Prior authorization required for listed analgesics

Obtain prior authorization when prescribing analgesic products listed with 'PA' or when Step Therapy is not met; high‑strength opioid formulations explicitly require PA before coverage.

• PA applies if Step Therapy is not met (see header/footer legend).
• High‑strength opioid formulations (e.g., fentanyl patches, morphine ER, hydrocodone ER) are labeled 'High Strength Requires PA'.

PA required for multiple analgesics including high‑strength opioids

Prior authorization is required for many analgesic listings; prescribers must request PA for products showing 'PA' and for high‑strength opioid formulations.

• Examples include XTAMPZA ER CAP 36MG (ST, PA, QL) and BELBUCA high‑strength films labeled 'High Strength Requires Prior Auth'.
• Morphine, hydrocodone, fentanyl high‑strength entries indicate PA.

PA required for listed specialty agents (e.g., CABENUVA, valganciclovir, EPCLUSA)

Prior authorization is required for the specialty agents shown on the formulary; entries often pair PA with quantity limits or loading‑dose rules.

• CABENUVA kits: 'PA QL (1 kit every 30 days)' and loading dose allowance for initial fill.
• Valganciclovir oral solution: 'PA, QL (1000 mL every 30 days)'.
• EPCLUSA entries: 'PA, QL (28 tabs every 28 days)'.

PA required for listed hepatitis C agents

Prior authorization applies to specified hepatitis C agents and their pack sizes; these entries commonly include quantity limits and, in some cases, Step Therapy.

• EPCLUSA and HARVONI entries show 'PA, QL (28 tabs every 28 days)'.
• SOVALDI entries include 'ST, PA, QL (28–56 pellets per 28 days)'.

PA required for specified hepatitis B agents (entecavir, BARACLUDE SOL)

Prior authorization is required for select hepatitis B agents; entecavir tablets and BARACLUDE solution are labeled with PA and specified quantity limits.

• entecavir tab 0.5 mg and 1 mg — 'Requirements/Limits = PA, QL (30 tabs every 30 days)'.
• BARACLUDE SOL — 'Requirements/Limits = PA, QL (630 mL every 30 days)'.

PA required for many antineoplastics

Many antineoplastic agents require prior authorization; oncology listings frequently include PA paired with numeric quantity limits that must be observed.

• VENCLEXTA (venetoclax): 'PA, QL (120 tabs every 30 days)'.
• PADCEV: 'PA, QL (21 vials every 28 days)'.
• Multiple cytotoxic and targeted agents are annotated 'PA' in the oncology section.

PA plus Quantity Limits for specialty oncology agents

Prior authorization and quantity limits apply to many specialty oral and injectable oncology agents; providers must secure PA and adhere to the QL when prescribing these drugs.

• Nilotinib: 'PA, QL (120 caps every 30 days)'.
• RYDAPT: 'PA, QL (224 caps every 28 days)'.
• VERZENIO: 'PA, QL (56 tabs every 28 days)'.

PA indicated for specific products/classes (e.g., MULTAQ 400 mg)

Obtain prior authorization for specific products and therapeutic classes annotated 'PA' (example: MULTAQ TAB 400MG) as shown in product rows and class headers.

• MULTAQ TAB 400MG is annotated with 'PA'.
• Class‑level and product rows display 'PA' indicating PA is required before coverage.

PA applies when Step Therapy not met

If Step Therapy (ST) is not satisfied for a product marked 'ST', the prescriber must obtain prior authorization for coverage; the document notes 'PA Applies if Step is Not Met'.

• Header/footer legend: 'PA Applies if Step is Not Met'.
• Several product entries show both 'ST' and that PA will apply when ST is not met.

PA required for listed high‑tier/PA drugs (nitrates, PAH agents)

Prior authorization is required for many high‑tier or high‑cost drugs listed (e.g., nitrates, pulmonary arterial hypertension agents); lack of PA may result in claim denial.

• Ranolazine ER: 'PA, QL (360 caps every 30 days)'.
• ADEMPAS: 'PA, QL (90 tabs every 30 days)'.
• PAH agents (ambrisentan, bosentan, tadalafil) show 'PA' with QL.

Obtain PA where 'PA' or 'PA**' is shown (e.g., EMSAM, TRINTELLIX)

Products listed with 'PA' or 'PA**' require prior authorization; examples in this segment include EMSAM and TRINTELLIX where PA and/or ST are noted.

• EMSAM transdermal patches: 'Requirements/Limits = PA'.
• TRINTELLIX tablets: 'Requirements/Limits = ST; PA**'.

PA required when indicated (e.g., pregabalin entries)

Products annotated 'PA' or 'PA**' (e.g., pregabalin strengths) will require prior authorization; providers should not dispense without an approved PA when indicated.

