DraftHealth NetPolicy N/A

Pharmacy and specialty drug formulary — coverage criteria (partial list)

Governs coverage, prior authorization (PA), quantity limits (QL), and medical necessity designations for pharmacy and specialty drugs; applies to prescribers and pharmacists processing Health Net member benefits.

Policy Summary

PayerHealth Net

PolicyPharmacy and specialty drug formulary — coverage criteria (partial list)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document clinical justification for any product annotated with 'PA' and ensure dispensing stays within listed quantity limits (QL).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15+pages/sections referenced

Multipledrugs with PA in extract

Somedrugs with QL noted

NCapplicable state

severalbrand restrictions

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

PA + Quantity Limit Requirements

Coverage requires meeting payer-specified prior authorization and quantity limits as noted for each product.

PA and QL apply where indicated: If a product entry is annotated with 'PA' the provider must obtain prior authorization before benefit payment; if annotated with 'QL' dispensing is limited to the specified quantity per time period shown for that product.See product-specific QL values (e.g., ACTEMRA QL 3.6 mL per 28 days; BENLYSTA QL 8 mL per 28 days; ENBREL QL 8 mL per 28 days)

Specific clinical documentation requirements for individual PA requests are not included in this excerpt; follow Health Net PA submission processes and cite product labeling when available.

Product-specific coverage flags

Coverage and utilization management depend on the utilization flags shown on each formulary line.

Formulary entry: Each drug line lists formulation, strength, and utilization flags (examples: PA, PA-NS, ST, QL, LA). Coverage is contingent on meeting any indicated prior authorization (PA/PA-NS), complying with step therapy (ST) where shown, and adhering to quantity limits (QL).Refer to per-product QL entries (e.g., armodafinil QL 30 EA per 30 days; ZURZUVAE QL 28 EA per 365 days)

This extract provides product-level flags rather than full clinical eligibility criteria.

Formulary Coverage Annotations

Formulary lines include inline annotations that indicate coverage constraints and limits.

Formulary entry requirements: Drug coverage is indicated per product line with annotations such as 'PA' (prior authorization required), 'PA-NS' (prior authorization - non‑standard), 'ST' (step therapy), 'LA' (limited access), and 'QL' (quantity limit). Providers must obtain any required PA and request quantities consistent with the listed QL unless an approved exception is obtained.Examples of QL annotations in this segment: tramadol 50 mg QL (240 EA per 30 days); fentanyl buccal lozenge QL (120 EA per 30 days); acetaminophen-codeine oral solution QL (2700 mL per 30 days); morphine oral solution QL (900 mL per 30 days)

Where 'PA' appears next to a product, documentation supporting medical necessity should be submitted with the PA request.

The table excerpt includes several vaccine and preventive product entries that are explicitly designated NM (Not Medically Necessary) for specified age groups or indications. Examples from the listing include ABRYSVO (marked NM for age 19 and older) and multiple routine vaccine presentations (e.g., ADACEL and other immunizations) that show a second-column flag of NM for particular uses or populations. SHINGRIX is listed with a specific QL but also contains an NM designation for certain lines, with an exception note that a third dose may be considered post-transplant (PA required) where clinical criteria apply.

Some biologic product listings restrict coverage to particular NDCs. For example, the HUMIRA entries state that Only Humira NDCs starting 00074 are covered, and quantity limits are provided per presentation (e.g., QL values shown alongside the covered NDC restriction). Providers must confirm the NDC on the claim matches the covered NDCs indicated in the formulary.

Within this partial extract there is no standalone exclusions section; the document fragment does not present an explicit list of items labeled as excluded. Formulary rows instead use inline flags (e.g., PA, QL, PA-NS, NM) to convey coverage constraints.

The excerpt functions as a product index/formulary listing and does not include a separate exclusion list. Many products are enumerated with utilization-designation flags and quantity limits, but no explicit global exclusion statements or a consolidated exclusion table appear in these chunks.

Numerous individual table entries are explicitly marked NM (Not Medically Necessary) for specified ages or uses. Examples include immunization entries (multiple vaccines show a second-column value of NM), and SHINGRIX lines that identify NM in some rows while noting limited exceptions (e.g., post‑transplant dosing requiring PA). These line-level NM flags indicate the product is not covered for that listed indication or population unless otherwise specified.

