Independent Health Part D Formulary Coverage Update | OpenPayer
CurrentIndependent HealthPolicy N/A
Medicare Advantage Part D Formulary (Drug List) - Coverage Criteria
This document is Independent Health's Medicare Advantage Enhanced Part D formulary describing covered drugs, restrictions (prior authorization, quantity limits, step therapy), and member processes for exceptions and transitions; it applies to members of Independent Health's Medicare Advantage plans referenced in the document.
Policy Summary
PayerIndependent Health
PolicyMedicare Advantage Part D Formulary (Drug List) - Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes noted
Effective Date5/1/2026
Next Review DateN/A
Key ActionObtain prior authorization when a drug is marked 'PA' or 'PA New Starts' to avoid denial or noncoverage.
No material clinical or coverage changes in this revision.
5/1/2026formulary effective/last updated date shown
monthlyformulary updates posted online
72hstandard exception decision timeframe
24hexpedited exception decision timeframe
tiers 1-5formulary tier levels present
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100+individual product/strength lines
Coverage Criteria and General Rules
General coverage, restrictions, exceptions, and transitions
Covered when ALL of the following are met:
Formulary coverage general conditions: Drug is listed on the Independent Health formulary, is medically necessary, prescribed by a provider, and filled at an Independent Health network pharmacy
From formulary general description
Restrictions that may apply: Prior authorization (PA), quantity limits (QL), or step therapy (ST) may be required as indicated in the Requirements/Limits column
See Requirements/Limits and 'Are there any restrictions' sections
Exception requests: Members or prescribers may request exceptions to cover non‑formulary drugs, waive restrictions (PA, ST, QL), or request lower tiering; prescriber must provide supporting medical rationale
Decision timelines: standard = 72 hours; expedited = 24 hours when waiting may cause serious harm
Transition/continuity of care: New or continuing members transitioning between plans or care settings may receive a one‑time temporary transition supply while an exception or alternative is pursued
Retail: one‑time 30‑day supply (refills to total 30 days if needed). Long‑term care (LTC): 34‑day emergency/transition supply (refills to total 34 days if needed); LTC admission/discharge protections apply
Formulary placement with utilization management
Coverage varies by product; many are covered conditional on administrative controls
Formulary placement and administrative controls: Drugs are assigned tiers and may have requirements such as 'PA New Starts', 'PA', 'LA', 'ST', 'EDS', 'BD', or 'QL' as shown in the formulary
Use the formulary Requirements/Limits column to determine applicable administrative controls; clinical medical‑necessity criteria are not included in these listings
Formulary coverage flags
Coverage and utilization controls as listed in the table of contents apply to individual drug entries as indicated by Requirements/Limits flags.
Formulary listing requirement: Drug coverage is determined by tier placement and any Requirements/Limits codes (for example: PA, PA New Starts, QL, ST, LA, EDS, BD)
Refer to the formulary legend (page VI) and the specific line entry for the exact code(s) that apply to a product
If a prescribed drug is not included on the Independent Health formulary and an exception is not approved, the plan will not provide coverage for that drug. Members or prescribers may request an exception (see formulary exception procedures) but coverage is not available unless an exception is granted.
The provided formulary excerpt does not include specific clinical exclusion conditions tied to individual drug entries; instead it lists products with associated tiering and Requirements/Limits flags (e.g., PA New Starts, LA, QL). Clinical exclusion rules for particular indications are not present in this segment.
Within these excerpts no explicit exclusion criteria (for example, diagnosis‑based contraindications or defined patient populations excluded from coverage) are stated. The listing focuses on formulary tier placement and Requirements/Limits codes (PA, QL, EDS, LA) rather than standalone exclusion rules.
For WEGOVY (multiple subcutaneous strengths) the Requirements/Limits column in this extract indicates PA and explicitly states Not covered for weight management for the listed strengths, with accompanying quantity limits (e.g., QL (2 mL per 28 days) or QL (3 mL per 28 days) depending on strength).
Some specific strengths/forms of WEGOVY in this excerpt are flagged as Not covered for weight management in the Requirements/Limits field. This indicates a product‑level coverage exclusion for the weight management indication for those presentations, combined with prior authorization and quantity‑limit entries.
Across these chunks there are no general explicit exclusion statements listed (for example, a list of medical conditions that automatically exclude coverage). Individual formulary lines may show Requirements/Limits flags (PA, QL, EDS, LA) but exclusion rules or broad 'not covered' lists are not provided here.
