Qualified Health Plan Prescription Drug Formulary / Coverage Criteria
Customize your policy alerts
Sign up for all Health Alliance Plan (HAP) policy alerts
Know when Health Alliance Plan (HAP) releases new policies or updates existing guidance.
Monitor payer policy activity
Defines the prescription drugs covered for Qualified Health Plans (QHPs), how the formulary is organized, tiers, and coverage controls (prior authorization, quantity limits, step therapy, specialty pharmacy). Affects members and prescribing providers using HAP QHPs.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Placement
General Coverage Criteria
Covered when following general conditions are met
Formulary applies to outpatient prescription drugs only; medical‑administered drugs are covered under the medical benefit (Tier 7).
Specific drugs list PA/QL/ST/SP flags in formulary entries.
Product-specific coverage controls
Coverage and utilization controls as listed per product — stance varies by drug and note
This segment provides per-product tiering and utilization notes; no single enrollment or clinical criteria are given in this segment.
Formulary coverage with utilization controls
Coverage entries are subject to utilization controls; drugs listed are covered per formulary tier when associated requirements are met.
Specific clinical criteria not provided in this extract; prior authorization needed where PA indicated
Formulary controls (PA / SP / QL)
Coverage and utilization controls in this excerpt apply as follows when ALL noted controls are met
This is an administrative formulary listing; individual medical necessity criteria are not included in this section
The formulary applies to outpatient prescription drugs only; medications administered in a provider office or inpatient setting are medical-benefit drugs and generally not governed by this outpatient formulary. General exclusions include: drug products used for cosmetic purposes, over-the-counter medications (unless specifically listed), experimental drugs or investigational use, and replacement of lost or stolen medication. Check the member's Summary of Benefits and Coverage for plan-specific limits and cost-sharing.
Items explicitly marked Non-Formulary on the drug list are treated as non-formulary for the pharmacy benefit. Members or prescribers may request a formulary exception; if approved the drug will be covered at the appropriate non‑formulary copayment and non‑formulary specialty approvals are limited to up to a 30‑day supply and may be required to be dispensed through the designated specialty pharmacy (Pharmacy Advantage).
Many specific products are listed as Non-Formulary across therapeutic classes. Examples in this extract include inhaled/nebulized agents (e.g., tobramycin inhalation solution 300 mg/4 mL), certain IV antibiotics (e.g., ZEVTERA IV), and multiple antifungal and other agents (e.g., NOXAFIL oral suspension). Non‑formulary designation often appears together with notes such as SP (specialty channel) and QL (quantity limits).
For antifungal agents the listing shows both formulary and non‑formulary statuses with utilization controls. For example, CRESEMBA entries include PA and specific QL values for IV and oral presentations, while NOXAFIL oral suspension 200 mg/5 mL is designated Non‑Formulary and includes ALT/PA/QL notes in the formulary excerpt.
Non‑formulary listing implies restricted coverage: claims for non‑formulary drugs may be denied or require higher member cost sharing unless an exception is approved. Non‑formulary entries commonly trigger administrative actions such as prior authorization (PA), specialty sourcing (SP), or documentation of alternative therapies, and some approvals are limited to specialty dispensing through Pharmacy Advantage.
Additional non‑formulary examples in respiratory and specialty categories include inhalers and nebulizer products (e.g., DUAKLIR PRESSAIR, STRIVERDI RESPIMAT, SYMBICORT, VENTOLIN HFA) and many high‑cost specialty injectables and blood derivatives that are shown as Non‑Formulary in the excerpt.
A Non‑Formulary listing may effectively indicate exclusion from preferred tiers and that coverage will require either a formulary exception or adherence to the payer's alternative‑therapy routing. Where approved, Non‑Formulary specialty drugs may still be covered but typically at the highest specialty copayment and with specialty pharmacy dispensing and quantity limits applied.
Numerous items across classes are explicitly labeled Non‑Formulary in the formulary excerpt (for example: NUZYRA, SEYSARA, certain doxycycline or minocycline formulations, and several oncology products). This designation signals they are not on preferred tiers and are subject to the plan's non‑formulary processes and any applicable PA/QL/SP requirements.
The extract lists specific non‑formulary drug examples used in routine care, such as prenatal preparations (e.g., PRENATE ELITE) and cardiovascular agents (e.g., BRILINTA) that are annotated Non‑Formulary and include notes for covered alternatives and quantity limits.
Non‑formulary inhalers and related respiratory products shown in the excerpt (for example DUAKLIR PRESSAIR, PERFOROMIST, SYMBICORT, VENTOLIN HFA) include ALT (covered alternatives) and QL annotations. Providers should follow the listed alternatives and document the rationale when requesting exceptions.
Many specialty biologics and blood‑derivative products are identified as Non‑Formulary or are flagged with PA and SP requirements (examples: ADVATE, ALPROLIX, AFSTYLA, NOVOEIGHT). These entries routinely require prior authorization and specialty pharmacy routing and often include strict quantity limits (for example, QL = 1 unit per day for many factor products).