Certain portions of the extracted listing do not contain explicit Not Medically Necessary language; many rows instead show utilization controls such as PA, PA-NS, and QL. In this fragment (e.g., behavioral health/CNS agents) product lines are shown with PA/QL markers but not with explicit NM text.

This excerpt does not systematically list any items as broadly not medically necessary. Coverage constraints here are primarily indicated by line annotations such as PA, QL, and occasional PA-NS flags rather than a declarative NM exclusion for the listed products.

Coding, NDCs and formulary flags

Header codes/snippetsmixed

LX	Unknown short code appearing in header: 'LX rizatriptan Smg 53'

Listed drug products and strengthsmixed

bosentan oral tablet 125 mg, 62.5 mg	bosentan oral tablet formulations listed with PA/LA/QL notations
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE,50-25 MCG/DOSE	inhaler product with QL (60 EA per 30 days) indicated
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML	biologic with PA; LA; QL (1 ML per 28 days)
HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT	hereditary angioedema product with PA; LA; QL (30 EA per 30 days)
KALYDECO ORAL GRANULES IN PACKET 13.4 MG,5.8 MG	cystic fibrosis modulator with PA; QL (56 EA per 28 days)
OFEV ORAL CAPSULE 100 MG, 150 MG	antifibrotic with PA; QL (60 EA per 30 days)
TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75	cystic fibrosis modulator with PA; QL (84 EA per 28 days)
XOLAIR SUBCUTANEOUS AUTO-INJECTOR 150 MG/ML	omalizumab product with PA; QL (8 ML per 28 days)
PROMACTA ORAL POWDER IN PACKET 12.5 MG	eltrombopag with PA; LA; QL (360 EA per 30 days)
XARELTO ORAL TABLET 10 MG,20 MG	rivaroxaban with QL (30 EA per 30 days)

NDC/Formulation listings and plan annotations (no formal CPT/HCPCS/ICD codes in this segment)mixed

No codes listed

Drug list (product-level entries)NDC-like/product

No codes listed

Formulary flags and quantity codesmixed

PA-NS	Prior authorization - non-standard (as listed)
PA	Prior authorization required
QL (28 EA per 28 days)	Quantity limit example
LA	Limited access (plan designation)
BD	Benefit/designation code as listed
B/D	Benefit/department designation
NT	Noted as NT in list

Selected dermatologic formulations with QL/PA annotationsNDC/description

metronidazole topical gel 0.75%	listed with QL (45 GM per 30 days)
metronidazole topical lotion 0.75%	listed with QL (59 ML per 30 days)
myorisan oral capsule 10 mg,20 mg,30 mg,40 mg	listed
tazarotene topical cream 0.1%	PA; QL (60 GM per 30 days)
tazarotene topical gel 0.05%,0.1%	PA
tretinoin topical cream 0.025%,0.05%,0.1%	PA; QL (45 GM per 30 days)
tretinoin topical gel 0.01%,0.025%	PA; QL (45 GM per 30 days)
tretinoin topical gel 0.05%	PA; QL (45 GM per 30 days)

Ophthalmic agents with PA/QL annotationsNDC/description

betaxolol ophthalmic 0.5%	listed
timolol maleate ophthalmic 0.25%,0.5%	listed
TOBRADEX ophthalmic ointment 0.3-0.1%	listed
CYSTARAN ophthalmic drops 0.44%	PA; LA (limited access) indicated
OXERVATE ophthalmic drops 0.002%	PA indicated
XDEMVY ophthalmic drops 0.25%	PA; QL (10 ML per 42 days)

Specialty biologics and injectablesNDC/description

ACTEMRA ACTPEN 162 mg/0.9 mL	PA; QL (3.6 ML per 28 days)
BENLYSTA IV 120 mg,400 mg	PA
BENLYSTA SC 200 mg/mL	PA; LA; QL (8 ML per 28 days)
ENBREL products (various)	PA; QL (8 ML per 28 days)
HUMIRA products (various)	PA; Only Humira NDCs starting 00074 are covered; QL (varies)

Bone metabolism and other selected agents with QL/PANDC/description

colchicine 0.6 mg	QL (120 EA per 30 days)
alendronate oral solution 70 mg/75 mL	QL (300 ML per 28 days)
PROLIA subcutaneous syringe 60 mg/mL	QL (1 ML per 180 days)
TERIPARATIDE pen injector 20 mcg/dose	PA; QL (2.48 ML per 28 days); Only specific NDC covered for one product

NDC-specific coverageNDCCovered

NDC 47781065289

Only Teriparatide NDC covered (document states only this NDC is covered)

Drug listing (no explicit billing codes in extract)mixed

N/A	This extract lists NDC/CPT codes are not provided; items are drug name and formulation entries with utilization flags.

