Currentharvard pilgrim health carePolicy N/A

Pharmacy Program — Preferred Drug List (PDL) and Specialty Pharmacy Program

Describes the payer's pharmacy program including the Preferred Drug List (PDL), prior approval, step therapy, quantity limits, generic-first policies, specialty pharmacy services, and multilingual/accessibility information; affects providers prescribing and pharmacists dispensing drugs for Tufts Health Plan members.

Policy Summary

Payerharvard pilgrim health care

PolicyPharmacy Program — Preferred Drug List (PDL) and Specialty Pharmacy Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with clinical documentation when a drug is marked PA to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Optum® Specialty Pharmacydesignated specialty pharmacy

1-5PDL tiers

PA, ST, QL, NTM, ALcoverage flags/limits

Multilingual serviceslanguage assistance

05/15/26last update

Coverage criteria — when drugs are covered

General pharmacy coverage criteria

Covered when ALL of the following are met

Prescription requirement: Medication is prescribed by a licensed provider and is requested for a covered member (first-time prescription or refill).

Source: chunk 0

OTC with prescription: Over-the-counter drugs are covered only when a licensed provider writes a prescription and the medication is filled at a pharmacy.

Source: chunk 0

Generic-first / brand coverage: Brand-name drugs are covered only when no therapeutically equivalent generic exists or when prior authorization is granted per the payer's Generic First rules.

Source: chunk 1; chunk 6

Prior authorization (PA): Drugs listed as requiring prior approval must have PA before coverage; PA requests are reviewed by a clinician and coverage is granted only if there is a medical reason and, when applicable, prior trials of PDL drugs have failed or are not appropriate.

Source: chunk 3

Step therapy (ST): When step therapy applies, the member must have used first-level PDL drugs before a non-preferred agent will be covered unless PA is granted; providers may request PA with clinical rationale for exceptions.

Source: chunk 4

Quantity limits (QL): Medications with specified quantity limits are limited to stated amounts; PA is required and will be reviewed by a clinician for requests exceeding those limits based on medical necessity.

Source: chunk 5

The Preferred Drug List (PDL) applies to outpatient pharmacy claims processed through the Prescription Drug Benefit. PDL rules do not apply to drugs provided during a hospital inpatient stay; inpatient drugs are covered as part of the facility stay and are not adjudicated under the PDL.

This formulary excerpt presents coverage as tier assignments and inline limitations rather than explicit medical‑necessity exclusion statements. Many entries show tier placement and use notes such as PA (prior authorization), QL (quantity limit), or benefit routing language (e.g., “Covered under the Prescription Drug Benefit when self‑administered”), conveying coverage conditions through formulary notation instead of standalone exclusion text.

Throughout the listing the coverage stance is communicated by formulary tier plus line‑level annotations (for example, PA, ST, and specific QL values). The document does not frame these as conventional medical‑necessity determinations within this excerpt; instead the PDL uses tiering and notes to indicate when prior authorization, step therapy, or quantity limits apply to a given product.

Drug listings, codes and example limits

Drug list — psychotropic examplesmixed

PERSERIS 120 MG	PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG
PERSERIS 90 MG	PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 90 MG
QUETIAPINE ER 150 MG	quetiapine fumarate er oral tablet extended release 24 hour 150 mg
QUETIAPINE ER 200 MG	quetiapine fumarate er oral tablet extended release 24 hour 200 mg
QUETIAPINE ER 300 MG	quetiapine fumarate er oral tablet extended release 24 hour 300 mg
QUETIAPINE ER 400 MG	quetiapine fumarate er oral tablet extended release 24 hour 400 mg
QUETIAPINE ER 50 MG	quetiapine fumarate er oral tablet extended release 24 hour 50 mg
QUETIAPINE 100 MG	quetiapine fumarate oral tablet 100 mg
QUETIAPINE 200 MG	quetiapine fumarate oral tablet 200 mg
QUETIAPINE 25 MG	quetiapine fumarate oral tablet 25 mg

1–10 of 26

1/3

Antivirals and HIV agents examplesmixed

EMTRIVA SOL 10 MG/ML	EMTRIVA ORAL SOLUTION 10 MG/ML
ENTECAVIR 0.5 MG	entecavir oral tablet 0.5 mg
ENTECAVIR 1 MG	entecavir oral tablet 1 mg
EPCLUSA PACK 200-50 MG	EPCLUSA ORAL PACKET 200-50 MG
EPCLUSA 200-50 MG	EPCLUSA ORAL TABLET 200-50 MG
EPCLUSA 400-100 MG	EPCLUSA ORAL TABLET 400-100 MG
ETRAVIRINE 100 MG	etravirine oral tablet 100 mg
ETRAVIRINE 200 MG	etravirine oral tablet 200 mg
GENVOYA 150-150-200-10 MG	GENVOYA ORAL TABLET 150-150-200-10 MG
HARVONI 45-200 MG	HARVONI ORAL TABLET 45-200 MG

1–10 of 13

1/2

Blood products and biologics examplesmixed

ARANESP 100 MCG/ML	ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML
ARANESP PREFILLED 10 MCG/0.4ML	ARANESP PREFILLED SYRINGE 10 MCG/0.4ML
BENEFIX KIT 1000 UNIT	BENEFIX INTRAVENOUS KIT 1000 UNIT
COAGADEX 250 UNIT	COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT
GRANIX 480 MCG/0.8ML	GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML
HEMLIBRA 105 MG/0.7ML	HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML
HEMOFIL M 1000 UNIT	HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT
NEULASTA ONPRO 6 MG/0.6ML	NEULASTA ONPRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML
NEUPOGEN 300 MCG/ML	NEUPOGEN INJECTION SOLUTION 300 MCG/ML
RELEUKO 300 MCG/0.5ML	RELEUKO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML

NDC/Codes not listedmixed

Various NDCs

NDCs and specific billing codes not listed in this excerpt; product presentations and strengths are provided in-line