Practical impact for providers: obtain prior authorization when a product is labeled PA, route specialty prescriptions to Pharmacy Advantage when labeled SP (contact and process noted in the formulary), and ensure documented justification when requesting a non‑formulary exception. Forms and instructions for PA or formulary exception requests are available on the payer website.
Additional non‑formulary examples include bradykinin receptor antagonists and TTR amyloidosis agents (e.g., FIRAZYR, icatibant, VYNDAQEL, VYNDAMAX) which are shown as Non‑Formulary and also carry PA, SP and QL notes in the formulary excerpt.
Exceptions and exclusions: Non‑formulary drugs are not guaranteed coverage; a prescriber or member may request a formulary exception and HAP clinical staff will evaluate the request. Per the formulary, replacement for lost or stolen medication and investigational/experimental uses are not covered even if the product is otherwise listed.
Some non‑formulary entries include additional restrictions beyond the Non‑Formulary flag — for example, specialty channel sourcing (SP) or specific QL values — but the extract does not consistently include an explicit 'No Medical Necessity' (NMN) statement in every non‑formulary segment.
The provided extract does not contain explicit blanket statements using the phrase 'not medically necessary' for listed drugs; instead, coverage limitations are expressed via formulary flags (PA, QL, SP, Non‑Formulary) and the documented exception process.
Across the excerpt there are no single‑line NMN declarations; coverage decisions for non‑formulary items are governed by the exception and prior‑authorization processes documented elsewhere in the formulary and by clinical review.
Formulary Codes, Legends and Quantity Examples
| PA | Prior Authorization |
| QL | Quantity Limits |
| ST | Step Therapy |
| SP | Must be obtained at Pharmacy Advantage (specialty pharmacy) |
| HCR | Health Care Reform rules apply |
| PF | Partial Fill Program |
| TD | New HAP members: one 30-day fill in first 90 days |
| AG | Age Restriction |
| penicillamine oral tablet 250 mg | listed with DRUG TIER = 2; NOTES = PA; SP; QL (4 tablets per 1 day) |
| ELMIRON ORAL CAPSULE 100 MG | DRUG TIER = 4; NOTES = PA; QL (3 capsules per 1 day) |
| leucovorin calcium oral tablet 5-25 mg | DRUG TIER = 2 |
| mesna oral tablet 400 mg | DRUG TIER = 2; NOTES = QL (6 Tablets per Day) |
| MESNEX ORAL TABLET 400 MG | DRUG TIER = Non-Formulary; NOTES = ALT (Covered Alternatives: Mesna 400mg tablet) |
| VISTOGARD ORAL GRANULES 10 GRAM | DRUG TIER = Non-Formulary; NOTES = SP |
| clemastine oral tablet 2.68 mg | DRUG TIER = 2; alternate non-formulary branded CLEMSZA listed with ALT and QL |
| cyproheptadine oral syrup 2 mg/5 ml | DRUG TIER = 2 |
| hydroxyzine hcl oral tablet 25 mg | DRUG TIER = 2; NOTES = QL (4 tablets per 1 day) |
| bepotastine besilate ophthalmic drops 1.5 % | DRUG TIER = 2; QL (0.2 ml per 1 day) |
| azelastine nasal spray | DRUG TIER = Non-Formulary; NOTES = ALT; QL (1 gram per 1 day) |
| cetirizine oral tablet 5-10 mg | DRUG TIER = 2 |
| cefadroxil oral capsule 500 mg | DRUG TIER = 2 |
| cefazolin in dextrose IV piggyback 3 gram/150 ml | DRUG TIER = 7 |
| cephalexin oral capsule 250-750 mg | DRUG TIER = 2 |
| cefdinir oral capsule 300 mg | DRUG TIER = 2 |
| ceftriaxone injection recon soln 2 gram | DRUG TIER = 7 |
| tobramycin inhalation solution 300 mg/4 ml | DRUG TIER = Non-Formulary; NOTES = SP; QL (280 ampules per 30 days) |
| tobramycin with nebulizer inhalation solution 300 mg/5 ml | NOTES = PA; SP; QL (280 ampules per 30 days) |
| TOBI inhalation solution 300 mg/5 ml | DRUG TIER = Non-Formulary; NOTES = SP |
| 0.15% | ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % (product strength listed) |
| 5% | ZOVIRAX TOPICAL CREAM 5 % |
| 200 mg/5 ml | azithromycin oral suspension for reconstitution 200 mg/5 ml |
| 250 mg, 500 mg, 600 mg | azithromycin oral tablet strengths |
| 200 mg | fidaxomicin oral tablet 200 mg |
| 600 mg | linezolid tablet 600 mg |
| 450 mg | BAXDELA ORAL TABLET 450 MG |
| 200 mg, 550 mg | XIFAXAN ORAL TABLET strengths |
| 3 gram | fosfomycin tromethamine oral packet 3 gram |
| 100 mg, 50 mg | doxycycline hyclate oral capsule strengths |
