Commercial Prescription Drug Formulary — Coverage Criteria
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This document is HAP's commercial prescription drug formulary describing covered drugs, tiering, utilization management (PA, QL, ST), specialty pharmacy requirements, and how members/providers can request exceptions; it applies to HAP commercial health plans.
No material clinical or coverage changes in this revision.
Formulary Coverage & Utilization Management
Formulary utilization management criteria
Coverage is determined by drug-specific formulary entries and utilization management rules; certain drugs require meeting PA, QL, or ST requirements.
(see chunks 13)
(see chunk 13)
(see chunks 7, 53)
(see chunks 7, 6)
Indication-limited coverage
Coverage notes observed in this excerpt:
(see chunks 57, 62)
(see chunks 71, 72, 73)
Authorization/dispensing constraints
Special handling and authorization:
Contact vendor numbers and dispensing vendor instructions appear on product lines (see chunks 71, 73).
(see chunks 13, 71)
Formulary coverage examples
Coverage indicated by formulary tier and notes; examples below illustrate covered vs non‑formulary status and utilization controls.
See individual line items for QL/PA/SP notes (chunk 110).
(see chunk 110 and 116)
(see chunk 116 and 119)
Preventive vaccine coverage notes
Coverage and zero cost-share annotations for listed vaccines and selected drugs
(see chunks 216, 221, 229)
(see chunks 223, 227, 229)
Formulary assignment and utilization controls
Coverage and utilization controls applied to listed drugs
Follow the per‑product entry for the exact combination of tier and controls.
(see chunks 246, 234)
(see chunks 234, 235, 246)
Coverage excludes drugs used for cosmetic purposes, over-the-counter medications and their equivalents unless specifically listed, and experimental drugs or drugs used experimentally. The formulary also does not cover replacement of lost or stolen medication. These exclusions apply to outpatient prescription benefits; medical benefit drugs administered in office or hospital settings are not included on the outpatient drug list unless specifically designated as specialty medical drugs dispensed through the payer's specialty pharmacy.
The formulary listing marks numerous specific products as Non-Formulary. Examples in this extract include ZEVTERA IV 667 mg, TOBI inhalation solution for nebulization 300 mg/5 mL and certain topical/brand agents (e.g., some retinoid/topical products), which are shown as Non-Formulary in the drug-tier column and notes.
Several antimalarial entries are explicitly limited to treatment use and state they are not covered for prophylaxis. For example, atovaquone‑proguanil (MALARONE) and chloroquine are listed as “Covered for Malaria Treatment; not prophylaxis,” indicating prophylactic use is excluded.
Products designated Non-Formulary are not on the preferred formulary and therefore may be denied or billed at less favorable cost‑sharing unless an exception is approved or prior authorization is obtained. The listing also indicates alternate coverage pathways: some non‑formulary items include an ALT (covered alternatives) or a requirement for PA (prior authorization) or specialty dispensing (SP) to pursue coverage.
The formulary explicitly lists multiple agents as Non-Formulary, for example several oseltamivir (TAMIFLU) entries and other higher‑cost antivirals or specialty agents. When drugs are marked Non‑Formulary in the drug‑tier column and notes, they are treated as non‑preferred and subject to utilization controls and exception processes described in the formulary.
Additional products are shown as Non-Formulary in other segments of the list; examples include branded topical agents such as CARAC 0.5% topical cream and certain oncology or specialty branded items that are labeled Non‑Formulary in the listing and notes.
This segment includes numerous specialty and oncology agents that are labeled Non-Formulary (or Non‑Preferred). Examples shown include select oral anticancer agents and related high‑cost products that the formulary lists as Non‑Formulary, indicating they are excluded from preferred coverage unless exceptions or PA/SP arrangements are in place.
Several product lines are explicitly marked Non-Formulary in the table; those markings signal they are designated non‑formulary and therefore managed via exception, substitution to an ALT, or PA/SP processes as applicable.
All listed Palforzia formulations in this extract (initial, level, up‑dose and maintenance products) are shown as Non-Formulary and include specialty dispensing notes directing providers to the designated specialty vendors.