Selected product strengths/formulations from excerptmixed

200 MG/1.14ML	DUPIXENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14ML
300 MG/2ML	DUPIXENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 300 MG/2ML
200 MG/1.14ML	DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML
300 MG/2ML	DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML
2.4 %	QBREXZA EXTERNAL PAD 2.4 %
0.5 MG/0.1ML	GVOKE HYPOPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML
1 MG/0.2ML	GVOKE HYPOPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1 MG/0.2ML

inv-10: Diclofenac / Flector patch limits

Diclofenac / FLECTOR patch — 30‑day limitMax of 60 patches per 30 days

Diclofenac / FLECTOR patch — annual limitMax of 90 days per year

FLECTOR external patch notePA required (prior authorization) as noted in formulary entry

inv-11: Ketorolac injection/solution QL

Ketorolac injection/solution — typical IV/IM QL20 mL per 5 days (varies by presentation; e.g., 30 mg/mL formulation lists 20 mL/5 days)

What prescribers and pharmacists must do

Prior Authorization

Prior approval required

This medication requires prior approval (PA) before coverage; one of the payer's clinicians will review the request for medical necessity and prior therapy as applicable. If PA is not obtained the claim may be denied and can be appealed per the Member Handbook.

Provider must submit a PA request when the formulary entry is annotated 'PA'.
Clinical rationale and prior therapy information should be included for clinician review.

Prior Authorization

Prior authorization required for select agents

Many opioid, extended‑release, abuse‑deterrent and certain other analgesic products are annotated 'PA' and require prior authorization before coverage; providers should submit PA per the formulary notes to avoid denial.

Step therapy rules and affected drugs

Requirement	Summary
Must try first-level PDL drugs prior to covering alternate agent unless PA granted
Step therapy program: member must trial preferred first-line PDL agents before coverage of a non‑preferred drug; provider may request prior authorization with clinical rationale if first‑line therapy is inappropriate

Agent examples	Step therapy (ST) noted
desvenlafaxine ER
venlafaxine ER — listing shows "NOTES = ST" for extended‑release tablet formulations

Example	ST annotation
febuxostat
zolmitriptan (nasal and oral entries show "NOTES = ST" for some formulations)

Products	Implication
Formulary entries with "ST" in notes
Entries marked ST require attempted use of specified alternatives (first‑line PDL drugs) before coverage; PA may be requested if clinically appropriate

Observation	Note
Some drugs are tiered which may imply coverage hierarchy
Tiering can result in step edits even when explicit ST language is not detailed in the excerpt

Product	ST indicated
amlodipine-olmesartan (oral tablet combinations)
Notes indicate "ST" meaning step therapy applies to these combination products

Coverage/PA rule	Relevance to step therapy / age rules
Prior authorization (PA) applies to many stimulant/ADHD medications for members 25 and older
Age‑based PA interacts with step/coverage rules: methylphenidate and other stimulants note PA for members 25+ and QL limits per day — providers should follow PA and step requirements where indicated

Topical agent	ST note
adapalene external cream/gel
Listed with "NOTES = ST" indicating step therapy is required before coverage

Tazarotene product	Step therapy flag
tazarotene external cream/gel/foam formulations
Entries include "NOTES = ST" for several tazarotene presentations, indicating step therapy must be followed before coverage

Quantity limits (QL) and supply restrictions

inv-110: Diclofenac patch / FLECTOR

Diclofenac / FLECTOR patch — 30‑day limitMax of 60 patches per 30 days

Diclofenac / FLECTOR patch — annual limitMax of 90 days per year

PA notePA indicated in limitations/notes for FLECTOR

inv-111: Ketorolac injection/solution

Ketorolac injection/solution — common QL20 mL per 5 days (varies by presentation)

Ketorolac 15 mg/mL presentationQL noted as 40 mL per 5 days for specific 15 mg/mL presentation

Ketorolac oral tablet QL

Where drugs are covered (retail, specialty, medical benefit)

Note

Key terms and flags used in the formulary

inv-89: NTM / PA / QL definitions

NTM — definitionNew‑to‑Market drug: not covered until reviewed and a coverage decision is made

PA — definitionPrior Approval: authorization required from the payer before the drug will be covered

QL — definitionQuantity Limit: a maximum amount of a drug allowed without prior approval

inv-90: PA / QL / ST notes

QL — definition and examplesQuantity Limit: restriction on amount dispensed per time period (examples listed inline such as 8 mL per 14 days, 1 EA per 1 day)

PA — specialty productsPrior Authorization: approval required before coverage for many specialty injectables; often noted in limitations/notes

Document background and scope

Background: This document is a segment of the Harvard Pilgrim pharmacy formulary showing medication listings by drug name, formulation, strength, tier, and any limitations or notes (for example, PA and QL). It is intended to guide prescribing, dispensing, and benefit administration rather than to provide clinical treatment guidance.

Policy Summary

Payerharvard pilgrim health care

PolicyPharmacy Program — Preferred Drug List (PDL) and Specialty Pharmacy Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with clinical documentation when a drug is marked PA to avoid coverage denial.

SourceLink

On This Page

Ketorolac 15 mg/mL injection QL

40 mL per 5 days (per specific presentation)

Ketorolac IM 60 mg/2 mL QL10 mL per 5 days (for IM 60 mg/2 mL presentation)

inv-12: Licart patch limit

LICART external patch 24‑hour 1.3%1 EA per 1 day

LICART notePA indicated in limitations/notes

TierTier 2 as listed

inv-13: ARANESP prefilled syringe QL

ARANESP prefilled syringe — quantity limit4 mL per 30 days

Benefit routingCovered under the Prescription Drug Benefit when self‑administered

Presentation examplesMultiple strengths listed (e.g., 10 mcg/0.4 mL, 100 mcg/0.5 mL); QL applies to total mL per 30 days

inv-14: EPOGEN QL

EPOGEN injection solution — quantity limit10 mL per 14 days

Benefit routingCovered under the Prescription Drug Benefit when self‑administered (per formulary note)

Strengths listedMultiple unit strengths (10000 U/mL, 2000 U/mL, etc.) with QL expressed as mL

inv-15: Oseltamivir QL

Oseltamivir (oral) — per‑fill limit20 tablets per fill

Oseltamivir — annual fills limitMaximum of 2 fills per year

Formulation noteLimit applies to oral therapy packs/tablet presentations as listed

inv-16: Quantity limits examples

Example — mL per 14 days8 mL per 14 days (example for some prefilled syringes like GRANIX variants)

Example — small‑volume QL0.6 mL per 14 days (NEULASTA ONPRO example)

Example — syringes per 14 days / EA per day10 syringes per 14 days; 1 syringe per 14 days; 2 EA per 1 day (various product examples)

Examples include BELBUCA (PA; QL 2 EA/day), fentanyl transdermal patches (PA; QL 10/30 days), hydrocodone ER formulations (PA; QL limits).
If PA is not obtained claims for these agents may be denied.

