CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Drug formulary: ADHD/amphetamines coverage and requirements

Portions of Neighborhood Health Plan of Rhode Island's prescription drug formulary covering ADHD/anti-narcolepsy/amphetamine class medications, tiers, and specific requirements (prior authorization, step therapy, quantity limits) for ACCESS and TRUST plan members effective January 1, 2026.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDrug formulary: ADHD/amphetamines coverage and requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document prior authorization for new starts of products listed as 'PA for new starts' (e.g., chewable lisdexamfetamine and selected branded stimulants).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-01-01formulary effective date for ACCESS/TRUST

No copaymember cost-sharing

PA / QL / STutilization controls common

1/daytypical stimulant QL

Age/QLopioid controls

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Formulary Coverage and Utilization Controls

Formulary coverage conditions

Covered when plan tier and utilization rules are met per formulary entries

Formulary tier and pharmacy: Medication is covered when it is listed on the member's formulary at the assigned plan tier (e.g., Tier 1 or Tier 2) and the prescription is dispensed through a participating pharmacy.

From formulary header and Requirements/Limits

Utilization controls (PA, ST, QL)

Coverage requires meeting the following utilization controls for listed formulations

Utilization controls: For chewable lisdexamfetamine formulations, selected lisdexamfetamine capsule strengths, and VYVANSE chewable formulations: Step therapy (ST) may apply; Prior Authorization (PA) is required for new starts when indicated; Quantity Limits (QL) apply as specified (typical QL = 1 tab/cap every 1 day).QL = 1 per day

See Requirements/Limits and Drug Name table

Per-product utilization management

Coverage and utilization management rules in this section apply as listed per-product

Per-product rules: Each listed drug line includes its formulary tier and any utilization management flags that must be met for coverage: Prior Authorization (PA) when indicated; Step Therapy (ST) when indicated; Quantity Limits (QL) as specified; Age limits where provided; OTC status where provided.

See individual product rows for exact requirement combinations (e.g., 'ST, PA, QL (1 tab every 1 day); PA for new starts')

General coverage condition

Covered when drug-specific tier and utilization controls are met

General requirement: Prescribed drug must be on the formulary and adhere to the utilization management requirements shown on the product line (PA, ST, QL, AGE, OTC) to be covered; supporting documentation must be provided where PA or diagnosis-based QL is indicated.

See product rows for exact limits

Opioid coverage criteria

Opioid agents are subject to additional quantity and age controls

Opioid quantity and age limits: Prescriptions for listed opioid products are subject to specified Quantity Limits (QL) and minimum age restrictions (AGE) where stated; claims exceeding QL or for patients outside age limits require prior authorization or will be denied.varies by product (see product line)

Exceeding limits requires PA or may be denied

Prior Authorization and Quantity Limits (selected agents)

Coverage subject to plan-level utilization management for selected branded and specialty agents

PA_and_QL_for_selected_drugs: Prior Authorization AND adherence to the specified Quantity Limits are required for selected branded and specialty drugs (examples shown: TRYVIO TAB 12.5MG, FIRDAPSE TAB 10MG, ONUREG, FRUZAQLA, INLYTA, LENVIMA).see QL per drug

Requirements vary by product and strength; PA generally required for these agents

Generic Tier 1 coverage

Generic drugs and combination antihypertensives

Generic_Tier1_coverage: Multiple generic antihypertensive combinations and other generic products are assigned to Tier 1 and generally have no additional utilization requirements specified in these product lines; some items note availability for 90-day fills.N/A

See product lines for exceptions

Oral oncology agents — PA and QL

Antineoplastic oral agents

Oral_oncology_PA_QL: Oral antineoplastics and targeted agents are listed with Prior Authorization (PA) and product-specific Quantity Limits (QL) (examples: ONUREG 14 tabs/28 days; FRUZAQLA 84 caps/28 days; INLYTA 8 or 4 tabs per day depending on strength; LENVIMA strength-specific caps/day).see product QL entries

PA generally required for these agents

The formulary lists ALLI CAP 60MG as an OTC product. As indicated in the drug table, OTC-designated items are presented without prescription utilization enforcement in this listing (Requirements/Limits = OTC). Providers should note that OTC designation means the formulary line does not apply the PA/QL controls shown for prescription agents in this section.

Source: the formulary line for ALLI CAP 60MG shows Requirements/Limits = OTC, indicating over‑the‑counter status and exclusion from the prescription PA/QL enforcement described elsewhere in the drug list.

Several formulations in the analgesic and related drug sections are explicitly identified as OTC (for example, naproxen sodium 220 mg). When a product is marked OTC in the Requirements/Limits field, it is listed as available over‑the‑counter and is not subject to the prescription utilization controls (PA, ST, QL) applied to prescription formulations in this document.

