CurrentHealthPartnersPolicy N/A

2025 HealthPartners HSA Plus Formulary (Part 1) - Pharmacy Coverage Criteria

Defines the HealthPartners HSA Plus 2025 pharmacy formulary structure, tiering, specialty medicine definitions, and common limits/restrictions that govern outpatient prescription coverage for plan members and providers.

Policy Summary

PayerHealthPartners

Policy2025 HealthPartners HSA Plus Formulary (Part 1) - Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateOct 1, 2025

Next Review DateMar 1, 2025

Key ActionObtain prior authorization when a drug is marked PA and include required documentation (diagnosis, prior therapies tried, and quantity justification).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-10-01Effective date of formulary

6Named drug tiers

PA / QLUtilization management types

OncoHealthOncoHealth / Specialty

QuarterlyFormulary review cadence

Formulary Coverage Rules

Formulary coverage requirements

Formulary coverage and member cost-sharing depend on tier, specialty status, and whether edits (PA, ST, ALI, AQ1, QL, TD, ONC) are met.

Formulary application: Member coverage follows the formulary tiering and plan benefits; specialty drugs may require specialty pharmacy and have separate benefits.

Tier determines member cost-share; see plan summary for copay/coinsurance specifics.

Prior authorization (PA): If a drug is marked PA, coverage requires prior authorization per HealthPartners criteria.

Providers must submit PA documentation; failure to obtain PA can result in denial (see prior authorization guidance).

Step therapy (ST): If a drug is marked ST, patient must have trial and failure (or intolerance) of required agents before coverage at preferred cost-share.

Providers should document trials of required agents or request an exception with clinical rationale.

Quantity limits and age edits (QL, ALI, AQ1): Drugs with QL, ALI, or AQ1 are limited by quantity or age; requests above limits are reviewed for medical necessity.Examples: per-day or per-fill caps (e.g., 60 mL/1 day, 24 mg/28 days) and minimum age requirements (e.g., at least 12 years).

Documentation should include diagnosis, prior therapies tried, prior use within limits, and evidence for the requested quantity.

Trial Drug Program (TD): When a product is designated TD, initial fills are limited under the Trial Drug Program to assess tolerability, cost, or waste.First 6 fills may be limited to less than one month supply

If tolerated and effective, subsequent fills may be authorized to full month supply; copay rules apply as described.

Oncology / OncoHealth (ONC) handling: Drugs flagged ONC/OncoHealth must be processed through the designated oncology specialty channel and are subject to program-specific routing and requirements.

Failure to route via the OncoHealth/specialty channel or meet program requirements may result in denial.

Conditional coverage entries

Coverage and restrictions are product-specific as listed; where PA, QL, Specialty, or SC appear coverage is conditional per those restrictions.

Product-level conditional coverage examples: Coverage for a listed product is conditional on the Limits & Restrictions noted for that product (e.g., PA, QL, Specialty, S, ONC, TD, SC).

Examples from the formulary: SUNLENCA = PA + Specialty; YEZTUGO = QL PA Specialty; PREVYMIS = PA; PAXLOVID entries = QL with specified pill-count pack limits.

Specialty designation: Products listed as Specialty or S are subject to specialty pharmacy benefit rules and handling; claims must be processed through the designated specialty channel.

Examples include PEGASYS, LIVTENCITY and other specialty antiviral or oncology agents marked 'Specialty' or 'S'.

Coverage contingent on meeting listed restrictions: If the product entry lists QL, PA, TD, ONC, or similar flags, coverage is allowed only when those conditions are satisfied.

Providers should consult the specific product entry on the formulary for the exact restriction wording and required documentation before dispensing.

antiviral quantity limits

Quantity-limited antiviral coverage examples

Neuraminidase inhibitor (oseltamivir) limits: Oseltamivir 6 mg/mL suspension: limited to 180 mL per fill; oseltamivir capsules: limited to 20 or 10 capsules per fill depending on formulation.180 mL / 1 fill; 20 caps fill; 10 caps fill

Observe the per-fill limits when submitting claims or prior authorization requests.

Paxlovid dispense packs: PAXLOVID 150/100 mg and 300/100 mg dose packs are quantity-limited to pack sizes consistent with the course of therapy (20 tablets for the 150/100 mg pack; 30 tablets for the 300/100 mg pack).20 tabs (5 days) or 30 tabs (5 days) per course depending on pack

Dispense must reflect the authorized pack size; documentation should indicate the pack used.