Quantity Limits (examples)mixed

QL (240 EA per 30 days)	Quantity limit for tramadol 50 mg tablets
QL (2700 ML per 30 days)	Quantity limit for acetaminophen-codeine oral solution
QL (360 EA per 30 days)	Quantity limit for acetaminophen-codeine oral tablet 300-15 mg

Quantity Limits (additional examples)mixed

QL (120 EA per 30 days)	Quantity limit shown for fentanyl buccal lozenge on a handle
QL (10 EA per 30 days)	Quantity limit for fentanyl transdermal patch 72 hour 100 mcg/hr
QL (180 EA per 30 days)	Quantity limit for endocet 10-325 mg

Product-index mappings (textual)mixed

No codes listed

Topical quantity limits — examples

Metronidazole topical gel 0.75%QL 45 GM per 30 days

Metronidazole topical lotion 0.75%QL 59 ML per 30 days

Tazarotene topical cream 0.1%QL 60 GM per 30 days; PA

Tretinoin topical formulationsQL 45 GM per 30 days (cream/gel as listed); PA on select strengths

Biologic quantity-limit examples

ACTEMRA ACTPEN 162 mg/0.9 mLQL 3.6 mL per 28 days; PA

BENLYSTA subcutaneous 200 mg/mLQL 8 mL per 28 days; PA; LA

ENBREL (various presentations)QL 8 mL per 28 days; PA

Quantity-limit examples (varied)

PROLIA subcutaneous syringe 60 mg/mLQL 1 mL per 180 days

DESCOVY oral tabletQL 30 EA per 30 days

SKYRIZI subcutaneous wearable injectorQL 1.2 mL per 56 days (specific wearable presentation) or QL 6 mL per 365 days for other presentations

BONSITY / Teriparatide penQL (Teriparatide) 2.48 mL per 28 days; Only specific NDC covered for one pen formulation

INVEGA TRINZA per 90 days — strength-specific volumes

INVEGA TRINZA 273 mg / 0.88 mLQL 0.88 mL per 90 days

INVEGA TRINZA 410 mg / 1.32 mLQL 1.32 mL per 90 days

INVEGA TRINZA 546 mg / 1.75 mLQL 1.75 mL per 90 days

INVEGA TRINZA 819 mg / 2.63 mLQL 2.63 mL per 90 days

ZURZUVAE annual limits by strength

ZURZUVAE 20 mg / 25 mgQL 28 EA per 365 days

ZURZUVAE 30 mgQL 14 EA per 365 days

Prior authorization, documentation, and denial risk

Prior Authorization

Prior authorization required when indicated

Many drugs listed in the formulary table are subject to prior authorization (PA) and/or limited-access (LA) controls. When a drug entry includes PA, PA-NS, LA, or PA; LA flags, providers must obtain prior authorization before the plan will cover the medication. Claims submitted without required prior authorization are at risk for denial.

Apply PA when table shows 'PA', 'PA-NS', or 'PA; LA'.
Limited-access (LA) items require use of specified distribution channels or additional plan documentation.

Documentation Required

Topical agents PA/QL

Topical dermatologic agents in the formulary may carry PA and/or quantity limits (QL). Examples include branded topical patches and compounded topical products that show 'PA' or explicit QL entries; providers should include indication and quantity justification when requesting coverage.

Adhere to QL entries (e.g., topical patches QL (90 EA per 30 days)).
Submit clinical rationale for non-routine topical products marked PA.

Prior Authorization

INBRIJA PA & QL

INBRIJA inhalation capsules are listed with PA and a specific quantity limit: PA; QL (300 EA per 30 days). Prior authorization requests for INBRIJA must include the clinical indication and the quantity requested consistent with this QL.

INBRIJA (42 mg) — PA; QL (300 EA per 30 days).
Include diagnosis and dosing schedule when submitting PA.