Prior Authorization

Prior authorization required for select medications

Specific branded or restricted products listed in the formulary are marked 'PA' and require prior authorization before coverage; submit PA following plan processes to support coverage decisions.

Examples include BAXDELA (PA), DIFICID (PA; QL 136 mL per fill), NUZYRA (PA), NAYZILAM (PA; QL 1 per fill).
One of the plan clinicians will review PA requests for medical necessity.

Prior Authorization

Prior authorization required for selected agents

Certain agents shown in the formulary are annotated 'PA' and require prior authorization; providers must obtain PA before dispensing to avoid claim denial.

Examples in this extract include VALTOCO nasal formulations (PA; QL 1 box per fill), vigabatrin (PA), rufinamide (PA).

Prior Authorization

PA for selected antidepressants

Several branded antidepressant products are noted as requiring prior authorization (PA); submit PA with clinical justification when prescribing these agents.

Examples include EMSAM (PA; QL 1 EA/day), EXXUA (PA; QL 1 EA/day), FETZIMA (PA; QL 1 EA/day), TRINTELLIX (PA; QL 1 EA/day).

Prior Authorization

Prior authorization required for PA entries

Many products in the partial formulary are marked 'PA' (prior authorization); providers must submit PA requests for these entries per plan instructions.

Each product line annotated 'PA' indicates a required prior authorization before coverage will be approved.
Failure to submit PA may result in denial of coverage.

Prior Authorization

Prior authorization required where noted

Many listed drugs include a note '*NOTES = PA' following limitations; providers must obtain prior authorization where this note appears to ensure coverage.

Claims submitted without required PA when '*NOTES = PA' is present may be denied.

Prior Authorization

Prior authorization required

The formulary contains multiple entries with 'PA' in the limitations/notes field, indicating prior authorization is required; prescribers should submit PA documentation before dispensing.

Examples include PERSERIS (PA), quetiapine ER (PA), REXULTI (PA; QL 1/day).

Prior Authorization

Prior authorization required for many specialty agents

The majority of specialty IV and subcutaneous biologic and clotting factor products listed are subject to prior authorization; providers must secure PA prior to provision of these specialty agents.

Examples include HEMLIBRA, HEMOFIL M, NEULASTA ONPRO — entries note 'PA' and many are covered under the Prescription Drug Benefit when self‑administered with QLs.

Prior Authorization

Prior Authorization required for listed drugs

Several specialty and high‑cost drugs require prior authorization; providers must obtain PA to avoid claim denial for these agents.

Examples include REPATHA (PA; QL 2 mL/28 days), JUXTAPID (PA), NEXLETOL/NEXLIZET (PA), VYNDAMAX (PA; QL 1/day).

Prior Authorization

Prior authorization required for many listed products

Prior authorization is required for many listed products and may depend on member age; prescribers must submit PA where noted and observe age‑based PA rules.

PA applies to many stimulant/ADHD agents for members 25 and older; check notes for age‑specific PA and AL limits.

Prior Authorization

Products requiring prior authorization

Multiple products (including Dupixent formulations and various topical agents) are listed with 'PA' — providers must secure prior authorization prior to dispensing these items.

Examples include DUPIXENT auto‑injectors/prefilled syringes (PA; QL specified), imiquimod (PA; QL), and other topical agents with PA notes.

Prior Authorization

PA required for select drugs

Certain specialty drugs such as carglumic acid and deferasirox formulations are annotated 'PA' and require prior authorization; submit PA documentation when prescribing these agents.

Examples: carglumic acid (PA), deferasirox granules/tablets/packets (PA), deferiprone (PA).

Prior Authorization

Prior authorization required

Multiple listed drugs are noted as 'PA' — prescribers must obtain prior authorization before dispensing to avoid denial of coverage.

Check each formulary line for the 'PA' annotation and submit PA per plan process.

Prior Authorization

Prior authorization required for selected products

Selected specialty injectables and certain oral agents carry 'PA' in their notes; providers must obtain prior authorization before coverage will be approved.

Examples include EGRIFTA SV (PA), INCRELEX (PA), LUPRON DEPOT variants (PA), MYCAPSSA (PA).

Prior Authorization

Prior authorization required for select specialty agents

Certain specialty medications (e.g., ACTEMRA, adalimumab products, ALYGLO) require prior authorization and often have quantity limits; providers must obtain PA per notes and respect QLs.

ACTEMRA: PA; QL 4 syringes per 28 days. Adalimumab biosimilars: PA; QL limits (2 per 28 days). ALYGLO: PA applies with age limits noted.

Step Therapy

Step therapy program

Step therapy requires trying first‑level PDL drugs before covering other drugs in the same class; providers may request PA with clinical rationale if first‑line therapy is inappropriate.

If the provider requests a non‑preferred drug before trying PDL first‑line agents, submit a PA with supporting clinical justification for clinician review.
Failure to follow step therapy may result in PA denial (appeal available per Member Handbook).

Note

Tier‑based preference (informational)

Tiering shows preferred coverage hierarchy; while tier assignments imply preference, explicit step algorithms are not listed for all agents in this excerpt.

Providers should review notes for ST or PA flags per drug line rather than relying solely on tier level.

Step Therapy

Step therapy present

Some agents are annotated 'ST' (step therapy) in the formulary; providers must ensure required prior steps are documented or request PA to bypass step therapy.

Example entries with 'ST' include desvenlafaxine ER and venlafaxine ER.

Step Therapy

Step therapy indicated where marked

Entries that include 'ST' require that preferred alternatives be tried first; providers should document prior trials or submit PA with rationale if alternatives are unsuitable.

Examples: febuxostat and zolmitriptan entries annotated 'ST'.

Step Therapy

Step therapy noted

When a formulary entry includes 'ST' providers must follow the step requirements or submit PA documenting why step therapy is not appropriate for the patient.