| 200 MG | ODOMZO ORAL CAPSULE 200 MG |
| 100 MG, 150 MG, 50 MG | OGSIVEO ORAL TABLET |
| 25 MG/ML | OJEMDA ORAL SUSPENSION FOR RECONSTITUTION 25 MG/ML |
| 1 MG - 240 MG (various levels) | PALFORZIA oral capsule sprinkle (multiple levels) |
| No codes listed |
| 5 MG (74 TABS) | ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 MG (74 TABS) |
| 2.5 MG, 5 MG | ELIQUIS ORAL TABLET 2.5 MG, 5 MG |
| 0.5 MG | ELIQUIS ORAL TABLET FOR SUSPENSION 0.5 MG |
| 400-12 MCG/ACTUATION | DUAKLIR PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400-12 MCG/ACTUATION |
| 100-5 MCG/ACTUATION | DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION |
| 20 MCG/2 ML | PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML |
| 2.5-2.5 MCG/ACTUATION | STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION |
| 1,000 MG | ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG |
| 68.8 MG | RYPLAZIM INTRAVENOUS RECON SOLN 68.8 MG |
| ADVATE | ADVATE INTRAVENOUS RECON SOLN (multiple unit sizes) - NOTES = PA; SP; QL (1 unit per 1 day) |
| ADYNOVATE | ADYNOVATE INTRAVENOUS SOLUTION (multiple unit sizes) - DRUG TIER = Non-Formulary; NOTES = QL; SP |
| AFSTYLA | AFSTYLA INTRAVENOUS RECON SOLN (multiple unit ranges) - NOTES = PA; SP; QL (1 unit per 1 day) |
| ALHEMO PEN | ALHEMO PEN SUBCUTANEOUS PEN INJECTOR 60 MG/1.5 ML - DRUG TIER = Non-Formulary; NOTES = SP |
| ALPHANATE | ALPHANATE INTRAVENOUS RECON SOLN (VWF-containing) - NOTES = PA; SP; QL (1 unit per 1 day) |
| AMICAR (aminocaproic acid) | AMICAR ORAL SOLUTION 250 MG/ML - DRUG TIER = Non-Formulary; NOTES = QL (237 units per 60 days) |
| BENEFIX | BENEFIX INTRAVENOUS RECON SOLN (multiple sizes) - NOTES = PA; SP; QL (1 unit per 1 day) |
| COAGADEX | COAGADEX INTRAVENOUS RECON SOLN (250, 500 unit ranges) - NOTES = PA; SP |
| ELOCTATE | ELOCTATE INTRAVENOUS RECON SOLN (multiple sizes) - NOTES = PA; SP; QL (1 unit per 1 day) |
| HEMLIBRA | HEMLIBRA SUBCUTANEOUS SOLUTION (multiple concentrations) - NOTES = PA; SP; QL (examples: 0.01 mL per day) |
| metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg | DRUG TIER = 2 |
| nadolol oral tablet 20 mg, 40 mg, 80 mg | DRUG TIER = 2 |
| nebivolol oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg | DRUG TIER = 2; NOTES = QL (1 tablet per 1 day) |
| pindolol oral tablet 10 mg, 5 mg | DRUG TIER = 2 |
| FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML | DRUG TIER = Non-Formulary; NOTES = SP; QL (0.01 ml per 1 day) |
| icatibant subcutaneous syringe 30 mg/3 ml | DRUG TIER = 5; NOTES = PA; SP; QL (0.01 ML per 1 day) |
| VYNDAQEL ORAL CAPSULE 20 MG | DRUG TIER = Non-Formulary; NOTES = PA; SP; QL (4 capsules per 1 day) |
| VYNDAMAX ORAL CAPSULE 61 MG | DRUG TIER = Non-Formulary; NOTES = PA; SP; QL (1 capsule per 1 day) |
| ranolazine oral tablet extended release 12 hr 1000 mg, 500 mg | DRUG TIER = Non-Formulary; NOTES = QL (2 tablets per 1 day) |
| CORLANOR ORAL TABLET 5 MG, 7.5 MG | DRUG TIER = Non-Formulary; NOTES = ALT (Covered Alternatives: IVABRADINE TABLETS); QL (2 tablets per 1 day) |
What Providers Must Do / Authorization & Fulfillment Rules
Prior authorization (PA) applies
Certain drugs listed on the formulary are subject to Prior Authorization (PA); without PA the drug may not be covered and the prescriber must submit the PA request to HAP for clinical review.
- PA is an administrative requirement that must be satisfied before coverage is approved.
PA required for flagged products (examples)
Some specific products are flagged with 'PA' in the formulary notes and require the prescriber to obtain prior authorization before dispensing (examples shown in formulary entries).
- Example: penicillamine oral tablet 250 mg is listed with NOTES = PA; SP; QL (4 tablets per 1 day).
- Example: ELMIRON oral capsule 100 mg is listed with NOTES = PA; QL (3 capsules per 1 day).
PA required for selected products (tobramycin, CRESEMBA)
Selected products include a PA note in their entry and require prior authorization before coverage; examples include tobramycin formulations and CRESEMBA.
- Tobramycin with nebulizer: NOTES = PA; SP; QL (280 ampules per 30 days).
- CRESEMBA oral capsule 186 mg: NOTES = PA; QL (70 capsules per 1 fill).
