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    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsIndependent Health Part D Formulary Coverage Updat…
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    CurrentIndependent HealthPolicy N/A

    Medicare Part D Formulary (Assure Advantage® HMO C-SNP) — Drug List / Coverage Criteria

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    This document is Independent Health's Part D drug formulary for the Assure Advantage® (HMO C-SNP) plan and governs which prescription drugs are covered, any coverage restrictions, and how members and prescribers may request exceptions. It affects plan members, prescribers, and network pharmacies using Independent Health's Medicare Advantage Part D benefit.

    Policy Summary
    PayerIndependent Health
    PolicyMedicare Part D Formulary (Assure Advantage® HMO C-SNP) — Drug List / Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAnnual formulary update (no material changes noted)
    Effective DateDec 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when a drug is flagged 'PA' to avoid denial of coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12/1/2025formulary effective/updated date
    72/24hstandard / expedited exception timeframes
    30-dayretail transition supply
    34-dayLTC transition supply
    30 daysadvance notice for removals/restrictions
    severalspecialty agents with PA

    Coverage rules and general provisions

    General coverage and transition provisions

    Covered when ALL of the following are met

    Formulary coverage basics: Drug is on Independent Health's formulary, is medically necessary, is prescribed and filled at an Independent Health network pharmacy, and other plan rules are followed.

    See formulary overview

    Prior authorization and other requirements: If the drug has additional requirements (e.g., Prior Authorization, Quantity Limits, Step Therapy), those requirements must be met before coverage is approved.

    See formulary Requirements/Limits and PA process

    Temporary transition supply: For drugs not on the formulary or with coverage restrictions, a one-time transition supply is available: 30-day retail supply for new/continuing members or 34-day supply for long-term care residents while pursuing coverage or alternatives.30 days retail; 34 days LTC
    Policy Summary
    PayerIndependent Health
    PolicyMedicare Part D Formulary (Assure Advantage® HMO C-SNP) — Drug List / Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAnnual formulary update (no material changes noted)
    Effective DateDec 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when a drug is flagged 'PA' to avoid denial of coverage.
    SourceLink
    On This Page
    Coverage rules and general provisionsFormulary product listings, codes and flagsWhat prescribers and pharmacies must doPolicy background and scopeKey term definitions and abbreviationsStep therapy requirements and affected productsQuantity limits for select productsPrescriber or site-specific PA exemptions

    Transition and continuity of care provisions apply

    Device and insulin supplies — covered with utilization controls

    Coverage entries with conditions or limits as listed below

    Insulin devices and supplies: Insulin delivery devices, pens, pods and related supplies are covered at the tiers indicated but are subject to utilization controls including claim edits (EDS) and specified quantity limits (for example: pods limited to 15 EA per 30 days; introduction kits limited to 1 EA per 365 days; SOLIQUA pens limited to 15 mL per 25 days).See product-specific QL (e.g., 15 EA/30 days; 1 EA/365 days; 15 ML/25 days)

    Pharmacy claims subject to EDS/QL enforcement

    Claims editing and documentation: Products flagged with EDS require claim-level edits and documentation per payer rules; pharmacies must document days' supply and quantities to comply with limits.

    EDS enforcement per formulary entries

    Specialty/hematology — covered with PA

    Specialty agents (examples below) are covered only with prior authorization and any listed LA/QL constraints

    Prior authorization required: Specialty and hematology agents (examples include FILSPARI, PYRUKYND, CABLIVI, UDENYCA, RETACRIT) require prior authorization before dispensing.

    PA required per formulary entries

    Additional utilization controls: Some specialty agents also have limited access (LA) designations and specific quantity limits (e.g., FILSPARI QL 30 EA per 30 days; PYRUKYND QL 56 EA per 28 days or as specified for taper packs).See product QL entries

    LA and QL enforced alongside PA

    Anticoagulants and cardiovascular agents — covered with edits

    Cardiovascular and anticoagulant classes are covered as listed but subject to formulary edits

    Coverage with edits: Anticoagulants and cardiovascular agents (e.g., dabigatran, apixaban/ELIQUIS, enoxaparin, ACE inhibitors, ARBs, beta blockers, calcium channel blockers) are covered at the tiers shown but are subject to claim-level edits (EDS) and, where noted, product-specific requirements or quantity limits.

    EDS and QL flags appear in formulary entries

    Strength- or product-specific controls: Certain strengths or presentations may have additional controls (for example, ELIQUIS entries include claim edits; some agents list PA or QL for specific presentations).

    Check Requirements/Limits for product-level rules

    Drugs that are not included on Independent Health's formulary are not covered unless one of two conditions is met: the plan approves a formal exception request, or the prescriber selects an alternative drug that is covered by the formulary. Members should contact Member Services to confirm coverage and to request either a list of covered alternatives or information on how to submit an exception request.

    This extract does not list any standalone clinical exclusions; the formulary instead marks products with utilization controls and tier designations. Coverage distinctions in this excerpt are expressed as flags in the Requirements/Limits column (for example PA, QL, ST, and LA) rather than as explicit condition-based exclusions.

