Commercial Prescription Drug Formulary and Utilization Management (Pharmacy & Specialty Drugs)
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Governs the prescription drugs covered for Health Alliance Plan (HAP) commercial health plans, including tiers, utilization management (PA, QL, ST), specialty pharmacy requirements, and how to request exceptions or prior authorization. Affects members, prescribers, pharmacies, and specialty pharmacy vendors for HAP commercial plans.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Controls
Formulary coverage general criteria
Covered when requirements below are met
See specific drug entries for tier, QL, PA, SP designations, and covered alternatives.
Non-formulary exception criteria
Non-formulary drugs may be approved when:
If approved, non-formulary generics/brands are billed at highest brand copay; non-formulary specialty billed at highest specialty copay and may require Pharmacy Advantage dispensing; approvals limited to up to 30-day supply.
Coverage notes and therapy-specific constraints
Coverage and limits apply per drug entry; many products are covered for malaria treatment but not prophylaxis as noted.
Refer to each product line for exact QL and PA requirements
Formulary product-level controls
Coverage and utilization controls are indicated per-product using listed flags; coverage depends on member benefits and any PA or SP requirements.
Use these flags to determine whether additional authorization or specialty dispensing is required
Formulary controls (observational)
Coverage and utilization controls observed in this segment
Examples: XIFAXAN shows PA; SP; QL. Many antineoplastics show PA; SP; QL.
Per-drug formulary coverage conditions
Coverage determinations per listed drug depend on tier status and noted controls
See individual drug entry notes (PA, SP, QL, ALT, PF).
ACA preventive vaccine coverage
Preventive vaccine coverage notes
Age-specific zero-cost coverage noted for many vaccines (e.g., Gardasil 9 ages 9-45).
Drugs are excluded from outpatient pharmacy coverage when used for cosmetic purposes, when they are over-the-counter products (unless specifically listed), when they are experimental or used experimentally, or when they are replacements for lost or stolen medication. These exclusions apply across HAP commercial prescription drug benefits; check the member's benefit plan and the Subscriber Contract for plan-specific variations. For drugs that are medical benefit items (administered in a doctor's office or hospital) coverage is managed under the medical benefit rather than the outpatient drug list; specialty medical drugs in that category are coordinated through Pharmacy Advantage.
Some products in the formulary are designated Non‑Formulary. Examples in the listing include emergency glucagon products (GVOKE), certain naloxone nasal sprays (NARCAN designated Non‑Formulary while other naloxone presentations appear in lower tiers), and allergy/antihistamine agents (e.g., ZERVIATE, ZYRTEC) — these entries indicate they are not on the preferred formulary and may have alternate covered products listed. Non‑Formulary designation generally implies higher member cost‑sharing or the need for an exception request.
Several specific drug products are listed as Non‑Formulary in the formulary detail. Examples include intravenous agents such as ZEVTERA (ceftaroline) and inhaled/nebulized antibiotics (e.g., TOBI inhalation solution), and antiparasitic/anthelmintic agents like ivermectin (STROMECTOL) which appear as Non‑Formulary in certain strengths. Each Non‑Formulary product line includes notes (e.g., QL, SP, ALT) that indicate any applicable quantity limits, specialty dispensing vendor, or covered alternatives.
Some formulations and presentations are specifically excluded from standard outpatient pharmacy coverage or are marked Non‑Formulary. Examples in the antifungal and antiviral sections include posaconazole delayed‑release tablets and certain intravenous or oral suspension formulations; many of these entries carry ALT (covered alternatives), PA, and/or QL annotations that dictate coverage conditions and permissible dispensing channels.
The formulary marks multiple products across therapeutic classes as Non‑Formulary, including select topical, ophthalmic, and systemic agents (examples: BAXDELA, VIGAMOX ophthalmic drops, AZULFIDINE). Where Non‑Formulary status is shown, the entry may also note ALT (covered alternative products), quantity limits, or specialty dispensing requirements that affect how the item may be obtained or whether an exception is needed.
