CurrentNeighborhood Health Plan of Rhode IslandPolicy 00026453

Neighborhood INTEGRITY for Duals — List of Covered Drugs (Drug List / Formulary)

List of Covered Drugs for Neighborhood INTEGRITY for Duals describing covered drugs, OTC items, and rules (prior authorization, quantity limits, step therapy) and how members/providers are affected.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNeighborhood INTEGRITY for Duals — List of Covered Drugs (Drug List / Formulary)

Policy CodePolicy 00026453

Change TypeNo material changes noted

Effective DateEFFECTIVE 1/1/2026

Next Review Date

Key ActionObtain prior authorization from the plan before dispensing drugs flagged 'PA' or the plan may not cover the drug.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MonthlyDrug List updates posted online

72 hoursstandard exception decision time

90-daymax supply (most drugs)

30-dayTier 5 max supply

1/1/2026effective date shown

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Coverage and Formulary Criteria

General formulary coverage

Covered when ALL of the following apply

Formulary coverage conditions: Drug is listed in Section C1 of the Drug List and is determined to be medically necessary by the prescriber and the plan; prescription is filled at a Neighborhood INTEGRITY for Duals network pharmacy.

Per Drug List Section C1 and plan coverage rules.

Administrative requirements: Any required administrative actions shown on the Drug List entry (e.g., PA, ST, QL) have been satisfied prior to dispensing.

See 'Restrictions/limits' legend; lack of required PA may result in noncoverage.

Transitional/short-term coverage

Temporary transitional coverage for new members or level-of-care transitions

Temporary supply for new members: May cover a temporary 30‑day supply during the first 90 days of membership when the prescribed drug is not on the Drug List, plan rules prevent dispensing the ordered amount, prior authorization would delay access, or step therapy would otherwise block immediate access.30 days

Applies during first 90 days of membership; allows multiple refills to reach 30 days.

Level-of-care transition (long‑term care): For members entering or leaving a long‑term care facility within the allowed period, plan will cover a cumulative 31‑day supply as needed to avoid disruption of therapy.31 days

Applies to long‑term care residents or recent transitions as described.

Drug list coverage criteria (partial)

Drug coverage and restrictions as listed on the Drug List (partial):

Exception review timelines: After receiving a prescriber supporting statement, the plan will decide on an exception within 72 hours; expedited exceptions with prescriber support will be decided within 24 hours.

Providers should fax supporting statement to 1-855-829-2875.

Supply limits: Mail‑order and selected retail programs may provide up to a 90‑day supply with the same copay as a 30‑day supply; medications designated Tier 5 are limited to a maximum 30‑day supply.90-day; 30-day for Tier 5

Per mail-order/retail program and Tier designations.

Cost‑sharing tiers: Drugs are assigned to tiers (Tier 1–5) which determine member cost‑sharing; Tier and copay guidance is provided and Extra Help (LIS) affects copays.

See Tier descriptions for copay structure.

Coverage stance for listed products

Formulary coverage and management flags for listed analgesic and NSAID products

Tier and flags on analgesics/NSAIDs: Each analgesic or NSAID listed includes a tier assignment and may include flags such as DP, QL or PA; coverage requires adherence to those flags (e.g., obtain PA if indicated; observe QL).

Examples: celecoxib QL entries; diclofenac potassium QL; many OTC analgesics shown Tier 1 with DP flags.

Formulary tiering and utilization management per product

Coverage and restrictions as listed per product (tier and necessary actions):

Per‑product tiering and utilization management: Each drug entry states the formulary tier and, where applicable, necessary actions (PA, QL, ST, DP). Coverage for a given product requires meeting the tier‑related administrative rules and any listed utilization controls.

Examples: ibuprofen products generally Tier 1; antifungals and specialty anti‑infectives frequently Tier 4–5 with PA/QL.