Vaccine entries annotated with HCR note that ACA preventive benefit rules apply for zero cost‑share where criteria are met, but the listing also clarifies the ACA preventive benefit does not apply to Grandfathered Plans for those vaccines.
The formulary identifies some branded products explicitly as Non-Formulary in the drug tier column; these entries often include notes that PA, substitution to an ALT, or other utilization controls may be required before coverage is approved.
Multiple additional examples of Non-Formulary drugs appear throughout the list (e.g., methocarbamol 1,000 mg, SOMA, brand Zanaflex entries). The Non‑Formulary designation in the table indicates these products are non‑preferred and subject to the formulary's exception and utilization management processes.
As stated in the coverage limits, drugs used for cosmetic purposes, most OTC products unless specifically listed, and experimental uses are excluded. In addition, many items identified as Non‑Formulary in the formulary may be excluded from coverage absent an approved exception or prior authorization.
Products marked Non‑Formulary in the formulary may be excluded from coverage unless a formal exception is granted or the member obtains prior authorization; the formulary uses the Non‑Formulary flag rather than specific 'not medically necessary' clinical language to indicate restricted coverage.
This extract does not use explicit phrasing such as 'not medically necessary' to manage coverage; instead, the listing relies on formulary status (e.g., Non‑Formulary) and utilization flags (PA, QL, SP, ST) to communicate coverage restrictions and requirements.
The provided sections do not include standalone clinical 'not medically necessary' rules; restrictions and access controls in this extract are driven by the drug's formulary designation (such as Non‑Formulary), and by utilization management flags like PA, QL, SP and ST.
Formulary Codes, Tiers & Quantity Examples
| PA | Prior Authorization |
| QL | Quantity Limit |
| ST | Step Therapy |
| SP | Specialty Pharmacy (Pharmacy Advantage) |
| HCR | Health Care Reform (preventive zero cost-share rules) |
| TD | For new to HAP members only: one 30-day fill in first 90 days |
| PF | Partial Fill Program |
| AG | Age Restriction |
| ivermectin oral tablet 6 mg | ivermectin oral tablet 6 mg — Non-Formulary; QL (2 Fills per Year); ALT (Covered Alternatives: Ivermectin Tablet); QL (8 Tablets per 30 Days) |
| praziquantel oral tablet 600 mg | praziquantel oral tablet 600 mg — Tier 2 |
| griseofulvin microsize oral suspension 125 ml mg/5 | griseofulvin microsize oral suspension 125 ml mg/5 — Tier 2 |
| STROMECTOL ORAL TABLET 3 MG | STROMECTOL ORAL TABLET 3 MG — Non-Formulary |
| atovaquone-proguanil oral tablet 250-100 mg | atovaquone-proguanil oral tablet 250-100 mg — Tier 2; QL; Covered for Malaria Treatment; not prophylaxis |
| MALARONE ORAL TABLET 250-100 MG | MALARONE ORAL TABLET 250-100 MG — Non-Formulary; QL; Covered for Malaria Treatment; not prophylaxis |
| chloroquine phosphate oral tablet 250 mg, 500 mg | chloroquine phosphate oral tablet 250 mg, 500 mg — Tier 2; Covered for Malaria Treatment; not prophylaxis; QL |
| DARAPRIM ORAL TABLET 25 MG | DARAPRIM ORAL TABLET 25 MG — Non-Formulary; QL; SP (Dispensed by Pharmacy Advantage) |
| doxycycline hyclate oral capsule 100 mg | doxycycline hyclate oral capsule 100 mg — Tier 2; MDL |
| hydroxychloroquine oral tablet 200 mg | hydroxychloroquine oral tablet 200 mg — Covered for Malaria Treatment; not prophylaxis; MDL; QL |
| Tier 1 | Select Generic |
| Tier 2 | Generic and Select Brand |
| Tier 3 | Preferred Brand |
| Tier 4 | Non-Preferred Brand and Generic |
| Tier 5 | Preferred Specialty |
| Tier 6 | Non-Preferred Specialty |
| Tier 7 | Medical Coinsurance |
| PA | Prior Authorization |
| QL | Quantity Limits |
| SP | Pharmacy Advantage specialty dispensing |