Step therapy flags (ST) are present on select medications; failure to document prior trials may lead to denial.

Step Therapy

Step therapy presence

Some products marked 'ST' require documented trials of alternatives before coverage; providers should follow the ST annotation and submit PA if seeking an exception.

Example: amlodipine‑olmesartan is noted with 'ST'.

Prior Authorization

Age‑based PA / additional requirements

Certain ADHD and stimulant agents have age‑based PA or additional PA requirements; verify member age and submit PA when required for members aged 25 and older.

PA applies to many methylphenidate and stimulant products for members 25 and older; some products have AL (age limit) notes (e.g., Max 24 Years).
Providers must include age and any additional PA criteria when submitting requests.

Step Therapy

Step therapy annotations for selected agents

Some topical dermatologic agents are annotated 'ST' indicating step therapy applies; document prior use of first‑line topical options or request PA with justification.

Examples: adapalene external cream/gel entries flagged 'ST'.

Step Therapy

Step therapy indicators

Certain topical tazarotene products are flagged 'ST'; providers must document trials of required alternatives or submit PA to obtain coverage for non‑preferred formulations.

Tazarotene external cream/gel entries show 'ST' in limitations/notes.

Documentation Required

Step therapy not specified

FIRST‑LANSOPRAZOLE ORAL SUSPENSION is annotated with PA for members 14 and older; the formulary excerpt does not provide a specific step‑therapy algorithm for this product — submit PA when indicated.

PA applies to members 14 and older for FIRST‑LANSOPRAZOLE; include age in documentation when submitting PA.

Documentation Required

PA documentation expectations

PA requests are reviewed by a clinician and should document medical necessity and, when applicable, prior trials of PDL drugs or why generics/first‑line agents are inappropriate.

Include prior treatment history, diagnosis, dosing, and rationale for the requested agent when submitting PA.
Clinician review determines approval based on medical necessity and prior therapy.

Documentation Required

PA and QL presence

Products marked 'PA' require prior authorization and many products include specific quantity limits (QL) that will be enforced; submit PA when requesting coverage or quantities above QL.

Check each formulary line for both 'PA' and 'QL' annotations before prescribing or dispensing.
Requests to exceed QL should include justification and be submitted as PA requests.

Documentation Required

Follow PA/QL notes

Follow the PA and QL instructions shown in each formulary entry; when notes indicate PA or QL, providers must submit authorization requests and adhere to the stated quantity limits unless PA to exceed is approved.

Examples: DIFICID (PA; QL 136 mL per fill), vancomycin oral solution (QL 1 bottle per 10 days), XIFAXAN (PA; QL per strength).

Note

90‑day fill note

Selected antidementia agents may be filled up to a 90‑day supply per the formulary notes; providers should observe this allowance when authorizing refills.

Agents include donepezil, galantamine, memantine, rivastigmine where 'Medication can be filled for up to a 90 day supply' is noted.

Billing Rule

Quantity limits documented

Some products list explicit quantity limits (QL) in their limitations (e.g., AJOVY, EMGALITY); providers must adhere to these QLs or submit PA to request exceptions.

AJOVY: PA; QL Max 1 injection per 30 days. EMGALITY: PA; QL 1 mL per 30 days (2 injections permitted first month).

Documentation Required

Quantity limit/documentation requirements

Quantity limits and supply restrictions are specified for many medications; providers should document dosing and quantity consistent with listed QLs to support PA or benefit adjudication.

Examples of QLs: 24 EA per 30 days, 20 EA per 90 days, 1 EA per day — include dosing schedule in documentation when requesting exceptions.

Billing Rule

Quantity limits and benefit routing

Some self‑administered injectables are covered under the Prescription Drug Benefit when self‑administered and have quantity limits; when submitting PA include documentation of the administration setting if relevant.

Example: ARANESP prefilled syringes are 'Covered under the Prescription Drug Benefit when self‑administered' and have QL 4 mL per 30 days.

Documentation Required

Documentation for QL and benefit routing

Formulary notes that list QL values and benefit routing indicate required documentation (dosing, administration setting) when requesting coverage or exceptions for QL or medical‑benefit items.

Include administration setting (self‑administered vs medical benefit) and dosing records when submitting PA to justify coverage under Prescription Drug Benefit.

Billing Rule

Supply and quantity notes

Many oral medications in the formulary can be filled for up to a 90‑day supply where noted; providers should prescribe consistent quantities and note supply limits in PA requests.

Examples: multiple cardiovascular and other oral agents show 'Medication can be filled for up to a 90 day supply.'

Documentation Required

Quantity‑limit documentation needed

When a QL is listed on a drug line, providers should document dosing consistent with that QL to support coverage; requests to exceed QL require submission of PA with justification.

Examples include QL 1 EA per day, QL 30 mL per day — include clinical need and dosing records in PA.

Documentation Required

PA documentation

Prescribers must submit prior authorization per the plan's PA process for drugs annotated 'PA'; the formulary excerpt does not list full clinical documentation fields, so include diagnosis, prior therapy, dosing, and relevant labs where applicable.

PA submission should include clinical justification and any prior treatment failures to facilitate clinician review.

Documentation Required

Age and supply documentation notes

Notes include age‑based PA application and supply limits for some products; include member age and applicable supply instructions when submitting PA to ensure correct adjudication.

Example: FIRST‑LANSOPRAZOLE — PA applies to members 14 and older. Sucralfate oral suspension — PA applies to members 12 and older.

Documentation Required

Quantity limit documentation

Some formulary entries state explicit QLs (e.g., 'QL (1 tab/day)' or 'QL (1 EA per 1 day)'); when requesting quantities or overrides include documentation supporting the requested quantity and clinical necessity.

Include expected duration of therapy and prior dosing in PA to justify requests exceeding QL.

Prior Authorization

Submit PA where indicated

The formulary entries indicate which agents are flagged 'PA' and/or have 'QL'; providers should submit prior authorization documentation for agents flagged 'PA' prior to dispensing.

Review each product's notes for 'PA' and 'QL' indicators and submit required documentation to the plan.

Billing Rule

Prior authorization and quantity limits

Products listed with 'PA' require prior authorization and some also have specified quantity limits (e.g., ACTEMRA QL 4 syringes/28 days); providers must obtain PA and adhere to QLs or document justification for exceptions.