Note

Prior authorization requirement implied from table

The table format itself implies prior authorization and utilization controls where flags (PA, PA-NS, LA, QL, BD, B/D, ST) appear. Providers should treat flagged products as requiring prior authorization or subject to plan limits even when a full clinical rule set is not reproduced here.

Treat any product with PA/PA-NS/LA/BD/ST as requiring prior approval.
When no explicit clinical criteria are listed in this excerpt, use the formulary flags as the operational trigger for PA submission.

Prior Authorization

Prior authorization required for selected specialty inhalation agents

Selected specialty inhalation and nebulized agents (e.g., ARIKAYCE, CAYSTON, inhaled tobramycin entries, various nebulized budesonide/formoterol products) are annotated PA and often LA/QL. These high-cost inhalation therapies require prior authorization and may be limited to specific quantities or distribution channels.

ARIKAYCE inhalation suspension — PA; LA.
CAYSTON inhalation solution — PA; LA; QL (84 ML per 56 days).
Nebulized agents with PA or LA must have supporting clinical documentation.

Denial Risk

Quantity-limit related denial risk

Claims exceeding listed quantity limits (QL) or that do not include required PA/LA documentation are at risk for denial. Quantity-limit exceedances should be anticipated and addressed in the initial PA submission with dose frequency and duration details.

Claims exceeding QL (e.g., INBRIJA 300 EA/30 days, various oncology QLs) may be denied if not authorized.
Request exceptions only with supporting medical necessity documentation.

Denial Risk

Utilization control triggers denial

Utilization controls noted in the table (PA, PA-NS, LA, QL, BD, B/D, ST) are active denial triggers. Prescriptions lacking the required authorization or exceeding QL may be rejected at point-of-sale or on medical claim adjudication.

PA-NS and PA entries commonly apply to oncology and specialty oral agents; absence of PA may lead to denial.
BD/B/D entries indicate specialty or limited distribution — confirm dispensing channel prior to submission.

Prior Authorization

PA/QL present for biologics and topicals

Many high-cost biologics and specialty injectables are marked PA and include QL constraints (e.g., DUPIXENT, COSENTYX, SKYRIZI, STELARA, TREMFYA, ACTEMRA, BENLYSTA, ENBREL, HUMIRA). Prior authorization submissions should include prior treatment history, diagnosis, and intended dosing consistent with plan QLs.

Biologics commonly require PA and have per-period ML or EA limits (see QL entries adjacent to each product).
Provide prior therapy and objective measures when applicable (e.g., trial of preferred agents if applicable).

Prior Authorization

PA for selected ophthalmic agents

Certain specialty products listed for ophthalmic use (e.g., CYSTARAN, OXERVATE) and select other specialty therapies are marked PA and/or LA. For ophthalmic agents flagged PA/LA, include ocular diagnosis, previous therapies, and anticipated duration of therapy in the PA documentation.

CYSTARAN ophthalmic drops — PA; LA.
OXERVATE ophthalmic drops — PA.

Documentation Required

Required documentation for PA/LA/QL

When PA is indicated (PA, PA-NS, PA; LA), submit documentation supporting medical necessity: diagnosis, relevant prior treatments, dosing regimen, and the quantity requested. For LA or BD items, confirm the permitted dispensing site or specialty pharmacy before submitting an authorization request.

Include prior treatment attempts and outcomes when applicable.
For LA/BD items, document the requested dispensing channel or confirm specialty pharmacy availability.

Documentation Required

Documentation for PA/QL requests

Documentation expectations include: clinical indication consistent with FDA labeling or accepted off‑label use, dosing and duration, prior therapy history, and justification for quantities exceeding routine dosing when requesting exceptions. Evidence of medical necessity will be required for PA approval.

Evidence of medical necessity: diagnosis, labs or objective measures (if applicable), prior agent failures or intolerances.
When requesting a quantity-limit override, include expected duration and monitoring plan.

Step Therapy

Tier/step and preferred/step implications

Some formulary entries include tiering, step-therapy indicators (ST), or numeric tier labels (e.g., 1 =, 2 =, 3 =, 4 =, 5^ =). While step therapy rules are not fully reproduced in this excerpt, providers should recognize that step edits or preferred-product requirements may apply and consult the complete policy or PBM portal for specific step requirements.

Numeric tier indicators reflect formulary tiering or specialty tiers.
ST marking denotes step-therapy may apply — check complete policy for required prior agents.