| HCR | Health Care Reform rules apply (preventive zero-cost rules) |
| ST | Therapy Required Step |
| TD | New-to-HAP initial fill rule |
| PF | Partial Fill Program |
| AG | Age Restriction |
| None listed | This segment does not include explicit CPT/HCPCS/ICD-10/NDC codes; only product names, formulations, tiers and notes are present. |
| AUVI-Q 0.1 MG/0.1 | AUVI-Q INJECTION AUTO-INJECTOR 0.1 MG/0.1 — DRUG TIER = Non-Formulary; QL (4 Injectors per 1 Fill) |
| EPIPEN 0.3 MG/0.3 ML | EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML — DRUG TIER = Non-Formulary; QL (4 pens per 30 days) |
| EPIPEN JR 0.15 MG/0.3 ML | EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML — DRUG TIER = Non-Formulary; QL (4 pens per 30 days) |
| CLARITIN-D 5-120 MG | CLARITIN-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG — DRUG TIER = Non-Formulary; QL (2 tablets per 1 day) |
| CLARITIN-D 10-240 MG | CLARITIN-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG — DRUG TIER = Non-Formulary |
| TRELEGY ELLIPTA 100-62.5-25 MCG | TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG — NOTES = PA; TF (one 30-day fill for new-to-HAP members in first 90 days) |
| TRELEGY ELLIPTA 200-62.5-25 MCG | TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 200-62.5-25 MCG — NOTES = PA; TF |
| BACLOFEN 10 mg/5 ml | baclofen oral solution 10 mg/5 ml — DRUG TIER = Non-Formulary; NOTES = SP (Dispensed by Pharmacy Advantage); QL (80 ML per 1 day) |
| DANTROLENE 25 MG | DANTRIUM ORAL CAPSULE 25 MG — DRUG TIER = Non-Formulary |
What Providers Must Do / Denial Risks
Obtain prior authorization — 15 days standard / 72 hours urgent
Certain drugs require prior authorization before fill. Standard PA decisions are made within 15 calendar days; urgent requests are decided within 72 hours.
Submit PA and route to specialty pharmacy when PA/SP flagged
When a formulary entry is annotated with PA or SP, prescribers must both submit a prior authorization request and arrange dispensing through the designated specialty pharmacy listed in the notes (e.g., Pharmacy Advantage).
- SP entries indicate the product "can only be obtained at Pharmacy Advantage" and include the specialty phone number (800-456-2112).
- PA entries require submission of the payer's prior authorization before coverage.
PA required for inhaled aminoglycosides (e.g., tobramycin, ARIKAYCE)
Prior authorization is required for inhaled aminoglycosides and other specialty inhaled products (examples include tobramycin inhalation solutions and ARIKAYCE inhalation suspension).
- Tobramycin inhalation solution notes include PA; SP dispensing and QL (280 ampules per 30 days).
- ARIKAYCE inhalation suspension is listed Non-Formulary with QL and SP notes.
Check NOTES — PA or SP flagged drugs require authorization or specialty dispensing
Many products in the formulary are marked with PA or SP and must have authorization or specialty dispensing arranged prior to coverage — check the NOTES column for each line item.
- PA = Prior Authorization; SP = Specialty Pharmacy (designated vendor) as defined in the formulary legend.
- Follow the product-specific NOTES for required vendor and any supply/QL limits.
PA required — examples (voriconazole, LIVTENCITY, PAXLOVID)
Selected non-unique examples of products marked PA include voriconazole oral suspension, LIVTENCITY oral tablet, and PAXLOVID (per-line NOTES show PA where applicable).
- Voriconazole oral suspension: NOTES = PA; QL 10 mL per day.
- LIVTENCITY oral tablet: NOTES = PA; listed as Tier 5.
- PAXLOVID: NOTES = PA; QL 5 days per 180 days.
PA required for select agents (e.g., BARACLUDE, DESCOVY)
Certain named agents are noted with PA in their NOTES (example lines include BARACLUDE oral solution and DESCOVY where PA is indicated).
- BARACLUDE oral solution: NOTES = PA; SP (Pharmacy Advantage) and QL specified.
- DESCOVY oral tablet: NOTES = PA; ALT listed in NOTES.
