HealthPartners Pharmacy Formulary Coverage Update

Quantity Limit Review Criteria

Coverage decisions and overrides

Quantity limit override: Requests above the quantity limit will be reviewed for medical necessity and must include evaluation of the diagnosis, alternatives previously tried, prior use of the requested product within the quantity limit, and evidence of efficacy and safety at the quantity requested.QL exceeded

Supports prior authorization review

Step Therapy Coverage

Step therapy coverage logic

Step therapy requirement: A medicine with step therapy will be covered if the member has already tried the required prior medicine(s); if prior steps have not been completed, prior approval from HealthPartners is required before the medicine will be covered at the lower cost-share.prior trial of specified agents

Approval needed if prior steps not met

Formulary administrative criteria

Coverage and administrative requirements as listed for products in this section

Formulary entries: Products are listed with a Drug Tier and 'Requirements Limits' flags (examples shown: ACA, PA, QL, S, ONC, TD). Coverage for each product follows the listed requirement: ACA indicates mandated/ACA-related coverage, PA indicates prior authorization is required before coverage, QL indicates a numeric quantity limit, and S/ONC/TD indicate specialty/program routing or trial distribution requirements.

Administrative flags reflect coverage pathways; no clinical medical necessity criteria are provided in these chunks.

Coverage stance by formulary entry

Formulary coverage and requirements as listed per product entry

Entry-level: Each product row indicates Drug Tier and Requirements Limits; coverage is subject to those stated requirements. Examples: contraceptives and related devices marked 'ACA' are covered under ACA provisions; products marked 'PA' require prior authorization before coverage; products with 'QL' are limited to the stated quantity (e.g., ANNOVERA QL 1 per 273 days; emergency oral levonorgestrel QL 3 per 30 days; condoms QL 60 per 30 days).

Reflects product-level coverage stance as listed in the formulary table.

Failure to obtain required Prior Authorization (PA) may result in a prescription not being covered under the HealthPartners pharmacy benefit. Drugs that are flagged with PA in the formulary must have prior approval from the payer before coverage will be provided.

Within the provided formulary excerpts there are no explicit medical exclusions stated. Product rows show administrative flags such as PA, QL and ACA, but the text in these chunks does not list medicines as specifically excluded for medical reasons.

The excerpted lines do not present explicit exclusion statements. Entries list device and product coverage annotations (for example ACA, QL, PA) but do not identify any products as expressly excluded from coverage for clinical or medical-necessity reasons.

This section only shows product-level requirement and limit codes (e.g., PA, QL) for ophthalmic and related entries. There are no explicit exclusion rules stated in the provided lines — only the per-product requirement/limit annotations are shown.

Within the supplied extract there are no statements identifying items as 'not medically necessary'. The lines include requirement flags and tiering but do not contain explicit 'not medically necessary' determinations.

Formulary Listings and Coding Examples

Formulary drug listings and limits (examples)mixedCovered

NOXAFIL ORAL SUSP,DELAYED RELEASE FOR RECON 300 MG	listed with Drug Tier = 3, Requirements Limits = PA
nystatin oral suspension 100,000 unit/ml	listed with Drug Tier = 3, Requirements Limits = QL (480 per 30 days)
posaconazole oral suspension 200 mg/5 ml (40 mg/ml)	listed with Drug Tier = 3, Requirements Limits = PA
voriconazole oral tablet 200 mg, 50 mg	listed with Drug Tier = 3, Requirements Limits = PA
abacavir oral tablet 300 mg	listed with Drug Tier = 3, Requirements Limits = .
acyclovir oral tablet 400 mg, 800 mg	listed with Drug Tier = 3, Requirements Limits = .