PA required for specified products (additional examples)
Multiple other formulary lines are annotated 'PA' indicating prior authorization is required for coverage of those products.
- CRESEMBA IV recon soln 372 mg: QL (0.01 Vial per 90 of Treatment per 180 Days) and SP noted.
- PAXLOVID oral tablets: NOTES = PA; QL (5 days of treatment per 180 days).
PA required for HIV/HCV and other agents
HIV/HCV agents and other antiviral/antiretroviral entries include PA or SP annotations — providers must obtain PA when the NOTES field indicates.
- DESCOVY entries note PA and covered-alternative (ALT) information.
- Several HCV agents (e.g., HARVONI, ledipasvir-sofosbuvir) are marked SP and QL and may require PA.
PA required for oncology and specialty drugs
Many oncology and other specialty drugs are annotated with 'PA' and will require prior authorization prior to coverage; prescribers must request PA for these agents.
- Examples: BALVERSA (NOTES = PA; SP; QL), CABOMETYX (NOTES = PA; SP; QL).
PA annotation requires provider to request authorization
Formulary entries routinely include a 'PA' annotation; when present the provider must submit a prior authorization request to HAP before dispensing.
- The formulary legend defines PA = Prior Authorization and many product lines include this note.
PA required for many specialty drugs
Numerous specialty and high-cost agents are annotated with PA and often SP; providers must obtain prior authorization and follow specialty dispensing processes for these drugs.
- Examples include ODOMZO (NOTES = PA; SP; QL) and other oncology/specialty listings.
PA for immunoglobulins (IV/SC IG products)
Many intravenous and subcutaneous immunoglobulin products are noted with 'PA' (and often SP and QL); prescribers must obtain PA for coverage and follow specialty channel requirements.
- Examples: CUVITRU NOTES = PA; QL (0.01 ML per 1 day); GAMMAGARD listings include NOTES = PA; SP; QL.
Prior authorization required (TRELEGY ELLIPTA example)
Specific products such as TRELEGY ELLIPTA are annotated 'PA' in the formulary and require prior authorization before coverage will be approved.
- TRELEGY ELLIPTA NOTES = PA; TD; QL (1 DEVICE per 30 days).
PA required for assorted products (examples)
Additional assorted products across therapeutic areas are marked with PA in the NOTES field; prescribers must request prior authorization where PA is shown.
- Examples include TAGRISSO (NOTES = PA; SP; QL) and PALFORZIA entries marked SP/PA as noted in formulary.
PA required for select specialty and blood products
Select specialty and blood-derivative products are annotated 'PA' (and often 'SP'); prescribers must obtain prior authorization to secure coverage and correct specialty sourcing.
- Examples: ARALAST NP, PROLASTIN-C, ADVATE entries include NOTES = PA; SP; QL.
PA required for IV hemostatics and specialty agents
Many intravenous hemostatic and other specialty agents include 'PA' in their formulary notes; the prescriber must obtain prior authorization before the plan will cover these agents.
- ADVATE NOTES = PA; SP; QL (1 unit per 1 day); ALTUVIIIO NOTES = PA; SP; QL (0.01 Vial per 1 day).
PA requirement (CABLIVI, EVKEEZA examples)
Certain named specialty agents (e.g., CABLIVI, EVKEEZA) require prior authorization and may also require specialty procurement through Pharmacy Advantage.
- CABLIVI INJECTION KIT NOTES = PA; SP; QL (1 vial per 1 day).
- EVKEEZA INTRAVENOUS SOLUTION NOTES = PA; SP.
PA required for selected specialty drugs (icatibant, VYNDAQEL, CAMZYOS, ATTRUBY)
Selected specialty drugs such as icatibant, VYNDAQEL, CAMZYOS and ATTRUBY are listed with 'PA' — prescribers must secure prior authorization for these therapies.
- VYNDAQEL NOTES = PA; SP; QL (4 capsules per 1 day).
- icatibant NOTES = PA; SP; QL (0.01 ML per 1 day).
Step Therapy (ST) applies — provider implication
Step Therapy (ST) requires that a specified alternative drug(s) be tried first before the requested drug will be covered; providers must follow ST when it is indicated in the formulary notes.
- ST = Step Therapy Required — trial of listed alternative(s) needed prior to coverage.
Step therapy legend — ST defined
The formulary legend defines ST as 'Step Therapy Required' and indicates ST flags on entries where step therapy applies.
- Refer to the formulary legend for the ST definition and presence of ST flags.
Step therapy may be required — provider must follow ST
When an individual drug entry is marked 'ST' the prescriber must follow the step therapy requirement (attempt required alternatives) before the formulary agent will be covered.
- Providers should document trials of required alternatives when submitting PA or exception requests where ST applies.
Step therapy flag present in legend and entries
The formulary includes an ST flag in its legend and on product entries where step therapy applies; providers must check entries and comply with ST edits.
- ST appears as a program control in the formulary legend and on some product lines.
ST reference — legend indicates ST applies
The formulary's legend and header note that ST = Step Therapy Required; when present on a product the prior trial requirement applies though specific step sequences are not shown in this excerpt.