Submit PA for specialty and oral oncology agents
Many specialty and oral oncology products are marked PA and require the provider to submit a prior authorization to HAP before the drug will be covered.
- Examples: IBRANCE, various specialty oral oncology agents — NOTES include PA and SP (Pharmacy Advantage) with up-to-30 supply per fill.
- Prescribers must submit PA requests to HAP for these PA-marked specialty/oncology drugs.
PA required — specialty drugs in this listing
Drugs listed with 'PA' in this segment require prior authorization before coverage will be provided; verify PA status on each specialty drug line before dispensing.
- Many specialty entries show PA and designate specific specialty dispensers in NOTES.
- Coverage is contingent on obtaining PA per the formulary entry.
PA required for specialty oral oncology agents (examples given)
Numerous specialty oral oncology agents are annotated PA in the formulary notes — providers must obtain prior authorization for the listed strengths/formulations to secure coverage.
- Examples include sorafenib, sunitinib, TAGRISSO, and others with NOTES = PA; SP (Pharmacy Advantage).
- Follow the line-item PA instruction for the specific strength/formulation.
PA required for IV/SC immunoglobulins — obtain PA before coverage
Many intravenous and subcutaneous immunoglobulin products are listed with PA (and often SP); providers must obtain prior authorization before these IV/SC immunoglobulins will be covered.
- Examples: GAMMAGARD, GAMMAKED, FLEBOGAMMA — NOTES include PA; QL; SP and home-infusion routing when applicable.
- If home infusion is requested, follow the SP/home-infusion vendor instructions in the NOTES.
PA flag = prior authorization required (no CPT/HCPCS listed)
Formulary entries flagged 'PA' indicate prior authorization is required; the document does not provide CPT/HCPCS codes for PA—use the product NOTES and HAP PA process.
- PA flag in NOTES denotes plan-level prior authorization requirement.
- Submit PA via the HAP Pharmacy Care Management process referenced in the formulary.
PA required — examples include glycopyrrolate inj and TRELEGY devices
Selected agents such as glycopyrrolate injection solution and TRELEGY ELLIPTA devices are noted with PA (and TF/TD where applicable); prior authorization must be obtained prior to coverage.
- Glycopyrrolate injection solution: NOTES = PA; QL specified.
- TRELEGY ELLIPTA: NOTES = PA; TF (one 30‑day transition fill for new-to-HAP members).
PA required for select listed products (e.g., dihydroergotamine)
Some products in the list (for example, dihydroergotamine injection solution) are annotated with PA; providers must secure prior authorization before these products are covered.
- Dihydroergotamine injection solution: NOTES = PA; QL (0.01 mL per day).
- Dihydroergotamine nasal spray: NOTES = PA; QL (8 vials per 30 days).
Follow step therapy — try required alternatives first
Step therapy (ST) may require trying specified alternative drugs first; coverage of the requested drug can be contingent on documented failure or intolerance of those alternatives.
- ST = Therapy Required Step per the formulary legend.
- Documented trial and failure or intolerance of the required alternative(s) is needed where ST applies.
ST flag present — check line items for step therapy
The formulary legend includes an ST flag (Therapy Required Step) indicating some drugs are subject to step therapy; specific step requirements are not shown in the extract and must be checked per product.
- ST appears in the legend as 'Therapy Required Step'.
- Review the individual product line for any ST designation and applicable required steps.
ST = Therapy Required Step (legend entry)
The formulary legend reiterates ST = Therapy Required Step; where ST is applied, providers must comply with the therapy-step program before the requested drug will be covered.
- ST is a program code used to enforce therapy steps where listed.
- Specific step rules are located elsewhere in the formulary for products with ST noted.
ST indicated — follow therapy-required step when listed
The formulary notes that 'ST = Therapy Required Step' for select products; if ST applies, coverage depends on documented trials of required alternatives (details not included here).
- When ST is present on a product line, follow the formulary's step therapy program requirements.
- If specifics are needed, request the full formulary rule for that product.
ST referenced as program code — check product rules
ST is referenced as a program code in the legend and indicates some products will require prior trial of alternatives; product-specific ST rules are not provided in this extract.