Formulary coverage with utilization controls

Coverage and utilization controls are specified per drug/formulation as follows (must meet listed controls):

Per‑drug utilization controls: Coverage for each listed formulation is conditional on satisfying the utilization controls shown on the Drug List (e.g., obtaining prior authorization for items marked PA; not exceeding quantity limits for items marked QL; complying with step therapy for items marked ST).

Examples: EPCLUSA (PA); PAXLOVID packs (QL limits shown); PREVYMIS (PA; QL 28 tabs/28 days).

Formulary access (PA + QL)

Coverage and access rules for listed drugs

Formulary access requirements (PA + QL): Many specialty and high‑cost drugs require prior authorization and are subject to quantity limits as specified per product (examples shown on the Drug List include ODOMZO 30 caps/30 days; OGSIVEO 56 tabs/28 days; OJEMDA 96 mL/28 days).

Submit PA documentation and request quantities consistent with the listed QL for the specific strength/formulation.

General formulary coverage rules

Coverage and utilization management are applied as listed per product

Application of formulary rules: For each product and strength, apply the exact formulary attributes shown: tier placement; Prior Authorization (PA) where flagged; Quantity Limit (QL) with specified amount and time period; and Step Therapy (ST) when indicated. Coverage requires satisfying the stated requirement(s).

Follow the Drug List entries for strength‑ and formulation‑specific rules (e.g., QL values, PA requirements, ST flags).

Drugs that are determined to be unsafe or that are removed from the market will be taken off the Drug List and will no longer be covered. When such removals occur the plan will send notice after the change and provide instructions for follow-up with the prescriber and pharmacy.

Entries marked with the DP symbol indicate the drug is not a Medicare Part D drug. DP-designated drugs follow different coverage and appeal rules than Part D drugs; members and prescribers should consult the Member Handbook or contact Member Services for appeal processes and plan-specific guidance.

The formulary uses a DP flag to show that a listed item is not a Part D drug. Where present, this flag signals alternate coverage handling (and different appeal procedures) compared with typical Part D medications.

Within the excerpted formulary sections there are no explicit clinical exclusion criteria listed; the document shows tiers and utilization-management flags (for example, PA, QL, ST, DP) adjacent to drug entries but does not set out standalone clinical exclusion rules in these chunks.

This portion of the Drug List provides tier assignments and utilization annotations for products but does not include standalone exclusion language or condition-based clinical exclusion statements in the provided extract.

No explicit clinical exclusions are present in these extracted sections; coverage entries focus on tiering and required administrative controls (e.g., PA, QL) rather than listing clinical exclusion criteria.

The extract does not include detailed clinical criteria for prior authorization decisions. It shows that certain drugs require PA, but specific clinical eligibility criteria used to approve or deny PA requests are not listed in these chunks.

The plan may determine a drug "is not covered" and, where applicable, members or prescribers may appeal such decisions. For items flagged DP (not a Part D drug) the coverage and appeal pathways differ from standard Part D processes; members should follow the Member Handbook and the notice provided for instructions on appeals.

No statements explicitly using the term "not medically necessary" (NMN) appear in these extracted chunks; the document instead annotates drugs with administrative flags (PA, QL, ST, DP) and provides quantity limits and tiering.

The extract does not present explicit "not medically necessary" determinations. Coverage status in these sections is expressed via formulary placement, utilization-management flags (e.g., PA, QL, ST) and the DP designation for non‑Part D drugs rather than NMN language.

Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Requirements and Denial Risk

Prior Authorization Required for Some Drugs — Some drugs on the Drug List require prior authorization (PA) from Neighborhood INTEGRITY for Duals before they can be dispensed. PA appears as the PA flag in the "Necessary actions, restrictions, or limits on use" column for many products across therapeutic classes (including numerous oncology, pulmonary arterial hypertension, antidementia/memantine, CNS/psychiatric/antipsychotic agents, and other specialty agents). If PA is required and not obtained, the plan may deny coverage for the drug.