Providers should confirm whether an OTC designation applies to the specific strength/formulation being prescribed; the formulary line for each product indicates the OTC status in the Requirements/Limits column.

Within the extracted chunks there are no explicit formulary exclusion statements beyond the OTC designations noted for certain items. The generic antihypertensive and other generic lines in these chunks (Tier 1 entries) are listed with no Requirements/Limits annotations that would indicate specific exclusions.

If a formal exclusion exists it is not present in these cited segments; coverage determinations should rely on the complete formulary lines and any separate exclusion schedules maintained by the plan.

The reviewed chunks do not contain explicit 'not medically necessary' declarations for any listed products. Coverage stance in these segments is described as covered with criteria where PA, ST, QL, age limits, or OTC status are shown — but no items are labeled as not medically necessary in the cited text.

For definitive not‑medically‑necessary determinations, refer to the full policy or exclusion sections outside these chunks; none are present in the provided excerpts.

Codes, Quantity Limits and Examples

Authorization, Documentation, and Denial Risk

Prior Authorization

Prior Authorization Required — general

Prior Authorization (PA) is required for many specialty, branded, and certain generic products listed on the formulary. Failure to obtain PA when indicated may result in claim denial or delay. For products flagged as "PA for new starts", prescribers must document whether the member is a new start and supply supporting clinical justification.

Obtain PA for all drugs with the PA flag before dispensing; missing PA is a common denial trigger.
When a product is marked "PA for new starts", include documentation that the patient is initiating therapy and the medical indication.
Quantity limits (QL) shown on formulary entries must be respected; requests exceeding QL require prior clinical justification and are subject to denial.

Prior Authorization

PA and Quantity Limits for Biologics/Targeted Therapies

Prior Authorization and quantity limits apply to many biologic and targeted therapies. Providers must document diagnosis and clinical rationale to meet PA and QL requirements.

Anti‑TNF, JAK inhibitors, interleukin agents and other biologics often require PA and have explicit QL (for example, ENBREL, RINVOQ, XELJANZ entries).

New-Start Controls and Initiation Requirements

New start controls

Requirements for new starts

New start requirements: Prior authorization is required for new starts of specified products (examples include chewable lisdexamfetamine formulations and VYVANSE chewables). Step therapy and quantity limits also apply as listed on product rows.

PA for new starts explicitly noted in Requirements/Limits

OTEZLA initiation

Brand PDE4 inhibitor initiation

threshold":"55 tabs/28 days","note":"See product row for strength-specific QL","children":[]}

PA requirement for new starts

Prior authorization for new starts

Step Therapy Requirements

Product	Requirement
lisdexamfetamine dimesylate chew tab 10 mg (generic)	ST, PA, QL (1 tab every 1 day); PA for new starts
lisdexamfetamine dimesylate chew tab 20 mg (generic)	ST, PA, QL (1 tab every 1 day); PA for new starts
lisdexamfetamine dimesylate chew tab 30 mg (generic)	ST, PA, QL (1 tab every 1 day); PA for new starts
lisdexamfetamine dimesylate chew tab 40 mg (generic)	ST, PA, QL (1 tab every 1 day); PA for new starts
lisdexamfetamine dimesylate chew tab 50 mg (generic)	ST, PA, QL (1 tab every 1 day); PA for new starts
lisdexamfetamine dimesylate chew tab 60 mg (generic)	ST, PA, QL (1 tab every 1 day); PA for new starts
VYVANSE CHW 10 mg (brand)	ST, PA, QL (1 tab every 1 day); PA for new starts
VYVANSE CHW 20 mg (brand)	ST, PA, QL (1 tab every 1 day); PA for new starts

Product	Requirement
AZSTARYS CAP 39.2-7.8 (brand)	ST, PA, QL (1 cap every 1 day); PA for new starts (alternative listing: PA, QL 2 tabs every 1 day)
AZSTARYS CAP 52.3-10 (brand)	ST, PA, QL (1 cap every 1 day); PA for new starts (alternative listing: PA, QL 2 tabs every 1 day)
QELBREE ER (QuilliChew CHW) 20/30/40 mg (brand)	ST, PA, QL (1 tab every 1 day); PA for new starts
AZSTARYS and select lisdexamfetamine chewable strengths (see product rows)	ST applies; PA and QL as specified per strength; PA for new starts where listed

Product	Requirement
methylphenidate HCl tab ER osmotic release (e.g., CONCERTA) 54 mg (generic)	Requirements vary by form; transdermal patches list ST, PA, QL (1 patch every 1 day); PA for new starts
methylphenidate TD patch (Daytrana) 10/15/20/30 mg/9hr (generic)	ST, PA, QL (1 patch every 1 day); PA for new starts
QuilliChew CHW 20/30/40 mg ER (brand)	ST, PA, QL (1 tab every 1 day); PA for new starts
modafinil 100 mg and 200 mg (generic)	QL (2 tabs every 1 day); ST not indicated