Sample formulary entriesmixed

nystatin oral suspension 100,000 unit/ml	Listed with Drug Tier = 3; QL (480 per 30 days)
posaconazole oral suspension 200 mg/5 ml (40 mg/ml)	Drug Tier = 3; Requirements Limits = PA
voriconazole oral tablet 200 mg, 50 mg	Drug Tier = 3; Requirements Limits = PA
abacavir oral solution 20 mg/ml	Drug Tier = 3
BIKTARVY ORAL TABLET 30-120-15 MG	Drug Tier = 3
EPCLUSA ORAL TABLET 200-50 MG	Requirements Limits = PA; S
HARVONI ORAL TABLET 45-200 MG	Requirements Limits = PA; S
LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG	Drug Tier = 6; Requirements Limits = PA; S
MAVYRET ORAL TABLET 100-40 MG	Drug Tier = 6; Requirements Limits = PA; S

Antiviral dose packs and QLsmixedCovered

oseltamivir oral capsule 30 mg	Drug Tier = 3; QL (20 per 30 days)
oseltamivir oral capsule 45 mg, 75 mg	Drug Tier = 3; QL (10 per 30 days)
PAXLOVID ORAL TABLETS, DOSE PACK 150	Drug Tier = 3; QL (4 per 1 day)
PAXLOVID ORAL TABLETS, DOSE PACK 300 MG	Drug Tier = 3; QL (6 per 1 day)

Misc antiinfectives with PA/QLmixed

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML	Drug Tier = 4; Requirements Limits = PA; QL (180 per 30 days)
linezolid oral tablet 600 mg	Drug Tier = 3; Requirements Limits = QL (2 per 1 day)
XIFAXAN ORAL TABLET 200 MG, 550 MG	Drug Tier = 3; Requirements Limits = PA

Antibiotics (selected entries)mixed

amoxicillin oral suspension for reconstitution 125 mg/5 ml	Drug Tier = 3
amoxicillin oral tablet 500 mg	Drug Tier = 3
amoxicillin-pot clavulanate oral tablet 250-125 mg	Drug Tier = 3
ampicillin oral capsule 500 mg	Drug Tier = 3
dicloxacillin oral capsule 250 mg	Drug Tier = 3

Fluoroquinolones & Sulfonamidesmixed

ciprofloxacin hcl oral tablet 250 mg	Drug Tier = 3
levofloxacin oral tablet 250 mg	Drug Tier = 3
moxifloxacin oral tablet 400 mg	Drug Tier = 3
sulfadiazine oral tablet 500 mg	Drug Tier = 4; Requirements Limits = PA
sulfamethoxazole-trimethoprim oral tablet 400-80 mg	Drug Tier = 3

Antineoplastic & immunosuppressant agentsmixed

abiraterone oral tablet 250 mg	Requirements Limits = PA; ONC; TD; S
anastrozole oral tablet	Drug Tier = 7; Requirements Limits = ONC
capecitabine oral tablet 150 mg	Requirements Limits = ONC; S
dasatinib oral tablet 100 mg	Requirements Limits = PA; ONC; TD; S
everolimus (antineoplastic) oral tablet 10 mg	Requirements Limits = PA; ONC; TD; S; QL (1 per 1 day)

Targeted cancer therapiesmixed

ROZLYTREK ORAL CAPSULE 100 MG	Requirements Limits = PA; ONC; TD; S; QL
TAGRISSO ORAL TABLET 40 MG	Drug Tier = 7; Requirements Limits = PA; ONC; TD; S; QL (1 per 1 day)
TAFINLAR ORAL CAPSULE 50 MG	Requirements Limits = PA; ONC; S

Product entries (no billing codes in this excerpt)mixed

N/A	No explicit CPT/HCPCS/ICD-10/NDC codes present in these chunks; only product names, formulations, and tiers are listed.