- Check the full formulary or PA criteria for specific step requirements per product.
Step therapy general note — ST indicated
Some agents may be marked 'ST' in the header legend; individual drug lines may require step edits — providers should follow step therapy instructions when noted.
- ST is a plan control flagged on the formulary; specifics are found in product-specific rules.
ST noted in legend — may apply to listed drugs
Drugs that show 'ST' in the policy legend may require a prior trial of alternatives; providers must adhere to those requirements where indicated on drug lines.
- Example: some amlodipine-atorvastatin combinations are marked ST in the NOTES.
Step therapy (legend) — ST defined and applies
ST is defined in the formulary legend as 'Step Therapy Required' and may apply to some listed products; providers should confirm and follow any ST edits before prescribing.
- If ST is present, document prior therapy trials when requesting PA or exceptions.
Step therapy flag — ST may apply to listed products
The ST flag is present in the plan controls and will apply to drugs annotated 'ST' in the formulary; prescribers must comply with step therapy requirements where present.
- Some COPD/inhaled products include TD and ST annotations with listed alternatives that should be tried first.
Step Therapy / Transition — some items include ST/TD and alternatives
Products annotated 'ST' require following step therapy prior to coverage; examples in the formulary include WELCHOL and certain amlodipine-atorvastatin combinations.
- WELCHOL NOTES = QL (1 unit per 1 day) and may be marked ST where indicated.
Step therapy defined in legend
The formulary explicitly defines ST = Step Therapy Required in its legend; where ST is shown the prescriber must try required alternatives first.
- ST is a plan control; specific step sequences are shown in product-specific rules (not in this excerpt).
ST applicable where noted in legend
Where the formulary legend includes ST, that flag may be applied to products; providers must check individual entries and comply with step therapy requirements when present.
- ST indicates prior trial of specified therapy is required.
Step therapy legend — ST listed
The formulary legend lists ST as a control; products marked ST require prior trial of alternatives and providers must follow the policy edits for coverage.
- No specific step paths are provided in this extract — check product-level criteria.
Step therapy flag present in formulary legend
ST flags appear in the formulary legend and on some products; providers should verify ST status on the product line before prescribing and document prior therapies as required.
- ST = Step Therapy Required; follow documented step edits when present.
Step therapy requirements — examples where ST applies
Step therapy applies to multiple products (examples include WELCHOL and some amlodipine-atorvastatin combinations); when ST is present the provider must attempt required alternatives first.
- Amlodipine-atorvastatin entries include NOTES = TD; ST (Step Therapy Required); QL (1 tablet per 1 day).
How to request prior authorization or exception
To request a prior authorization or formulary exception, the prescriber must submit the required forms and rationale via the portals/forms available at hap.org/providers.
- The prescriber must explain why formulary requirements should not apply when requesting an exception.
Authorization note definitions (PA/QL/SP)
The formulary legend defines authorization notes: PA = Prior Authorization; QL = Quantity Limits; SP = obtainable only at Pharmacy Advantage (specialty pharmacy).
- Use the legend to interpret PA, QL, SP, ST and other administrative flags on product lines.
Standard PA/SP documentation — document indications
When submitting PA or dispensing SP products, prescribers and pharmacies must document the clinical indication and support required by the PA process and adhere to specialty pharmacy sourcing when indicated.
- Documentation should support medical necessity and any required trials of alternatives.
Quantity limits enforced (example PAXLOVID)
Quantity limits shown on many formulary entries will be enforced at claim adjudication; providers must not exceed noted QL or obtain PA/exception where clinically justified.
- Example: PAXLOVID NOTES = PA; QL (5 days of treatment per 180 days).
Formulary legend and administrative flags — provider implication
The formulary legend lists administrative flags (PA, QL, SP, HCR, ST, PF, TD, AG) which appear next to many drugs; providers must follow payer procedures associated with these flags when prescribing or requesting authorization.
- Ensure claims include required annotations and supporting documentation per the flag definitions.
Specialty pharmacy sourcing — use Pharmacy Advantage for SP items
Products marked 'SP' must be obtained via Pharmacy Advantage (specialty pharmacy) — providers should route prescriptions to Pharmacy Advantage when SP is indicated and include PA documentation as required.
- Pharmacy Advantage contact: (800) 456-2112; SP fills are limited to up to a 30-day supply at a time.
Specialty pharmacy routing — route SP items correctly
Specialty medications flagged 'SP' must be obtained through Pharmacy Advantage; providers must follow specialty routing and include PA documentation to avoid denials or sourcing issues.
- SP indicates specialty fulfillment only; up to 30 supply at a time.
Follow PA & specialty sourcing processes
Providers must follow PA processes for drugs labeled 'PA' and procure specialty products via Pharmacy Advantage when 'SP' is indicated; failure to follow these processes may result in denial.
- Submit PA requests and route SP prescriptions to Pharmacy Advantage with supporting documentation.
Required administrative actions — follow plan procedures
Administrative flags adjacent to drug entries (PA, QL, SP, HCR, ST, PF, TD, AG) are defined in the legend and must be followed; providers should consult these flags when prescribing and include required documentation.