Product	Requirement
ARIKAYCE SUS (amikacin liposome inhalation suspension) (brand)	PA (listed); ST noted for aminoglycoside class entries; PA for new starts as indicated
tobramycin nebulizer solution 300 mg/5 mL (Kitabis Pak generic)	ST, PA, QL (10 mL every 1 day); PA for new starts
Adalimu- (adalimumab biosimilars/brands) injections (various presentations)	ST, PA, QL (product-specific limits such as syringes per 28 days); PA required
HADLIMA INJ 40/0.4 mL (brand)	ST, PA, QL (1.6 mL every 28 days); PA required

Product	Requirement
acetaminophen chew tabs/liquid/susp (OTC-designated formulations)	ST, PA, QL (29 tabs every 42 days) noted for these analgesic entries; OTC designation present
selected non-opioid analgesics (e.g., ketorolac 10 mg) and other OTC items	Some entries list ST in addition to PA and QL indicating step therapy may be required before coverage

Product	Requirement
BREO ELLIPTA (fluticasone furoate-vilanterol) and generics	ST, PA, QL (1 inhaler every 30 days) indicated for fluticasone furoate-vilanterol formulations
DULERA AER 50-5MCG / 100-5MCG / 200-5MCG (brand)	ST, PA (listed); step therapy required prior to PA/coverage
fluticasone furoate-vilanterol aero powd ba 100-25 mcg/act (generic)	ST, PA, QL (1 inhaler every 30 days); PA required

Product	Requirement
FYCOMPA SUS 0.5 mg/mL (perampanel suspension) (brand)	ST, PA, QL (8 mL every 1 day); PA for new starts
perampanel tabs (2,4,6,8,10,12 mg) (generic of FYCOMPA)	ST, PA, QL (strength-specific; many list 1 tab every 1 day or 2 tabs every 1 day); PA for new starts

Product	Requirement
TRINTELLIX TAB 5/10/20 mg (brand)	ST, PA, QL (1 tab every 1 day); PA for new starts

Product	Requirement
alogliptin-metformin combinations (various strengths) (generic)	ST, PA (step therapy plus prior authorization) as listed
MOUNJARO INJ pens (various strengths) (brand)	ST, PA, QL (4 pens every 28 days); PA for new starts
JARDIANCE (empagliflozin) and selected SGLT2 combinations	ST, PA, QL (1 tab every 1 day); PA for new starts where indicated
OZEMPIC / RYBELSUS / other GLP-1 combinations (selected strengths)	ST and PA indicated for many branded GLP-1 products; QL as specified per product

Product	Requirement
granisetron HCl tab 1 mg (generic)	ST, PA indicated for some 5-HT3 agents (granisetron listed with ST, PA)
ondansetron HCl oral solution / tabs (generic)	Some ondansetron entries show QL; select agents show ST in Requirements/Limits field indicating step therapy may apply

Product	Requirement
eplerenone tab 25 mg / 50 mg (generic of INSPRA)	ST, PA; PA for new starts (step therapy required prior to PA for new starts)
TRYVIO TAB 12.5 mg (brand) - related listing	PA, QL (1 tab every 1 day) noted in same section; eplerenone explicitly lists ST prior to PA for new starts

Quantity Limits by Product and Strength

inv-129: lisdexamfetamine (capsule and chewable formulations) — QL entries

Lisdexamfetamine QL1 cap/tab every 1 day

FormulationsApplies to capsules and chewable tablets across listed strengths

Associated controlsST and PA often indicated for chewable strengths (PA for new starts)

inv-130: lisdexamfetamine (caps & chew tabs) — 1 cap/tab every 1 day

Quantity limit1 cap/tab every 1 day

Applies toLisdexamfetamine capsules and chew tabs (multiple strengths)

Reference

Policy Background and Scope

This section of the formulary enumerates multiple analgesic drug categories and places them in the plan formulary context with tier assignments and utilization controls. Categories represented include nonsteroidal anti‑inflammatory drugs (NSAIDs) such as naproxen and meloxicam, PDE4 inhibitors (e.g., OTEZLA), soluble TNF receptor agents (ENBREL), and a range of opioid agonists and partial agonists with product‑specific quantity and age limits.

The formulary entries show that many analgesic and related agents are assigned to Tier 1 or Tier 2 and that utilization management is applied per product: Prior Authorization (PA) and Quantity Limits (QL)QL = 55 tabs/28 days), while some OTC analgesics (e.g., naproxen sodium 220 mg) are marked OTC and not subject to PA/QL enforcement in these listings. Opioid lines specifically include age and quantity controls (e.g., fentanyl patches with QL = 10 patches/30 days), reflecting safety controls for that class.