ST indicates therapy step may apply
Products annotated 'ST' in the legend mean a therapy-required step may apply; providers should follow the formulary's step therapy requirements where indicated.
Adhere to ST when present on product lines
Where the ST annotation appears on a product line, the requested drug may be subject to step therapy; follow the formulary's step requirements when listed.
ST references and transition-fill considerations
The formulary includes multiple references to ST in the legend; if a product shows the ST flag, providers must ensure required prior therapies have been tried and documented.
- ST/TF/TD also impacts transition fills for new members (see TF/TD notes).
ST annotation — follow formulary step rules
The ST annotation in the legend signals therapy-step enforcement for some products; specific step directives are maintained elsewhere in the formulary and must be followed where shown.
General ST legend — check full formulary for details
The general formulary legend documents ST (Therapy Required Step) as an enforcement mechanism; product-level ST entries are not present in this extract and should be reviewed on the full formulary.
ST may apply — follow step therapy where listed
Entries marked 'ST' in the legend indicate therapy-step requirements may apply to certain products; providers must follow those step requirements when present on a product line.
Transition fill limits for new members — one 30-day fill in first 90 days
For new-to-HAP members TF/TD transition fill rules apply: TD/TF allows one 30-day fill for new members within the first 90 days; providers should plan initial dispensing accordingly.
- TF/TD = transition fill rules for new members (one 30‑day fill in first 90 days).
Include provider statement for non-formulary/PA requests
Non-formulary exception and PA requests must include a supporting statement from the prescribing provider describing medical necessity and why covered alternatives are unsuitable.
- The provider's statement is required to support non-formulary exception or prior authorization requests.
Provide required documentation for PA/SP requests
Documentation must support PA and SP requests: include clinical rationale, relevant prior therapy history, and any supporting medical records when submitting authorization requests.
- PA/SP notes in product lines indicate documentation and specialty dispensing steps are required for approval.
- Follow the plan's PA submission instructions and include requested clinical details.
Use formulary legend — PA, QL, SP definitions
Refer to the formulary legend for abbreviations: PA = Prior Authorization, QL = Quantity Limits, SP = Specialty Pharmacy—these flags indicate required provider actions.
- Use the NOTES and legend to determine whether PA, QL, SP or ST apply for a product.
Route SP items to the named specialty vendor(s)
Specialty-dispensed products list the required dispensing vendor(s) in the NOTES (examples include Pharmacy Advantage, Cardinal, Optum Specialty, Walgreens Specialty); route prescriptions to the listed vendor.
- VISTOGARD: SP via Cardinal Specialty Pharmacy (866-677-4844).
- Palforzia levels: SP via Optum Specialty (877-977-9118) or Walgreens Specialty (888-782-8443).
Include clinical details on PA/QL requests (indication, prior therapy, dosing)
Examples of required supporting information for PA/QL requests include clinical indication, prior therapies tried, dosing/supply requested, and any relevant lab or diagnostic data as specified in the PA form.
- Complete the PA/non-formulary exception form available at hap.org/mrf and include the prescribing provider's justification.
- Include documentation showing failure/intolerance to alternatives when ST applies.
PA + SP marked products — obtain PA and dispense via designated specialty pharmacy
When a product is marked both PA and SP, the product requires prior authorization and must be dispensed by the specified specialty pharmacy (e.g., many oncology and specialty antivirals).
- PA and SP markings together indicate both authorization and channel restrictions for coverage.
- Follow vendor contact and supply-per-fill limits listed in the NOTES.
SP dispense source — up to 30-day supply per fill
Specialty-dispensed products are typically limited to up to a 30-day supply per fill; comply with the supply limits noted on the product line when arranging dispensing.
- Many SP entries state 'up to a 30 supply per fill' alongside the specialty vendor contact.
Route SP prescriptions to the vendor named in product NOTES
Prescribers must route prescriptions for SP items to the specified specialty pharmacy vendor listed in the product NOTES (examples include Pharmacy Advantage, Walgreens Specialty, Biologics, Onco360).
- Follow the vendor routing instructions in the NOTES to avoid coverage delays or denials.
Use specialty pharmacy contact info in NOTES when arranging SP fills
Contact and vendor instructions for SP-only products are provided in the NOTES (for example Pharmacy Advantage: (800) 456-2112; Optum Specialty and Walgreens Specialty numbers are provided for Palforzia products).