ACTEMRA: PA; QL 4 syringes per 28 days. Adalimumab biosimilars: PA; QL 2 syringes/28 days.
Failure to obtain PA may result in denial of coverage.

Denial Risk

Prior approval requirement and appeal

Failure to obtain required prior approval (PA) will result in non‑coverage; denied decisions can be appealed following the Member Handbook grievance and appeals process.

If PA is denied, the member or authorized representative may file an appeal per the Member Handbook.

Denial Risk

Step therapy requirement

Not following step therapy (ST) — i.e., not trying first‑line PDL drugs before requesting a non‑preferred agent — may trigger PA denial; providers can request PA with clinical justification to override ST.

Include clinical rationale for bypassing step therapy when submitting PA.

Denial Risk

Quantity Limit exceedance

Requests exceeding stated quantity limits (QL) without an approved prior authorization may be denied; submit PA with clinical justification if greater quantity is medically necessary.

Example: QL exceedance requests must include supporting documentation of medical need.

Denial Risk

PA/QL enforcement

Requests for products annotated 'PA' or for quantities exceeding QL may be denied if PA is not obtained; providers should check product notes and submit PA prior to dispensing.

Claims for PA‑marked drugs submitted without authorization risk denial at adjudication.

Denial Risk

PA required for some listed drugs

Some formulary items explicitly note 'PA' — coverage for these listed drugs may be denied without prior authorization; providers should verify PA requirements before prescribing.

Examples: BAXDELA, DIFICID (fidaxomicin) are annotated 'PA' and may be denied if PA not obtained.

Denial Risk

Quantity limit enforcement

Quantity limits (QL) specified for certain drugs (e.g., DIFICID 136 mL per fill; vancomycin oral 1 bottle/10 days; XIFAXAN QLs) will be enforced and requests exceeding these limits without PA may be denied.

Providers must respect QLs or submit PA with clinical justification to avoid denial.

Prior Authorization

PA/QL indicated

Coverage for some listed products may be subject to prior authorization or quantity limits (e.g., VALTOCO, vigabatrin, XCOPRI); obtain PA and follow QL guidance to avoid denial.

Check each product's limitations/notes for PA and QL entries prior to prescribing.

Prior Authorization

PA/QL indicated

Certain antiemetic and antidepressant branded products require PA and have QLs; providers should submit PA and ensure quantity requests align with the listed QL.

Examples: EMSAM, EXXUA, FETZIMA, VARUBI are annotated with PA and QL values.

Denial Risk

Prior authorization required for PA‑marked products

Entries annotated 'PA' indicate that coverage may be denied without prior authorization; providers must obtain PA for PA‑marked products to reduce risk of non‑coverage.

Examples provided include naftifine external cream and NOXAFIL oral packet noted as 'PA'.

Denial Risk

Prior authorization triggers

Claims for medications listed with '*NOTES = PA' may be denied if PA is not obtained; check product lines for this annotation and secure PA prior to dispensing.

Many entries list '*NOTES = PA' in the limitations/notes field — absence of PA can trigger denial.

Denial Risk

Prior authorization required for select drugs

Coverage for listed products may be denied if prior authorization is not obtained; providers should verify PA requirements for items such as PERSERIS, REXULTI, VRAYLAR before prescribing.

Obtain PA for PA‑annotated psychiatric products to avoid claim denials.

Denial Risk

Prior Authorization triggers

Many specialty injectables and selected other drugs require prior authorization; absence of PA at the time of claim submission may trigger denial — obtain PA in advance.

Specialty clotting factors and biologics frequently list 'PA' in limitations/notes.

Prior Authorization

PA requirements noted

PA is required for multiple listed products across the formulary (e.g., fenofibrate formulations, fluvastatin ER, JUXTAPID, NEXLETOL); providers must submit PA requests where 'PA' is noted to avoid denial.

Confirm PA requirements in product notes before prescribing high‑cost or specialty therapies.

Prior Authorization

PA triggers for age and product‑specific items

PA applies to many agents with age‑ or product‑specific triggers (e.g., PA applies to methylphenidate products for members 25+); verify member age and PA notes before prescribing.

Include member age in PA submissions for stimulant and ADHD medications as required.

Prior Authorization

PA for select CNS/weight‑loss agents

Many CNS and weight‑loss agents are annotated 'PA'; providers must obtain prior authorization for agents such as CONTRAVE, ORLISTAT, AUSTEDO per formulary notes.

Verify PA and QL requirements for CNS/weight‑loss drugs prior to prescribing.

Denial Risk

Prior authorization triggers

Prescriptions for listed dermatologic and diabetes agents may be denied without prior authorization where PA is indicated; providers should secure PA per the product note.

Multiple dermatologic agents in this excerpt are marked 'PA' (e.g., imiquimod, KLISYRI).

Prior Authorization

Prior Authorization required for select products

Several specialty agents are marked 'PA' (e.g., carglumic acid, deferasirox, deferiprone); obtain prior authorization for these medications to prevent denial of coverage.

Providers should submit PA documentation consistent with clinical need for these specialty drugs.

Denial Risk

Quantity limit enforcement

Some items list QLs (e.g., omeprazole‑sodium bicarbonate QL 1 EA/day) that will be enforced; requests exceeding these limits without PA may be denied.

Include dosing justification in PA requests to exceed QLs when medically necessary.

Denial Risk

Prior authorization required (general)

Claims for drugs annotated 'PA' across the formulary may be denied without prior authorization; providers should confirm PA requirements on the drug line before dispensing.

Multiple entries are annotated with 'PA' — absence of PA can lead to claim denial.

Prior Authorization

PA required for selected specialty agents

Numerous specialty products are noted as requiring prior authorization; providers should obtain PA for these agents (e.g., EGRIFTA SV, INCRELEX, LUPRON DEPOT) to avoid denials.

Specialty injectables and kits in this section include PA notes and may require supporting documentation.

Denial Risk

Quantity limits enforcement

Quantity limits such as '1 mL per day', '2 mL per day', and EA/day caps are specified for some specialty agents; exceeding these without approved PA may result in denial.

Examples: octreotide (PA; QL 1 mL/day), ORILISSA (PA; QL 1‑2 EA/day).