Molnupiravir (LAGEVRIO) EUA pack: LAGEVRIO (EUA) is subject to a QL of 40 capsules for a 5-day course when distributed under EUA or public health supply rules.

Some medicines on the formulary are designated Specialty. Specialty medicines are typically high-cost treatments for chronic or complex conditions that require additional management. These products are often not stocked at retail pharmacies and must be filled at an authorized specialty pharmacy. Specialty placement can change how the drug is billed and may be covered under a separate benefit with different member cost-sharing than non-specialty prescriptions.

The formulary includes a Limits & Restrictions field for many entries. In this excerpt those fields are present as placeholders indicating program flags (for example, PA, QL, ST, ONC) and age/packaging notes, but full, product-specific criteria are not included in the provided fragment.

Within the portion of the document provided there are no explicit product-level exclusions listed. The extract shows many vaccine and PPI entries with tiering and limits fields but does not enumerate any items that are declared excluded from coverage in this fragment.

Requests that exceed published quantity limits (QL) will be reviewed for medical necessity. Such reviews evaluate the diagnosis, prior alternatives tried, prior use within the stated limits, and evidence of efficacy and safety at the requested quantity. If the request lacks supporting documentation, the request may be deemed not medically necessary and denied.

The excerpt does not contain any statements that explicitly declare specific items to be not medically necessary. No NMN (not medically necessary) determinations are listed in this fragment.

Listed Products and Code / Dispense Details

Selected listed products and limits from Part 1mixed

dihydroergotamine 1 mg/ml amp	listed with TIER = 4; LIMITS & RESTRICTIONS = QL PA; 24 MG (AMPS) 28 DAYS
ergoloid mesylates	TIER = 3; LIMITS & RESTRICTIONS = PA
ERGOMAR	LIMITS & RESTRICTIONS = QL PA; 20 TABS 30 DAYS
ergotamine-caffeine	LIMITS & RESTRICTIONS = QL PA; 40 TABS 30 DAYS
phenoxybenzamine hcl	TIER = 4; LIMITS & RESTRICTIONS = PA
alfuzosin hcl er	TIER = 3
silodosin	TIER = 3
tamsulosin hcl	TIER = 3
JOURNAVX	TIER = 3; LIMITS & RESTRICTIONS = QL PA; 29 TABS 90 DAYS
acetaminop-codein 240-24 mg/10	TIER = 3; LIMITS & RESTRICTIONS = QL ALI; 60 ML 1 DAY; At least 12 yrs old

1–10 of 19

1/2

PCSK9 Inhibitors / REPATHA productsmixedCovered

REPATHA PUSHTRONEX	Tier 3; LIMITS & RESTRICTIONS = QL PEN 28 DAYS ST
REPATHA SURECLICK	Tier 3; LIMITS & RESTRICTIONS = 2 PENS 28 DAYS
REPATHA SYRINGE	Tier 3; LIMITS & RESTRICTIONS = QL 2 PENS ST

Selected antineoplastics / targeted therapiesmixedCovered

IBRANCE	Tier 6; LIMITS & RESTRICTIONS flags include QL PA S OH
IMBRUVICA 140 MG CAPSULE	Tier 6; LIMITS & RESTRICTIONS include QL PA = S OH; example qty '3 CAPS 1 DAY'
IMBRUVICA 420 MG TABLET	Tier 6; LIMITS & RESTRICTIONS include QL PA S OH ONC; example qty '3 CAPS 1 DAY'
KISQALI (200/600 MG)	Multiple tier entries; limits include QL PA, S, OH; qty examples '21 TABS 28 DAYS', '63 TABS 28 DAYS'
KOSELUGO (10/25 MG)	Tier 6 and 5 entries; limits include QL PA S; qty examples '8 CAPS 1 DAY', '4 CAPS / 1 DAY'

Classical cytotoxic agentsmixedCovered

METHOTREXATE	Tier 3; product forms listed (2.5 mg tablet, vials); LIMITS & RESTRICTIONS include PA S OH ONC and Specialty/OncoHealth routing
MELPHALAN	Tier 3; LIMITS & RESTRICTIONS include PA S OH ONC and Specialty/OncoHealth routing
MERCAPTOPURINE 50 MG TABLET	Tier 3; LIMITS & RESTRICTIONS include PA S OH ONC and Specialty/OncoHealth routing