PA = Prior Authorization: approval from the plan is required before the drug can be dispensed.
Examples of PA usage in the Drug List: antiviral agents (EPCLUSA, MAVYRET, VOSEVI), biologic and specialty oncology agents (many entries marked PA; see Oncology section), PAH agents (ADEMPAS, OPSUMIT, UPTRAVI, etc.), memantine formulations (memantine ER, solution, tablets marked PA), selected CNS/antipsychotic agents (e.g., clozapine dispersible formulations, quetiapine ER) and numerous others.
Drugs marked with DP are not Part D drugs; they follow different coverage and appeals rules and may affect the available appeal remedies.
Products flagged with PA frequently also carry QL (quantity limits) and/or ST (step therapy) flags; adherence to all indicated flags is required for coverage.
If a PA is required but not obtained, the plan may deny coverage (denial triggers include missing PA, DP designation, or exceeding QL).
Providers should check the specific Drug List entries in Section C1 for the exact PA, QL, and ST requirements for each drug and strength.

Documentation Required

Quantity Limits and Documentation

Quantity Limits and PA/QL Documentation — Many drugs on the Drug List include Quantity Limits (QL) and PA alongside QL. Quantity limits are numeric limits (for example, "QL; 30 tabs every 30 days"). Prescribers and pharmacies must supply documentation supporting medical necessity and the requested quantity when submitting PA or override requests.

QL = Quantity Limit: plan-enforced limits on amount dispensed (per day, per 30 days, per year, etc.).
Many high-tier and specialty drugs list both PA and QL (e.g., REPATHA: PA; QL; 6 syringes every 28 days; INQOVI: PA; QL; 5 tabs every 28 days).
Exceeding a QL without prior authorization or documentation may trigger denial at point of sale.
When requesting PA or quantity-limit overrides, include clinical rationale and supporting records per the plan's PA process.

Step Therapy

Step Therapy Requirements

Step Therapy (ST) — Some drugs are subject to step therapy (ST) requiring trial of preferred agents before coverage of the requested product. The ST flag in the Drug List indicates when a step requirement applies; specific step protocols and exceptions are detailed on the plan website and within the Drug List entries.

ST = Step Therapy: member must try specified alternative(s) first before the requested drug is covered.
Some formulations are specifically noted as subject to ST (e.g., certain dispersible or oral film forms, lamotrigine ER marked ST).
If prescriber documents that a preferred agent is not appropriate, an exception can be requested (see exception process).

Documentation Required

Exception Requests and Required Supporting Documentation

Exceptions and Prescriber Supporting Statement — Providers and members may request exceptions to PA, QL, or ST requirements. For standard exceptions, once the plan receives a prescriber's supporting statement the decision will be made within 72 hours. For expedited exceptions (if waiting could harm the member), submit the prescriber's supporting statement and the plan will decide within 24 hours.

Fax prescriber supporting statement to 1-855-829-2875.
Provide clinical rationale indicating why the member cannot use the preferred drug(s), why the requested quantity is medically necessary, or why PA should be granted.
Keep documentation concise but sufficient to support medical necessity for the requested exception.

Note

Operational Checklist for Providers

Provider Actions and Coverage Checks — Always verify the Drug List entry for the exact necessary actions (PA, QL, ST, DP, BID). Check online at WWW nhpri.org/INTEGRITYDuals or call Member Services if uncertain. Failure to follow listed actions (missing PA, exceeding QL, ignoring ST) can result in claims denials or noncoverage.

DP flag denotes "Not a Part D drug" — these drugs follow different coverage and appeals rules; check Chapter 9 of the Member Handbook for appeal guidance.
BID indicates drugs that may be covered under Medicare Part B or D; additional information about setting and site-of-care must be supplied for coverage determination.
When multiple flags appear (e.g., PA; QL; ST), the provider must satisfy all applicable requirements.
Contact Member Services or review the Drug List online for monthly updates and the most current PA/QL/ST rules.