    The VABOMERE intravenous solution entry is listed with PA but includes a specialty prescriber exception: prior authorization is not required for nephrologists or infectious diseases specialists. This specialty-based exception should be followed when the listed specialists prescribe VABOMERE IV.

    No additional specific coverage criteria or exclusion statements are shown in this excerpt beyond the utilization flags and tiering noted in the formulary table.

    WEGOVY® products in the listing carry utilization controls and an explicit coverage limitation: they are marked PA and are not covered for weight management for the specified strengths; quantity limits are also shown (for example QL 4 mL per 224 days or QL 3 mL per 28 days depending on strength).

    Some topical products that are otherwise marked PA include a prescriber-specialty exception: for example, diclofenac topical formulations are listed with PA but note that prior authorization is not required for dermatologists or oncologists when they prescribe the product.

    There are no explicit 'not medically necessary' (NMN) determinations stated in this excerpt of the formulary; the document focuses on formulary flags (PA, QL, ST, LA, EDS) and tier assignments rather than NMN language.

    Formulary product listings, codes and flags

    What prescribers and pharmacies must do

    Prior Authorization

    Prior authorization required

    Drugs listed with a 'PA' in the formulary Requirements/Limits column require prior authorization. Prescribers or pharmacies must obtain Independent Health approval before dispensing; failure to obtain prior authorization may result in the drug not being covered. This applies to drugs flagged 'PA', 'PA New Starts', and products carrying both PA and other utilization controls (LA, QL, EDS, BD).

    • Prior authorization (PA) is required for drugs marked PA in the formulary.
    • PA New Starts: many specialty, oncology, and high‑tier agents are marked 'PA New Starts' — prior authorization must be obtained when initiating therapy.
    • LA (limited/limited access) and QL (quantity limits) frequently accompany PA; requests should document dispensing source and days' supply where noted.
    Prior Authorization

    Strength-specific PA and quantity limits

    Some formulary entries include strength- or product-specific PA and QL instructions. For example, XIFAXAN 200 mg has a QL (9 tablets per 3 days) while XIFAXAN 550 mg is PA; SIVEXTRO (tedizolid) is listed as PA for both IV and oral formulations. Pharmacies must follow the strength-specific rules when adjudicating claims.

    • SIVEXTRO INTRAVENOUS SOLUTION 200 mg — Requirements/Limits = PA.
    • SIVEXTRO ORAL TABLET 200 mg — Requirements/Limits = PA.
    • XIFAXAN ORAL TABLET 200 mg — QL (9 EA per 3 days); XIFAXAN 550 mg — PA.
    Documentation Required

    Quantity limits for therapy packs

    Therapy packs and starter/maintenance kits often carry quantity limits and may require PA or be limited to specific dispensing pharmacies (LA). Prescribers should document the intended pack and duration; pharmacies must verify and apply the QL when processing.

    • Therapy packs (e.g., XCOPRI, ABILIFY MYCITE starter/maintenance kits, PIQRAY therapy packs) list QLs (units per days period) and may be PA New Starts.
    • Some therapy packs are LA-restricted to certain dispensing sites; check formulary 'LA' notes before dispensing.
    • Claims exceeding stated QLs (units per period) risk denial unless an approved exception or PA documents justify an override.
    Prior Authorization

    Prior authorization and utilization controls for specialty/high‑tier drugs

    Many specialty, hematology, oncology, and branded products are subject to prior authorization and additional utilization controls (LA, EDS, BD, QL). Examples include IMBRUVICA, REVLIMID, VENCLEXTA, PRALUENT/REPATHA, PYRUKYND, CABLIVI, FILSPARI, and others — these may require PA New Starts, LA, and/or QL. Prescribers must submit clinical documentation according to Independent Health's prior authorization process.

    • PA New Starts is commonly applied to oral oncology and specialty agents (multiple examples in formulary).
    • LA indicates limited dispensing or specialty pharmacy requirement; EDS/BD flags indicate extra documentation or billing edits.
    • Prescriber supporting statement and clinical rationale must accompany exception or PA requests; Independent Health typically adjudicates requests per their PA turnaround rules.
    Step Therapy

    Step therapy and how to confirm requirements

    Step therapy (ST) flags are present for some agents; where 'ST' appears in the Requirements/Limits column, the plan requires trials of preferred drugs before covering the listed product. The formulary excerpt does not include full step sequences — prescribers should consult the full Pharmacy Directory or contact Member Services for step details and for how to request an exception.

    • ST indicates a step-therapy requirement; failure to meet step criteria may require an exception request.
    • Some entries note 'PA New Starts' in lieu of or in addition to ST; both restrict initiation of therapy.
    • For complete step sequences and allowable exceptions, contact Independent Health or review the Pharmacy Directory.
    Note

    Specialist exemptions and provider-based PA notes

    Specialty prescriber and provider‑type exemptions are noted on some drugs: certain prior authorizations are not required if ordered by a specific specialist (for example, prior authorization not required for oncologists for some fentanyl products; not required for nephrologists or infectious disease specialists for VABOMERE; not required for neurologists for some seizure rescue nasal therapy packs). Always check the formulary notes for specialty exemptions before initiating a PA.