- Use the phone numbers listed in the NOTES to coordinate specialty fills and PA routing.
Use designated specialty dispenser and observe supply limits
Designated specialty dispensers are required for SP items and supply limits are specified per product; check NOTES for the required dispenser and adhere to the stated days‑supply/QL limits.
- Products marked SP often include QL or PF limits and the specialty dispenser contact.
PA/SP labeled products — submit documentation and use designated specialty dispenser
Products labeled PA and SP indicate that prior authorization and documentation plus specialty dispensing steps are required; include the required documentation when submitting the PA and ensure dispensing through the named vendor.
- PA indicates authorization requirement; SP indicates specialty pharmacy channel restriction.
- Claims should reflect the PA approval and specialty dispensing to avoid denial.
Document PA/QL/SP elements on requests and claims
The formulary legend and product NOTES list required documentation elements (PA, QL, SP); include these abbreviations and supporting clinical information on PA requests and claims per plan guidance.
- Document the PA rationale, quantities requested, and specialty vendor where applicable.
- Use the plan's PA forms and include the provider statement of medical necessity for non-formulary exceptions.
PA and SP enforcement — obtain PA and use specified specialty pharmacy
Products marked PA require prior authorization; products marked SP must be dispensed by the specified specialty pharmacy (e.g., Pharmacy Advantage, Maxor Specialty); follow the NOTES for vendor and fill-limit instructions.
- PA and SP flags are enforced per product line — failure to follow both may lead to denial.
Denial risk — no PA may result in non-coverage
Failure to obtain prior authorization when required may result in the drug not being covered; obtain PA before dispensing PA‑flagged drugs to avoid denial.
QL exceedance may trigger denial — follow listed quantity limits
Exceeding quantity limits noted on product lines may trigger denial or require justification; follow the QL values (for example KLOXXADO 1 box/2 per 90 days; naloxone nasal spray 2 doses per 90 days).
- KLOXXADO: QL = 1 Box (2 per 90 days).
- Naloxone nasal spray: QL = 2 doses per 90 days.
PA/QL enforcement example — tobramycin inhalation solution
PA and QL enforcement is active on certain products (example: tobramycin inhalation solution requires PA and has a QL of 280 ampules per 30 days); ensure PA approval and adhere to QL to avoid denial.
- Tobramycin inhalation solution: NOTES = PA; SP; QL 280 ampules per 30 days.
Denial risk — Non-Formulary, PA or SP without required steps may be denied
Non-Formulary products or those annotated with PA or SP may be denied if prior authorization or required specialty dispensing arrangements are not completed.
- Non-Formulary listings and PA/SP flags denote utilization controls that must be satisfied for coverage.
Non-Formulary status may lead to denial or higher member cost-sharing
Formulary status affects coverage and cost-sharing; Non-Formulary drugs may be denied or billed at higher copays unless an approved exception is obtained.
- If a non-formulary exception is approved, non-formulary generic/brand drugs are billed at highest applicable copay; non-formulary specialty drugs billed at highest specialty copay and may require Pharmacy Advantage dispensing.
Risk of denial if PA process not completed
Requests for drugs labeled 'PA' that are submitted without completing HAP's prior authorization process risk denial or non-payment; secure PA before dispensing.
Denial risk — not dispensing from specified specialty pharmacy
Coverage can be denied if a specialty product is not obtained from the specified specialty pharmacy vendor; obtain PA and dispense through the listed SP to maintain coverage.
- Examples: many oncology and specialty agents list Pharmacy Advantage or other specialty vendors in NOTES; failure to use these vendors may result in denial.
Obtain PA for PA‑flagged products to avoid denials
Prior authorization is required for many PA‑flagged products listed in the formulary; providers must obtain PA to avoid claim denials.
PA/SP required for immunoglobulins — obtain PA and use listed infusion vendors
Prior authorization is required for many of the immunoglobulin products and associated home‑infusion dispensing; obtain PA and follow SP/home-infusion vendor instructions to secure coverage.