- Claims may be denied or require higher cost-share if flags are not followed.
Required annotations on claims for flagged products
When product notes include PA, QL or SP, providers must ensure claims/requests include the appropriate annotations and support; vaccine and specialty items commonly include these flags.
- Document age restrictions (AG) and HCR requirements for preventive vaccines where indicated.
Document alternatives and site when dispensing
If a product entry shows 'ALT' or 'SP', providers should document the selected alternative and the site/source when dispensing or requesting authorization.
- Document covered alternatives (ALT) when using them in place of non-formulary agents.
Document quantity limits and alternatives
When a product entry indicates QL or ALT, prescriptions should document applicable quantity and covered-alternative considerations to support PA or claim adjudication.
- Example: Duaklir and ProAir entries include QL/ALT notes that should be recorded when prescribing.
Documentation required for PA and QL
Providers must supply documentation supporting medical necessity when requesting PA for products with QL or specialty sourcing notes; missing documentation may result in denial.
- Documentation should reference applicable QL values and clinical rationale for exceeding limits if requested.
Prior authorization and specialty pharmacy documentation required
Many specialty or high-cost agents (e.g., CABLIVI, EVKEEZA) have PA and SP notes; prescribers must submit PA requests and procure these agents through the designated specialty channel to obtain coverage.
- Failure to obtain PA or use Pharmacy Advantage for SP products can result in claim denial.
PA and specialty sourcing — provider must comply
Products marked PA require prior authorization; products marked SP must be obtained via Pharmacy Advantage (800-456-2112) as indicated in the formulary notes — providers must meet both requirements where shown.
- Pharmacy Advantage is the designated specialty distributor for SP-marked items.
PA required — denial risk if not obtained
Drugs requiring prior authorization may not be covered without prior approval; PA requests must be submitted by the prescriber and will be evaluated by HAP clinical specialists.
- If PA is not obtained, the claim may be denied at adjudication.
PA and QL triggers — check product entries
Prior Authorization (PA) and Quantity Limits (QL) are applied to specific listed products; providers should check product entries and obtain PA or adhere to QL to avoid coverage issues.
- Examples: penicillamine NOTES = PA; SP; QL (4 tablets per 1 day); ELMIRON NOTES = PA; QL (3 capsules per 1 day).
PA/SP and high QL items (tobramycin)
Some inhalation products (notably tobramycin formulations) include PA and SP annotations plus high QL limits; failure to meet PA/SP or exceed QL may trigger denial.
- Tobramycin inhalation solution NOTES = SP; QL (280 ampules per 30 days); tobramycin with nebulizer NOTES = PA; SP; QL (280 ampules per 30 days).
Quantity limit and specialty routing enforcement — denial risk
Requests exceeding specified quantity limits or not following required specialty pharmacy routing may be denied or not covered; providers must obtain PA or route through Pharmacy Advantage when required.
- Example: exceeding 280 ampules per 30 days for tobramycin inhalation may lead to denial.
PA required for selected antifungals (CRESEMBA)
Coverage for some antifungals (e.g., CRESEMBA) may be restricted or denied without prior authorization; prescribers must request PA for these agents as noted.
- CRESEMBA oral capsule 186 mg NOTES = PA; QL (70 capsules per 1 fill).
Non-formulary products — restriction and exception process
Non-formulary products listed on the formulary may be subject to coverage restrictions or require exception approval; providers should request exceptions when clinically necessary.
- Non-formulary specialty drugs when approved may be required to be dispensed by Pharmacy Advantage and processed at the highest specialty copayment.
Non-formulary / QL / PA exceedance — denial or higher cost-share risk
Non-formulary items, failure to obtain PA, or exceeding QL can trigger denial or higher member cost-sharing; providers must document medical necessity and request exceptions when appropriate.
- Exception approvals for standard non-formulary medications process at the highest non-specialty copayment; non-formulary specialty drugs process at the highest specialty copayment.
Specialty products not sourced via SP may be denied
Specialty products flagged 'SP' must be obtained via Pharmacy Advantage; claims for specialty drugs not sourced through the designated specialty channel may be denied.
- Pharmacy Advantage contact: (800) 456-2112; SP fills limited to up to 30-day supply at a time.
Submit PA requests — denial risk if lacking PA
Providers must submit PA requests for drugs annotated 'PA' — lack of PA at the time of claim adjudication may result in denial of coverage.
- Many oncology and specialty agents include NOTES = PA; obtain PA before dispensing to avoid denials.
PA required for oncology specialty agents
Oncology specialty drugs in the formulary frequently include PA and SP notes; prescribers must secure PA and follow specialty fill requirements to avoid claim denials.
- Examples: many antineoplastic agents list NOTES = PA; SP; QL — follow PA process before dispensing.
Lack of PA may result in denial
If prior authorization is not obtained for drugs listed with 'PA' coverage may be denied or restricted; providers should confirm PA status prior to dispensing.
- Coverage may be denied or restricted if PA is not obtained for PA-annotated drugs.