    • Prior authorization not required for oncologists for some fentanyl buccal products (but QL still applies).
    • VABOMERE IV: PA; prior authorization not required for nephrologists or infectious disease specialists.
    • VALTOCO therapy packs: PA New Starts; prior authorization not required for neurologists.
    • CORLANOR: PA; prior authorization not required for cardiologists.
    Documentation Required

    Authorization documentation and exception process

    Documentation and authorization logistics: when PA, PA New Starts, LA, EDS, BD, or QL flags are present, prescribers must provide supporting clinical information per Independent Health's PA process. Quantity limits must be documented on claims (days' supply and units). Exception requests (formulary/tiering or restriction waivers) require the prescriber's supporting statement; Independent Health generally responds within 72 hours (24 hours for expedited requests when clinically necessary).

    • Prescriber's supporting statement is required for formulary/tiering exceptions and to waive PA/QL/ST restrictions.
    • Independent Health decision timelines: standard — within 72 hours of receiving prescriber documentation; expedited — within 24 hours if clinically appropriate.
    • Claims should include documentation of QL (units per time period) and, where EDS/BD/LA apply, the dispensing pharmacy or enhanced documentation as required.
    Note

    How to get formulary and prior authorization details

    How to obtain details: consult the Pharmacy Directory or call Independent Health Member Services for specifics on PA forms, specialty pharmacy requirements, and the most recent formulary updates. Online resources at www.IndependentHealth.com/Medicare list PA, QL, LA, ST rules and contact information.

    • Member Services: (716) 250-4401 or 1-800-665-1502 (TTY 711) — seasonal hours noted in the formulary header.
    • Pharmacy Directory and plan website provide formulary specifics, PA forms, and specialty pharmacy guidance.

    Policy background and scope

    This formulary groups covered drugs by medical condition and provides requirements or limits next to each product line. Utilization controls visible in the table include prior authorization (PA), quantity limits (QL), step therapy (ST), and limited access (LA), and many items also show claim edits (EDS). The document also describes transitional coverage provisions: a one-time retail 30-day transition supply (and 34-day supply for long-term care) may be provided while a member pursues coverage decisions or alternatives.