Drugs that are withdrawn from the market by the manufacturer or removed by the FDA for safety or effectiveness reasons may be immediately removed from the formulary and will not be covered by the plan.
This excerpt does not contain any explicit statements labeling medications as 'not medically necessary.' No 'not medically necessary' determinations are listed in these chunks.
Within this segment there are no entries that state a drug is 'not medically necessary.' The content focuses on tiering and Requirements/Limits flags rather than NMN designations.
Formulary Listings and Code Tables
Prior Authorization, Step Therapy, and Provider Responsibilities
Prior Authorization
Prior Authorization, Step Therapy, and Provider Responsibilities
Independent Health requires prior authorization (PA) for many drugs listed in the formulary. Drugs flagged with PA, PA New Starts, PA New Starts; LA, or similar codes in the Requirements/Limits column must have approval before the plan will cover the medication. This includes many high‑tier (Tier 5 and select Tier 3/4) specialty and biologic agents, selected antivirals and oral specialty therapies, select high‑cost GLP‑1 and antidiabetic injectables at initiation, and numerous oncology, immunologic, and injectable products. Therapy packs and titration/step packs (for example, certain oncology or CNS therapy packs and EXXUA titration packs) may have specific quantity and pack documentation requirements. Quantity limits (QL) shown in the formulary must be supported when submitting a PA; exceeding documented QLs may lead to denial or coverage delays.
Prior authorization required for select drugs identified with 'PA' or 'PA New Starts' in the Requirements/Limits column
Prior authorization required for many high‑tier and specialty agents (e.g., oncology, biologics, immunoglobulins) — often labeled 'PA New Starts' or 'PA'
PA is required for many listed products across therapeutic classes (neurology, oncology, cardiology, dermatology, endocrinology, infectious disease, etc.)
PA New Starts applies to initiation of therapy for numerous agents; continuation/renewal workflows may differ
Selected antiviral agents require PA (e.g., MAVYRET, SOFOSBUVIR‑VELPATASVIR, PREVYMIS, MAVYRET listed as PA)
Initial Therapy and Titration Requirements
Titration / Initial therapy requirements
Titration and new start management
Titration packs and PA: Some products (for example EXXUA titration pack, FETZIMA titration pack) are listed with therapy/titration packs and have 'PA New Starts' and QL requirements for initiation
Titration pack QL and PA New Starts flags require following the formulary Requirements/Limits when initiating therapy
Quantity limits for titration: When a titration or starter pack is used, quantity limits specific to the pack (e.g., QL 32 EA per 32 days for EXXUA titration pack) apply and must be documented
See formulary therapy pack line for exact QL and PA requirements
Initial therapy prior authorization — 'PA New Starts' require PA at initiation
Products marked 'PA New Starts' require prior authorization at initiation.
Transition Supplies and Continuity of Therapy
Transition supplies — continuity of care provisions for members starting or changing plans
Transition/continuity of care provisions for members starting or changing plans or care settings
Retail transition supply: A one‑time 30‑day transition supply will be authorized at retail (unless prescription is written for fewer days); refills may be allowed to total 30 days while an exception or alternative is pursued
Applicable for new or continuing members during initial plan transition period
Long‑term care (LTC) transition supply: Residents of long‑term care facilities may receive a 34‑day emergency/transition supply (unless prescription is written for fewer days); refills may be allowed to total 34 days while pursuing an exception
LTC admission/discharge protections: early‑refill edits will not limit appropriate access; E‑Box emergency supplies permitted
Notice following transition supply: After authorizing the temporary transition supply, the plan will send a mailed notice within three business days to the member (and a copy to the prescriber) explaining the temporary nature of the supply and the member's right to request a formulary exception or alternatives
Step Therapy Rules and Notes
Step therapy guidance
Try formulary-preferred agents first when 'ST' applies (member must try preferred drug prior to coverage of non-preferred; if preferred agent fails, alternative will be covered)
PA New Starts notation — anticonvulsants / specialty agents
Certain specialty anticonvulsants are labeled 'PA New Starts' indicating prior authorization is required when initiating therapy (examples: DIACOMIT, EPIDIOLEX, FINTEPLA). This may trigger step edits or additional utilization controls for new starts
Titration / therapy pack requirement — EXXUA