• Pregabalin caps (multiple strengths): 'Requirements/Limits = ST; PA**'.
• Vigabatrin entries: 'PA, QL (180 packets/tabs every 30 days)'.

PA required for many specialty/select agents (e.g., EVRYSDI, Betaseron)

Prior authorization is required for many specialty and selected agents (examples: EVRYSDI, AUSTEDO, BETASERON, fingolimod, glatiramer); PA often accompanies stated QLs.

• EVRYSDI: 'PA, QL (2 bottles every 24 days or 30 tabs every 30 days)'.
• BETASERON, fingolimod, glatiramer entries list 'PA, QL' as applicable.
• KESIMPTA: 'PA, QL (1 pen every 28 days)'.

PA required for SGLT2/combo antidiabetics when ST not met (e.g., SYNJARDY)

Prior authorization applies to several antidiabetic combination products; SYNJARDY, GLYXAMBI, and JARDIANCE are listed as ST with PA noted (PA required if step not met).

• SYNJARDY: 'Requirements/Limits = ST; PA**'.
• GLYXAMBI and JARDIANCE: 'Requirements/Limits = ST; PA**'.

Step Therapy required for listed analgesics (PA if step unmet)

Step Therapy is required for certain analgesics; if the required step(s) are not met the prescriber must obtain prior authorization for the requested product.

• Header/footer legend: 'PA Applies if Step is Not Met'.
• Many analgesic rows are annotated 'ST' indicating step edits apply before coverage.

ST applies to XTAMPZA ER, BELBUCA, buprenorphine patches

Certain specific products are subject to Step Therapy prior to coverage; examples include XTAMPZA ER, BELBUCA, and buprenorphine transdermal patches which show 'ST' in their entries.

• XTAMPZA ER (various strengths): 'Requirements/Limits = ST, QL (60–90 caps)'.
• BELBUCA films: 'Requirements/Limits = ST' for multiple strengths.
• Buprenorphine TD patches: entries show 'ST, QL (4 patches every 30 days)'.

Step Therapy noted in header/footer — PA applies if step unmet

The document header and footers repeatedly indicate 'ST Therapy Step' and 'PA Applies if Step is Not Met', signaling that Step Therapy may be enforced for products marked ST though specific algorithms are not shown here.

• Footer/header legend present across formulary pages referencing ST and PA interplay.
• Specific step sequences or failure requirements are not provided in this excerpt.

ST applies to select HCV agents (e.g., SOVALDI)

Select hepatitis C entries list Step Therapy in addition to prior authorization and quantity limits; SOVALDI is shown with 'ST, PA, QL'.

• SOVALDI PAK/TAB entries: 'Requirements/Limits = ST, PA, QL (28–56 pellets every 28 days)'.
• EPCLUSA and HARVONI also show PA and QL; some packs include ST notation.

Step Therapy referenced in footers — PA if step unmet

Step Therapy is referenced in footers and legends across the formulary indicating ST may apply where specified on product rows; when ST is indicated PA will apply if the step is not met.

• Footer legends: 'ST Therapy Step' present in several chunks.
• Product rows marked 'ST' indicate step edits — details reside in full formulary.

PA applies if required Step Therapy not completed

The formulary notes that PA applies when Step Therapy is not met; explicit step algorithms are not included in this excerpt, so obtain PA if ST cannot be demonstrated.

• 'PA Applies if Step is Not Met' header/footer statement.
• Multiple product rows show ST with PA noted (e.g., pregabalin entries 'ST; PA**').

Step Therapy headers present — follow ST where indicated

Step Therapy headers are present on multiple pages indicating ST is a utilization control used across drug classes; prescribers must follow ST requirements where the product row indicates 'ST'.

• 'ST Therapy Step' header appears in several chunks.
• Products marked 'ST' require attempting preferred agents before higher‑tier drugs per the formulary.

ST cited as utilization control (details not in this excerpt)

Step Therapy is referenced as a utilization requirement in many product rows; specific step failures or required prior agents are not included in this excerpt.

• Entries show 'ST' for various drugs but do not list the required prior agents in these chunks.
• Providers should consult the full formulary for specific step algorithms.

ST shown for ranolazine — PA applies if step not met

Some products (e.g., ranolazine) explicitly show Step Therapy indicators with PA applying if the step is not met — obtain PA when ST cannot be documented.

• Ranolazine ER 500 mg: 'Requirements/Limits = ST; PA**' and 'PA, QL (360 caps every 30 days)'.

ST required for select Tier 4/specialty agents (e.g., TRINTELLIX, APOKYN)

Step Therapy is applied to several Tier 4 medications (e.g., TRINTELLIX) and to specialty agents such as APOKYN where entries show 'ST, PA, QL'; prescribers must meet ST or obtain PA.