Note

No explicit authorization or denial criteria present in excerpt

Some segments of the table excerpt do not include explicit clinical criteria or authorization instructions. Where no authorization requirements are specified in this fragment, follow the plan's standard PA submission process and reference the formulary flags; contact the plan's provider helpdesk for missing or ambiguous guidance.

If the table segment lacks PA/QL text, verify coverage via provider portal or contact Health Net.
Do not assume coverage in absence of explicit 'NM' or 'covered' status — use plan systems to confirm.

Terminology and abbreviations

Definitions — PA / QL / NM / LA

PAPrior authorization required before benefit payment when 'PA' appears in table

QLQuantity limit — maximum units allowed per specified time period as listed (e.g., '14 EA per 28 days', '4 ML per 28 days')

NMNot Medically Necessary — designation appearing in the table for certain uses or ages

LALimited Approval / limited access designation shown as 'LA' adjacent to product entries

Coverage shorthand — PA / PA-NS / ST

PA (shorthand)'PA' used in listings to indicate prior authorization is required

PA-NS'PA-NS' marker used for prior authorization - non-standard entries

ST'ST' indicates Step Therapy is present for some agents (rules not included in excerpt)

Quantity limit (QL) shorthand and examples

QL examples (format)Quantity limits shown as e.g., '30 EA per 30 days', '120 EA per 30 days', '3 ML per 28 days'

QL with PASome entries show both 'PA' and explicit QL (e.g., fentanyl buccal lozenge PA; QL 120 EA per 30 days)

QL timeframesQLs use days, 28-day, 30-day, 90-day or annual (365 days) periods as specified per product

Other table annotations — LA / BD / NM

LA (Limited Approval)'LA' appears next to some products indicating limited access or restricted benefit/site; check plan rules

B/D or BDBenefit/designation markers (e.g., 'B/D', 'BD Preferred') used to indicate coverage preferences

NM labeling'NM' appears for certain vaccines or age-limited indications (e.g., SHINGRIX entries)

QL shorthand examples

QL sample formatExamples in table: '30 EA per 30 days', '14 EA per 7 days', '300 ML per 28 days'

QL unitsUnits appear as EA (each), ML (milliliter), GM (gram) depending on formulation

Time windowsLimits specified per 7, 28, 30, 56, 90, 180, or 365 day periods

LA / limited access examples

FASENRA PEN 30 mg/mLQL 1 mL per 28 days; PA; LA

FASENRA syringe 10 mg/0.5 mLQL 0.5 mL per 28 days

Bosentan oral tabletsQL 10.7 GM per 30 days; QL 60 EA per 30 days noted in listing

PA-NS (Prior Authorization - Non-Standard)

PA-NSMarker 'PA-NS' indicates prior authorization - non-standard; appears in multiple oncology and specialty listings

Use in listingsPA-NS entries often accompany QL and LA flags (document shows many PA-NS examples)

Quantity limit (QL) — definition and examples

QL (format) reiteratedQuantity limit defined as maximum units allowed per specified time period (e.g., '30 EA per 30 days')

Examples in table'30 EA per 30 days', '120 EA per 30 days', '84 ML per 56 days' as shown for various products

ST — Step Therapy (marker explanation)

ST (Step Therapy)'ST' indicates step therapy is applied for specified products (examples: AUVELITY flagged ST); explicit sequences not included here

PresenceStep therapy markers appear in product lines though full step rules are not present in excerpt

Step therapy and tier indications

Summary
No explicit step-therapy sequences are listed in the provided formulary extract; entries show utilization flags such as PA, QL, LA, PA-NS, and NM but do not define step-by-step required prior agents or tiers.

Product / Note
Some insulin and device listings show 'BD Preferred' or brand restrictions (e.g., Novolin/Relion entries note 'brand RELION not covered'), implying preferred-brand or formulary-preference behavior that may reflect step or therapeutic interchange intent.

Annotated Tier Indicators
Several antiretroviral and specialty agents are annotated with numeric/tier markers (examples: multiple HIV agents marked '5^' or '4'), and high-tier oncology agents also show '5^' — these tier markers imply specialty or higher-tier coverage status though explicit step rules are not provided.

Formulary Notation	Meaning (per extract)
1 =, 2 =, 3 =, 4 =, 5^ =
Numeric indicators used next to product entries to denote formulary tier/coverage category; '5^' frequently marks specialty/high-tier products. The extract shows these markers but does not specify step-therapy sequences.