EXXUA includes a titration pack listed with Requirements/Limits = 'PA New Starts; QL (32 EA per 32 days)', indicating a therapy/titration pack is required or specified for initiation of EXXUA
febuxostat — step therapy flag
febuxostat oral tablet entries show 'Requirements/Limits = ST; EDS', indicating that step therapy (ST) applies and electronic drug screening/edit (EDS) is specified
Prior authorization and LA flags for new starts
Multiple products are noted as 'PA' or 'PA New Starts' and some include 'LA' (limited approval) — prior authorization is required for new starts and LA denotes additional utilization controls or limited approval processes
Some formulations are specifically marked 'ST' (step therapy) in the Requirements/Limits column — examples include aripiprazole oral tablet dispersible (Requirements/Limits = ST; QL; EDS) and other formulations noted as ST in the table of contents
Step therapy sequences not specified in excerpt
The document lists ST flags and tier/requirements codes but does not provide explicit step-by-step fail-first sequences for most agents; only the presence of 'ST' or other requirement codes is shown
Tiering may influence step/PA requirements
Formulary tier placement (Tiers 1‑5) is shown for products and may influence whether step therapy or prior authorization applies; tiering alone does not define specific step edits in this excerpt
Aliskiren fumarate — ST flag
Aliskiren fumarate is listed with 'ST' in the Requirements/Limits column, indicating a step therapy requirement applies to this agent
PA / PA New Starts for specialty agents
Several specialty agents are designated 'PA' or 'PA New Starts' in the Requirements/Limits column (examples include REPATHA entries and multiple Tier 5 specialty products), requiring prior authorization for initiation or coverage
Products with 'ST' flag — general note
Some products carry an explicit 'ST' flag indicating step therapy applies; however, specific step requirements or the required prior agent(s) are not provided in these chunks
Tier 5 with PA / LA implying step edits or limited approval
Designations of Tier 5 accompanied by 'PA' and 'LA' suggest additional utilization management such as prior authorization, limited approval, or step edits may apply (examples: EVRYSDI, CERDELGA, HAEGARDA entries)
No explicit ST sequences — only flags and tiering shown
The excerpt contains requirement flags (PA, QL, EDS, LA, ST) and tier assignments but does not include explicit step therapy sequences or criteria detailing which preferred agents must be tried first
TRELSTAR — ST noted
TRELSTAR (leuprolide depot) appears in the listing with 'ST' noted in Requirements/Limits indicating step therapy applies to this entry
Quantity Limits (QL) by Product
Various plan-specific quantity limits
Plan-specific example — digoxin 125 mcgDigoxin 125 mcg: 30 tablets per prescription (example plan-specific QL)
Plan-wide noteQuantity limits may be specified per prescription or per time period and vary by strength/formulation
Documentation requirementPrescribed quantity/days' supply should match QL when submitting claims or PA
buprenorphine transdermal patch — QL 4
Buprenorphine patch QLQL (4 EA per 28 days)
Formulary placementListed under opioid long-acting patch formulations with QL specified
Site-of-Care Notes
Note
Formulary Background and Scope
The formulary organizes drugs by medical condition and therapeutic class and distinguishes brand versus generic and biological products versus biosimilars. Entries show tier assignments and may list different presentations (brand/generic or biologic/biosimilar) within those groups.
Key Definitions and Legend Items
generic drug
Generic drug — definitionGeneric drugs: FDA-approved drugs with the same active ingredient as brand-name drugs and often substitutable at the pharmacy.
Substitution noteGenerics usually can be substituted for brand without new prescription depending on state law.
Cost implicationGenerics often cost less than brand-name drugs.
biosimilar / original biological product
Biosimilar / original biological product — definitionOriginal biological products are complex drugs; biosimilars are alternative biological products that may be interchangeable depending on state law.
Substitution policySome biosimilars designated interchangeable may be substituted without a new prescription per state law.
Biosimilar Policy Notes
Billing Rule
Be aware of immediate biosimilar substitutions and re‑tiering
Biosimilar policy: the plan may immediately add interchangeable biosimilars and re‑tier or remove original biologics; pharmacists may substitute interchangeable biosimilars per state substitution rules — prescribers should be aware substitutions can occur without prior notice.
Immediate substitution/removal or re‑tiering of original biologics when interchangeable biosimilars are added.