    Key term definitions and abbreviations

    Formulary / Drug List definition
    Formulary / Drug ListA list of covered drugs selected by Independent Health; coverage depends on medical necessity, filling at network pharmacies, and plan rules
    Selection processFormulary developed in consultation with health care providers representing therapies necessary for quality treatment
    Coverage conditionIndependent Health will generally cover drugs on the formulary when medically necessary and plan rules are followed
    Biosimilar / Interchangeable biosimilar definition
    Biosimilar definitionA biosimilar is an alternative to an original biological product; interchangeable biosimilars may be substituted at the pharmacy without a new prescription depending on state laws
    Interchangeability noteSubstitution of interchangeable biosimilars is subject to applicable state laws
    Cost and equivalenceBiosimilars generally work like the original biological product and may cost less
    PA definition — Prior authorization
    Prior authorization (PA)A requirement that the member or prescriber obtain approval from Independent Health before the drug will be covered; drugs listed with 'PA' require this approval
    Denial riskFailure to obtain PA may result in the drug not being covered
    Where indicatedPA is noted in the Requirements/Limits column of the formulary entries
    QL definition — Quantity limits
    Quantity limits (QL)A maximum amount of drug the plan will cover in a specified time period; drugs listed with 'QL' have limits on dispensing quantities
    Example illustrationExample: 30 tablets per prescription for digoxin 125 mcg
    Formulary locationQL is shown in the Requirements/Limits column for relevant products
    LA definition — Limited availability
    LA — Limited availabilityDrugs listed with 'LA' may be available only at certain pharmacies; consult the Pharmacy Directory or Member Services for details
    Access controlLA often appears alongside PA and QL for specialty products
    Routing for infoMember Services contact info provided in formulary
    ST definition — Step therapy
    ST — Step therapyDrugs with 'ST' require trying specified preferred alternatives first before coverage of another drug is allowed
    ProcessIf first-line drug does not work, the plan may then cover the alternative
    Indication in formularyST appears in the Requirements/Limits column for applicable products
    PA / QL combined definition note
    PA and QL combinedPA indicates prior authorization may be required; QL indicates a quantity limit — both flags may appear together in a product's Requirements/Limits and are enforced per formulary rules
    EnforcementProducts with PA and QL may require both approval and adherence to quantity limits to be covered
    Provider guidanceConsult formulary entries and Member Services for specific PA/QL criteria
    PA definition (alternate)
    PA (alternate)Prior authorization requires payer approval before the benefit is granted for listed products; noted in product entries
    New startsSome products specify 'PA New Starts' indicating PA is required for initiation of therapy
    DocumentationWhen PA is indicated, prescribers must submit authorization documentation per the payer process
    QL definition (alternate)
    QL (alternate)Quantity limit — maximum supply allowed in the specified time period (examples shown as EA per days or ML per days)
    Claim editsPharmacy claims must support days' supply and quantity consistent with QL entries
    Examples providedMultiple QL examples appear in the formulary entries (e.g., 15 EA per 30 days; 30 EA per 30 days)
    Tier — formulary tier definition
    Formulary tier (Tier)Formulary tier indicates the member cost‑sharing level for the listed drug (tier shown in formulary columns)
    Tier rangeFormulary entries in this extract include tiers 1–5
    ImpactTier affects copayment/coinsurance and may influence step or PA requirements
    EDS — edit/clinical edit definition
    EDS — Edit / clinical editEntries with 'EDS' indicate an edit or clinical edit applied to claims; EDS listings may permit extended day supply for certain tiers
    Supply implicationsEDS drugs on Tier 1 can be filled for a 100‑day supply; Tiers 2–4 for a 90‑day supply as noted
    UsageEDS appears in Requirements/Limits and indicates claim‑level processing rules
    PA (specialty) definition
    PA (specialty) — specialty agent PAMany specialty/hematology agents are listed with 'PA' requiring prior authorization before coverage (examples: FILSPARI, PYRUKYND)
    Additional flagsSpecialty entries often include LA or QL in addition to PA
    Tier implicationMost specialty agents appear in higher tiers (Tier 4–5) and require PA/LA controls
    QL (examples) definition
    QL examples in documentThe formulary shows numerous QL examples across products (EA per days, ML per days) — consult specific product rows for exact limits
    Therapy pack QLsTherapy packs often have different QLs (e.g., 28–56 EA per 28–30 days) shown
    Strength‑dependent QLsSome strengths of the same product have different QLs (see fentanyl patch and other entries)
    LA — utilization management control definition
    LA — utilization controlLA indicates limited availability or restricted dispensing (may be available only at certain pharmacies); check Pharmacy Directory for details
    Associated controlsLA commonly accompanies PA and QL for specialty drugs
    Provider actionPrescribers should consult Member Services or Pharmacy Directory for LA handling
    PA / Prior Authorization definition (alternate)
    PA / Prior Authorization (alternate)Prior authorization requires approval from Independent Health before coverage; listed as 'PA' in Requirements/Limits
    Where describedExplained in 'Are there any restrictions on my coverage?' and product entries
    Exception processMembers may request exceptions to PA/limits per formulary procedures
    EDS / Expanded Drug Steering definition
    EDS / Expanded Drug SteeringEDS is a utilization or dispensing flag applied to select products (e.g., electrolytes, extended supplies) indicating special claim edits or extended day supply allowance
    Supply rulesEDS entries specify extended day supply allowances for certain tiers as noted in formulary overview
    DocumentationEDS may require additional claim documentation or adherence to dispensing rules
    BD — billing/dispensing flag definition
    BD — billing/dispensing flagBD indicates a billing or dispensing placement flag used for certain parenteral nutrition and IV solutions (e.g., Clinimix/Intraflipid)
    ApplicabilityBD appears in Requirements/Limits for IV nutrition/emulsion products
    Reimbursement noteBD may signal that coverage determination could fall under Part B or Part D depending on setting and documentation