Formulary products (examples)NDC|product

XELJANZ XR 11 MG, 22 MG

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

Selected products with PA notedproduct

BIJUVA	BIJUVA ORAL CAPSULE 0.5-100 MG, 1-100 MG
DUAVEE	DUAVEE ORAL TABLET 0.45-20 MG
MYFEMBREE	MYFEMBREE ORAL TABLET 40-1-0.5 MG
ORIAHNN	ORIAHNN ORAL CAPSULE, SEQUENTIAL 300-1-0.5MG(AM) /300 MG(PM)
OSPHENA	OSPHENA ORAL TABLET 60 MG

Contraceptive devices and patchesproductCovered

ANNOVERA	ANNOVERA VAGINAL RING 0.15-0.013 MG/24 HOUR
TWIRLA	TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24 HR
VCF	VCF CONTRACEPTIVE FILM VAGINAL FILM 28 %

Oral contraceptives — tiers and limitsmixedCovered

QL (3 per 30 days)	Quantity limit for certain oral contraceptives (3 per 30 days)
Drug Tier = 3	Tier assignment for listed oral contraceptives
Requirements Limits = ACA	Coverage requirement/limit code (ACA)

Ophthalmic products — tiers and requirement codesmixedCovered

PA	Prior authorization required (appears for several ophthalmic agents)
QL (5 per 30 days)	Quantity limit for CYSTADROPS
QL (15 per 30 days)	Quantity limit for CYSTARAN
S	Specialty or site restriction
Drug Tier = 4	Tier assignment for some ophthalmic products (e.g., LEVOFLOXACIN 0.5% listed as Tier 4)

inv-25: nystatin oral suspension limit — 480 per 30 days

Productnystatin oral suspension 100,000 unit/ml — QL 480 per 30 days

Limit value480 per 30 days

Formulary tier/contextListed as Drug Tier = 3 with Requirements Limits = QL

inv-26: Quantity limits examples

Nystatin suspensionQL 480 per 30 days

Oseltamivir oral capsule 30 mgQL 20 per 30 days

ALINIA oral suspension 100 mg/5 mLQL 180 per 30 days

inv-27: Quantity limits examples

Tetracycline oral capsule 250 mgQL 56 per 30 days

Fosfomycin tromethamine oral packet 3 gramQL 3 per 30 days

Formulary contextBoth entries show explicit QL values in the Requirements Limits column

inv-28: Example Quantity Limits — includes per day and per 30 day fractions

Per-day fractional QLs (examples)QL values expressed as fractions per day (e.g., QL 1 per 1 day; QL 2 per 1 day)

Per-30-day QLs (example)QL entries also shown as 'per 30 days' in the table

Usage noteFormulary displays QL using both per-day fractions and per-30-day totals depending on product presentation

inv-29: Quantity Limits examples — multiple fractional/day examples

Fractional/day examplesQLs expressed as fractional per day values (e.g., 0.4 per 1 day; 0.429 per 1 day; 0.167 per 1 day)

Higher per-day QLsExamples include QL 4 per 1 day and QL 2 per 1 day for certain products

Extended-period examplesSome QLs reference multi-day denominators (e.g., 28 per 273 days) as shown in the table

inv-30: Acyclovir topical quantity limit — 15 per 30 days

Productacyclovir topical ointment 5% — QL 15 per 30 days

Formulary tier/contextListed with Requirements Limits = QL in topical antivirals section

Coverage implicationRequests exceeding QL may be reviewed for medical necessity per documentation guidance

inv-31: Nystatin/topical powder quantity limit — 240 per 30 days

Productnystatin topical powder 100,000 unit/gram — QL 240 per 30 days

Related topical entriesTopical antifungals show QL examples such as mupirocin 44 per 30 days and other QLs per day or per 30 days

Formulary contextTopical powders/creams display QL in Requirements Limits column

inv-32: Baqsimi / glucagon kit quantity limit — 4 per 30 days

BAQSIMI nasal spray 3 mgQL 4 per 30 days

Glucagon emergency kit (human)QL 4 per 30 days

Formulary noteEmergency glucagon products are documented with QL entries in the formulary table

inv-33: Quantity limits examples — SHINGRIX QL 1 per 30 days; biologics as per-day fractions

SHINGRIX (vaccine)QL 1 per 30 days (ACA-designated) — example

BiologicsMany biologics display fractional per-day QL values (e.g., 0.129 per 1 day in selected entries)

Provider actionProducts with QL require adherence to listed quantities; PA may also apply for biologics

inv-34: Quantity limits examples — 2 per 1 day; 60 per 30 days; 1 per 273 days; etc.