No CPT/HCPCS/ICD-10 codes presentmixed

No codes listed

Antivirals with dispense/pack detailsmixed

PAXLOVID 150-100 MG	PAXLOVID 150-100 MG (MODERATE) — QL 20 TABS 5 DAYS
PAXLOVID 300-100 MG	PAXLOVID 300-100 MG DOSE PACK — QL 30 TABS 5 DAYS

Neuraminidase inhibitor antivirals (oseltamivir) quantity limitsmixed

oseltamivir 6 mg/ml suspension	QL 180 ML / 1 FILL
oseltamivir 30 mg capsule	QL 20 CAPS FILL
oseltamivir phosphate (45 mg, 75 mg)	QL 10 CAPS FILL

Quantity-limited anxiolytics and barbituratesmixed

butalb-acetamin-caff 50-325-40	QL 6 TABS 1 DAY
diazepam rectal gel kits	QL 4 KITS 30 DAYS
diazepam 5 mg/5 ml solution	QL 40 ML 1 DAY

Smoking cessation agentsmixed

nicotine patch/lozenge/gum

Smoking cessation products — QL/SC designations and per-day limits (e.g., '2 TABS 1 DAY')

Specialty quantity limitsmixed

9 ML / 1 FILL

icatibant: 9 ML / 1 FILL (Specialty)

Quantity limits (examples)mixed

2 TABS 1 DAY	Common daily quantity limit noted for several smoking cessation products (e.g., nicotine lozenge/gum)
53 TABS 28 DAYS	varenicline starting month box quantity (53 tabs/28 days)

Specialty/pack quantity limitsmixed

56 TABS 28 DAYS	PYRUKYND quantity limit
70 TABS 28 DAYS	AUSTEDO start/titration pack limit

Quantity / age limit examples — per-drug per-period

Examples of per-period QLsDihydroergotamine: 24 MG (amps) per 28 days

Ergomar (ergotamine tartrate)20 tabs per 30 days

Ergotamine‑caffeine40 tabs per 30 days

Journavx29 tabs per 90 days

Codeine/acetaminophen liquids

Authorization, Documentation & Step Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for numerous drugs listed in the formulary. Products flagged with PA, QL PA, PA S, PA TD, PA S OH, QL PA S, or similar indicators must have an approved prior authorization before the pharmacy benefit will cover the medicine. Claims submitted without an approved PA are at risk for denial.

Examples of products with PA and QL flags: ERGOMAR (QL PA), albendazole (PA), RYBELSUS (QL PA), TRULICITY (QL PA), PREVYMIS (PA), LIVTENCITY (PA S), SUNLENCA (PA S), YEZTUGO (QL PA S), IMBRUVICA (QL PA), INLYTA (QL PA), KISQALI (QL PA), COMETRIQ (QL PA), NEXAVAR (QL PA TD), IMBRUVICA 420 MG (QL PA S OH ONC).
CFTR modulators require PA and often have quantity limits and specialty routing: ORKAMBI (QL PA S), SYMDEKO (QL PA), TRIKAFTA (QL PA S), KALYDECO (QL PA).
Specialty, OncoHealth, or Oncology-designated products require PA and routing through the specialty oncology channel (OncoHealth) where noted: many oncology agents are flagged with OH, ONC, OncoHealth, TD (Trial Drug), and S (Specialty). Examples: BALVERSA (PA TD S OH ONC), BRUKINSA (PA TD S OH), NEXAVAR (TD S OH ONC), XPOVIO (TD S Specialty OH OncoHealth ONC).
Selected cardiovascular and other specialty products with PA: CORLANOR oral solution (PA), alvimopan (PA), MOVANTIK (QL PA), eltrombopag olamine (PA S).
Quantity limits and specialty fill limits examples: ORENCIA (4 syringes/28 days Specialty; QL noted), AUSTEDO (70 tabs/28 days Specialty; QL PA S), AUSTEDO XR (PA S).

Trial Drug & Initiation Rules

Trial Drug Program (initial therapy)

Trial Drug Program (TD) initial therapy rules when TD applies.

TD initial fills limitation: When a drug is designated TD (Trial Drug Program), the first 6 fills may be limited to less than a full month supply to assess tolerability, safety, cost, or waste.First 6 fills

If the medication is tolerated and clinically appropriate, the remainder of the monthly supply may be authorized at usual benefit levels.