Key Terms and Legend

Prior authorization / step therapy / generics (definitions)

Prior Authorization (PA)Permission from the plan before a prescription can be filled; plan may not cover the drug if PA is not obtained

Step Therapy (ST)Requirement to try drugs in a specified order (try preferred drug first) before coverage of another drug

Generic drugsDrugs with the same active ingredients as brand-name drugs; may be substituted without a new prescription depending on state law

Step therapy — definition and notes

Step therapy (ST)A requirement to try drugs in a specified order for a medical condition; the plan lists ST in the formulary legend

PA (Prior Authorization)Drugs annotated 'PA' require prior authorization from the plan before dispensing

ST absence of detailed protocolsSpecific step protocols are not detailed in these Drug List excerpts — check per‑drug entries for 'ST' where present

Generic drugs; biologics & biosimilars; OTC note

Generic drugsSame active ingredient as brand-name drugs; usually lower cost and substitutable at pharmacy subject to state law

Biosimilars vs original biologicsBiosimilars are similar versions of complex biological products; some are interchangeable per state substitution rules

OTC coverageSome OTC drugs are covered when written as prescriptions; check Drug List or supplemental benefits for details

Original biologics, biosimilars, OTC and non‑drug OTC coverage

Original biological products and biosimilarsBiological products are complex; biosimilars may be interchangeable depending on state laws and substitution rules

OTC drugs coverageOver‑the‑counter drugs may be covered when written as prescriptions

Non‑drug OTC productsCertain non‑drug OTC items (e.g., testing supplies) may be covered with a prescription or via supplemental benefits

DP — 'The drug is not a Part D drug' (legend flag)

DP flagDocument flag indicating 'The drug is not a Part D drug' (DP) — denotes non‑Part D coverage and different appeal rules

BID flag'BID' noted where Medicare Part B or D coverage may apply depending on setting

Legend referencesSee formulary legend for DP, PA, QL, ST and other abbreviations used next to product entries

Legend abbreviations — PA / QL / ST

PA / QL / ST legendPA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy (as shown in the formulary legend)

BIDBID appears in legend to indicate coverage under Medicare Part B or D depending on setting

DPDP indicates drug is not a Part D drug

PA — Prior Authorization definition

PA — Prior AuthorizationAdministrative approval required from the plan before the drug will be covered or dispensed

Prescriber actionProviders must submit PA requests and supporting documentation (fax/process as specified) when product entry shows 'PA'

Denial riskFailure to obtain required PA may result in noncoverage

QL — Quantity Limit definition

QL — Quantity LimitMaximum quantity allowed per specified time period (examples shown per drug entry, e.g., per 30 days, per 28 days, per year)

Examples of unitsLimits specified as tabs, caps, mL, patches, syringes or packs depending on product

EnforcementExceeding QL may lead to denial; providers should document medical necessity for exceptions

ST — Step Therapy definition

ST — Step TherapyRequirement to try specified therapies (usually preferred agents) before coverage of another product is provided

ST in legendST appears in the formulary legend; per‑drug ST flags indicate where step therapy applies

ST specificsSpecific step protocols are not detailed in this excerpt — check per‑drug entries for ST annotations

Step therapy overview
Members may be required to try preferred drugs first per plan step therapy rules

ST meaning
ST indicates a requirement to try an alternate drug before coverage of the listed drug will be approved

Legend note
Step Therapy (ST) is indicated in the document legend; specific per-drug step details are not present in these sections

Legend presence
ST appears in the formulary legend but no specific per-drug step edits are shown in these chunks

Antiviral entries
At least one antiviral entry (section Antivirals) includes 'ST', indicating step therapy applies to certain formulations

ST annotation
Drugs annotated 'ST' in the listing are subject to step therapy prior to coverage of the listed agent

ST listed
Step Therapy (ST) is included among formulary control annotations (PA, QL, ST, BID); specific ST rules are not detailed in these chunks