Prior Authorization

PA and QL noted

Many specialty products (e.g., ACTEMRA, adalimumab biosimilars, ALYGLO) are annotated with PA and QLs; providers must obtain prior authorization and observe QLs to ensure coverage.

ACTEMRA: PA; QL 4 syringes/28 days. Adalimumab biosimilars: PA; QL 2 syringes/28 days. ALYGLO: PA with age limits.

20 EA per 30 days for oral tablet presentation

inv-112: LICART external patch 24 hour 1.3%

LICART external patch 24 hr 1.3% — daily limit1 EA per 1 day

PA notePA indicated in limitations/notes

TierTier 2

inv-113: FLECTOR EXTERNAL PATCH 1.3%

FLECTOR external patch 1.3% — quantity60 (per documented period as noted in formulary QL)

Limit periodQL stated as Max of 60 patches per 30 days; annual cap of 90 days per year

PA notePA required per limitations/notes

inv-114: BELBUCA BUCCAL FILM

BELBUCA buccal film — example QL2 (EA per 1 day) noted as QL in formulary

PA notePA required per limitations/notes

StrengthsMultiple microgram strengths listed (e.g., 75 mcg–900 mcg)

inv-115: fentanyl transdermal patch

Fentanyl transdermal patch — example QL10 (EA per 30 days)

PA notePA required as indicated in limitations/notes

Multiple strengthsVarious mcg/hr strengths listed in formulary

inv-116: hydrocodone bitartrate ER capsules

Hydrocodone bitartrate ER capsules — example QL2 EA per 1 day

PA notePA required per limitations/notes

Formulation12‑hour ER capsules listed with per‑day QL

inv-117: lidocaine external ointment

Lidocaine external ointment — example QL50 (GM per 30 days)

Presentation5% ointment formulation noted

TierTier 1 as listed

inv-118: DIFICID (fidaxomicin) oral suspension

DIFICID (fidaxomicin) oral suspension — QL136 mL per fill

PA notePA indicated in limitations/notes for DIFICID

FormulationReconstituted 40 mg/mL suspension listed

inv-119: linezolid oral suspension/tablet

Linezolid oral suspension — QL60 mL per day (suspension)

Linezolid tablets — QL2 EA per day (tablet)

Formulation noteBoth suspension and tablet limits are specified separately

inv-120: vancomycin HCl oral solution

Vancomycin HCl oral solution — QL1 bottle per 10 days

FormulationOral solution (bottle) limit specified in formulary

PA notePA may apply for certain presentations as noted elsewhere

inv-121: XIFAXAN oral tablet 200 mg / 550 mg

XIFAXAN 200 mg tablet — QL9 EA per 30 days

XIFAXAN 550 mg tablet — QL2 EA per 1 day

PA notePA indicated in limitations/notes for some presentations

inv-122: ORLYNVAH oral tablet

ORLYNVAH oral tablet — QL10 tabs per 30 days

PA notePA indicated in limitations/notes

TierTier 2 as listed

inv-123: SIVEXTRO oral tablet

SIVEXTRO oral tablet — annual QL6 EA per 365 days

PA notePA indicated in limitations/notes

TierTier 2 as listed

inv-124: NAYZILAM nasal solution

NAYZILAM nasal solution — per‑fill limit1 EA per fill; Max 1 box (2 sprays) per fill

PA notePA required as listed in limitations/notes

TierTier 2

inv-125: VALTOCO (all listed strengths)

VALTOCO (all strengths) — per‑fill limit1 box per fill

PA notePA required as listed in limitations/notes

PackagingBoxes (therapy packs) noted across strengths

inv-126: EMSAM

EMSAM transdermal patch — daily QL1 EA per 1 day

PA notePA required per limitations/notes

24‑hour patch strengthsMultiple strengths (6 mg/24 hr, 9 mg/24 hr, 12 mg/24 hr) listed

inv-127: EXXUA

EXXUA oral tablet ER — daily QL1 EA per 1 day

PA notePA required per limitations/notes

Titration packTitration pack presentations listed with same QL

inv-128: FETZIMA

FETZIMA oral capsule — daily QL1 EA per 1 day

PA notePA required per limitations/notes

Titration packTitration therapy packs listed with same QL

inv-129: VARUBI (180 mg dose pack)

VARUBI 180 mg dose pack — per‑fill limit2 tablets per fill

VARUBI — 30‑day maxMaximum 6 tablets per 30 days

PA notePA indicated in limitations/notes

inv-130: aprepitant

Aprepitant — monthly QL6 EA per 30 days

FormulationsIncludes single‑agent and therapy packs with same 30‑day QL

Therapeutic classAntiemetic agents (aprepitant family)

inv-131: AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 225 MG/1.5ML

AJOVY auto‑injector — injection limitMax. 1 injection (per 30 days)

PA notePA required per limitations/notes

Presentation225 mg/1.5 mL auto‑injector and prefilled syringe presentations listed

inv-132: EMGALITY AUTO-INJECTOR 120 MG/ML

EMGALITY auto‑injector — monthly QL1 mL per 30 days (2 injections permitted first month)

EMGALITY prefilled syringe — monthly QLMax. 1 injection per 30 days (100 mg/mL prefilled syringe)

PA notePA required per limitations/notes

inv-133: EMGALITY PREFILLED SYRINGE 100 MG/ML

EMGALITY prefilled syringe 100 mg/mL — QLMax. 1 injection per 30 days

PA notePA required per limitations/notes

Alternate presentation100 mg/mL and 120 mg/mL syringe/auto‑injector formats listed

inv-134: NURTEC ORAL TABLET DISPERSIBLE 75 MG

NURTEC ODT 75 mg — monthly QL8 EA per 30 days

PA notePA required per limitations/notes for some migraine agents

Therapeutic classAntimigraine agents (formulary examples)

inv-135: COARTEM oral tablet

COARTEM oral tablet — QL24 EA per 30 days

Formulation20/120 mg presentation example listed

Therapeutic classAntiparasitic (malaria) agents

inv-136: ivermectin oral tablet

Ivermectin oral tablet — QL20 EA per 90 days

Formulary noteIncluded in Extended Family Planning formulary for some presentations