Palforzia (peanut oral immunotherapy) presentations are listed as Non‑Formulary with specialty dispensing contacts provided (e.g., Optum Specialty, Walgreens Specialty) and supply limits noted. Non‑Formulary designation for Palforzia indicates it is not on the preferred outpatient formulary tier and will follow the plan's non‑formulary exception and specialty dispensing rules.
Vaccines annotated with HCR are treated as ACA preventive benefits and are covered at zero cost share when ACA criteria and plan limits are met; examples include FLUZONE and GARDASIL‑9 (Gardasil 9 is noted as covered at zero cost for ages 9 through 45 when ACA criteria are satisfied). The formulary explicitly states that the ACA preventive benefit does not apply to Grandfathered Plans.
Epinephrine auto‑injectors are listed with specific notes: branded devices such as AUVI‑Q, EpiPen and EpiPen Jr appear in the formulary and are marked Non‑Formulary in these entries; quantity limits are specified (e.g., QL = 4 injectors per fill / 4 pens per 30 days). Alternate coverage or covered alternatives are noted where appropriate.
Additional branded products shown as Non‑Formulary in the listing include certain D‑containing loratadine formulations and other consumer‑facing products; the Non‑Formulary flag signals they are not preferred and may be subject to higher member cost‑sharing or require an exception for coverage.
Experimental drugs or drugs used in an experimental manner are explicitly excluded from coverage under the outpatient drug list. The formulary does not present explicit 'not medically necessary' (NMN) clinical determinations for listed products in these excerpts; instead, coverage status is conveyed via formulary tier and management flags (e.g., Non‑Formulary, PA, QL, SP), with NMN exclusions limited to experimental use.
Across the formulary segments provided there are no explicit clinical determinations labeled as 'Not Medically Necessary' beyond the general exclusion for experimental use. Most operational coverage outcomes in the extract are driven by formulary placement and utilization management flags rather than standalone NMN statements.
Similarly, other parts of the listing use Non‑Formulary status and management annotations (PA, QL, SP) to indicate restricted coverage rather than explicit 'Not Medically Necessary' findings in the text excerpts shown.
Formulary Drug Listings and Coding Tables
Prior Authorization, Step Therapy, and Dispensing Actions
Prior Authorization Required
Many drugs listed on the formulary require prior authorization (PA) before coverage will be provided. Providers or members must obtain approval from HAP prior to dispensing PA‑marked drugs; without authorization, claims may be denied.
- PA = Prior Authorization — approval required before fill; lack of PA may result in denial
- PA-marked drugs across the formulary require submission of an authorization request prior to dispensing
- Examples of PA triggers in the formulary: certain antivirals, antifungals, inhaled tobramycin products, many specialty oncology and immunoglobulin agents (see formulary notes)
Prior Authorization for Specialty/Channel Dispensing
Many specialty agents and non-formulary specialty products require prior authorization and may also be limited to dispensing through a specialty channel (Pharmacy Advantage or named specialty/vendor). When a specialty dispensing requirement (SP) applies, the drug must be obtained from the listed vendor (e.g., Pharmacy Advantage: 800-456-2112; Home Infusion: 800-884-1474; Cardinal Specialty 866-677-4844; MMS Solutions 866-716-5486). Failure to use the required specialty channel may lead to claim denial or non-coverage.
- Many specialty drugs = PA + SP (dispensed by Pharmacy Advantage or specified vendor)
- If authorized as a non-formulary specialty drug, plan may require specialty channel dispensing and will bill at highest specialty copay
- Specialty drugs often limited to a 30‑day supply per fill when dispensed via specialty vendor
Formulary Restrictions and Utilization Controls
Formulary controls include PA (prior authorization), QL (quantity limits), ST (step therapy), SP (specialty dispensing), HCR (ACA/preventive rules), TD (new member fill restrictions), PF (partial fill), and AG (age restrictions). Providers should review the formulary notes on each product for specific utilization controls and program codes before submitting a claim or prior authorization request.
