar and Insulin Alternatives

Billing Rule

LANTUS (insulin glargine)**

LANTUS (insulin glargine)** is listed as a formulary‑covered insulin glargine alternative and is shown with no formulary restrictions noted in the mapping table.

Entry shows SEMGLEE and LANTUS as formulary‑covered insulin glargine alternatives with FORMULARY RESTRICTIONS = None.

Billing Rule

HUMIRA (adalimumab)**

HUMIRA (adalimumab)** is listed with covered adalimumab biosimilar alternatives (e.g., CYLTEZO, YUFLYMA) and the formulary mapping indicates these alternatives have PA and QL restrictions.

The HUMIRA mapping explicitly lists FORMULARY RESTRICTIONS = PA, QL for its covered alternatives.

OpenPayer