PA/QL flags require authorization or are subject to limits
Products flagged with PA and QL will either require prior authorization or will be limited by the specified quantity limits; providers must obtain PA if requesting quantities beyond QL.
- SP flags indicate specialty sourcing via Pharmacy Advantage which may impact fulfillment and require coordination.
PA/QL violations may trigger denial
Products annotated with PA or QL may trigger denial if PA is not obtained or QL is exceeded; prescribers should document clinical justification and submit PA for exceptions.
- Example: dihydroergotamine injection solution is listed with PA and QL; follow PA and QL rules to avoid denial.
PA for blood derivatives and specialty agents — denial risk
Products with PA or SP notes (including many blood derivatives and specialty agents) require prior authorization and specialty distribution; claims lacking required PA or SP routing may be denied.
- Examples: ARALAST NP, GLASSIA, PROLASTIN-C list NOTES = PA; SP; QL.
Coverage denial risk for non-formulary/ALT drugs
Coverage may be denied for non-formulary products or when covered alternatives exist and no exception is approved; providers should request exceptions with clinical rationale when needed.
- Example: BRILINTA is Non-Formulary with ALT: Ticagrelor — consider alternatives or request an exception.
Specialty and PA noncompliance may cause denial
Failure to meet prior authorization or specialty sourcing requirements for specialty products (PA/SP) may result in coverage denial; providers must both request PA and use Pharmacy Advantage when SP is indicated.
- Example: FIRAZYR NOTES = SP; QL (0.01 ml per 1 day) — ensure PA/SP compliance to obtain coverage.
Legend & Definitions
Step Therapy Program
| Policy feature | Description |
|---|---|
| Step therapy (ST) flag on formulary | Indicates that a member must try specified alternative drug(s) first before coverage of the requested drug will be allowed. |
| Applicability | ST applies to individual drug entries where 'ST' is noted in the formulary NOTES or legend. |
| Operational effect | Coverage is conditional on documented trial and failure or intolerance of required alternative(s) prior to approval of the requested agent. |
| Item | Detail |
|---|---|
| ST defined in legend | ST = Step Therapy Required (listed in the formulary legend). |
| Specific step sequences | No product-specific step sequences or ordered step paths are provided in the cited formulary excerpts; the legend only defines ST as a program flag. |
| Context | Implication |
|---|---|
| Legend and NOTES field | Step therapy may be required where 'ST' is indicated in the NOTES field for individual drug entries; providers must follow ST when specified. |
| Provider action | Prescribers should document prior trials of alternatives when requesting coverage for drugs flagged ST. |
| Observation | Notes |
|---|---|
| ST flag present | Formulary excerpts include 'ST = Step Therapy Required' as a program flag in the header/legend; specific flag presence is noted but per-drug detail not shown in these chunks. |
| Supply channel info often adjacent | ST is shown alongside other administrative flags (PA, QL, SP) in the formulary legend entries. |
| Rule | Application |
|---|---|
| ST applies where indicated | The legend states 'ST = Step Therapy Required' and ST applies to those formulary entries explicitly marked with ST; the excerpts reaffirm ST as an administrative control applied per product when present. |
| Definition | Operational note |
|---|---|
| ST = Step Therapy Required | Defined in the formulary legend; when 'ST' appears for a product the member is required to try specified alternative therapy(ies) before the requested product is covered. |
| Header statement | Meaning |
|---|---|
| 'ST = Step Therapy Required' in header/legend | Indicates presence of step therapy program; specific per-product step requirements are not included in these excerpted header lines. |
| Legend item | Interpretation |
|---|---|
| ST indicated in legend | The legend includes ST among administrative flags; individual drug lines may require a prior trial of alternatives when ST is shown. |
| Flag | Implication |
|---|---|
| ST flag defined | ST is a plan control flag in the formulary legend and may apply to some products though the cited segments do not include step paths or sequences. |
| Example area | Formulary annotations |
|---|---|
| COPD / inhaled products | Some COPD and inhaled products include 'TD' (transition) and 'ST' annotations and list covered alternatives; where ST is present prescribers must follow step edits before coverage. |
| Statement | Clarification |
|---|---|
| Step Therapy Required defined | The formulary legend explicitly lists 'ST = Step Therapy Required' though the specific step rules for individual products are not shown in these excerpts. |
| Practice point | Detail |
|---|---|
| ST may apply when noted | When the NOTES field for a product includes 'ST', step therapy requirements apply; providers should document prior alternative therapy trials when requesting coverage or PA. |
| Legend entry | Observed limitation |
|---|---|
| ST appears in legend | The legend lists ST but the excerpt does not include specific operational rules or ordered step sequences for products marked ST. |
| Flag | Application |
|---|---|
| ST flag exists | ST is a recognized administrative flag in the formulary; it may be applied to listed drugs where indicated, but the detailed step requirements are not present in these chunks. |
| Products marked ST | Examples / implication |
|---|---|
| Examples noted in extract | The brief and formulary indicate some products are marked ST (examples cited in inventory: WELCHOL and certain amlodipine-atorvastatin combinations); when ST is shown those products require step therapy prior to coverage. |
Quantity Limits (Examples and Per-Drug Values)
Where Drugs Are Dispensed / Specialty Sourcing
Outpatient applicability — pharmacy vs medical benefit
The formulary applies to outpatient prescriptions — drugs administered in a medical setting are covered under the medical benefit (Tier 7); providers should route medical-administered drugs through the medical benefit.