Policy Summary
PayerIndependent Health
PolicyMedicare Advantage Part D Formulary (Drug List) - Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes noted
Effective Date5/1/2026
Next Review DateN/A
Key ActionObtain prior authorization when a drug is marked 'PA' or 'PA New Starts' to avoid denial or noncoverage.
Paxlovid therapy packs have quantity limits and require adherence to the QL noted (e.g., QL per 365 days for various pack sizes) — submit supporting documentation when requesting PA
PA New Starts required for selected GLP‑1/antidiabetic injectables (examples: MOUNJARO, OZEMPIC, RYBELSUS) with specified quantity limits
Prior authorization and limits (PA, QL, LA, EDS, ENH) are encoded in the Requirements/Limits column — reference formulary legend on page VI for symbol meanings
Prior authorization is required for select specialty biologics and injectables (examples: DUPIXENT, REPATHA, OTEZLA, STELARA, SKYRIZI, many others)
PA and Limited Access (LA) flags imply utilization management and possible site/provider requirements or specialty pharmacy routing
Certain products carry provider specialty exceptions (e.g., PA not required for neurologists, cardiologists, gastroenterologists, oncologists for specified drugs) — check entry-level notes
Quantity limits and pack configuration (therapy packs, titration packs) must match prescribing and claim submissions; provide QL support with PA requests
Failure to obtain required prior authorization may result in noncoverage or claim denial — obtain PA before dispensing when required
PA required for new starts: Prior authorization is required when initiating therapy for products labeled 'PA New Starts' in the formulary (examples include MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY)
Failure to obtain PA at initiation may result in noncoverage or claim denial
Procedure and timelines described in formulary transition provisions
Requirement context
Quantity limit applies to listed strengths indicated in formulary table of contents
PAXLOVID total-year examplesExamples of Paxlovid QL: 80; 44; 120 EA per 365 days (per pack configurations)
Pack-dependent limitsDifferent therapy pack configurations have distinct annual QLs listed
Enforcement noteExceeding listed annual QL may trigger utilization controls
Select oral agents examples — QL 30
Select oral agents QLMany oral antidiabetic and related agents listed with QL (30 EA per 30 days)
Examplesdapagliflozin (FARXIGA), JANUVIA, JARDIANCE shown with QL 30 per 30 days where indicated
EDS contextSome entries include EDS in addition to QL for extended-day supply rules
MOUNJARO / OZEMPIC / TRULICITY examples
MOUNJARO example QLQL (2 mL per 28 days) — typical MOUNJARO 10 mg/0.5 mL formulation
OZEMPIC example QLQL (3 mL per 28 days) — OZEMPIC pen formulations
TRULICITY example QLQL (2 mL per 28 days) for many TRULICITY strengths
OMNIPOD PODS — QL examples
OMNIPOD pods QLQL (15 EA per 30 days) for pods (Gen 4/Gen 5)
OMNIPOD intro kit QLQL (1 EA per 365 days) for intro kit
Supply cadencePods are limited monthly while intro kit is an annual allowance per formulary
SOLIQUA — QL 15 ML per 25 days
SOLIQUA QLQL (15 ML per 25 days)
Formulation noteApplied to SOLIQUA pen formulation as per Requirements/Limits
Claims implicationPrescribed mL per 25 days must align with QL when billed
CAMZYOS — QL 30 EA per 30 days
CAMZYOS QLQL (30 EA per 30 days)
Therapy classListed among cardiovascular/arrhythmia agents with PA; LA flags where applicable
Authorization notePA may be required in addition to QL for CAMZYOS per formulary
digoxin formulations — QL varies by strength
Digoxin QL — strength-dependentQL (35 EA per 30 days) and QL (30 EA per 30 days) depending on strength
Strength examplesDigoxin 125 mcg: QL 35 per 30 days; other strengths show QL 30 per 30 days as listed
PA exceptionsPA may not be required for cardiologists or for members under certain ages as noted
WEGOVY — QL by strength (2 mL / 3 mL per 28 days)
WEGOVY QL — smaller strengthQL (2 mL per 28 days) for select strengths
WEGOVY QL — larger strengthQL (3 mL per 28 days) for other strengths