Therapeutic classAntiparasitics

inv-137: NOURIANZ oral tablet

NOURIANZ oral tablet — daily QL1 EA per 1 day

PA notePA indicated in limitations/notes

TierTier 2 as listed

inv-138: tolcapone oral tablet

Tolcapone oral tablet — QL6 EA per day

PA notePA indicated in limitations/notes; may be filled up to 90‑day supply where noted

Therapeutic classParkinson's disease agents

inv-139: quetiapine fumarate oral tablet

Quetiapine fumarate oral tablet — daily QL3 EA per day

FormulationsIR and ER presentations listed; ER noted PA in some entries

NotesQL applies to specific tablet strengths as listed

inv-140: quetiapine fumarate oral tablet

Quetiapine fumarate oral tablet (duplicate entry) — QL3 EA per day

ReasonMultiple entries list same QL for different strengths/presentations

Formulation noteSee IR/ER distinctions in formulary

inv-141: SECUADO transdermal patch

SECUADO transdermal patch — daily QL1 (EA per day)

PA notePA required as listed in limitations/notes

Presentation24‑hour transdermal patch strengths listed

inv-142: PAXLOVID therapy pack

PAXLOVID therapy pack — per‑fill QL20 (EA per fill) — example for 150/100 therapy pack

Alternative pack sizesOther PAXLOVID pack sizes have different QLs (e.g., 11 EA per fill, 30 EA per fill)

Therapeutic useAntiviral therapy — QL varies by pack

inv-143: ARANESP prefilled syringe

ARANESP prefilled syringe — QL (mL)4 mL per 30 days

Covered when self‑administeredCovered under the Prescription Drug Benefit when self-administered

Multiple strengths notedExamples include 10 mcg/0.4 mL, 100 mcg/0.5 mL (QL expressed as total mL)

inv-144: EPOGEN injection solution

EPOGEN injection solution — QL (mL)10 mL per 14 days

Covered when self‑administeredCovered under the Prescription Drug Benefit when self-administered

Multiple unit strengthsFormulary lists 10000 U/mL and other concentrations; QL expressed in mL

inv-145: GRANIX prefilled syringe

GRANIX prefilled syringe — QL8 mL per 14 days (for 480 mcg/0.8 mL prefilled syringe example)

PA notePA indicated and covered under Prescription Drug Benefit when self‑administered

Alternate presentationsOther GRANIX presentations list differing mL QLs (e.g., 5 mL per 14 days)

inv-146: NEULASTA ONPRO prefilled syringe

NEULASTA ONPRO prefilled syringe — QL0.6 mL per 14 days

PA and benefit notePA indicated; Covered under the Prescription Drug Benefit when self‑administered

Presentation6 mg/0.6 mL presentation referenced

inv-147: NEUPOGEN injection formulations

NEUPOGEN injection formulations — QL10 mL per 14 days (example for injection presentations)

PA and benefit notePA indicated; Covered under the Prescription Drug Benefit when self‑administered for some presentations

Prefilled syringe QLPrefilled syringe presentations also list 10 mL per 14 days in some entries

inv-148: NYPOZI / NYPOZI prefilled syringes

NYPOZI prefilled syringes — QL examples10 syringes (5 mL) per 14 days or 10 syringes (8 mL) per 14 days depending on presentation

PA notePA indicated in limitations/notes

Covered when self‑administeredSome presentations noted as covered under Prescription Drug Benefit when self‑administered

inv-149: STIMUFEND prefilled syringe

STIMUFEND prefilled syringe — QL1 syringe per 14 days

PA notePA indicated in limitations/notes

Presentation6 mg/0.6 mL prefilled syringe example

inv-150: TAVALISSE ORAL TABLET

TAVALISSE oral tablet — daily QL2 EA per 1 day

PA notePA indicated in limitations/notes

Strengths100 mg and 150 mg tablet presentations listed

inv-151: Various oral cardiovascular medications

Oral cardiovascular medications — supply noteMany oral meds can be filled up to a 90‑day supply where noted

PA noteSome cardiovascular agents require PA per formulary entries

ExamplesAmlodipine‑olmesartan noted ST; other agents list 90‑day fill allowance

inv-152: REPATHA

REPATHA — QL (mL)2 mL per 28 days

PA notePA indicated in limitations/notes

Presentation140 mg/mL prefilled syringe/auto‑injector presentations listed

inv-153: dextroamphetamine sulfate oral solution

Dextroamphetamine sulfate oral solution — QL40 (mL per day) as listed

PA/age notePA applies to members 25 and older for many stimulant products

FormulationOral solution presentations specified separately from tablets

inv-154: amphetamine-dextroamphetamine oral tablet

Amphetamine‑dextroamphetamine oral tablet — QL3 EA per 1 day (example for some tablet presentations)

PA/age notePA applies to members 25 and older for many formulations

Formulation noteMultiple strengths/formulations listed with differing QLs

inv-155: methylphenidate hcl er (cd) oral capsule

Methylphenidate HCl ER (CD) — per‑day QL2 capsules per day (example for ER CD formulations)

PA/age notePA applies to members 25 and older; QL ranges 1–3 units/day depending on formulation

Various presentationsER, LA, OSM, and other ER forms listed with different QLs

inv-156: methylphenidate ER products

Methylphenidate ER products — QL rangeQL ranges from 1–3 units per day depending on formulation

PA/age notePA applies to members 25 and older for many methylphenidate products

ExamplesSome presentations list 1 EA/day, others 2–3 EA/day as specified

inv-157: Quillivant XR oral suspension

Quillivant XR oral suspension — QL30 mL per day

PA notePA indicated in limitations/notes

FormulationReconstituted ER oral suspension 25 mg/5 mL example

inv-158: Dimethyl fumarate starter pack

Dimethyl fumarate starter pack — lifetime QLMax. 1 pack per lifetime

FormulationStarter pack therapy pack noted in formulary

PA notePA may apply depending on product entry

inv-159: Glatiramer acetate 40 mg/mL

Glatiramer acetate 40 mg/mL — QL12 mL per 28 days

Formulation notePrefilled syringe presentations listed with mL limits

Alternative presentation20 mg/mL presentations list 1 mL per day in other entries

inv-160: Kesimpta auto-injector

Kesimpta auto‑injector — monthly QL1 auto‑injector per 30 days

Formulation20 mg/0.4 mL auto‑injector presentation listed

PA/QL noteQL specified in formulary; PA may apply to some specialty injectables

inv-161: Mayzent starter pack

Mayzent starter pack — lifetime QL12 EA per lifetime (starter pack)