- Outpatient pharmacy drugs are governed by the formulary; medical-administered drugs are billed under the medical benefit (Tier 7).
SP indicates obtainment via Pharmacy Advantage
Products marked 'SP' must be obtained via Pharmacy Advantage; providers should direct patients/prescriptions to Pharmacy Advantage for specialty fills.
- Pharmacy Advantage phone: (800) 456-2112; SP fills typically limited to up to a 30-day supply.
Specialty pharmacy — obtain via Pharmacy Advantage
Specialty products identified as 'SP' must be sourced from Pharmacy Advantage; prescribers should coordinate fulfillment through the designated specialty channel.
- SP is defined as 'This can only be obtained at Pharmacy Advantage' in the formulary legend.
SP = Pharmacy Advantage specialty pharmacy
SP flag indicates specialty pharmacy sourcing through Pharmacy Advantage is required; providers must follow this sourcing instruction when the product entry includes SP.
- Specialty routing may affect site of care and supply limits (up to 30-day supply).
Specialty pharmacy = Pharmacy Advantage (contact provided)
The formulary defines SP as specialty pharmacy obtained from Pharmacy Advantage (phone provided) and limited to up to a 30-day supply; providers must use this channel for SP-marked products.
- Contact Pharmacy Advantage at (800) 456-2112 for specialty fills.
SP items must be obtained via Pharmacy Advantage (contact provided)
Products marked SP must be obtained via Pharmacy Advantage; the formulary notes the contact number and that specialty supplies are limited to up to a 30-day supply at a time.
- Providers should include PA documentation and route prescriptions to Pharmacy Advantage for SP products.
Infusion-center specialty sourcing — Pharmacy Advantage required
Certain specialty drugs intended for infusion or complex administration must be obtained through Pharmacy Advantage (specialty channel); providers should coordinate with Pharmacy Advantage for infusion/medical-administered specialty products.
- Infusion-center administered specialty products may still require SP sourcing and PA per formulary notes.
SP must be obtained via Pharmacy Advantage (sourcing requirement)
When a product is annotated SP, it must be obtained via Pharmacy Advantage specialty pharmacy; providers should ensure prescriptions and PA requests are routed accordingly to avoid fulfillment issues.
- SP routing requirement appears throughout specialty and high-cost agent listings.
SP indicates specialty fulfillment only via Pharmacy Advantage
Formulary entries noted 'SP' indicate fulfillment only via Pharmacy Advantage; providers should contact Pharmacy Advantage for specialty dispensing instructions and ensure PA is submitted when required.
- Pharmacy Advantage may direct the specific site or supplier for specialty products.
SP routing and supply limits — contact Pharmacy Advantage
Items annotated 'SP' must be obtained at Pharmacy Advantage (800-456-2112) and are typically limited to up to a 30-day supply; providers should coordinate with Pharmacy Advantage for specialty fills and documentation.
- Providers should include PA documentation when submitting to Pharmacy Advantage.
SP routing — Pharmacy Advantage handles specialty products
Specialty products marked 'SP' are routed through Pharmacy Advantage; providers must use the specialty channel and submit required authorization documents to ensure coverage and fulfillment.
- SP items often have accompanying QL that will be enforced by the specialty pharmacy.
SP items obtained via Pharmacy Advantage or specialty distribution
Products marked 'SP' may be obtained only via Pharmacy Advantage or specified specialty distribution; providers should coordinate procurement and authorization with Pharmacy Advantage for these items.
- Many blood derivatives, immunoglobulins, and specialty injectables carry SP notes and require specialty sourcing.
SP = obtain through Pharmacy Advantage (phone provided)
When a drug is marked 'SP' the provider must obtain it through Pharmacy Advantage (phone provided); routing through the designated specialty pharmacy is required for coverage.
- Providers should use Pharmacy Advantage contact (800-456-2112) for SP fulfillment and PA coordination.
SP for infusion-center specialty items — procure via Pharmacy Advantage
Specialty products noted with SP must be obtained via Pharmacy Advantage specialty channel; providers should route PA and prescriptions through the specialty channel to ensure coverage and proper sourcing.
- Infusion-center administered specialty products may also require SP routing through Pharmacy Advantage.
Infusion/specialty products — obtain via Pharmacy Advantage (contact)
Certain specialty products require acquisition via Pharmacy Advantage; providers must contact Pharmacy Advantage (800-456-2112) and follow their specialty fill process to obtain these items.
- Ensure PA is submitted and approved prior to ordering SP-designated specialty products.
Background and Policy Scope
Background: Specialty drugs are defined as biologics or other medications requiring close monitoring for safety and efficacy. The formulary notes that specialty products may require dispensing through the contracted specialty pharmacy (Pharmacy Advantage) and that these items frequently carry utilization controls such as PA and QL.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.