Documentation required during TD period: Providers should document tolerability, adverse effects, and clinical response during the trial period to support authorization of ongoing therapy.

If a copay applies, the member will pay no more than one copay per one-month supply; exceptions can be requested with clinical justification.

Transition to standard coverage:

Step Therapy Requirements

Example	Requirement
General step therapy (ST)
Patient must have trial and failure or intolerance of specified prior medicines before coverage at preferred copay/coinsurance; providers must document trials or request exception/approval.

Product / class	Age-based PA / ALI example
Extended-release tramadol (multiple ER tramadol entries)
Listed with QL PA ALI or QL PA ALI and specific age limits (examples: '3 TABS 1 DAY At least 12 yrs old', '1 TAB 1 DAY At least 12 yrs old'); PA and ALI must be met prior to coverage.

Product	Step therapy flag
Mupirocin 2% ointment / related topical agents (ALTABAX context)
Listed with 'ST' indicator in Limits & Restrictions in proximity to topical anti-infective listings, indicating step therapy may apply.

Class / product	Step therapy (ST) indicator
PHOSPHODIESTERASE‑4 INHIBITORS (class entries)
Entries show 'QL PA S' with 'ST' (step therapy) noted in Limits & Restrictions, indicating step therapy may be required prior to coverage.

Observation	Implication
No explicit step sequences provided in this excerpt
Many agents are marked with PA, QL, Specialty or other flags; although ST is referenced elsewhere, explicit step-by-step sequences or required failures are not listed here.

Flag / designation	Meaning in this excerpt
TD (Trial Drug) designation on selected oncology agents
'TD' indicates trial or trial‑drug program status which functions like a step/trial requirement prior to standard coverage enrollment.

Context	Trial/step examples
Multiple oncology agents (e.g., XPOVIO, XTANDI, ZEJULA)
Listed with 'Trial', 'TD' or 'Trial Specialty' flags (e.g., 'TD Trial S Specialty OH OncoHealth ONC') indicating trial enrollment or step‑type requirements before full coverage.

Note	Detail
Step therapy sequences not present
The excerpt references step therapy generally but does not include explicit multi‑step sequences or required predecessor therapies in this fragment.

Product group	Smoking cessation QL / tier note
Smoking cessation products (varenicline, nicotine replacement)
Listed with tier and QL SC flags (examples: varenicline starting month box: '53 TABS 28 DAYS'; NICORETTE 2 MG LOZENGE: 'QL SC' and '2 TABS 1 DAY'); no explicit ST sequence provided.

Product	Limits & Restrictions
MOVANTIK (opioid antagonist for OIC)
Listed with 'QL PA' under Limits & Restrictions, indicating a quantity limit plus prior authorization requirement as part of the coverage workflow.

Per-Product Quantity and Pack Limits

Multiple product QL examples across document

Dihydroergotamine ampules24 MG (amps) per 28 days

ERGOMAR (ergotamine) tablets20 tabs per 30 days

Hydrocodone-acetaminophen (tablets)8 tabs per day (IR formulations)

Hydrocodone-acetaminophen (liquid)120 mL per day

Butalbital-acetaminophen6 tabs per day

Hydrocodone-acetaminophen formulation limits

Hydrocodone-acetaminophen (IR tablets)

Specialty Pharmacy & Infusion Routing

Note

Abbreviations and Flags

Abbreviations: PA / QL / ST definitions

PAPrior authorization required — coverage requires administrative approval prior to dispensing

QLQuantity Limit — maximum quantity allowed per fill or time period as shown alongside product entries

STStep therapy required — must try specified therapies first per entry where ST appears

PA — Prior authorization

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

PA SPrior Authorization Specialty — PA applicable to specialty presentations

Supporting Context

Background: Specialty medicines are generally high-cost agents used to treat chronic or complex diseases. They typically require more clinical management, may have programmatic routing (for example, oncology products routed through an OncoHealth program), and are frequently dispensed through an authorized specialty pharmacy. The formulary is maintained by the HealthPartners Pharmacy & Therapeutics process and includes tiering, utilization management flags (such as PA, QL, ST, TD, ONC), and quantity or age-based limits that affect member coverage and cost-sharing. The drug list is reviewed regularly and these policies govern outpatient prescription coverage and provider documentation requirements.

Document Status & Updates

2025-10-01effective_dateLatest

Formulary effective date set for HealthPartners HSA Plus 2025 formulary (effective October 1, 2025).