Common examplesQL 2 per 1 day; QL 60 per 30 days; QL 1 per 273 days — shown in contraceptive/device and other product rows

Emergency contraceptionlevonorgestrel oral tablet 1.5 mg — QL 3 per 30 days (example of 30-day QL)

Long-interval deviceANNOVERA vaginal ring — QL 1 per 273 days (device-specific QL)

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required — Flagged Products

Certain medicines listed in the drug table are designated with requirement flags (for example: PA, S, ST, QL, ONC, ACA). When a product is marked PA (Prior Authorization) the prescriber or member must obtain prior authorization from HealthPartners before the drug will be covered under the pharmacy benefit. Failure to secure required PA may result in claim denial or non‑coverage.

PA indicates Prior Authorization is required before coverage.
S indicates specialty routing or specialty program requirements.
ST indicates Step Therapy — preferred alternatives must be tried first.
QL indicates a Quantity Limit — requests above the listed amount will be reviewed.

Prior Authorization

Prior Authorization Required for Many Agents

Many specialty, oncology, injectable, and select oral agents in the formulary are subject to prior authorization. Examples include oral oncology agents, biologics, palforzia allergy products, select antiviral and specialty antiviral agents, and many GLP‑1 / diabetes agents (liraglutide, semaglutide products, tirzepatide, etc.). For these products the Requirements Limits field will include PA, often together with S (specialty) and/or QL.

Specialty and oncology agents commonly show PA; some also require specialty routing (S) and have quantity limits (QL).
Selected antiviral regimens and hepatitis C agents include PA and may also include S.
Selected GLP‑1 and other diabetes agents are listed with Requirements Limits = PA and may have QLs.

Documentation Required

Documentation and Quantity‑Limit Overrides

Prescribers must submit supporting documentation with PA requests and for any requests that exceed a product’s quantity limit. Documentation should demonstrate medical necessity and include diagnosis, prior therapies tried (including dates and outcomes), relevant lab or clinical data, and rationale for the requested quantity or agent.

Requests above a QL are reviewed for medical necessity and require documentation of diagnosis and alternatives tried.
Program‑specific flags (ONC, TD, S, QL) require corresponding documentation per HealthPartners procedures.
When a product is flagged PA or S, include clinical rationale and any specialty pharmacy routing details in the submission.

Denial Risk

Denial Risk — PA and Quantity Limits

PA and QL flags on the drug list are operational triggers — claims submitted for products marked PA without an approved authorization or for quantities exceeding the listed QL are at risk of denial at point of adjudication. Providers should verify authorization status before dispensing and follow HealthPartners’ PA submission process.

Claims for PA‑listed drugs may be denied if an authorization is not in place.
Claims exceeding QL will be subject to review and may be denied without adequate supporting documentation.
Specialty program flags (S) and step‑therapy flags (ST) can also trigger coverage edits or channeling to a specialty pharmacy.

Step Therapy

Step Therapy and Specialty Program Indicators

Step therapy and specialty program indicators appear on some entries. ST indicates a step‑therapy requirement (for example, certain PCSK9/REPATHA entries), and S indicates specialty pharmacy routing or program participation. Where step therapy applies, members must have trialed required alternatives or obtain an exception/approval.

ST = Step Therapy; patient must try specified preferred medicines first or obtain approval.
S = Specialty program or specialty pharmacy routing required.
If step therapy or specialty routing is listed, include prior treatment history and rationale when requesting PA.

