Pharmacy and specialty drug formulary — coverage criteria (partial list)
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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.
No material clinical or coverage changes in this revision.
Coverage criteria and product annotations
PA + Quantity Limit Requirements
Coverage requires meeting payer-specified prior authorization and quantity limits as noted for each product.
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.
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.
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
| LX | Unknown short code appearing in header: 'LX rizatriptan Smg 53' |
| 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) |
| No codes listed |
| No codes listed |
| 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 |
| 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) |
| 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) |
| 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) |
| 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 47781065289 | Only Teriparatide NDC covered (document states only this NDC is covered) |
| N/A | This extract lists NDC/CPT codes are not provided; items are drug name and formulation entries with utilization flags. |
| 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 |
| 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 |
| No codes listed |
Prior authorization, documentation, and denial risk
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.
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.
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.
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 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.
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.
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.
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).
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.
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 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.
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.
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.
Document context and scope
Background: the provided material is a partial formulary/index from Health Net's pharmacy and specialty drug policy. It enumerates products, formulations, and plan annotations (e.g., PA, QL, NM, LA) at the line level to indicate coverage requirements and utilization management controls rather than providing full clinical criteria within this extract.
Terminology and abbreviations
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)
Biosimilar preferences and brand restrictions
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