Glossary and Abbreviations

inv-107: Age Limit — AGE

AGEAge Limit (AGE) indicated on product rows where applicable

ExamplePhenytoin chewable tab 50 mg: Age Max 12; many opioid entries list Age Min 18

PurposeAge limits are enforced alongside QL and PA as specified

inv-108: Prior Authorization — PA

PAPrior Authorization — required when listed on product row (PA)

ImplicationClaims submitted without required PA may be denied or delayed

Documentation

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDrug formulary: ADHD/amphetamines coverage and requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document prior authorization for new starts of products listed as 'PA for new starts' (e.g., chewable lisdexamfetamine and selected branded stimulants).

SourceLink

On This Page

Quantity limits for some biologics are diagnosis‑based — include supporting diagnosis documentation when requesting PA.

Follow the specified QL (e.g., ENBREL: quantity limit based on diagnosis; RINVOQ: 12 mL/day for solution) when submitting requests.

Step Therapy

Step Therapy + Prior Authorization — selected products

Step therapy (ST) is required for selected agents and may be coupled with PA. For products with ST, prior trials of preferred alternatives must be documented; failure to meet ST requirements can result in denial even when PA is obtained.

Combination inhalers such as BREO ELLIPTA, DULERA, and fluticasone‑furoate/vilanterol list ST and PA — document prior therapies and clinical rationale.
ST applies to multiple classes (e.g., select amphetamine products, some ADHD meds, antidiabetic combos, GLP‑1/GLP‑1‑related injectables).
When both ST and PA are required, demonstrate that ST criteria were met or provide justification for bypassing ST (e.g., intolerance or contraindication).

Prior Authorization

Product-specific PA and Quantity Limits (examples)

Specific product groups require PA and have defined quantity limits or level‑based limits. Providers must follow these product‑specific rules when requesting authorization.

Methylphenidate transdermal patches (Daytrana generics): ST, PA, QL (1 patch/day); PA is required for new starts — document prior therapies and new‑start status.
Palforzia (peanut allergen immunotherapy) levels: PA required with level‑specific QL (level‑based caps or packets per day as listed).
Aminoglycosides: ARIKAYCE SUS and tobramycin nebulizer solution require PA; tobramycin nebu soln QL is 10 mL/day.
Ztalmy: PA and QL (1,100 mL every 30 days).
Xcopri: PA and QL specified per pack/strength (e.g., 1 tab/day for many packs) — include dosing regimen in request.

Prior Authorization

PA and QL for Oncology and Selected Specialty Agents

Oncology and other specialty agents frequently list PA plus specific QL per strength or pack. Requests must include regimen details and diagnosis to support medical necessity.

Many antineoplastic and targeted oral agents require PA and list QL by strength or pack (examples include LENVIMA, VENCLEXTA, ONUREG, FRUZAQLA, XPOVIO).
TRYVIO and other specialty branded oncology agents require PA and have per‑day QL (e.g., TRYVIO 1 tab/day).
For oncology agents, include treatment intent, line of therapy, weight or BSA if dosing is weight‑based, and expected duration when requesting PA.

Documentation Required

Documentation Expectations and Denial Risk

Documentation must accompany PA requests. Provide diagnosis, prior treatment history, age limits (when applicable), dosing schedule, and justification for exceptions or QL overrides.

Diagnosis‑required QL (e.g., ENBREL): include supporting diagnosis and relevant clinical notes.
Document age limits where specified (e.g., phenytoin chewable tablets have a maximum age indication); claims outside age limits may be denied.
For GLP‑1 agonists and antidiabetic injectables (e.g., MOUNJARO, OZEMPIC, RYBELSUS), include prior therapy trials and indicate if PA is for a new start.
TRYVIO and other branded agents: supply clinical documentation sufficient to support PA and adherence to the per‑day QL.
General PA documentation: medication history, rationale for chosen agent, recent labs or imaging if relevant, and notation whether member is a new start.

Denial Risk

Quantity and Age Limit Enforcement — denial triggers

Quantity limits and age restrictions are actively enforced. Claims exceeding QL or falling outside age restrictions without adequate documentation are at high risk for denial.

Review formulary QL entries (examples: OTEZLA 55 tabs/28 days; HUMULIN R U‑500 QL; many oncology agents' tab/cap limits).
For drugs with explicit daily or per‑28‑day limits, include clinical justification for larger quantities when warranted.
Age limits (e.g., certain chewable formulations) must be documented; requests for patients outside the age range require medical justification.