- QL = Quantity Limits — per fill or per time period (examples shown per drug notes)
- ST = Step Therapy — may require trial of specified alternatives before coverage
- HCR = Health Care Reform/ACA preventive documentation required for zero cost-share
- TD = Limited first fills for new members (TF/TD examples noted in formulary legend)
Specific Product Limits and Prior Authorization Examples
Specific products listed in the formulary carry explicit PA and/or QL notations. Examples include (not exhaustive): tobramycin inhalation solutions (PA; SP; QL), certain antifungals (voriconazole: PA; QL), PAXLOVID (PA; QL — 5 days/180 days), DESCOVY (PA; QL 1 tablet/day), many oncology and hepatitis agents (PA; SP; QL). Check the drug-specific notes for the exact PA, SP, QL, PF and TF/TD flags.
- Tobramycin inhalation products: PA; SP (Pharmacy Advantage); QL (ampules per 30 days)
- PAXLOVID: PA; QL (5-day treatment per 180 days)
- DESCOVY and related antiretrovirals: PA; QL (1 tablet per day); HCR flags for preventive use
Prior Authorization and Non‑Formulary Risk / Exceptions
Non‑formulary drugs present additional risk of non-coverage unless an exception is granted. Providers may request a non‑formulary exception by submitting clinical documentation supporting medical necessity. If approved, non‑formulary drugs may be limited (e.g., 30‑day supply) and specialty non‑formulary approvals may require specialty dispensing and higher copay tiers.
- Submit non-formulary exception or PA forms to HAP Pharmacy Care Management (mail/fax) or via hap.org
- Non-formulary approvals for brand or specialty drugs billed at highest applicable copay
- Non-formulary specialty approvals commonly limited to 30-day supply per fill
Required Documentation and Program Codes for PA/Exceptions
When submitting PA or non-formulary exception requests, include required documentation and program codes: clinical rationale, supporting statement from the prescriber, diagnosis, prior therapy and outcomes, dosing and anticipated duration, and any relevant lab or imaging results. Use program legends (PA, QL, SP, ST, TD, PF, AG, HCR) to document the request and indicate any specialty vendor routing required.
- Required documentation: prescriber statement of medical necessity, prior treatment attempts, supporting clinical records
- Include formulary program codes (PA, QL, SP, ST, HCR, TD, PF, AG) on requests to ensure correct handling
- For specialty or home-infusion requests, indicate requested dispensing vendor and site of administration (if applicable)
Prior Authorization Timing and Decisionframes
Timeframes and decision windows: standard prior authorization decisions are completed within 15 calendar days of receiving a request; urgent authorization requests must be decided within 72 hours. Non‑formulary exception decisions are completed within 72 hours (or 24 hours if urgent). Providers should mark urgent requests clearly and supply supporting clinical rationale.
- Standard PA decision: within 15 calendar days
- Urgent PA decision: within 72 hours
- Non‑formulary exception decision: within 72 hours (24 hours if urgent)
Therapy Step and New‑Member Fill Restrictions
Therapy-step and new member fill restrictions (ST, TF/TD): some items require step therapy (trial of preferred agents) and/or are limited for new members to a single 30‑day fill during the first 90 days of enrollment. Check TF/TD flags and ST indicators on product entries before dispensing to avoid denial.