• TRINTELLIX tabs: 'Requirements/Limits = ST; PA**'.
• APOKYN injections: 'Requirements/Limits = ST, PA, QL (20 cartridges every 30 days)'.

ST precedence noted ('ST; PA**') — pregabalin example

When product listings display 'ST; PA**' (for example, pregabalin entries), Step Therapy must be satisfied before coverage without PA; otherwise obtain prior authorization.

• Pregabalin multiple strengths: 'Requirements/Limits = ST; PA**'.
• PA is required if ST is not demonstrated.

ST applies to migraine biologics and related agents (Aimovig, Emgality, gepants)

Step Therapy applies to specified migraine and biologic agents; AIMOVIG/EMGALITY and gepants/triptans are annotated 'ST' and often have QLs and PA flags.

• Aimovig: 'Requirements/Limits = ST, QL (2 injections every 30 days)'.
• Emgality: 'ST, QL (2 injections every 30 days); loading dose allowed'.

ST required for select antidiabetic combinations (PA if step unmet)

Step Therapy applies to certain antidiabetic combination products (SYNJARDY, GLYXAMBI, JARDIANCE) per product rows; PA applies when ST is not met.

• SYNJARDY, GLYXAMBI, JARDIANCE entries: 'Requirements/Limits = ST; PA**'.
• Prescribers must document ST completion or submit PA.

Include documentation supporting PA/QL requests

When a product row shows a Quantity Limit (QL) or initial fill limit, providers must include documentation supporting the PA/QL request (diagnosis, intended duration, and justification for exceeding QL if applicable).

• Examples: morphine oral solutions and many tablets are 'Subject to initial 7‑day limit'.
• QA/QL entries (e.g., EPCLUSA, CABENUVA, valganciclovir) indicate PA plus specified QLs that require justification.

Document initial short‑duration fills (initial 7‑day limit)

Some immediate‑release liquids and solution formulations are subject to an initial 7‑day fill limit; document the clinical rationale if requesting a larger initial supply.

• Entries such as morphine oral solutions and other immediate‑release products are labeled 'Subject to initial 7‑day limit'.
• Providers should document need for extended initial dosing when requesting PA.

PA documentation expectation — include diagnosis and intended duration

Prescribers should provide clinical documentation to support prior authorization requests for PA‑listed drugs, including diagnosis and intended duration of therapy consistent with product rows and QLs.

• Examples where documentation is implied: CABENUVA, valganciclovir solution, EPCLUSA/HARVONI and PEGASYS injections.
• When 'PA, QL' is shown the PA request should include clinical justification for the quantity requested.

Provide documentation matching PA/QL requirements

Provide documentation consistent with PA and QL entries (e.g., clinical justification for exceedance requests, previous therapy trials if ST applies) when submitting prior authorization requests.

• IV vials and oral courses with QLs require documentation of indication and intended course length.
• If Step Therapy applies, include evidence of prior agent trials or rationale for bypassing ST.

Submit PA with clinical justification when 'PA' or 'PA, QL' is listed

When a drug row shows 'Requirements/Limits = PA' or 'PA, QL (...)', submit a prior authorization request that includes clinical justification and adhere to the stated quantity limits.

• Oncology and specialty agents frequently pair PA with QL; PA requests must support the requested quantity.
• Failure to obtain PA or to adhere to QL may lead to denial.

Adhere to REPATHA quantity limits in PA/claims

Quantity limits for REPATHA products are specified and must be followed; providers should include these QLs in PA requests when applicable.

• REPATHA INJ 140MG/ML: 'QL (3 syringes every 28 days)'.
• REPATHA PUSH INJ 420/3.5: 'QL (1 injection every 28 days)'; REPATHA SURE INJ: 'QL (3 pens every 28 days)'.

Follow PA/QL/ST utilization controls and document accordingly

The formulary repeatedly lists PA, QL, and ST as utilization controls; providers must follow these controls and supply supporting documentation when requesting PA.

• Header/footer and multiple product rows display 'PA', 'QL', and 'ST' flags.
• Specific documentation requirements are not detailed in every entry — include diagnosis, prior treatments, and intended duration as standard PA support.

PA often paired with QL — include dosing schedule in PA

When PA is required, quantity limits are often specified concurrently (e.g., nitrates and some PAH agents); include the intended dosing schedule in the PA request and adhere to the QL.

• Ranolazine and nitrates list 'PA, QL (360 caps every 30 days)'.
• ADEMPAS entries: 'PA, QL (90 tabs every 30 days)'.