PA for new starts: Prior authorization is required for new starts of multiple specified agents across the formulary (examples include chewable lisdexamfetamine strengths, VYVANSE chewables, and certain GLP-1 receptor agonist pens such as MOUNJARO which note 'PA for new starts').

Providers must document indication and new-start status when seeking PA

See product Requirements/Limits rows

inv-131: WEGOVY, ZEPBOUND — 4 pens every 28 days

WEGOVY / ZEPBOUND pen QL4 pens every 28 days

Applies toWEGOVY and ZEPBOUND injectable pens across listed strengths

AuthorizationPA required as indicated in product rows

inv-132: WAKIX — 2 tabs every 1 day

WAKIX QL2 tabs every 1 day

ProductWAKIX (pitolisant) 4.45 mg

RequirementPA and QL listed on product row

inv-133: methylphenidate chew tabs (2.5,5,10 mg) — 3 tabs every 1 day; Age Max 17

Chewable methylphenidate QL3 tabs every 1 day

Age limitMax age 17

Strengths2.5 mg, 5 mg, 10 mg chew tabs

inv-134: methylphenidate solution (5 mg/5 mL; 10 mg/5 mL) — 30 mL every 1 day; Age Max 17

Methylphenidate solution QL30 mL every 1 day

Age limitMax 17

Concentrations5 mg/5 mL and 10 mg/5 mL formulations listed

inv-135: dexmethylphenidate ER caps — 1 cap every 1 day

Dexmethylphenidate ER QL1 cap every 1 day

Applies toMultiple ER strengths of dexmethylphenidate (Focalin XR generics)

NotesSome strength rows also list PA and alternative QLs (2 tabs) mapped to 1 cap/day

inv-136: methylphenidate TD patch (Daytrana) generics — 1 patch

Daytrana patch QL1 patch every 1 day

Applies toMethylphenidate TD patch (Daytrana) generics, multiple strengths

ControlsST and PA noted; PA for new starts

inv-137: modafinil 100 mg and 200 mg — 2 tabs

Modafinil QL2 tabs every 1 day

Strengths100 mg and 200 mg strengths listed with QL = 2/day

Applies toModafinil (Provigil) generics/brands

inv-138: Palforzia CAP levels — varies by level (examples provided)

Palforzia QL variationsVaries by level (e.g., Escalation: 13 caps/day; Level 1: 3 caps/day; Level 2: 6 caps/day)

Applies toPalforzia capsule levels and powder packet levels

PAPA required for Palforzia products

inv-139: tobramycin nebu soln 300 mg/5ml — 10 mL

Tobramycin nebu soln QL10 mL every 1 day

ProductTobramycin nebulizer solution 300 mg/5 mL (Kitabis Pak generic)

AuthorizationST and PA indicated; PA required per product row

inv-140: selected biologics QL examples — product-specific QL (adalimumab, Rinvoq, etc.)

Biologics QL examplesProduct-specific QLs (e.g., adalimumab entries: 2 syringes every 28 days or 1.6–3.2 mL every 28 days; Rinvoq: 1 tab every day)

ExamplesFASENRA, NUCALA, XOLAIR, Hadlima, Simponi, Rinvoq listed with PA and QL

DocumentationDiagnosis-based QL may require supporting documentation for PA

inv-141: NSAID examples QL/OTC status — celecoxib 400 mg; ketorolac; other NSAIDs

NSAID examplesCelecoxib 400 mg: QL = 1 cap/day; Ketorolac: QL = 20 tabs every 30 days

OTC statusSeveral NSAID formulations noted as OTC (e.g., naproxen 220 mg)

Applies toSelected NSAID rows in Analgesics section

inv-142: OTEZLA TAB 10/20/30 — 55 tabs every 28 days

OTEZLA QL55 tabs every 28 days

Strengths10/20/30 mg tablet formulations

AuthorizationPA indicated in product row

inv-143: FENTANYL TD PATCH 72HR — 10 patches

Fentanyl TD patch QL10 patches every 30 days

RangeApplies to multiple strengths of 72HR fentanyl patches

ControlsPA and AGE minimums noted for opioid products

inv-144: BUPRENORPHINE HCL SL TAB 2 MG — 12 tabs

Buprenorphine SL tab QL12 tabs (2 mg) or 3 tabs (8 mg) every 1 day depending on strength

ExampleBuprenorphine HCl SL tab 2 mg: QL 12 tabs every 1 day

UseMAT products listed with QL in Requirements/Limits

inv-145: FASENRA INJ 10MG/0.5 — 1 syringe

FASENRA QL1 syringe every 56 days

NUCALA QL1 syringe every 28 days (40 mg/0.4)

XOLAIR QL2 pens or 2 syringes every 28 days (75/0.5)

inv-146: NUCALA INJ 40MG/0.4 — 1 syringe

NUCALA QL1 syringe every 28 days (40 mg/0.4)