- ST = Step Therapy — must fail or have contraindication to required alternatives
- TD / TF = For new members: one 30‑day fill in first 90 days may apply
- Claims for ST/TD items without appropriate history or PA are at risk of denial
Dispensing Channels and Place-of-Service Rules
Legend and Program Code Definitions
Step Therapy Rules and Flags
| Policy item | Summary / definition | Applies where noted |
|---|---|---|
| Step therapy (ST) | Requires trial and failure of specified alternative agent(s) before the requested drug will be covered. | Status: neutral — applies to formulary entries marked 'ST' |
| ST presence on formulary entries | ST is indicated in formulary legend as 'Therapy Required Step' and denotes where step edits apply. | Status: neutral — applies where 'ST' appears on drug lines |
| Legend code | Meaning |
|---|---|
| ST | Therapy Required Step (step therapy) |
| Reference | Interpretation | Where to look |
|---|---|---|
| Formulary legend entry | ST is defined in the legend as Therapy Required Step and applies to drug lines marked 'ST'. | Drug-level NOTES field where 'ST' appears |
| Observation | Implication | Coverage label |
|---|---|---|
| ST flag present on some products | Indicates a therapy-required step per HAP policy — providers must document prior trials of required agents when requesting coverage for the ST drug. | Status: neutral |
| Note | What is included | Limitations in excerpt |
|---|---|---|
| ST indicated in legend | Legend lists ST = Therapy Required Step to denote step therapy program. | Specific step rules and product-specific step sequences are not detailed in this excerpt. |
| Flag | Effect on coverage | Evidence in document |
|---|---|---|
| ST flag | Indicates a therapy-required step may apply for some drugs; coverage contingent on following step therapy rules when present. | Formulary notes and legend referencing ST codes |
| Indicator | Meaning | Action for providers |
|---|---|---|
| ST flag on drug line | Denotes that a therapy-required step applies for that product (step therapy). | Providers should document prior trials/failures of required agents per PA/step-therapy process when submitting prior authorization or override requests. |
| Legend item | Definition | Citation |
|---|---|---|
| ST | Therapy Required Step | Defined in formulary legend |
| Finding | Consequence | Notes |
|---|---|---|
| ST flag present for certain drugs | Where present, step therapy requirements govern coverage; specific step sequences are located on individual drug lines elsewhere in the full formulary. | Excerpt does not list the step sequences themselves |
| Abbreviation | Expanded | Use |
|---|---|---|
| ST | Therapy Required Step | Used in legend to identify drugs subject to step therapy edits |
| Pattern | Interpretation | Provider implication |
|---|---|---|
| ST noted on some drug lines | Indicates step-therapy requirement prior to coverage of that drug. Specific step requirements are on product lines where 'ST' appears. | Providers must follow step therapy process and supply documentation of prior agent trials when requested. |
| Legend presence | Meaning for coverage | Limitations |
|---|---|---|
| ST in legend | Indicates therapy-required step program exists and applies to drugs marked 'ST'. | The excerpt does not enumerate the required prior agents or failure criteria for each ST-marked product. |
| Flag | Operational effect | Documentation |
|---|---|---|
| ST flag | May require documented trial/failure of specified alternatives before covering the requested therapy. | Document prior medication history and any PA forms when submitting exceptions or authorization requests. |
| Flags in notes | Implication for new-to-HAP members | Example |
|---|---|---|
| TF / TD / ST flags | Denote therapy-step or limited-fill rules for new-to-HAP members; TD/TF may limit initial fills (e.g., one 30-day fill within first 90 days of enrollment). | Example: TRELEGY — TF (one 30-day fill in first 90 days) noted in product NOTES. |
| TF / TD example | Restriction | Context |
|---|---|---|
| TF / TD new-member fill restrictions | For new-to-HAP members these flags can limit initial supply to one 30-day fill during the first 90 days of enrollment. | Documented on specific drug NOTES (e.g., carvedilol phosphate ER marked TF; TRELEGY marked TF in product NOTES). |
Quantity Limits (QL) — Per-Product Examples
Background and Scope
Background: Specialty drugs are biologics or other prescription medications that typically require special handling, provider coordination, and patient education. They are frequently dispensed via designated specialty pharmacies (for example, Pharmacy Advantage) and commonly subject to utilization management controls such as Prior Authorization (PA), Quantity Limits (QL), and specialty dispensing (SP). The formulary groups drugs by therapeutic category and annotates each product line with tier, PA/QL/SP flags, covered alternatives (ALT), and any age or new‑member transition restrictions.
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