Definitions and Abbreviations

inv-94: Specialty medicines — specialty medicines definition/notes

DefinitionSpecialty medicines: prescribed for chronic/complex diseases, often high-cost, requiring more management and specialty pharmacy fills

Benefit implicationSpecialty medicines are often covered under a different benefit and must be filled at a specialty pharmacy

Administration noteProviders and members should check plan benefits for specialty medicine coverage details

inv-95: Formulary abbreviations — PA, ST, QL, AL, ONC, OP, TD

PAPrior Authorization

STStep Therapy

QLQuantity Limit

ALAge Limit

ONCOncology Benefit

inv-96: PA — Prior Authorization definition

TermPrior Authorization (PA) — coverage requires approval prior to dispensing

ImplicationPrescriber must obtain authorization per plan processes or coverage may be denied

Table usePA appears in the Requirements Limits column next to affected products

inv-97: QL — Quantity Limit definition

TermQuantity Limit (QL) — maximum allowed quantity in specified time period

FormatQL values shown as numeric totals per time (e.g., per 30 days) or as fractional per-day values

Clinical actionRequests above QL reviewed for medical necessity and require supporting documentation

inv-98: S — Specialty or program-specific requirement (table indicator)

IndicatorS — Specialty or program-specific requirement (table indicator) — appears alongside PA/QL for some products

MeaningMay indicate specialty routing, step/supplemental program, or specialty pharmacy handling

ExamplesUsed for oncology and other specialty product rows in the formulary table

inv-99: ACA — Administrative/coverage annotation (table start reference)

TermACA — Affordable Care Act annotation indicating preventive/mandated coverage for specified products

Table usageAppears in Requirements Limits to denote ACA-mandated coverage for vaccines, contraceptives, some smoking cessation products

Coverage implicationACA-designated products may have different coverage rules; see table header and plan details

inv-100: Requirement/limit codes — mapping summary (PA, QL, ONC, TD)

PAPrior Authorization — requires pre-approval before coverage

QLQuantity Limit — numeric limit shown per time period

ONC/TD/SONC = Oncology Benefit; TD = Trial Drug; S = Specialty — program/handling flags

inv-101: PA — PA flag appearing in Requirements Limits

PA flagIndicates prior authorization requirement appearing in the Requirements Limits field

ImplicationClaims without PA may be denied for PA-flagged products

Provider actionObtain PA per HealthPartners processes before dispensing

inv-102: QL — Quantity Limit examples in Requirements Limits

QL examplesQuantity Limits shown numerically (e.g., '1 per 1 day', '4 per 30 days'); may be per day fractions or per 30 days

Table locationQL appears in Requirements Limits column next to product rows

ImplicationRequests exceeding QL will be reviewed for medical necessity

inv-103: ONC — Oncology-related requirement flag

PAPrior Authorization — coverage requires approval before dispensing

UseDenoted beside product entries to indicate PA requirement

ConsequenceFailure to obtain PA may lead to claim denial

inv-104: PA — Prior Authorization definition (re-iterated)

PA (re-iterated)Prior Authorization — requires pre-approval prior to dispensing; appears in Requirements Limits

Provider responsibilitySubmit supporting clinical information when requesting PA

Denial riskClaims may be denied without required PA

inv-105: QL — Quantity Limit (re-iterated)

QL (re-iterated)Quantity Limit — maximum allowed quantity per specified time period (numeric or fractional per day)

ExamplesShown as 'per 1 day' fractions or 'per 30 days' totals in product rows

OverrideRequests above QL require documentation for medical necessity

inv-106: S — Step therapy or supplemental requirement (re-iterated)

S (re-iterated)Specialty designation/step/supplemental requirement used in the table to indicate specialty handling or program-specific rules

ExamplesUsed for hepatitis C, oncology, and other specialty products (e.g., LEDIPASVIR-SOFOSBUVIR marked PA; S)

Operational noteS may indicate specialty pharmacy routing or enrollment requirements

inv-107: PA — Prior Authorization (definition)

PAPrior Authorization — coverage requires approval prior to dispensing (definition)

Table usageFlagged as PA in Requirements Limits column

Provider actionObtain PA per payer procedures before dispensing for PA items

inv-108: QL — Quantity Limit (definition)

QL — definitionQuantity Limit — numeric maximum permitted within specified time period; shown per day or per 30 days

FormatMay appear as absolute count (e.g., 15 per 30 days) or fractional per-day rate (e.g., 0.071 per 1 day)

ReviewOverrides require medical necessity documentation

inv-109: PA — Prior Authorization (definition repeated)