Other formsNUCALA 100 mg: 3 vials or 3 auto-injectors every 28 days

PAPA listed for NUCALA formulations

inv-147: XOLAIR INJ 75/0.5 — 2 pens or 2 syringes

XOLAIR QL2 pens or 2 syringes every 28 days (75/0.5)

Alternate strengthsXOLAIR 150 mg and 300 mg have higher QLs (8 pens or 4 pens every 28 days respectively)

PAPA required for XOLAIR entries

inv-148: budesonide inhalation susp — 4 mL

Budesonide inhalation suspension QL4 mL every 1 day

ProductsBudesonide inhalation suspension (Pulmicort generics) 0.5 mg/2 mL and 1 mg/2 mL

Inhaler comparatorsSome inhalers have 1 inhaler every 30 days or 2 inhalers every 30 days limits

inv-149: fluticasone propionate aero powder — 2 inhalers

Fluticasone powder QL2 inhalers every 30 days (250 mcg/act)

Other strengthsLower strengths often have 1 inhaler every 30 days limits

ProductsFluticasone propionate aerosol powder (various strengths)

inv-150: levalbuterol HCl nebu solutions — 90 mL

Levalbuterol nebule QL90 mL every fill

Applies toLevalbuterol HCl nebulizer solutions (various concentrations)

Fill frequencyQL specified per fill rather than per day for nebulizer solutions

inv-151: ELIQUIS ST P TAB 5MG — 75

ELIQUIS ST P 5 mg QL75 tabs every 30 days

ELIQUIS 2.5 mg QL2 tabs every 1 day

Related DOACsRivaroxaban 2.5 mg: 2 tabs/day; Xarelto STAR 15/20 mg: 55 tabs/30 days

inv-152: ELIQUIS TAB 2.5MG — 2

ELIQUIS 2.5 mg QL2 tabs every 1 day

UseApplies to apixaban low-dose tablets as listed

Note30-day QLs also specified for other strengths

inv-153: rivaroxaban tab 2.5 mg — 2

Rivaroxaban 2.5 mg QL2 tabs every 1 day

Applies toGeneric rivaroxaban 2.5 mg (Xarelto generic equivalence)

ContextUsed for combination antithrombotic dosing per formulary

inv-154: XARELTO STAR TAB 15/20MG — 55

XARELTO STAR 15/20 QL55 tabs every 30 days

XARELTO 10 mg QL1 tab every 1 day

XARELTO 15 mg QL2 tabs every 1 day

inv-155: XARELTO TAB 10MG — 1

XARELTO 10 mg QL1 tab every 1 day

UseTypically for prophylactic dosing post-procedure per product labeling

NotesOther Xarelto strengths have different QLs

inv-156: XARELTO TAB 15MG — 2

XARELTO 15 mg QL2 tabs every 1 day

Applies to15 mg strength product rows

Related QLs15/20 STAR pack QL differs (55/30 days)

inv-157: XARELTO TAB 20MG — 1

XARELTO 20 mg QL1 tab every 1 day

Applies to20 mg strength product rows

NotesQLs vary by strength and pack

inv-158: dabigatran etexilate caps — 2

Dabigatran QL2 caps every 1 day

Strengths75, 110, 150 mg strengths listed with QL 2/day

ContextApplies to dabigatran etexilate capsule entries

inv-159: FYCOMPA SUS 0.5MG/ML — 8

FYCOMPA suspension QL8 mL every 1 day

Perampanel tabs1-2 tabs/day depending on strength (PA for new starts)

ControlsST and PA indicated for FYCOMPA products

inv-160: perampanel tabs — 1-2

Perampanel tabs QL1–2 tabs every 1 day depending on strength

PA for new startsPA indicated for many perampanel entries

Example strengths2 mg: 2/day; 4–12 mg: 1/day mapping noted

inv-161: diazepam rectal gel delivery — 2

Diazepam rectal gel QL2 kits per fill

NAYZILAM / VALTOCONAYZILAM and VALTOCO: 5 boxes every 30 days

Use caseSeizure rescue medications limited by QL per fill/30 days

inv-162: NAYZILAM SPR 5MG — 5

NAYZILAM QL5 boxes every 30 days

VALTOCO QL5 boxes every 30 days (5,10,15,20 mg presentations)

ContextBenzodiazepine rescue spray products listed with 30-day box limits

inv-164: DIACOMIT CAP/PACK — 6

DIACOMIT QL6 caps/pack per day

EPIDIOLEX QL20 mL per day (100 mg/mL solution)

FINTEPLA QL12 mL per day (2.2 mg/mL solution)

inv-165: EPIDIOLEX SOL 100MG/ML — 20

EPIDIOLEX QL20 mL every 1 day (100 mg/mL)