2025-03-01scheduled_review

Next formulary review scheduled (quarterly review cadence noted; next review date listed as 2025-03-01).

Policy Summary

PayerHealthPartners

Policy2025 HealthPartners HSA Plus Formulary (Part 1) - Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateOct 1, 2025

Next Review DateMar 1, 2025

Key ActionObtain prior authorization when a drug is marked PA and include required documentation (diagnosis, prior therapies tried, and quantity justification).

SourceLink

On This Page

EUA/distribution notes may further constrain availability and coverage.

60 mL per 1 day (age limit: at least 12 years)

Per-day limits for select opioids and formulations

Oxycodone solution (5 mg/5 mL)40 mL per day

Oxycodone IR 10 mg tablet5 tabs per day

Oxycodone IR 20 mg tablet2 tabs per day

Oxycodone 100 mg/5 mL concentrate2 mL per day

Quantity limits examples for multiple specialty drugs

NUCALA (syringe)1 syringe per 28 days or 1 auto-injector per 28 days

FASENRA PEN1 syringe (pen) per 56 days — Specialty

Enoxaparin syringes/vialsExamples show 2 syringes (or 2 vials) per 1 day

Oseltamivir suspension limit example

Oseltamivir suspension (6 mg/mL)180 mL per 1 fill

Oseltamivir capsules (30 mg)20 capsules per fill (capsule entry)

Oseltamivir phosphate (45/75 mg)10 capsules per fill (other strengths)

Paxlovid dispense pack examples

PAXLOVID 150/100 mg pack20 tablets — 5 day course (pack)

PAXLOVID 300/100 mg dose pack30 tablets — 5 day course (dose pack)

PAXLOVID (EUA pack entries)Pack sizes correspond to 20 or 30 tablets for the 5-day course

Dispense-pack documentation: COVID antivirals (PAXLOVID packs) list specific pack/tablet counts (e.g., 20 tabs/5 days, 30 tabs/5 days) and requests must match the pack counts.

Denial Risk

Authorization Triggers & Denial Risk

Prior authorization triggers and denial risks: any PA, QL, TD, S, OH, ONC, or ST flag can trigger utilization management review. Requests exceeding quantity limits (QL) will be reviewed for medical necessity and may be denied if documentation does not support the higher quantity or PA criteria are not met.

PA/QL may trigger denial if PA is not obtained or criteria are unmet; quantity-limit exceedance reviews evaluate diagnosis, prior alternatives tried, prior use within limits, and evidence of efficacy/safety.
Authorization triggers include PA, QL, TD (Trial Drug), S (Specialty), OH/OncoHealth, and ST (Step Therapy); presence of these flags increases administrative requirements and denial risk.
Channel, PA and designation requirements: many oncology and specialty drugs must be processed through designated specialty or oncology channels (OncoHealth) and will be denied if routed incorrectly or without PA.
Examples where PA/QL may trigger denial: fentanyl patches (PA flagged), hydromorphone ER (PA), oxymorphone ER (PA), methadone products (PA), tramadol ER (QL PA ALI).

Documentation Required

Documentation Required for PA/QL Requests

Documentation requirements for PA, QL overrides, age limits, and specialty fills must be provided with authorization requests. Include clinical diagnosis, prior therapies tried (and dates), rationale for the requested product and quantity, patient age where age limits (ALI) apply, and dispense/packaging details when relevant.

Required documentation flags seen in the formulary: PA, QL, TD, S, OH, ONC — these indicate the type of documentation and routing needed (e.g., oncology specialty routing via OncoHealth).
Quantity-limit and specialty supply documentation examples: 1 SYRINGE/28 DAYS, 2 PENS/28 DAYS, 70 TABS/28 DAYS Specialty — requests must reference the listed packaging/period.
Age and indication documentation is required where ALI or age-based QL flags appear (e.g., acetaminophen-codeine products: At least 12 yrs old; certain formulations limited by age).
Dispense quantity documentation for specific packs (e.g., PAXLOVID 20 or 30 tabs per EUA pack) should match the requested fill.

Step Therapy

Step Therapy & Trial Requirements

Step therapy and trial designations: where ST (Step Therapy), Trial, TD (Trial Drug) or ST designators appear, providers must document prior trials of required agents or submit an exception request explaining why step therapy is inappropriate.