    Step therapy requirements and affected products

    Coverage labelDescription
    STMembers may be required to try preferred drugs first per step therapy ('ST' in Requirements/Limits) before other drugs will be covered. Reference: formulary 'Are there any restrictions on my coverage?' and 'Independent Health's Formulary' description of ST.
    Coverage labelDescription
    STDrugs marked with 'ST' in the Requirements/Limits column are subject to step therapy per the formulary; specific step sequences or required prior agents are not detailed in this extract.
    Product / labelRequirements implied
    DIACOMIT (stiripentol) oral capsule/packetRequirements/Limits = 'PA New Starts; LA' — implies prior authorization required for new starts and limited access (available at specified pharmacies); step sequencing not shown in excerpt.
    Product examplesRequirements/Limits (implication)
    BRIVIACT; EPIDIOLEX; FINTEPLA; other high-tier anticonvulsantsEntries note 'PA New Starts' (and sometimes LA) indicating prior authorization is required for initiation of new therapy; explicit step sequences not provided in the extract.
    ProductRequirements/Limits
    Febuxostat oral tablet (40 mg, 80 mg)Requirements/Limits = 'ST; EDS' — febuxostat is subject to step therapy and an edit (EDS) as listed in the formulary.
    Product examplesRequirements/Limits (implication)
    Multiple oral oncology and specialty agents (e.g., POMALYST, REVLIMID, XPOVIO therapy packs)Listings frequently show 'PA New Starts' and occasionally LA or QL flags — implying prior authorization for new therapy starts; no formal step sequences are shown in the excerpt.
    Product group / examplesRequirements/Limits
    Branded antipsychotics and specialty products (examples: ABILIFY MYCITE, CAPLYTA, INVEGA line, LYBALVI)Several entries are designated 'PA New Starts' or 'ST' (and some include BD/QL/EDS/LA), indicating prior authorization for new starts or step therapy restrictions for these branded products.
    ProductRequirements/Limits
    LYBALVI oral tabletRequirements/Limits = 'PA New Starts' — prior authorization required for new starts of LYBALVI as listed in the formulary.
    Product groupRequirements/Limits (flags observed)
    Multiple GLP-1 and related products (examples: MOUNJARO, OZEMPIC, RYBELSUS, SOLIQUA)Formulary entries show PA and QL flags (e.g., RYBELSUS entries include PA; QL values vary by strength). The extract does not provide step therapy sequencing for these agents.
    Product / examplesAdditional flags
    Various specialty agents (e.g., DIACOMIT, PYRUKYND, FILSPARI)Listings include 'LA' alongside PA for some specialty agents — indicating limited access or line-of-therapy designations in addition to prior authorization requirements.
    ProductRequirements/Limits
    Aliskiren fumarate oral tablet (150 mg, 300 mg)Requirements/Limits = 'ST; EDS' — aliskiren fumarate is listed with step therapy and an edit (EDS) in the formulary.
    Product examplesRequirements/Limits
    QELBREE; pregabalin ERExamples in the table show 'ST' (step therapy) required for these products prior to coverage; QELBREE also has QL and EDS noted.
    Product group / examplesRequirements/Limits (implication)
    Assorted specialty agents and branded products (e.g., EPIDIOLEX, CAPLYTA, PYRUKYND, FILSPARI)Many entries indicate 'PA New Starts' or 'ST' in Requirements/Limits — implying prior authorization or step therapy restrictions for initiation of these high-tier or specialty agents; exact step sequences are not provided in this extract.