FINTEPLA QL12 mL every 1 day (2.2 mg/mL)

ContextCannabidiol/related solutions with daily mL QLs

inv-167: lacosamide tabs — 2

Lacosamide QL2 tabs every 1 day

Strengths50–200 mg strengths listed with QL 2/day

ProductLacosamide (Vimpat) generic entries

inv-168: pregabalin caps (various strengths) — 2-4

Pregabalin QL range2–4 caps every 1 day depending on strength

Examples75/100/150 mg: 4/day; 200 mg: 3/day; 225/300 mg: 2/day

Product classPregabalin (various strengths) entries

inv-173: ZTALMY SUS 50MG/ML — 1,100

ZTALMY suspension QL1,100 mL every 30 days

ProductZTALMY SUS 50 mg/mL

AuthorizationPA indicated for ZTALMY entries

inv-174: XCOPRI packs and tablets — 1-2

XCOPRI QL1–2 tabs per day depending on pack/strength

ProductsXCOPRI PAK and tablet strengths list per-day QLs and PA

NoteSome pack/strength combinations have different QLs (1 vs 2/day)

inv-175: TRINTELLIX (5-20 mg) — 1

TRINTELLIX QL1 tab every 1 day

RequirementsST and PA for new starts are indicated

Strengths5–20 mg tablet strengths listed

inv-176: citalopram solution/tab — specified daily limits

Citalopram solution/tab QL30 mL solution or 6 tabs (10 mg) or 3 tabs (20 mg) per day as specified

ProductsCitalopram oral solution 10 mg/5 mL and tablet strengths

NotesHigher-strength tablet daily equivalents shown in QL mapping

inv-177: duloxetine capsules (20,30,60 mg) — 2

Duloxetine QL2 caps every 1 day

Strengths20, 30, 60 mg capsule strengths listed

ReferenceSSRI/SNRI section QLs

inv-178: desvenlafaxine ER — 1

Desvenlafaxine QL1 tab every 1 day

Strengths25, 50, 100 mg ER formulations listed

ContextSNRI class QLs noted

inv-179: phenytoin chewable tab 50 mg — Age limit Max 12

Phenytoin chewable age limitAge Max 12

ProductPhenytoin chewable tablet 50 mg (Dilantin Infatabs)

DocumentationAge limit should be documented when prescribing

inv-180: vilazodone — 1

Vilazodone QL1 tab every 1 day

Strengths10, 20, 40 mg tablet strengths listed

ContextAntidepressant entries list per-day QLs

inv-181: dapagliflozin-metformin 5-1000 mg — 2 tabs

Dapagliflozin-metformin 5-1000 QL2 tabs every 1 day

Dapagliflozin-metformin 10-1000 QL1 tab every 1 day

RequirementST and PA indicated for these combination ER products

inv-183: MOUNJARO pens — 4 pens

MOUNJARO pens QL4 pens every 28 days

OZEMPIC pens QL1 pen every 28 days

AuthorizationPA and ST apply; PA for new starts noted for MOUNJARO

inv-184: OZEMPIC pens — 1 pen

OZEMPIC pen QL1 pen every 28 days

Applies toOzempic injectable pens (various strengths)

ControlsST, PA, QL indicated on product rows

inv-185: RYBELSUS tablets — 30 tabs

RYBELSUS QL30 tabs every 180 days (for select strengths)

Alternate QLsSome strengths list 1 tab every day or 30 tabs/180 days as specified

RequirementST and PA indicated for many oral semaglutide strengths

inv-186: Insulin glargine products — 1-2 mL

Insulin glargine QL1–2 mL every 1 day depending on product

ProductsInsulin glargine products and other insulin formulations listed with mL/day QLs

NotesSome insulin products also list PA or OTC status depending on formulation

inv-187: TRULICITY pens — 4 pens

TRULICITY pens QL4 pens every 28 days

Applies toTrulicity injectable pens multiple strengths

AuthorizationPA indicated on product rows

inv-188: ondansetron oral soln 4 mg/5ml — 50 mL

Ondansetron solution QL50 mL every 30 days

Ondansetron 24 mg QL6 tabs every 30 days (Max 2 fills every 30 days)

Context5-HT3 antagonist entries list solution and tablet limits

inv-189: ondansetron 24 mg tab — 6 tabs

Ondansetron 24 mg QL6 tabs every 30 days (Max 2 fills every 30 days)

AKYNZEO QL2 caps every 21 days

DICLEGIS QL4 tabs every 1 day

inv-190: AKYNZEO CAP 300-0.5 — 2 caps

AKYNZEO QL2 caps every 21 days

DICLEGIS QL4 tabs every 1 day (doxylamine-pyridoxine)