Step/age interaction notes: some entries combine ST and ALI (age limits), implying age-based step requirements or age exceptions must be documented.
Step therapy examples and indicators: entries flagged 'ST' or 'TD' (e.g., RYTARY: PA S = ST; many oncology agents flagged TD indicate trial/step program enrollment).
If step therapy requirements are not met and no exception is approved, coverage may be limited or denied.

After successful completion of the trial period (as evidenced by tolerability and clinical benefit), subsequent fills may be authorized to full month supply and standard copay/coinsurance will apply.

Authorization to full supply follows standard PA/QL/benefit rules as applicable.

Hydrocodone-acetaminophen (solution/chewable/liquid)120 mL per day (age-limited where noted)

Hydrocodone-ibuprofen 7.5/2008 tabs per day

Morphine sulfate formulation limits

Morphine sulfate solution 10 mg/5 mL30 mL per day

Morphine sulfate IR 15 mg tablet5 tabs per day

Morphine sulfate IR 30 mg tablet2 tabs per day

Morphine suppositories8 suppositories per day

Dextroamphetamine / lisdexamfetamine per-day examples

Dextroamphetamine ER (Adderall XR) 25 mg cap2 caps per day

Dextroamphetamine IR 15–30 mg tabs2–3 tabs per day depending on strength

Lisdexamfetamine (capsule/tablet)1 cap or 1 tab per day for some formulations (see entries)

Methylphenidate ER/IR product limits

Methylphenidate ER (various caps)Examples include 1 cap/day or 2 caps/day depending on product and strength

Methylphenidate ER 18/27/36 mg tabs2 tabs per day (selected strengths)

Methylphenidate ER 40–60 mg caps1 cap per day for higher strengths

Armodafinil daily tablet limit

Armodafinil (150/200/250 mg tablets)1 tablet per day

Modafinil entriesExamples show 2 tabs per day for some tablet strengths

Armodafinil 50 mg tablet2 tabs per day (listed for that strength)

Sodium oxybate daily volume limit

Sodium oxybate18 mL per day (Specialty)

Sodium oxybate flagQL PA S (quantity limit, prior authorization, specialty)

Related wakefulness agentsSUNOSI and others have 1 tab per day examples

Ivermectin 3 mg tablet dispense example

Ivermectin 3 mg tablet40 tablets per Rx (course)

Ivermectin tieringListed as Tier 3 with QL

Dosage form noteEntry shows tablet-format QL (40 tabs) for the product

Fosfomycin tromethamine QL example

Fosfomycin tromethamineQL — 3 packets per Rx

FormulationSingle-dose packet format, quantity limited to 3 per prescription

TierListed under urinary anti-infectives (tier indicated in entry)

Mupirocin 2% ointment quantity limit

Mupirocin 2% ointmentQL 44 g per 1 fill

FormulationTopical ointment — gram-based QL

TierListed as Tier 3 in entry

NUCALA quantity limit examples

NUCALA (40 mg/0.4 mL; 100 mg/mL syringe)1 syringe per 28 days (Specialty) — or 1 auto-injector per 28 days

NUCALA auto-injector1 auto-injector per 28 days

TierTier 5 listing in document

FASENRA PEN quantity example

FASENRA PEN1 syringe (pen) per 56 days — Specialty

PresentationPen presentation is handled as specialty supply in the entry

TierListed as Tier 5 in document

SKYRIZI presentation-specific supply rules

SKYRIZI (syringe)1 syringe per 84 days (Specialty)

SKYRIZI (cartridge/on-body)1 cartridge per 56 days (Specialty)

SKYRIZI (pen)Pen presentation: pen 84 days; alternate: 2 pens per 28 days

Topical immunomodulators QL

Topical immunomodulators (pimecrolimus, tacrolimus)100 g per 30 days

Pimecrolimus entryAlso shows 2 pens per 28 days Specialty in presentation entries

Tacrolimus ointmentSame 100 g/30 days QL referenced

SKYRIZI alternate supply rules

SKYRIZI alternate supply2 pens per 28 days OR alternate: 1 syringe 84 days / 1 cartridge 56 days

NotesEntries show QL PA S and Specialty handling for presentations

ApplicabilityAlternate supply rules permit different packaging frequencies

Enoxaparin syringe quantity limit examples

Enoxaparin syringes/vials2 syringes (or 2 vials) per 1 day — examples across strengths

Examples includedEnoxaparin 300 mg/3 mL vial and multiple syringe strengths listed with 2 per day limits