PA (repeated)Prior Authorization — coverage requires approval before dispensing

ImplicationPA appears as a Requirements Limits flag and triggers prior review

DocumentationProviders must supply clinical rationale when seeking PA

inv-110: QL — Quantity Limit (definition repeated)

QL (repeated)Quantity Limit — maximum allowed units per specified time period; may be shown as per day or per 30 days

ExamplesExamples include QL (1 per 1 day) or QL (60 per 30 days)

Provider noteExceeding QL will prompt medical necessity review

inv-111: S — Specialty designation (definition repeated)

S — specialty designationIndicates specialty-managed product; specialty medicines require specialty pharmacy fills

Benefit noteSpecialty medicines often covered under a different benefit than retail drugs

Check planMembers/providers should verify specialty coverage via myHealthPartners or plan details

inv-112: Prior Authorization required for coverage — PA

PA requirementPrior Authorization required for coverage — products marked PA must have authorization before dispensing

ConsequencesFailure to obtain PA may result in the medication not being covered under pharmacy benefits

Provider actionSubmit PA per HealthPartners procedures with supporting clinical information

inv-113: Quantity Limit (numerical limit per time period shown) — QL

QL definitionQuantity Limit — numerical limit per time period shown in Requirements Limits (e.g., '4 per 30 days')

DisplayQLs appear alongside product rows as per-day fractions or per-30-day totals

Override processRequests exceeding QL reviewed for medical necessity and require documentation

inv-114: Step therapy requirement — S

S — step therapyIndicates a step therapy requirement where specified preferred medicines must be tried first

Operational noteIf prior steps not met, prior approval is required before coverage at lower cost-share

Table usageDenoted as 'S' or 'ST' in Requirements Limits for some products

inv-115: Coverage references/conditions — ACA / SC references present in table header

Coverage referencesACA / SC annotations appear in table header to indicate special coverage conditions (e.g., ACA-mandated preventive coverage)

InterpretationRefer to table header and plan details to interpret ACA/SC annotations

ExamplesVaccines and certain contraceptives are marked ACA in the formulary

inv-116: QL — QL examples (4 per 30 days)

Example QL valueQL 4 per 30 days (e.g., BAQSIMI, glucagon kits) — shown in the formulary table

InterpretationQL values may be per 30 days for emergency medications and per day fractions for chronic injectables

Provider actionAdhere to listed QL or submit documentation for exceptions

inv-117: PA — PA = prior authorization required

PA — summaryPA = prior authorization required (flag in Requirements Limits)

ActionObtain pre-approval per payer processes; lack of PA may cause denial

Where shownAppears next to many antiviral, specialty and other high-cost products in the formulary

inv-118: S — specialty designation / pharmacy requirement

S — specialty markerIndicates specialty designation, program or step requirement; may trigger specialty routing

ExamplesUsed for some hepatitis C and oncology agents in Requirements Limits

Provider implicationProducts marked S may require specialty pharmacy fill or program enrollment

inv-119: PA — PA indicated in Requirements Limits

PA indicator in tablePA is indicated in the Requirements Limits column for applicable products

ImplicationWhen PA is present, coverage depends on prior approval

Provider actionFollow payer PA submission processes and provide clinical justification

inv-120: QL — Quantity Limit (e.g., 1 per 1 day)

QL — numeric formatQuantity Limit entries such as '1 per 1 day' or fractional per-day values appear in Requirements Limits

ExamplesSome stimulant or migraine therapies show fractional/day QLs (e.g., 0.429 per 1 day)

Clinical noteQLs limit dispensed quantity; exceptions require documentation

inv-121: S — Specialty drug designation appears in Requirements Limits

S in Requirements LimitsS appears in Requirements Limits to denote specialty-managed products

ExamplesAppears for oncology, biologic and other specialty agents

Operational effectMay require specialty pharmacy dispensing or program enrollment

inv-122: ACA — ACA-related coverage flag in Requirements Limits

ACA mappingACA indicates Affordable Care Act-related coverage notation present in Requirements Limits for some agents