Product	Access Restriction
HUMIRA (various pen/syringe presentations)
Coverage restricted to specific NDCs — entries state 'Only Humira NDCs starting 00074 are covered', which functions as an access restriction before other brands are eligible.

Formulary Annotation	Implication
Numeric tier markers (e.g., '1 =', '2 =', '5^') and flags (PA; QL; LA)
These annotations indicate tier assignments and utilization controls (prior authorization, quantity limits, limited access) that determine coverage category and access requirements for each listed drug line.

Product	ST (Step Therapy) Designation
FANAPT titration pack
Marked 'ST' in the extract (e.g., FANAPT titration pack shows 'ST; QL ...'), indicating a step therapy edit applies before coverage.
OPIPZA oral film (various strengths)
Entries show 'PA; QL ... = ST' indicating step therapy requirement applies to these products prior to coverage.
AUVELITY
Listed with 'ST' designation in the extract indicating step therapy applies (specific step details not provided in excerpt).

Observation	Source Example
Numeric tier indicators (1,2,3,4,5^) appear throughout the formulary and likely reflect tier or step status; explicit step sequences are not specified in the provided extract.
Examples include antiretrovirals and specialty agents annotated '5^' and other products with '1 =' through '4 =' markers (see multiple entries in the extract).

Summary
The provided extract does not contain explicit step-therapy sequences or required predecessor agents; where step edits are implied the table uses 'ST' or tier markers but does not list step-by-step rules in this segment.

Quantity limits (examples and per-product values)

BETASERON quantity limit

BETASERONQL 14 EA per 28 days

ContextListed as QL adjacent to product in injectable/biologic section

PEGASYS — presentation-dependent limits

PEGASYS subcutaneous solution 180 mcg/mLQL 4 mL per 28 days; PEGASYS syringe 180 mcg/0.5 mL QL 2 mL per 28 days

Multiple presentationsDifferent PEGASYS presentations have different QLs per listing

CINACALCET quantity limit

CINACALCET oral tablet (30/60/90 mg)QL 60 EA per 30 days (listed for 30 mg and 60 mg strengths)

StrengthsListing shows 30 mg and 60 mg strengths with same 60 EA per 30 days QL

SHINGRIX quantity limit

SHINGRIX (intramuscular)QL 2 EA per 999 days; NM noted for some age groups and PA required for certain post-transplant dosing

NotesListing indicates possible third-dose consideration post-transplant with PA

Various quantity-limit examples

Examples across product typesVarious entries show QLs such as '60 EA per 30 days', '3.6 mL per 28 days', '180 mL per 30 days' depending on product

Forms and unitsQLs appear for EA, ML, GM depending on formulation (injectable, inhalation, topical)

Bosentan — QL and annotations

bosentan oral tablet 125 mg / 62.5 mgQL 10.7 GM per 30 days; listing also shows QL 60 EA per 30 days and PA/LA annotations

Coverage flagsEntry annotated with PA; LA; QL in table

FASENRA — pen/syringe QL examples

FASENRA pen 30 mg/mLQL 1 mL per 28 days; PA; LA

FASENRA syringe 10 mg/0.5 mLQL 0.5 mL per 28 days (syringe presentation)

KALYDECO quantity-limit example

KALYDECO oral tablet 150 mgQL 56 EA per 28 days; PA and LA annotations present for some presentations

Granules and packet formsGranules/packets also listed with same 56 EA per 28 days QL

Nebivolol / Atorvastatin — QL per strength

Nebivolol (various strengths)QL 30 EA per 30 days or QL 60 EA per 30 days depending on strength

AtorvastatinQL 30 EA per 30 days for some entries

Atorvastatin quantity-limit example

Atorvastatin oral tablet (various strengths)QL 30 EA per 30 days (listed for some tiered entries)

ContextShown in cholesterol/lipid section with QL annotation

Vancomycin — various QL limits

Vancomycin IV/oral preparationsMultiple QLs depending on formulation: e.g., 4000 mL per 10 days (IV piggyback), 20 EA per 10 days (oral capsule) — see listing

Formulation-specific limitsDifferent QLs apply to recon solutions, piggybacks and oral capsules

Inhaled antibiotics — QL examples (CAYSTON / ARIKAYCE / tobramycin)