TierListed as Tier 3 in entries

Pregabalin 150 mg capsule example

Pregabalin 150 mg capsule4 capsules per day (example)

Pregabalin solution 20 mg/mL30 mL per day (example for solution formulation)

TierEntries show QL PA S and Specialty flags

Gabapentin per-day caps and solution volume examples

Gabapentin capsules (various strengths)Examples include 12 caps per day or 9 caps per day depending on strength

Gabapentin solution72 mL per day (example for 250 mg/5 mL solution) — 12 caps day specialty mapping

Tier/flagsEntries show QL PA S and Specialty handling for some formulations

Formulation-specific per-day cap examples (gabapentin/lacosamide/rufinamide)

Gabapentin (across formulations)Per-day caps vary (examples: 12 caps/day, 9 caps/day) depending on strength/formulation

Lacosamide liquid40 mL per day (liquid) — tablets: up to 2 or 8 tabs/day depending on strength

Rufinamide examples200 mg tablet: 16 tabs/day; 40 mg/mL suspension: 80 mL per day; 400 mg tablet: 8 tabs/day

Lacosamide liquid and tablet limits

Lacosamide liquid40 mL per day

Lacosamide 50 mg tabletUp to 8 tablets per day (depending on entry) — other strengths show up to 2 tabs/day

QL flagEntries list QL for lacosamide formulations

Rufinamide tablet and suspension limits

Rufinamide 200 mg tablet16 tablets per day

Rufinamide 40 mg/mL suspension80 mL per day

Rufinamide 400 mg tablet8 tablets per day

Liraglutide 18 mg/3 mL pen supply example

Liraglutide 18 mg/3 mL pen5 pens per 30 days

Liraglutide age noteAt least 7 years old listed in the entries for some presentations

Tier/PAEntries show QL PA flags for incretin mimetics

MOUNJARO pen supply

MOUNJARO (2 mL pen)4 pens (2 mL) per 28 days

Age indicationAt least 7 years old noted for MOUNJARO entries

QL/PAEntry lists QL PA for MOUNJARO

RYBELSUS supply example

RYBELSUS (oral tablet via pen presentation)1 pen (3 mL) per 28 days — equivalent to 1 tablet per day

QL PARYBELSUS listed with QL PA flag

Packaging notePen supply equates to the per-day tablet allowance shown

REPATHA supply examples

REPATHA SURECLICK2 pens (per specified period — entry lists 2 pens 28 days)

REPATHA PUSHTRONEXQL — pen supply (per entry)

REPATHA syringeQL 2 pens (syringe equivalent) per period in entry

KISQALI daily dose supply examples

KISQALI 200 mg daily dose21 tablets per 28 days

KISQALI 600 mg daily dose63 tablets per 28 days

KISQALI co-pack examplesCo-pack entries list 63 tabs/28 days and other pack-based totals

KOSELUGO 10 mg capsule supply example

KOSELUGO 10 mg capsule8 capsules per day (entry) — other pack counts noted

KOSELUGO 25 mg capsule entriesCo-pack and per-day packet quantities listed elsewhere in document

Tier and flagsQL PA S indicated for KOSELUGO entries

ZEJULA and related per-day supply examples

ZEJULA (selected entry)2 tablets per day (trial/specialty entry)

ZEJULA (alternate entry)1 tablet per day (other listing)

XTANDITabs/caps listed as 1 per day in various entries

XTANDI per-day supply examples

XTANDI formulationsTabs 1 day / Caps 1 day (per entries)

XTANDI 40 mg capsule/tablet entriesListed under Trial/Specialty OncoHealth with per-day caps

NotesMultiple entries show per-day limits for XTANDI presentations

VRAYLAR supply example

VRAYLAR (capsules)1 capsule per day

QL/PA flagEntry lists QL PA for VRAYLAR in document

Strengths3 mg, 4.5 mg, 6 mg capsules shown with same per-day limit

PAXLOVID 150-100 mg and 300-100 mg pack examples

PAXLOVID 150/100 mg pack20 tablets (5-day course)

PAXLOVID 300/100 mg dose pack30 tablets (5-day course)

Documentation noteDispense quantities correspond to 5-day course pack sizes

Oseltamivir suspension and capsule examples

Oseltamivir suspension (6 mg/mL)180 mL per fill

Oseltamivir capsules (30 mg)20 capsules per fill

Oseltamivir other strengths10 capsules per fill for 45/75 mg entries

Butalbital-acetaminophen-caffeine supply example

Butalbital-acetaminophen-caffeine 50-325-406 tablets per day

Phenobarbital liquid/other formsQuantity entries present for multiple formulations (see document)