ContextAntiemetic product rows with PA/QL as specified

inv-192: CRESEMBA CAP 74.5MG — 5 caps

CRESEMBA QL5 caps every 1 day (74.5 mg) or 2 caps/day for alternate strength

VIVJOA QL18 caps every 365 days (150 mg)

PAPA and QL apply to these antifungal entries

inv-193: VIVJOA CAP 150MG — 18 caps

VIVJOA QL18 caps every 365 days

Strength150 mg formulation listed with annual QL

PAPA indicated for VIVJOA

inv-194: TRYVIO TAB 12.5MG — 1

TRYVIO QL1 tab every 1 day

AuthorizationPA indicated for TRYVIO product row

Product classEndothelin receptor antagonist entry

inv-195: FIRDAPSE TAB 10MG — 10

FIRDAPSE QL10 tabs every 1 day

ProductFIRDAPSE (amifampridine) 10 mg

AuthorizationPA indicated in product row

inv-196: pyrimethamine 25 mg — 3

Pyrimethamine QL3 tabs every 1 day

Strength25 mg tablet entry

ContextAntimalarial/antiparasitic entries list PA/QL as applicable

inv-197: ONUREG TAB 200/300MG — 14

ONUREG QL14 tabs every 28 days

StrengthsONUREG 200 mg and 300 mg both list 14 tabs per 28 days

AuthorizationPA indicated for ONUREG entries

inv-198: FRUZAQLA CAP 1MG — 84

FRUZAQLA QL (1 mg)84 caps every 28 days

FRUZAQLA QL (5 mg)21 caps every 28 days

AuthorizationPA required for FRUZAQLA entries

inv-199: INLYTA TAB 1MG — 8

INLYTA 1 mg QL8 tabs every 1 day

INLYTA 5 mg QL4 tabs every 1 day

AuthorizationPA and QL listed for INLYTA strengths

inv-202: LENVIMA — strength-specific caps/day limits

LENVIMA caps QLStrength-specific: 1–3 caps per day depending on strength

Examples4 mg: 1/day; 8 mg: 2/day; 12 mg: 3/day

AuthorizationPA required for Lenvima entries

inv-203: capecitabine — 4 tabs/day (150 mg) or 10 tabs/day (500 mg)

Capecitabine QL4 tabs/day (150 mg) or 10 tabs/day (500 mg)

Applies toCapecitabine tablet formulations listed in antimetabolites section

AuthorizationPA noted for capecitabine in product rows

inv-215: Example entries aggregated — assorted QL examples

Example aggregated QLsExamples include 14 tabs every 28 days; 1–3 caps every day; 42 tabs every 28 days

ContextAggregated from multiple oncology product rows showing PA and QL

Provider noteClaims may be denied without PA or if QL exceeded

inv-216: ropinirole hydrochloride ER — QL 1 tab every 1 day

Ropinirole ER QL1 tab every 1 day for listed ER strengths

Applies toRopinirole hydrochloride ER 2–12 mg strengths

ContextAntiparkinson adjunctive therapy listings show per-day ER QLs

Providers must supply supporting documentation for PA where indicated

inv-109: Quantity Limit — QL

QLQuantity Limit — specified amount per day or per 28 days (QL)

ExamplesCommon QLs include '1 tab every 1 day', '4 pens every 28 days', '55 tabs every 28 days'

EnforcementExceeding QL may require PA or result in denial

inv-110: Prior Authorization (alternate reference)

PA (alt ref)Prior Authorization (PA) — see product Requirements/Limits for PA status

EffectPA frequently paired with QL and ST for specialty agents

Provider actionObtain PA before dispensing if listed

inv-111: Quantity Limit (alternate reference)

QL (alt ref)Quantity Limit — amount per day or per 28 days as specified on product rows

MeasurementQL values presented in units: tabs, caps, pens, mL, syringes, inhalers

EnforcementPharmacy systems enforce QL based on these values

inv-112: PA — Prior Authorization

PA definitionPA — Prior Authorization is a utilization control requiring approval before coverage

When usedApplied to many branded, specialty, and some generic products in this formulary

OutcomeClaims may be denied without approved PA

inv-113: QL — Quantity Limit (amount per day or per 28 days)

QL definitionQL — Quantity Limit (specified as amount per day or per 28 days)

FormatPresented as 'X units every Y days' or 'X units every 1 day' in product rows

EnforcementClaims exceeding QL require PA justification or may be denied

inv-114: Tier — Formulary drug tier assignment (Tier 1 / Tier 2)

TierFormulary drug tier assignment (Tier 1 / Tier 2)

UseTier determines member cost-sharing and may be shown per product row

ExamplesMany generics Tier 1; many branded/specialty Tier 2