ST flag
A Step Therapy (ST) flag is present for some formulary entries indicating ST may apply to selected products

ST reference
ST is referenced in the document legend; the specific step requirements are not detailed in these chunks

Formulation-specific ST
Step Therapy is required for selected formulations (e.g., some dispersible or oral film forms) as noted by 'ST' in the listing

Lamotrigine ER (ST)
Lamotrigine ER oral tablet (extended release) is designated 'ST' (step therapy) in the listing

ST across categories
ST is indicated for some formulary categories and selected products; specific step definitions are not provided in these chunks

Quantity Limits by Product (Selected Examples)

Section C1 — drug list reference (quantity limits)

Section C1 drug list referenceQuantity limits and utilization controls are specified in Section C1 tables (see Drug List entries)

Colchicine 0.6 mgListed QL: 120 tablets every 30 days

Various entriesRefer to Section C1 for product‑specific QL and PA/ST annotations

Colchicine (0.6 mg) — QL

Colchicine oral tablet 0.6 mgQuantity limit: 120 tablets every 30 days

Tier assignmentColchicine listed as Tier 3 in the Drug List excerpt

Section effective dateEntries effective 1/1/2026

Tier 5 specialty drugs — maximum 30‑day supply

Tier 5 specialty drugs — supply limitMaximum supply: 30-day supply per fill for Tier 5 medications

Cost‑sharing noteTier 5 copays vary by Extra Help (LIS) level; see member materials

Mail/retail 90‑day exceptionTier 5 drugs are excluded from 90‑day mail/retail 90‑day fill allowance — limited to 30 days

Unspecified OTC analgesics — QL flag present

OTC analgesics group entriesSome OTC analgesic entries display 'QL' flag in the Drug List; numeric limits not provided in these chunks

DP flags on OTCsMany OTC entries are Tier 1 and may be flagged DP (not Part D) where noted

Refer to product rowCheck the specific Section C1 row for numeric QL where present

Lidocaine HCl injection — tier and BID flag

Lidocaine HCl injection solutionListed as Tier 3 in excerpt; 'BID' usage flag present (Medicare Part B or D context); no numeric QL provided in these chunks

Check per‑drug rowNumeric limits or billing instructions may be in full Drug List entry — review C1 table

Setting noteBID indicates possible Part B/D coverage depending on setting

Celecoxib 100/50/200 mg — QL

Celecoxib (100/50/200 mg)Quantity limit: 60 capsules every 30 days

TieringListed Tier 3 in Drug List excerpts

Effective dateEntry effective 1/1/2026

Celecoxib 400 mg — QL

Celecoxib 400 mgQuantity limit: 30 capsules every 30 days

TieringListed Tier 3 in Drug List excerpts

Refer to C1Confirm per‑strength QL in Section C1 table

Diclofenac potassium 50 mg — QL

Diclofenac potassium 50 mg (oral)Quantity limit: 120 tablets every 30 days

TieringListed Tier 2 in Drug List excerpts

Effective dateEntry effective 1/1/2026

Examples across formulary — numerical limits vary

Formulary numerical limits vary by productQuantity limits are strength/formulation‑specific — check each product row for exact numeric QL

Examples includedExamples throughout the Drug List show tabs, mL, patches, syringes and packs as QL units

Effective dateEntries effective 1/1/2026

Buprenorphine transdermal patch — QL

Buprenorphine transdermal patchQuantity limit: 4 patches every 28 days; PA/QL flags present where indicated

TieringAppears in opioid analgesics section — check per‑product tier

Provider actionPA required if 'PA' flag shown in product row

Fentanyl transdermal patch — QL

Fentanyl transdermal patch (72‑hour)Quantity limit: 10 patches every 30 days; PA required where indicated

TieringListed Tier 4 in excerpt

Effective dateEntry effective 1/1/2026

Methadone Intensol — QL

Methadone HCl Intensol oral concentrate (10 mg/mL)Quantity limit: 90 mL every 30 days