UsageUsed for vaccines, contraceptives, smoking cessation products in table examples

Coverage implicationACA-marked products may have mandated coverage per federal guidelines

inv-123: Requirements Limits abbreviations — ACA, PA, QL mapping

Abbreviations listRequirements Limits abbreviations include ACA, PA, QL (used in table to denote coverage/authorization rules)

Interpretation adviceRefer to table header and plan documentation for full meaning and implications

ExamplesACA — preventive; PA — prior authorization; QL — quantity limit

inv-124: Requirements Limits codes — ACA, PA, QL, S explained

Codes explainedRequirements Limits codes (ACA, PA, QL, S) indicate coverage restrictions such as ACA-mandated coverage, prior authorization, quantity limits, or specialty/site requirements

Provider actionFollow the indicated requirement for each product row to determine coverage and authorization steps

Where shownCodes appear in the Requirements Limits column throughout the formulary table

Step Therapy Rules

Step therapy statement	Notes / implication
Try specified preferred medicines first
A medicine with step therapy will be covered only if the member has already tried required prior medicine(s); if not, prior approval from HealthPartners is required before coverage at the lower cost-share.

Step therapy / specialty flag	Examples / implication
'S' indicator present on some hepatitis C agents
Examples include LEDIPASVIR‑SOFOSBUVIR and MAVYRET which are listed with Requirements Limits = PA; S, indicating specialty/step program requirements before coverage.

Flag(s)	Interpretation / example agents
'TD' and 'S' flags on oncology/specialty agents
Antineoplastic entries (e.g., abiraterone, everolimus) include PA; ONC; TD; S — indicating specialty distribution or program enrollment may be required as part of access prior to coverage.

Flag	Coverage implication / examples
'TD' or 'ONC' flags for oncology agents
Targeted cancer therapies (ROZLYTREK, TAGRISSO) and other oncology drugs show ONC or TD flags; these denote oncology benefit/specialty handling and may require specialty routing or program steps before coverage.

Designation	Meaning / examples
'S' designation on products
Several products (for example AUSTEDO, EVRYSDI) carry 'S' indicating step therapy or specialty clinical edit applies and must be followed per formulary requirements.

Observation	Implication
No explicit step sequences listed in some sections
Portions of the formulary list products with PA, QL, and Tier designations but do not provide step-by-step therapy algorithms; utilization management is implemented via PA, QL, and tiering where present.

Step therapy flag	Example / note
'ST' indicated for some agents
REPATHA SureClick and syringe entries are labeled ST; QL (0.071 per 1 day), indicating step therapy (ST) is required before coverage at the listed benefit level.

'S' specialty/step marker	Examples
'S' required for certain specialty oral agents
Examples include carglumic acid and deferasirox which are listed with Requirements Limits = PA; S, indicating specialty program or step requirements and that PA/submission is required.

PA noted	Examples (GLP‑1 / diabetes agents)
Prior authorization indicated for several GLP‑1 / diabetes agents
MOUNJARO, liraglutide and OZEMPIC entries are shown with Requirements Limits = PA and have numeric QL values (e.g., liraglutide QL 0.3 per 1 day), indicating PA applies for these agents.

Coverage annotation	Implication / examples
'ACA' or 'S' on vaccines and biologics
Some vaccines and biologics are annotated ACA (Affordable Care Act preventive coverage) or S (specialty); examples include AREXVY and PALFORZIA levels which show ACA or PA; S markings implying special coverage pathways or program requirements.

Observation	Interpretation
Step therapy often implied rather than explicit
In many formulary sections step therapy is implied by tiering and presence of PA/S/QL flags; explicit step-by-step sequences are not present within the extracted chunks.

OpenPayer

2026 Formulary (Drug List) — Pharmacy Coverage Criteria

Coverage Criteria

Formulary Listings and Coding Examples

Provider Actions and Authorization Requirements

Definitions and Abbreviations

Initial Therapy Criteria

Step Therapy Rules

Quantity Limits (Selected Items)

Site of Care and Specialty Pharmacy Routing

Background