Related barbiturate limitsSome formulations list per-day caps and QL flags

NICORETTE 2 mg lozenge example

NICORETTE 2 mg lozenge2 units per day (smoking cessation QL/SC)

Nicotine gum/lozenge2 units per day (per entries)

Patch formulationsPatch strengths listed with smoking cessation QL/SC flags

Varenicline starter pack supply

Varenicline starting month box53 tablets per 28 days (starter pack)

Varenicline maintenanceEntries list 2 tabs per day for some smoking cessation entries

QL SC flagSmoking cessation benefit and QL SC shown in entries

PYRUKYND supply example

PYRUKYND56 tablets per 28 days (Specialty)

Tier/flagListed as Tier 5 with Specialty in entry

Documentation noteSpecialty pack limits must be observed when submitting claims/PA

Icatibant supply example

Icatibant supply9 mL per 1 fill (Specialty)

PresentationBradykinin receptor antagonist — ml-based QL for specialty fill

Repeat entryIcatibant appears with same 9 mL/1 fill quantity in multiple listings

Lubiprostone / LINZESS / TRULANCE examples

Lubiprostone2 capsules per day

LINZESS1 capsule per day (entry)

TRULANCE1 tablet per day (entry)

Cystic fibrosis modulator and ALYFTREK examples

ALYFTREK3 tablets per day

ORKAMBI (tablets)Daily tablet limits listed for tablet formulations (varies by strength)

TRIKAFTA3 tablets per day OR 2 packets per day for packet formulations

ORENCIA quantity-limit example

ORENCIA (syringe presentations)4 syringes per 28 days (Specialty)

ORENCIA ClickJectListed with QL/ML and Specialty handling in entry

TierTier 5 listings for ORENCIA presentations

Calcipotriene and GALAFOLD supply QLs

Calcipotriene (cream/ointment/solution)120 g per 30 days

Topical pack noteGram-based QL applied to topical dermatologic preparations

GALAFOLD14 capsules per 28 days (specialty) — related specialty QL shown nearby

Providers must submit required documentation with PA requests (see documentation guidance)

ST — Step therapy

ST (Step Therapy)Step Therapy — requirement to try one or more specified therapies before coverage is allowed

Exception processProviders may request exception with clinical rationale when step therapy is not appropriate

Presence in documentST appears alongside QL/PA in multiple specialty entries

ALI / AQ1 — Age limit indicators

ALI (Age Limit)Age-limit indicator — denotes age-related restriction (e.g., 'At least 12 yrs old')

AQ1Age Quantity Limit — combined age and quantity restriction when shown

ExampleSeveral opioid entries show 'At least 12 yrs old' with per-day quantity limits

QL — Quantity Limit definition and examples

QL (Quantity Limit)Quantity Limit — a per-day or per-prescription cap on units dispensed (e.g., '8 TABS 1 DAY' or '2 PENS 28 DAYS')

ExamplesPer-day caps (e.g., '8 TABS 1 DAY') and period caps (e.g., '2 PENS 28 DAYS') are used across entries

ImpactRequests above QL will be reviewed for medical necessity and may be denied without justification/PA

TD — Trial Drug Program

TD (Trial Drug Program)Trial Drug Program — initial fills may be limited (example: first 6 fills limited) to assess tolerability/waste

Duration exampleDocument references '6 fills' as part of TD initial therapy limitations

ApplicationTD appears on several oncology/specialty entries where initial trial fills are controlled

ONC — Oncology program designation

ONC / OncoHealthOncology Benefit / OncoHealth — specialty oncology medicines routed through specialty (OncoHealth) channel

Routing requirementMany oncology agents list 'PA S', 'OH', or 'ONC' indicating specialty routing and prior authorization

Program flagsEntries include OH/ONC/OncoHealth to indicate oncology program management

QL — Quantity Limit (example and usage)

Definition of QL examplesQuantity limits shown as per-day (e.g., '1 TAB 1 DAY') or per-period (e.g., '2 PENS 28 DAYS') alongside product entries

Specialty QL examplesSpecialty supplies often use pens/syringes/cartridge counts (e.g., '1 SYRINGE 84 DAYS')

Use in claims/documentationQL entries must be observed when submitting claims or PA requests