PA/QL flagsEntry shows PA; QL where indicated — follow product row instructions

Effective dateEntry effective 1/1/2026

Morphine sulfate oral solution — QL

Morphine sulfate oral solutionQuantity limit: 900 mL every 30 days

Alternate formulationsMorphine tablets also have QLs (e.g., 180 tabs every 30 days for certain strengths)

Provider actionAdhere to QL when dispensing to avoid denial

Ivermectin 3 mg — QL

Ivermectin oral tablet 3 mgQuantity limit: 20 tablets every 90 days

PA flagEntry shows PA and QL in Drug List excerpt

Effective dateEntry effective 1/1/2026

Ivermectin 6 mg — QL

Ivermectin oral tablet 6 mgQuantity limit: 10 tablets every 90 days

PA flagEntry shows PA and QL in Drug List excerpt

Effective dateEntry effective 1/1/2026

Linezolid oral suspension — QL

Linezolid oral suspension (reconstituted) 100 mg/5 mLQuantity limit: 1800 mL every 30 days

Linezolid oral tabletsSeparate QL: 60 tablets every 30 days for 600 mg strength

IV formulationsIV forms listed without numeric oral QL in these chunks — check C1 for details

Vancomycin oral capsule QLs

Vancomycin HCl oral capsule 125 mgQuantity limit: 80 capsules every 180 days

Vancomycin 250 mgQuantity limit: 160 capsules every 180 days

IV vs oralIV vancomycin entries appear separately without long‑term oral QL in these chunks

PREZISTA — suspension & tablet QLs

PREZISTA oral suspension 100 mg/mLQuantity limit: 400 mL every 30 days

PREZISTA oral tablet 150 mgQuantity limit: 240 tablets every 30 days

PREZISTA oral tablet 75 mgQuantity limit: 480 tablets every 30 days

LIVTENCITY 200 mg — QL

LIVTENCITY oral tablet 200 mgQuantity limit: 336 tablets every 28 days

PA flagPA indicated for LIVTENCITY in product row

Effective dateEntry effective 1/1/2026

PAXLOVID — pack examples & QL

PAXLOVID therapy packsExamples of quantity limits by pack: 40 tabs every 90 days; 22 tabs every 90 days; 60 tabs every 90 days

TieringPAXLOVID listed as Tier 2 in excerpts

QL enforceableQL entries restrict dispensed amount and exceeding limits may lead to denial

Oseltamivir — annual QLs

Oseltamivir 30 mg capsuleQuantity limit: 168 capsules every year

Oseltamivir 45/75 mg capsuleQuantity limit: 84 capsules every year

Oseltamivir suspension 6 mg/mLQuantity limit: 1080 mL every year

PREVYMIS — QL

PREVYMIS oral tabletQuantity limit: 28 tablets every 28 days

PA flagPREVYMIS listed with PA and QL in product row

TieringListed Tier 5 in excerpt

NUZYRA 150 mg — QL

NUZYRA oral tablet 150 mgQuantity limit: 30 tablets every 14 days

IV formNUZYRA IV listed separately (Tier 5) — check C1 for IV controls

Effective dateEntry effective 1/1/2026

XOFLUZA — QL (per therapy pack)

XOFLUZA (40 mg & 80 mg therapy packs)Quantity limit: 1 tablet every 180 days

ST/BID notesXOFLUZA therapy pack entries show QL; ST not specified in these chunks