Coverage exclusionCertain WEGOVY presentations are marked 'Not covered for weight management' alongside PA and QL
FILSPARI — QL 30 EA per 30 days
FILSPARI QLQL (30 EA per 30 days)
Associated controlsListed with PA and LA in formulary Requirements/Limits
TieringPlaced in higher specialty tier with utilization management
KERENDIA — QL 30 EA per 30 days
KERENDIA QLQL (30 EA per 30 days)
Product listingKERENDIA oral tablet entries show PA and QL in Requirements/Limits
Dispensing noteQuantity limit enforced monthly per formulary
WEGOVY (select strengths) — 2 mL / 3 mL per 28 days
WEGOVY select strengths2 mL per 28 days for some strengths; 3 mL per 28 days for others
PA and coverage noteWEGOVY entries also include PA and a notation 'Not covered for weight management' for certain strengths
Provider actionConfirm strength-specific QL and coverage before prescribing or submitting PA
KERENDIA — 30 EA per 30 days (reiterated)
KERENDIA (alternate ref) QL30 EA per 30 days
Reinforced listingKERENDIA appears multiple times in the formulary with same QL and PA flags
Submission noteDocument QL when requesting PA for KERENDIA
icosapent ethyl / VASCEPA — QL 120 EA per 30 days
Icosapent ethyl (VASCEPA) QLQL (120 EA per 30 days) for 0.5 gm capsules
Strength noteOther strengths listed without QL in this excerpt
TieringListed under dyslipidemic agents with EDS as applicable
AUSTEDO — QL varies by strength (60/120/90 EA per 30 days examples)
AUSTEDO QL by strengthQL examples include 60, 120, 90 EA per 30 days depending on strength/formulation
PA/LA flagsAUSTEDO entries include PA and LA in Requirements/Limits
Dispense implicationCheck strength-specific QL before dispensing or authorizing
methylphenidate hcl er oral tablet — QL 90 EA per 30 days
Methylphenidate ER QLQL (90 EA per 30 days) for certain extended-release formulations
Multiple QLsOther methylphenidate ER formulations show QL (30 EA per 30 days) depending on strength
EDS noteMany ADHD formulations also include EDS indicating extended-day supplies
RADICAVA ORS — QL 50 mL (starter kit 70 mL) per 28 days
RADICAVA ORS QLQL (50 mL per 28 days); starter kit QL (70 mL per 28 days)
Kit vs maintenanceStarter kit has separate QL from ongoing supply per formulary lines
PA/LA flagsRADICAVA ORS entries include PA New Starts; LA in Requirements/Limits
tolvaptan oral tablet — QL 30 or 60 per 30 days
Tolvaptan QL optionsQL (30 EA per 30 days) or QL (60 EA per 30 days) depending on formulation
PA requiredTolvaptan entries include PA in Requirements/Limits in multiple listings
Therapy packsCertain therapy packs also carry QL (60 EA per 30 days)
LINZESS ORAL CAPSULE — 30 EA per 30 days
LINZESS QLQL (30 EA per 30 days)
Formulary placementLINZESS 145/72 mcg entries show 30-per-30-day QL where indicated
EDS noteSome LINZESS listings include EDS for extended-day supply rules
lubiprostone oral capsule 8 mcg — QL 60 EA per 30 days
Lubiprostone 8 mcg QLQL (60 EA per 30 days)
Strength-specific8 mcg capsule listing shows monthly QL with EDS
Provider actionEnsure monthly quantity aligns with QL when prescribing
VIJOICE — packet and therapy pack QLs
VIJOICE oral packet QLQL (28 EA per 28 days)
VIJOICE therapy pack 125/50 mg QLQL (28 EA per 28 days)
VIJOICE therapy pack 200 & 50 mg QLQL (56 EA per 28 days)
VIJOICE therapy pack 125 mg/50 mg — QL 28 EA per 28 days
VIJOICE 125/50 pack QLQL (28 EA per 28 days)
Multiple pack sizesPack QLs differ by pack composition as listed in formulary
Provider noteMatch pack QL when requesting authorization or dispensing
VIJOICE therapy pack 200 & 50 mg — QL 56 EA per 28 days
VIJOICE 200 & 50 mg pack QLQL (56 EA per 28 days)
Higher pack allowanceLarger pack configuration allows greater QL per 28 days
Therapy implicationConfirm pack dosing frequency with prescriber to align QL
EOHILIA ORAL SUSPENSION 2 MG/10ML — QL 600 ML per 30 days
EOHILIA suspension QLQL (600 ML per 30 days)
Large-volume productOral suspension limit specified in mL per 30-day period
Dispensing noteEnsure days' supply and volume match QL on claim submissions
cyanocobalamin injection solution 1000 mcg/ml — QL 4 ML per 28 days
Cyanocobalamin injection QLQL (4 ML per 28 days)
Parenteral vitamin QLCyanocobalamin 1000 mcg/ml listed with 4 mL per 28-day limit