CAYSTON inhalation solutionQL 84 mL per 56 days; PA; LA

ARIKAYCE inhalation suspensionPA; LA noted in listing

Tobramycin inhalationExample QLs include 280 mL per 28 days depending on presentation

DESCOVY — QL example

DESCOVY oral tabletQL 30 EA per 30 days

ContextListed in antiretroviral section with 30 EA per 30 days QL

PAXLOVID — QL example

PAXLOVID dose packQL 20 EA per 90 days (150/100 mg pack) or QL 30 EA per 90 days for alternate packings

Pack-dependent limitsDifferent PAXLOVID pack sizes have distinct QLs per 90-day window

PREZISTA — suspension QL example

PREZISTA oral suspension 100 mg/mLQL 400 mL per 30 days

PREZISTA tabletsSeparate QLs for tablet strengths (e.g., 240 EA per 30 days for 150 mg)

Voriconazole — QL example

Voriconazole oral tablet 200 mgQL 120 EA per 30 days

Other voriconazole formulationsSuspension and IV presentations have PA and different QLs noted

ALECENSA — QL example

ALECENSA oral capsule 150 mgQL 240 EA per 30 days; PA-NS; LA

ContextListed in oncology section with PA-NS and QL

Dasatinib / sunitinib — QL examples

Dasatinib (selected strengths)QL 30-60 (EA) per month depending on strength

Sunitinib malate oral capsuleQL 28 EA per 28 days

KISQALI — QL examples

KISQALI various packingsQL ranges shown 21-91 EA per 28-30 days depending on packing/ dosing regimen

ContextPack-specific QLs listed in oncology regimen entries

IMBRUVICA — QL example

IMBRUVICA (various formulations)QL 30 EA per 30 days noted for some listings

Formulation variationDifferent presentations may have same standard monthly QL

PIQRAY — QL examples

PIQRAY oral tabletQL 28 EA per 28 days (200 mg/day) and QL 56 EA per 28 days for alternate dosing regimens

PA-NSListed with PA-NS in oncology section

Sunitinib — QL example

Sunitinib malate oral capsuleQL 28 EA per 28 days

ContextOncology oral targeted agent with PA-NS and QL in listing

VENCLEXTA — QL example

VENCLEXTA oral tablet 10 mgQL 14 EA per 7 days (as listed)

Pack/starting regimensSpecific starting packs / dose packs also annotated with QL elsewhere in oncology section

ZEJULA — QL range example

ZEJULA oral tabletQL range 30-90 EA per 30 days depending on strength/presentations

NotesDifferent tablet strengths/prescribed regimens determine the specific QL

DUPIXENT — pen and syringe volumes

DUPIXENT PEN 200 mg / 1.14 mLQL 4.56 mL per 28 days

DUPIXENT PEN 300 mg / 2 mLQL 8 mL per 28 days

DUPIXENT syringe presentationsSyringe 200 mg/1.14 mL QL 4.56 mL per 28 days; syringe 100 mg QL 1.34 mL per 28 days

Fluorouracil topical — QL example

Fluorouracil topical cream 5%QL 40 GM per 30 days

Fluorouracil topical solutionQL 10 ML per 30 days (solution presentations)

Imiquimod — QL example

Imiquimod topical cream 5% (packet)QL 24 EA per 28 days

Presentation noteListed as packet with QL in dermatologic section

Lidocaine topical patch — QL example

Lidocaine topical adhesive patch, medicated 5%QL 90 EA per 30 days; PA noted in listing

Lidocaine other formsTopical ointment/solutions have separate QLs (e.g., 50 GM per 30 days)

Clobetasol topical — QL example

Clobetasol topical gel 0.05%QL 60 GM per 28 days

Scalp solutionClobetasol scalp solution QL 30 GM per 28 days (other conversions shown)

COSENTYX — QL examples

COSENTYX (various presentations)QL 10 mL per 28 days (pen presentations noted)

COSENTYX 75 mg/0.5 mLQL 2.5 mL per 28 days

COSENTYX 75 mg/0.5 mL — volume example

COSENTYX 75 mg/0.5 mL (specific)QL 2.5 mL per 28 days

Other COSENTYX formsFull biologic section lists 10 mL per 28 days for some presentations