Effective dateEntry effective 1/1/2026

INQOVI — QL

INQOVI oral tablet 35-100 mgQuantity limit: 5 tablets every 28 days

PA flagINQOVI listed with PA and QL in product row

TieringListed Tier 5 in excerpt

LONSURF — QL

LONSURF oral tablet 15‑6.14 mgQuantity limit: 100 tablets every 28 days

PA flagLONSURF listed with PA and QL in product row

TieringListed Tier 5 in excerpt

Lenalidomide — QL

Lenalidomide oral capsule (10–15 mg)Quantity limit: 28 capsules every 28 days

PA flagLenalidomide listed with PA and QL in product row

TieringListed Tier 5 in excerpt

POMALYST — QL

POMALYST oral capsuleQuantity limit: 21 capsules every 28 days

PA/QLPOMALYST listed with PA and QL in product row

TieringListed Tier 5 in excerpt

THALOMID — QL

THALOMID oral capsule 100 mgQuantity limit: 112 capsules every 28 days

PA/QLTHALOMID listed with PA and QL in product row

Other strengthsOther strengths have separate QLs (e.g., 50 mg: 84 caps/28 days)

ODOMZO — QL

ODOMZO oral capsule 200 mgQuantity limit: 30 capsules every 30 days

PA flagODOMZO listed with PA and QL in product row

TieringListed Tier 5 in excerpt

OGSIVEO — QLs

OGSIVEO oral tablet 100/150 mgQuantity limit: 56 tablets every 28 days

OGSIVEO 50 mgQuantity limit: 180 tablets every 30 days

PA flagOGSIVEO listed with PA and QL in product row

OJEMDA — QL

OJEMDA oral suspension 25 mg/mLQuantity limit: 96 mL every 28 days

PA/QLOJEMDA listed with PA and QL in product row

Tablet formsTablet packs have separate QLs (see C1 entries)

RETEVMO — strength‑based QLs

RETEVMO oral tablet — strength‑based limits40 mg: 90 tablets/30 days; 80 mg: 120 tablets/30 days; 120 mg: 60 tablets/30 days

PA flagRETEVMO listed with PA and QL in product rows

TieringListed Tier 5 in excerpt

ROZLYTREK 100 mg — QL

ROZLYTREK oral capsule 100 mgQuantity limit: 180 capsules every 30 days

PA/QLROZLYTREK listed with PA and QL in product row

TieringListed Tier 5 in excerpt

TECENTRIQ HYBREZA — QL

TECENTRIQ HYBREZA subcutaneous solutionQuantity limit: 1 vial (per specified dosing interval) as listed

PA flagPA indicated for TECENTRIQ entries in Drug List

TieringListed Tier 5 in excerpt

Multiple listed products — example QLs

Common QL patternsExamples include 30 or 60 tablets every 30 days; biologics/syringes limited to specified counts per 28/30/56/90/180 days

REPATHAQuantity limit: 6 syringes every 28 days (PA; QL)

CORLANOR oral solutionQuantity limit: 450 mL every 30 days

VERQUVO — QL

VERQUVO oral tabletQuantity limit: 30 tablets every 30 days

PA/QL noteVERQUVO listed with PA and QL in product row

Effective dateEntry effective 1/1/2026

ADEMPAS — QL

ADEMPAS oral tabletQuantity limit: 90 tablets every 30 days

PA/QLADEMPAS listed with PA and QL in product row

TieringListed Tier 5 in excerpt

ALYQ — QL

ALYQ oral tabletQuantity limit: 60 tablets every 30 days

PA/QLALYQ listed with PA and QL in product row

TieringListed Tier 5 in excerpt

Ambrisentan — QL

Ambrisentan oral tabletQuantity limit: 30 tablets every 30 days

PA/QLAmbrisentan listed with PA and QL in product row

TieringListed Tier 5 in excerpt

Bosentan & bosentan soluble — QLs

Bosentan oral tabletQuantity limit: 60 tablets every 30 days

Bosentan solubleQuantity limit: 120 tablets every 30 days (soluble form)

PA/QLBosentan products listed with PA and QL in product rows

PAH agents — QLs

Sildenafil citrate 20 mgQuantity limit: 360 tablets every 30 days

Tadalafil (PAH) 20 mgQuantity limit: 60 tablets every 30 days

UPTRAVI (various)Typical QL: 60 tablets every 30 days; UPTRAVI 200 mcg: 140 tabs every 28 days