Observe age‑specific QLs and document when requesting exceptions

Quantity limits apply to many products and may be age‑specific; providers must observe QLs and include age‑based justification when applicable (e.g., desipramine QLs for members 65+).

• Desipramine: 'QL applies to members age 65 and older'.
• Nortriptyline high‑strength entries note PA/Q L applicability for older members.

Contraceptive OTC coverage — 365‑day supply noted

Contraceptive OTC coverage is noted (365‑day supply as of 4/1/19); providers should be aware this coverage change may affect claims processing and documentation.

• Formulary notes: 'As of 4/1/19 contraceptives are covered for 365 days'.
• Entries and footers repeat OTC/PA/ST legends relevant to contraceptive coverage.

Document loading‑dose allowance for injectable migraine mAbs (Emgality)

For injectable migraine monoclonal antibodies with ST and QL (e.g., Emgality), initial loading doses are allowed and must be documented when requesting PA for the loading regimen.

• Emgality: 'ST, QL (2 injections every 30 days); PA = Loading dose of 2 injections in 30 days allowed for initial fill.'
• Document initial loading dose in PA submission.

Adhere to QLs for weight‑loss and related agents; PA for exceedance

Quantity limits must be observed for specified products (examples: SAXENDA 5 pens/30 days; WEGOVY/ZEPBOUND 4 pens/28 days; cinacalcet QLs); request PA for quantities above these limits with supporting justification.

• SAXENDA: 'PA, QL (5 pens every 30 days)'.
• WEGOVY/ZEPBOUND: 'PA, QL (4 pens every 28 days)'.
• Cinacalcet: 'PA, QL (60 or 120 tabs every 30 days)'.

PA triggers: ST not met and high‑strength formulations

Prior authorization is commonly triggered for analgesics when Step Therapy is not met and for high‑strength formulations; providers should secure PA or document ST completion to avoid denial.

• Header/footer: 'PA Applies if Step is Not Met'.
• High‑strength opioid entries are labeled 'High Strength Requires PA' and QLs—failure to obtain PA may result in denial.

Denial risk for high‑strength opioids without PA or when QL exceeded

High‑strength opioid formulations explicitly require prior authorization and exceeding quantity limits may trigger claim denial if PA is not obtained.

• Fentanyl high‑strength patches: 'High Strength Requires PA'.
• Hydrocodone ER high strengths: 'High Strength Requires PA' and specified QL/initial fill rules.

PA required for high‑cost specialty products (e.g., CABENUVA) — denial risk if missing

Prior authorization is required for certain high‑cost specialty products (e.g., CABENUVA) and loading‑dose rules are specified; dispensing without PA can lead to denial.

• CABENUVA SUS entries: 'PA QL (1 kit every 30 days)' and 'Loading dose of kit in 30 days allowed for initial fill.'
• Providers must obtain PA before dispensing CABENUVA kits.

PA required for hepatitis C/B agents — denial risk without PA

Prior authorization is required for listed hepatitis C and select hepatitis B agents (EPCLUSA, HARVONI, entecavir, BARACLUDE SOL); claims may be denied without PA.

• EPCLUSA/HARVONI: 'PA, QL (28 tabs every 28 days)'.
• entecavir and BARACLUDE SOL: 'PA, QL' entries.

PA required for select oncology agents — denial risk if not obtained

PA is required for selected oncology agents (e.g., azacitidine, decitabine, capecitabine, temozolomide); absence of PA or exceeding QL may result in claim denial.

• Decitabine for inj 50 mg: 'Requirements/Limits = PA'.
• VENCLEXTA and other antineoplastics annotated 'PA, QL'.

Age‑based PA for nitrofurantoin (70+ years) — denial risk if undocumented

Nitrofurantoin formulations are subject to age‑based PA for members age 70 and older; failure to document age‑based PA can cause denial.

• Nitrofurantoin macrocrystalline 25 mg/50/100 mg and suspensions: 'Requirements/Limits = PA; High Risk Medications require PA for members age 70 and older.'
• Document member age on PA request.

PA required — may trigger denial if not obtained

Drugs annotated 'Requirements/Limits = PA' will require prior authorization and may be denied without an approved PA; check product rows before dispensing.

• Multiple product entries across classes are marked 'PA'.
• Examples: many oncology, specialty, and some cardiovascular agents display 'PA'.

PA required for listed specialty products (e.g., PROLIA, TYMLOS, Lupron)

Prior authorization is required for many specialty products (examples include deferiprone, PROLIA, TYMLOS, Lupron depot); obtain PA before dispensing to avoid denial.

• PROLIA: 'PA, QL (60 mg every 24 weeks)'.
• TYMLOS: 'PA, QL (1 pen every 30 days)'.
• Lupron depot products: 'Requirements/Limits = PA'.