- Examples: GAMMAGARD, FLEBOGAMMA, GAMMAPLEX entries include PA; QL and SP/home-infusion routing.
Denial triggers — plan limits, HCR/ACA criteria, and missing PA
Denial triggers include noncompliance with plan limits, HCR/ACA criteria, or failing to obtain PA where indicated; check HCR notes for preventive coverage rules and ensure PA when required for zero cost-share.
- HCR notes must be met for preventive vaccines to qualify for zero cost-share; noncompliance may affect coverage.
Claims may be denied if QL/PA criteria not met
Claims may be denied or require intervention when QL or PA criteria are not met for listed products (examples: glycopyrrolate injection notes PA; multiple inhalers and epinephrine auto‑injectors have QL limits).
- Glycopyrrolate injection solution: NOTES = PA; QL (0.01 mL per day).
- Epinephrine auto-injectors: QL = 4 pens per 30 days.
PA/QL/SP enforcement may trigger denial — example dihydroergotamine
Prior authorization, quantity limits, and specialty dispensing requirements are enforced and may trigger denials if not followed (example: dihydroergotamine injection solution lists PA and QL).
- Dihydroergotamine injection solution: NOTES = PA; QL 0.01 mL per day.
Dispensing Channels & Administration Sites
Quantity Limits (QL) — Selected Product Examples
Legend & Abbreviations
Step Therapy & Transition Fill Rules
| Policy element | Summary |
|---|---|
| Step therapy (ST) | Must try required alternative drugs before coverage of the requested drug is allowed; coverage contingent on documented trial and failure or intolerance of specified alternatives. |
| ST legend/flag | ST appears as a legend/program code ("ST = Therapy Required Step") indicating step therapy rules apply to some formulary products; specific step requirements are listed on individual drug lines where applicable. |
| Legend flag | Meaning |
|---|---|
| ST | Therapy Required Step — indicates a step-therapy requirement may apply to the product. |
| Legend flag | Interpretation |
|---|---|
| ST | Referenced in the formulary legend to indicate some drugs may require prior trial of alternatives before coverage is approved. |
| Reference | Note |
|---|---|
| ST referenced in excerpts | ST is referenced in the document legend and on some entries, but specific step requirements for individual drugs are not included in the provided extract. |
| Legend flag present | Details available in extract? |
|---|---|
| ST = Therapy Required Step | Flag is present in the legend; the extract does not show the per-product step rules or the required alternative agents. |
| ST usage | Documentation in extract |
|---|---|
| ST applies to some agents | The brief and legend indicate ST applies to select agents, but the specific step sequences or alternative drugs are not provided in these chunks. |
| Guidance | Action |
|---|---|
| Follow formulary entries | When ST is indicated on a drug line, providers must follow the formulary’s step requirements as listed for that product (details appear on individual entries outside this extract). |
| Legend abbreviation | Definition |
|---|---|
| ST | ST = Therapy Required Step (per formulary legend). |
| Flag presence | Implication |
|---|---|
| ST flag present | Indicates a therapy step may be required prior to coverage for some products; check product-specific notes for requirements. |
| Observation | Limitation |
|---|---|
| ST included in legend | Although ST is shown in the legend, the provided extract does not include explicit per-product step requirements to reproduce here. |
| ST meaning | Coverage effect |
|---|---|
| ST = Therapy Required Step | Entries marked ST indicate a therapy-required step may be enforced prior to coverage; the extract does not include the specific alternative agents or trial durations. |
| Transition fills (TF/TD) | Policy |
|---|---|
| TF / TD | Transition fill limits: for new-to-HAP members, one 30‑day fill is allowed in the first 90 days (TF/TD noted in legend and on affected product lines). |
| ST usage noted | Summary |
|---|---|
| ST used for some products | The formulary uses ST (Therapy Required Step) for select products, implying required step-therapy prior to coverage for those agents; specifics are on individual drug entries not included in this excerpt. |
Background & Scope
Specialty drugs are biologics or prescription medications that require special handling, provider coordination and patient education. They commonly require prior authorization and are often dispensed through a designated specialty pharmacy; the formulary notes that specialty products may have additional requirements (PA, SP, QL) and that Pharmacy Advantage is the payer's designated specialty dispenser for many items.
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