UPTRAVI & YUTREPIA — QLs

UPTRAVI 200 mcgQuantity limit: 140 tablets every 28 days

UPTRAVI titration packQuantity limit: 1 pack every 28 days

YUTREPIA inhalation capsule 106 mcgQuantity limit: 224 capsules every 28 days

Selected CNS & related QLs

Lorazepam Intensol oral concentrateQuantity limit: 150 mL every 30 days

Donepezil (some forms)Quantity limit: 30 tablets every 30 days

Galantamine solutionQuantity limit: 200 mL every 30 days

Selected mental health drug QLs

AUVELITY oral tabletQuantity limit: 60 tablets every 30 days

DRIZALMA SPRINKLEQuantity limit: 60 capsules every 30 days

EMSAM patchQuantity limit: 30 patches every 30 days

FETZIMA and select antidepressant QLs

FETZIMA (various strengths)Quantity limit: 30 or 60 capsules every 30 days depending on strength

FETZIMA titration packQuantity limit: 2 packs every year

Paroxetine oral suspensionQuantity limit: 900 mL every 30 days

Selected Parkinson/antipsychotic QLs

INBRIJA inhalation capsule 42 mgQuantity limit: 300 capsules every 30 days

ABILIFY ASIMTUFIIQuantity limit: 1 syringe every 56 days

ABILIFY MAINTENAQuantity limit: 1 syringe/injection every 28 days

Various — common quantity limit patterns

Common QL examples across entries30 tabs every 30 days; 60 tabs every 30 days; 1 syringe every 28/56/90/180 days; 240 mL or 600 mL solution per 30 days

Injectable QLsLong‑acting injectables typically limited to 1 syringe/injection per specified interval

Solution volumesMany oral solutions have mL/month limits (e.g., 150–2160 mL depending on product)

FINTEPLA / FYCOMPA — QLs

FINTEPLA oral solution 2.2 mg/mLQuantity limit: 360 mL every 30 days

FYCOMPA oral suspension 0.5 mg/mLQuantity limit: 680 mL every 28 days

FYCOMPA tabletsQuantity limit: 30 tablets every 30 days for select strengths

Migraine biologics & acute QLs

AIMOVIG auto‑injectorQuantity limit: 1 pen every 30 days

EMGALITY (300 mg dose) prefilled syringeQuantity limit: 3 syringes every 30 days

VALTOCO nasal liquidQuantity limit: 10 blister packs every 30 days

VALTOCO, vigabatrin, vigafyde — QLs

VALTOCO nasal liquidsQuantity limit: 10 blister packs every 30 days

VIGABATRIN formulationsQuantity limit: 180 packets/tabs every 30 days (PA; QL)

VIGAFYDE solutionQuantity limit: 900 mL every 30 days (PA; QL)

Triptans & related QLs — examples

Ergotamine‑caffeine oral tablet 1–100 mgQuantity limit: 40 tablets every 28 days

Naratriptan 2.5 mgQuantity limit: 12 tablets every 30 days

NURTEC oral dispersible 75 mgQuantity limit: 16 tablets every 30 days

Sumatriptan formulations — QLs

Sumatriptan nasal solution 20 mgQuantity limit: 12 units every 30 days

Sumatriptan nasal solution 5 mgQuantity limit: 24 units every 30 days

Sumatriptan subcutaneous injectablesQuantity limit: 12–18 injections every 30 days depending on formulation

OpenPayer

Neighborhood INTEGRITY for Duals — List of Covered Drugs (Drug List / Formulary)

Coverage and Formulary Criteria

Formulary Codes, Flags and Quantity Examples

Authorization, Step Therapy, and Documentation Requirements

Policy Background and Scope

Key Terms and Legend

Initial Therapy and Fill Limits

Step Therapy Rules and Flags

Quantity Limits by Product (Selected Examples)