    Quantity limits for select products

    Unspecified example — digoxin QL
    Unspecified example30 tablets per prescription for digoxin 125 mcg (document example of a quantity limit)
    PurposeIllustrates how QLs may be applied in addition to standard one‑month or three‑month supplies
    Reference locationExplained in the 'Are there any restrictions on my coverage?' section
    buprenorphine transdermal patch — QL 4
    Buprenorphine transdermal patch (weekly)QL — 4 (EA) per 28 days as listed in the formulary table
    TierListed as Tier 3 in table of contents
    Formulary locationAppears under Opioid Analgesics, Long‑Acting in the table of contents
    fentanyl transdermal patch — QL 30
    Fentanyl transdermal patch (some strengths)QL — 30 EA per 30 days as listed for specified strengths
    Fentanyl transdermal patch (other strengths)QL — 15 EA per 30 days for lower strengths as shown
    Formulary placementListed under Opioid Analgesics, Long‑Acting entries
    fentanyl transdermal patch (other strengths) — QL 15
    Fentanyl transdermal patch (lower strengths)QL — 15 EA per 30 days as shown for 12/25/50 mcg/hr strengths
    Strength dependenceDifferent strengths carry different QLs in the formulary table
    Requirements/Limits columnQL shown explicitly next to listed strengths
    tramadol ER — QL 30
    Tramadol ER (various ER forms)QL — 30 EA per 30 days as listed in the formulary
    Forms includedVarious extended‑release tramadol products across entries show the same QL
    PlacementListed under Opioid Analgesics, Long‑Acting/ER sections
    fentanyl citrate buccal lozenge/tablet — QL 120
    Fentanyl citrate buccal lozenge/tabletQL — 120 EA per 30 days (listed alongside PA for many strengths)
    PA noteSome fentanyl transmucosal entries require PA and note oncologist exemption
    TieringTiers vary (some entries Tier 4–5) as shown in the table
    fosfomycin tromethamine oral packet 3 gm — QL 1 per 30 days
    Fosfomycin tromethamine oral packet 3 gmQL — 1 EA per 30 days
    Formulary placementListed in Antibacterials section with QL noted
    TierTier indicated in table (see contents)
    XIFAXAN ORAL TABLET 200 MG — QL 9 per 3 days
    XIFAXAN oral tablet 200 mgQL — 9 EA per 3 days
    XIFAXAN 550 mgListed with PA for that strength
    Coverage noteStrength‑specific PA/QL distinctions are shown in the formulary entries
    BRIVIACT ORAL TABLET 10 MG — QL 240
    BRIVIACT oral tablet 10 mgQL — 240 EA per 30 days
    BRIVIACT oral tablets 25/50/75 mgQL — 60 EA per 30 days for these strengths
    TierBRIVIACT listed as Tier 5 in entries
    BRIVIACT ORAL TABLET 25/50/75 MG — QL 60
    BRIVIACT oral tablets 25/50/75 mgQL — 60 EA per 30 days
    BRIVIACT 10 mg contrast10 mg form has a higher QL (240 per 30 days) listed separately
    RequirementsEntries show QL values in Requirements/Limits column
    BRIVIACT ORAL TABLET 10 MG — QL 240 (duplicate)
    BRIVIACT oral tablet 10 mg (repeat)QL — 240 EA per 30 days (table listing)
    Use notePharmacy claims must document days' supply consistent with QL
    TieringTier 5 listing with QL noted
    perampanel oral tablet — QL 30
    Perampanel oral tablet (various strengths)QL — 30 EA per 30 days as listed
    2 mg form2 mg form also carries QL 30 and may have EDS
    TierPerampanel listed as Tier 5 (most strengths)
    XCOPRI therapy packs / tablets — QL 28–56
    XCOPRI therapy packs / tabletsQL — 28–56 EA per 28–30 days depending on pack/strength
    Therapy pack examplesSome XCOPRI therapy packs listed as 56 EA per 28 days, others 28 EA per 28 days
    TierXCOPRI listed as Tier 4–5 with QL values
    LIBERVANT BUCCAL FILM — QL 10
    LIBERVANT buccal filmQL — 10 EA per 30 days
    PlacementListed under anticonvulsant/related entries with QL noted
    TieringTier indicated in the table (see contents)
    desvenlafaxine ER 50 mg — QL 30
    Desvenlafaxine ER 50 mgQL — 30 EA per 30 days
    Formulary contextListed under antidepressants with EDS and QL where specified
    Supply enforcementPharmacy must document days' supply consistent with the QL
    drizalma sprinkle — QL 60
    Drizalma sprinkle (20/30/40 mg)QL — 60 EA per 30 days as listed
    Therapy packs/strengthsListed with QL in antidepressant section entries
    TieringTier shown in table (see contents)
    QULIPTA oral tablet — QL 30
    QULIPTA oral tabletQL — 30 EA per 30 days
    Requirement flagsQULIPTA also shown with PA and EDS in some entries
    TierListed as Tier 3 in the contents snippet
    VIVJOA oral capsule therapy pack (150 mg) — QL 18 per 84 days
    VIVJOA therapy pack (150 mg)QL — 18 EA per 84 days
    Pack supply noteQuantity shown over 84‑day period consistent with therapy pack dosing
    TierListed as Tier 4 in table of contents
    ONUREG ORAL TABLET — QL 30
    ONUREG oral tabletQL — 30 (EA per 30 days) as listed
    Formulary placementListed with other oncology agents and PA New Starts where applicable
    Claims noteQuantity limits enforced per formulary Requirements/Limits
    XPOVIO therapy packs — regimen‑dependent QLs
    XPOVIO therapy packsQL — various regimen‑dependent limits (examples: 4–32 EA per 28 days); specific QL depends on pack/regimen
    PA/New Starts noteXPOVIO therapy packs carry PA New Starts and LA flags alongside QL