Requirement codeAlso marked ENH in Requirements/Limits indicating enhanced benefit handling
XIFAXAN ORAL TABLET 200 MG — QL 9 EA per 3 days
XIFAXAN 200 mg QLQL (9 EA per 3 days)
Course-limited QLShort-course therapy limit specified per 3-day period for traveler’s diarrhea/HE indication
Separate 550 mg listingXIFAXAN 550 mg has different Requirements/Limits (PA) per formulary
trospium chloride er oral capsule 60 mg — QL 30 EA per 30 days
Trospium ER 60 mg QLQL (30 EA per 30 days)
OAB agent listingTrospium chloride ER 60 mg entry shows monthly QL for bladder indications
Claim documentationQuantity/days' supply should reflect QL on prescriptions
transdermal patch examples — QL 8 or 4 EA per 28 days
Transdermal patch QL examplesQL (8 EA per 28 days) for twice-weekly patches; QL (4 EA per 28 days) for weekly patches
Products noteddotti patch and estradiol transdermal patches listed with these QLs
EDS associationSome transdermal patch entries include EDS alongside QL
ORILISSA — QL 30 EA per 30 days
ORILISSA QLQL (30 EA per 30 days)
PA requirementORILISSA listed with PA in Requirements/Limits alongside QL
TieringPlaced in higher tier with utilization management controls
RINVOQ / XELJANZ XR — QL examples
RINVOQ LQ solution QLQL (450 ML per 30 days) for RINVOQ LQ oral solution
XR tablet QLQL (30 EA per 30 days) for XR tablet formulations
Formulation-specificDifferent formulations (LQ vs XR) have distinct QLs in formulary
Cost and accessBiosimilars may cost less and plans may add or re-tier biosimilars relative to original biologics.
PA — Prior Authorization
PA — notation definitionPA indicates Prior Authorization is required for coverage of the listed drug.
Action requiredPrescriber or member must obtain approval from the plan before the prescription is filled to ensure coverage.
Where shownPA appears in the Requirements/Limits column next to specific formulary entries.
QL — Quantity Limit
QL — Quantity Limit notationQL denotes the numeric quantity allowed per specified time period (e.g., QL (240 EA per 30 days)).
FormatDisplayed as number + unit (EA/mL/ML) per days (e.g., per 28/30/365 days)
EnforcementPrescriptions exceeding QL may be subject to utilization edits or denial without PA/exception.
EDS — Electronic Data System / edit indicator
EDS — Edit/Extended-day SupplyEDS indicates extended-day supply or special edit allowing longer days' supply for certain tiers (e.g., Tier 1 = 100-day supply).
Operational meaningEDS entries permit extended fills (90–100 day supplies) per formulary legend
Where usedAppears in the Requirements/Limits column alongside QL/PA flags.
LA — utilization notation
LA — Limited Approval / utilization flagLA denotes a utilization control or limited approval designation used in Requirements/Limits (legend on page VI).
ContextOften appears with PA New Starts to indicate additional controls such as specialty review
Provider actionReference formulary legend and plan materials for operational meaning when LA is shown.
EDS / BD / ST — common requirement codes
EDS — edit/submission requirement (abbrev.)EDS indicates extended-day supply or special edit review for the listed product.
BD — billing/dispense designationBD denotes products where Part B vs Part D coverage may depend on use/setting; documentation may be required.
ST — Step TherapyST indicates step therapy requirement may apply; try preferred agents first per formulary rules.
PA New Starts — Prior authorization at initiation
PA New Starts — definitionPA New Starts indicates prior authorization is required when initiating therapy for the listed product.
ImplicationNew prescriptions will require PA even if refills later may not, depending on plan rules
ExamplesMany neurology and oncology products are labeled 'PA New Starts' in the formulary.
QL — Quantity Limit examples / format
QL — example formatsDisplayed as e.g., '8 EA per 28 days' or '4 EA per 28 days' in the Requirements/Limits column
Units usedEA (each), ML/mL (volume) and periodicity (per 3/28/30/365 days)
Reference guidanceRefer to formulary legend (page VI) for full abbreviation meanings and dispensing rules.