SKYRIZI — QL examples

SKYRIZI subcutaneous pen 150 mg/mLQL 6 mL per 365 days (subcutaneous); SKYRIZI IV solution QL 30 mL per 180 days

Notes on wearable injectorWearable injector presentations have separate per-56-day QLs (see SKYRIZI wearable entries)

STELARA — QL examples

STELARA 45 mg/0.5 mLQL 0.5 mL per 28 days; PA indicated for listed presentations

STELARA 90 mg/mLQL 1 mL per 28 days (syringe 90 mg/mL) depending on listing

TREMFYA — induction and maintenance QLs

TREMFYA pen induction (200 mg/2 mL)QL 12 mL per 180 days (induction PK-CROHN presentation)

TREMFYA maintenance presentationsQL 2 mL per 28 days

TREMFYA (maintenance) — QL example

TREMFYA maintenanceQL 2 mL per 28 days

Induction noteInduction PK-CROHN pen shows larger 12 mL per 180 days QL

Metronidazole / tazarotene / tretinoin topical QLs

Metronidazole topical gel 0.75%QL 45 GM per 30 days

Tazarotene topical cream 0.1%QL 60 GM per 30 days; PA on cream presentation

Tretinoin topical cream/gelQL 45 GM per 30 days; PA indicated on multiple formulations

Ophthalmic agents — PA/LA examples

CYSTARAN ophthalmic drops 0.44%PA; LA (limited access) indicated in listing; QL not specified in cited chunk

OXERVATE ophthalmic drops 0.002%PA indicated in listing

ACTEMRA — pen/syringe QL

ACTEMRA ACTPEN 162 mg/0.9 mLQL 3.6 mL per 28 days; PA indicated

ACTEMRA syringe presentationsSyringe listed with same 3.6 mL per 28 days QL

Colchicine — QL example

Colchicine 0.6 mgQL 120 EA per 30 days

Presentation noteListed for capsule and tablet forms with same QL

PROLIA / Inflectra — QL examples

PROLIA (denosumab) 60 mg/mL syringeQL 1 mL per 180 days

Inflectra IV recon soln 100 mgQL 20 EA per 30 days

PROLIA / Teriparatide — QL and NDC note

Prolia / STOBOCLO subcutaneous syringe 60 mg/mLQL 1 mL per 180 days

Teriparatide subcutaneous pen injectorQL 2.48 mL per 28 days; Only Teriparatide NDC 47781065289 is covered for one listed presentation

Teriparatide — QL and NDC-specific coverage

Teriparatide pen injectorQL 2.48 mL per 28 days; PA noted on some pen entries

NDC-specific coverageOnly Teriparatide NDC 47781065289 is covered for specified listing

Alosetron — QL example

Alosetron 0.5 mg / 1 mgQL 60 EA per 30 days; PA applies

Formulation noteBoth 0.5 mg and 1 mg strengths listed with same QL

Inflectra — QL example

Inflectra IV recon soln 100 mgQL 20 EA per 30 days; PA indicated

ContextListed in biologic/infusion section

SKYRIZI IV and wearable — QL examples

SKYRIZI IV solution 60 mg/mLQL 30 mL per 180 days; PA indicated

SKYRIZI wearable injectorSeparate per-56-day QLs (1.2 mL or 2.4 mL) depending on wearable presentation

Armodafinil — QL examples

Armodafinil (150-250 mg)QL 30 EA per 30 days; PA indicated for some strengths/presentations

Lower-strength armodafinil50 mg listed with QL 60 EA per 30 days

INVEGA TRINZA — per-90-day volume range

INVEGA TRINZA (various strengths)QL 0.88 - 2.63 mL per 90 days depending on strength (0.88, 1.32, 1.75, 2.63 mL listed)

INVEGA SUSTENNA/HAFYERASeparate per-28/180-day QLs also listed for other INVEGA products

ZURZUVAE — annual limits

ZURZUVAE 20 / 25 mgQL 28 EA per 365 days

ZURZUVAE 30 mgQL 14 EA per 365 days

Note

OpenPayer

Pharmacy and specialty drug formulary — coverage criteria (partial list)

Coverage criteria and product annotations

Coding, NDCs and formulary flags

Prior authorization, documentation, and denial risk

Document context and scope

Terminology and abbreviations

Step therapy and tier indications

Quantity limits (examples and per-product values)

Biosimilar preferences and brand restrictions