    Regimen examplesListed QLs include 4, 8, 16, 24, 32 EA per 28 days depending on pack and dosing frequency
    dasatinib oral tablet — QL 30 or 60
    Dasatinib oral tabletQL — 30 or 60 EA per 30 days depending on dose (dose‑dependent QL entries shown)
    PA New StartsDasatinib entries include PA New Starts in oncology listing where applicable
    Therapy contextListed among oral oncology agents with QL/PA/LA as noted
    LYTGOBI therapy packs — QL ranges
    LYTGOBI therapy packsQL — 84 / 112 / 140 EA per 28 days depending on daily dose (therapy pack dependent)
    PA New StartsLYTGOBI therapy packs listed with PA New Starts in oncology section
    Pack dosingQL varies by pack corresponding to daily dose (12/16/20 mg daily dosing examples)
    OJEMDA oral tablet 100 mg (pack sizes) — QL 16/24
    OJEMDA oral tablet 100 mg (pack sizes)QL — 16 EA per 28 days (16‑pack) or 24 EA per 28 days (24‑pack)
    PA/LA flagsOJEMDA entries include PA New Starts and LA with QL for pack sizes
    Therapy pack mappingPack size determines the QL shown in Requirements/Limits
    PEMAZYRE oral tablet — QL 30
    PEMAZYRE oral tabletQL — 30 EA per 30 days (listed with PA New Starts; LA)
    Specialty controlsPEMAZYRE entries include PA New Starts and LA along with QL
    TieringListed as Tier 5 in oncology agents section
    TRUQAP therapy pack — QL 64
    TRUQAP therapy packQL — 64 EA per 28 days (therapy pack limit)
    PA New StartsTRUQAP therapy packs listed with PA New Starts; LA may apply
    Regimen contextQL corresponds to pack dosing and is enforced per formulary
    XPOVIO therapy packs — QL ranges (repeat)
    XPOVIO therapy packs (range)QL — examples include 4–32 EA per 28 days depending on regimen; multiple pack entries list specific QLs
    Regimen examplesEntries show QLs of 4, 8, 16, 24, 32 EA per 28 days tied to dosing schedule
    Associated controlsPA New Starts and LA flags accompany these QLs in oncology listings
    ZEJULA oral tablet — QL 30
    ZEJULA oral tabletQL — 30 EA per 30 days (listed with PA New Starts; LA)
    Oncology listingZEJULA shown among oral oncology agents with QL and PA/LA flags
    Pack/strength noteSpecific QL applies per strength/pack entry in formulary
    COARTEM ORAL TABLET 20-120 MG — QL 24
    COARTEM oral tablet 20‑120 mgQL — 24 EA per prescription (as shown in table of contents)
    Antiprotozoal listingCOARTEM listed under antiprotozoals with QL specified
    TierListed as Tier 3 in contents
    ABILIFY MYCITE maintenance/starter kits — QL 30/60
    ABILIFY MYCITE maintenance/starter kitsQL — 30 EA or 60 EA per 30 days depending on pack (PA New Starts applies)
    PA New StartsABILIFY MYCITE kits listed with PA New Starts in Requirements/Limits
    Pack‑dependent QLDifferent kit pack sizes map to different QLs as shown
    COBENFY STARTER PACK — QL 56
    COBENFY starter packQL — 56 EA per 28 days (starter pack limit)
    PA New StartsCOBENFY starter pack listed with PA New Starts in Requirements/Limits
    Therapy pack noteStarter pack QL applies for initial therapy as listed
    various long-acting antipsychotics — QL examples
    Long‑acting antipsychotics (examples)QL — examples include 30 EA per 30 days, 90 EA per 30 days, 120 EA per 30 days as noted
    BD flag examplesSome intramuscular LA antipsychotics show BD in Requirements/Limits indicating billing/dispense flags
    Pack/strength dependenceQL varies by product and formulation per formulary entries
    asenapine sublingual tablet — QL 60
    Asenapine sublingual tabletQL — 60 EA per 30 days for specified strengths
    EDS noteListed with EDS in Requirements/Limits alongside QL
    TierListed as Tier 4 in contents
    risperidone dispersible (0.25/0.5 mg) — QL 90
    Risperidone dispersible (0.25/0.5 mg)QL — 90 EA per 30 days
    EDSEntries also list EDS in Requirements/Limits
    TieringListed in antipsychotic section with QL/EDS
    risperidone dispersible (1/2 mg) — QL 30
    Risperidone dispersible (1/2 mg)QL — 30 EA per 30 days
    Formulary contextShown with EDS and tiering in the contents listing
    Dispense rulesPharmacy should follow QL when filling dispersible formulations
    FARXIGA 5 mg — QL 30
    FARXIGA 5 mgQL — 30 EA per 30 days
    TierListed with EDS in formulary listings
    Quantity enforcementQL enforced per formulary Requirements/Limits
    MOUNJARO — QL (ML per period) examples
    MOUNJARO (certain strengths)QL — 2 ML per 28 days; 2 ML per 365 days for 2.5 mg strength (as listed)
    PA flagMOUNJARO entries include PA in Requirements/Limits
    EDSEDS applies to many insulin/devices listings
    OZEMPIC — QL 3 ML per 28 days
    OZEMPIC (various strengths)QL — 3 ML per 28 days (listed for multiple strengths)
    PA flagOZEMPIC entries include PA in Requirements/Limits
    EDSEDS listed for pen/insulin supplies alongside QL
    RYBELSUS — QL examples
    RYBELSUS (various strengths)QL — examples include 60 EA per 365 days and 30 EA per 30 days depending on strength
    PA and EDSRYBELSUS entries include PA and EDS flags depending on formulation/strength
    Strength dependenceExact QL varies by listed formulation in the formulary
    OMNIPOD 5 pods (GEN 5/4/3) — QL 15; kit limit