PA/QL noteStarter pack has lifetime QL; other presentations list daily QLs

TierTier 2 as listed

inv-162: Zeposia starter pack

Zeposia starter pack — lifetime QLMax. 1 pack per lifetime

PA notePA indicated in limitations/notes for starter pack

Presentation7‑day starter pack example (4x0.23 mg & 3x0.46 mg)

inv-163: Gabapentin oral capsule

Gabapentin oral capsule — daily QL3 EA per day (some strengths vary)

PA notePA indicated for some gabapentin presentations

FormulationOnce‑daily and other strengths listed with differing QLs

inv-164: Pregabalin oral solution

Pregabalin oral solution — daily QL30 mL per day

PA notePA indicated in limitations/notes

Formulation20 mg/mL oral solution example listed

inv-165: diclofenac sodium external gel 3%

Diclofenac sodium external gel 3% — 30‑day limit200 gm per 30 days

Annual capMaximum of 90 days per year

Formulation noteExternal gel presentation QL as listed in formulary

inv-166: DUPIXENT 200 mg/1.14 mL auto-injector

DUPIXENT 200 mg/1.14 mL auto‑injector — QL2.28 mL per 28 days

DUPIXENT 300 mg/2 mL auto‑injector — QL4 mL per 28 days

Prefilled syringe QL2 syringes per 28 days noted for prefilled syringe presentations

inv-167: DUPIXENT 300 mg/2 mL auto-injector

DUPIXENT 300 mg/2 mL auto‑injector — QL4 mL per 28 days

Prefilled syringe QL2 syringes per 28 days for prefilled syringes

PA notePA indicated in limitations/notes

inv-168: imiquimod external cream 3.75%

Imiquimod external cream 3.75% — QL28 EA per 14 days

PA and formulary notePA indicated; included in Extended Family Planning formulary

Alternate pump presentationPump lists 7.5 GM per 14 days QL in separate entry

inv-169: MOUNJARO pens

MOUNJARO pens — QL4 pens per 28 days

PA notePA indicated in limitations/notes for many GLP‑1 agents

PresentationPen presentations listed with per‑28‑day QL

inv-170: DEXCOM G6 sensor

DEXCOM G6 sensor — QL3 EA per 30 days

Device notesSensors and receivers have separate QLs (e.g., receivers 1 per 365 days)

PA notePA indicated for some CGM devices per formulary

inv-171: GVOKE HYPOPEN and related glucagon products

GVOKE HYPOPEN and related glucagon — QL examplesExamples include 0.2 mL, 0.4 mL per fill; 2 EA per fill for kit presentations

Presentation varietyMultiple strengths and pack sizes listed with differing QLs

Therapeutic useEmergency glucagon kits and auto‑injectors

inv-172: omeprazole-sodium bicarbonate oral capsule/packet

Omeprazole‑sodium bicarbonate oral capsule/packet — daily QL1 EA per 1 day

PA notePA indicated in limitations/notes

FormulationApplies to capsule and packet presentations as listed

inv-173: selected proton pump inhibitors

Selected PPIs — supply noteMedication can be filled for up to a 90‑day supply where noted

ExamplesEsomeprazole, lansoprazole, pantoprazole, rabeprazole entries note 90‑day fill allowance

PA notePA applies to some PPI presentations per formulary

inv-174: IQIRVO ORAL TABLET 80 MG

IQIRVO 80 mg — daily QL1 tab per day

PA notePA indicated in limitations/notes

TierTier 2 as listed

inv-175: LINZESS ORAL CAPSULE

LINZESS oral capsule — daily QL1 EA per 1 day

PA notePA indicated in limitations/notes

Strengths145 mcg, 290 mcg, 72 mcg presentations listed

inv-176: VOWST ORAL CAPSULE

VOWST oral capsule — per‑fill QL12 EA per 1 fill

PA notePA indicated in limitations/notes

Therapeutic classMicrobiota restoration therapy

inv-177: STRENSIQ subcutaneous solution

STRENSIQ subcutaneous solution — QL rangeExamples: 10.8 mL; 16.8 mL; 19.2 mL; 24 mL per 28 days depending on strength

PA notePA indicated per limitations/notes

Strength‑dependent dosingMultiple mL per 28 days limits tied to strength

inv-178: CRENESSITY

CRENESSITY — daily QL examples2 caps per day or 2 mL per day depending on presentation

PA notePA and QL indicated in limitations/notes

FormulationCapsule and solution presentations have separate daily QLs

inv-179: Unspecified general QL example

General QL example — mL per day2 mL per day (example entry)

ContextUsed as an illustrative unspecified general QL in formulary entries

ApplicabilityMay reflect liquid formulation daily limits

inv-180: octreotide acetate injection solution

Octreotide acetate injection solution — daily QL example1 mL per 1 day

RECORLEV — daily QL8 EA per 1 day

PA notePA indicated for many pituitary/hormonal agents

inv-181: RECORLEV ORAL TABLET 150 MG

RECORLEV 150 mg — daily QL8 EA per 1 day

PA notePA indicated in limitations/notes

Therapeutic classCushing's disease agents

inv-182: ACTEMRA (prefilled syringe and auto-injector)

ACTEMRA (prefilled syringe/auto‑injector) — QL4 (per 28 days as noted)

PA notePA indicated in limitations/notes

PresentationPrefilled syringe and auto‑injector formats listed

inv-183: ADALIMUMAB products (various presentations)

Adalimumab products — QL2 (auto‑injectors or syringes per 28 days)

PA notePA indicated in limitations/notes for biosimilars/products

PresentationMultiple adalimumab presentations/biosimilars listed with same QL

inv-184: ORIAHNN therapy pack

ORIAHNN therapy pack — QL2 (per pack/therapy as listed)

PA notePA indicated in limitations/notes

Therapy packPack QL specified in formulary entries

ST — definitionStep Therapy: requires trial of first‑line PDL drugs before covering non‑preferred agents (flagged as 'ST')