    Omnipod 5 pods (GEN 5/4/3)QL — 15 EA per 30 days; intro kits limited to 1 EA per 365 days
    Intro kit noteIntro kits (Gen 5/4/3) QL 1 per 365 days as listed
    EDSPods and kits entries include EDS in Requirements/Limits
    OMNIPOD pods — QL 15; intro kit 1 per 365 days (duplicate)
    Omnipod pods (repeat)QL — 15 EA per 30 days; intro kit 1 EA per 365 days
    EDS enforcementEDS edits apply to pod fills as noted
    TierListed as Tier 3 for devices and supplies
    SOLIQUA pen — QL 15 ML per 25 days
    SOLIQUA penQL — 15 ML per 25 days (listed with EDS)
    Formulary placementListed under insulin devices and pens with specified QL
    Claims notePharmacy claims should reflect ML per period to enforce QL
    FILSPARI — QL 30
    FILSPARIQL — 30 EA per 30 days; listed with PA and LA
    TierListed as Tier 5 in formulary entries
    EnforcementQuantity limit enforced alongside PA/LA utilization controls
    PYRUKYND — QL 56 per 28 days and taper pack QLs
    PYRUKYND (tablet)QL — 56 EA per 28 days
    Taper pack QLsTaper packs have specific QLs (7 EA per 7 days; 14 EA per 14 days) listed
    PA/LAPYRUKYND entries include PA and LA alongside QL
    FILSPARI — QL 30 (repeat)
    FILSPARI (repeat)QL — 30 EA per 30 days (listed with PA; LA)
    ContextSeen in cardiovascular/ specialty listings with PA/LA/QL flags
    TierTier 5 specialty agent
    CAMZYOS — QL 30
    CAMZYOSQL — 30 EA per 30 days (listed with PA; LA)
    TierListed as Tier 5 in the cardiovascular agents section
    Utilization controlsPA and LA accompany the QL in Requirements/Limits
    REPATHA — QL/PA notes
    REPATHA presentationsQL implicit via PA New Starts or EDS where specified; limited supply controls apply as listed
    PA New StartsREPATHA entries list PA New Starts and EDS in Requirements/Limits
    DispensingSome presentations use EDS/PA to control dispensing source and day supply
    WEGOVY — QL examples and coverage note
    WEGOVY (selected strengths)QL — examples include 4 mL per 224 days and 3 mL per 28 days; some strengths 'Not covered for weight management'
    PA and coverage noteWEGOVY entries include PA and explicit 'Not covered for weight management' language for certain strengths
    TierListed as Tier 5 specialty product
    KERENDIA — QL 30
    KERENDIAQL — 30 EA per 30 days (listed with PA; EDS)
    Formulary placementAppears in diuretics/mineralocorticoid receptor antagonist listings with PA/QL
    Claims enforcementEDS and QL applied to claims as noted
    lisdexamfetamine dimesylate — QL 30 (some 60)
    Lisdexamfetamine dimesylateQL — 30 EA per 30 days; some strengths QL 60 EA per 30 days
    ADHD agent listingAppears in CNS/ADHD entries with EDS and QL where specified
    Strength varianceHigher strengths may carry larger QLs per formulary rows
    AUSTEDO — QL 60 / 120 depending on strength
    AUSTEDO (selected strengths)QL — 60 EA per 30 days or 120 EA per 30 days depending on strength; therapy packs listed with other QLs
    PA/LAAUSTEDO entries include PA and LA flags where applicable
    Therapy pack examplesTitration kits and starter packs have specific QLs (e.g., 70 EA per 28 days) shown
    RADICAVA ORS — QL 50 mL (starter kit 70 mL)
    RADICAVA ORS (starter/new starts)QL — 50 mL per 28 days; starter kit QL 70 mL per 28 days
    PA New Starts/LARADICAVA ORS entries show PA New Starts and LA alongside QL
    TierListed as Tier 5 specialty with dispensing controls
    MAYZENT — QL examples by strength
    MAYZENT oral tabletQL — 120 EA per 30 days for 0.25 mg; QL 30 EA per 30 days for 1 mg/7 mg strengths as listed elsewhere
    Pack/strength dependenceDifferent strengths and starter packs have distinct QLs in the formulary
    PA/EDSSome MAYZENT entries include EDS or PA in Requirements/Limits
    tolvaptan — QL 30
    Tolvaptan (hyponatremia)QL — 30 EA per 30 days (listed with PA)
    PA flagTolvaptan entries include PA in Requirements/Limits
    TierListed as Tier 5 specialty agent in electrolytes/metal modifiers section
    cyanocobalamin injection solution 1000 mcg/ml — QL 4 mL
    Cyanocobalamin injection solution 1000 mcg/mlQL — 4 mL per 28 days (ENH; QL noted)
    ENH flagCyanocobalamin entry lists ENH alongside QL indicating special coverage handling
    TierListed as Tier 2 in contents
    LINZESS; RELISTOR; ZOKINVY; MYRBETRIQ — QL examples
    LINZESS; RELISTOR; ZOKINVY; MYRBETRIQ (examples)QL examples shown include 30 EA per 30 days and 120 EA per 30 days depending on product; some entries also list PA
    LINZESSQL — 30 EA per 30 days; EDS applies
    MYRBETRIQQL — 30 EA per 30 days; EDS applies
    XIFAXAN 200 mg; VIJOICE — QL examples
    XIFAXAN 200 mgQL — 9 EA per 3 days (listed in formulary)
    VIJOICEQL — 28 EA per 28 days as listed
    Strength distinctionsXIFAXAN 550 mg listed separately with PA for that strength
    PYRUKYND — QL 56 per 28 days; taper pack QLs
    PYRUKYND (repeat) — tablets & taper packsQL — 56 EA per 28 days for tablets; taper pack QLs include 7 EA per 7 days and 14 EA per 14 days
    PA/LAPYRUKYND entries include PA and LA flags in Requirements/Limits
    Therapy pack mappingTaper pack QLs defined per pack duration in the formulary

    Prescriber or site-specific PA exemptions

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