Neighborhood Health Plan RI Formulary Coverage & Prior Auth

Coverage Criteria and Formulary Rules

Coverage conditioned on PA and QL

Listed products are covered subject to the following conditions as specified per product. Where noted in the formulary (section C), coverage may be conditioned on Prior Authorization (PA), Quantity Limits (QL), Non-Extended Day Supply (NDS), Step Therapy (ST), designation as not a Part D drug (DP), or other restrictions. The following criteria summarize how these controls are applied and what they mean for providers and members.

ALL of the following

Prior Authorization (PA): Coverage for drugs marked with PA requires approval from Neighborhood Health Plan of Rhode Island before the drug will be covered. Prescribers must submit a PA request with clinical justification and any supporting records. Failure to obtain PA may result in denial of coverage.
Operational: Use the plan's PA form and follow submission instructions on nhpri.org/INTEGRITY.
Quantity Limits (QL): Drugs noted with a QL have a maximum permitted quantity and/or refill frequency (e.g., "QL (60 per 30 days)"). Prescribers must prescribe within the stated limits or request an override/exception. Overrides require clinical rationale demonstrating medical necessity for quantities beyond the limit.
Operational: QL values are listed per product in section C; verify limits when submitting PA or refill requests.
Non-Extended Day Supply (NDS): Some products are subject to NDS restrictions which limit eligibility for extended-day supplies (e.g., 90-day fills). When NDS is indicated, the product may only be dispensed in standard short fills consistent with the plan's supply rules unless an exception is granted.
Operational: Check NDS flags in section C before authorizing extended fills.
Step Therapy (ST): For drugs subject to step therapy, members must try and fail (or have contraindication/intolerance to) specified preferred therapies before the plan will cover the requested drug. Documentation of prior trials or reasons they are not appropriate must be provided for an exception or PA.
Operational: Step therapy pathways and required trial medications are described online and in the plan's PA guidance.
DP (Not a Part D Drug): Drugs marked DP are not covered under Medicare Part D benefits and may not count toward Part D out-of-pocket thresholds. Different rules for coverage, member cost-sharing, and appeals apply for DP products.
Operational: See section C index and member handbook for DP appeals and cost-sharing details.
Appeals and Exceptions: Members or prescribers may request a coverage exception, PA appeal, or an exception to quantity limits or step therapy. Exceptions must include supporting clinical information. The plan will notify members/providers of their right to appeal and the steps to take.
Operational: Follow timelines and procedures in the Member Handbook and on nhpri.org/INTEGRITY.
Transition and Temporary Supplies: For new members or level-of-care transitions, the plan may provide a temporary supply (e.g., up to 30 days for Part D drugs, 90 days for Rhode Island Medicaid-covered drugs, or a 31-day supply for long-term care residents) while the PA/exception is pursued or an alternative is arranged.
Operational: Transition supply rules are described in sections B9 and B14; coordinate with pharmacy to request transition fills.
Market Changes and Substitutions: The plan may modify coverage when a new generic or interchangeable biosimilar is added or if the FDA withdraws a drug. When substitutions occur, coverage rules or limits for the new product may differ; members/providers will be notified per regulatory requirements.
Operational: Requests for exceptions following market changes should document clinical need for the original product.

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Prior Authorization

Prior Authorization / Restrictions

Prior authorization (PA) and other restrictions apply to many drugs on the List of Covered Drugs. Prescribers must obtain PA from Neighborhood INTEGRITY before dispensing products marked "PA" in the formulary; failure to obtain required PA may result in non‑coverage or claim denial. Some products are also subject to Step Therapy (ST), Quantity Limits (QL), Non‑Extended Supply (NDS), or are designated DP (not a Part D drug) which affect appeals and catastrophic threshold handling.

PA = Prior authorization required before the drug can be filled
ST = Step therapy required (try specified alternative first)
QL = Quantity limits (maximum units per time window)
NDS = Non‑Extended Supply (not available >30 days)
DP = Not a Part D drug (different appeal rules and catastrophic implications)

Prior Authorization

Prior authorization required for select drugs

Numerous individual drugs and formulations across therapeutic categories require prior authorization. Examples include selected long‑acting and controlled opioids, antiviral/hepatitis agents, specialty and oncology agents, and various high‑cost or limited‑supply products. Prescribers should check the formulary lines for per‑product PA flags before prescribing.

Controlled/long‑acting opioid examples with PA: fentanyl transdermal patches, hydrocodone ER formulations, methadone, morphine ER, OXYCONTIN
Antivirals/hepatitis examples with PA: EPCLUSA, HARVONI, HARVONI/EPCLUSA packets
Select specialty/oncology examples with PA: dasatinib, erlotinib, KEYTRUDA, KANJINTI, multiple oral oncology agents

Prior Authorization

PA required for listed specialty/oncology drugs

Most specialty and oncology products listed are labeled PA and often carry QL and NDS flags. Prior authorization must be obtained before coverage for these agents (examples: KISQALI, VERZENIO, VENCLEXTA packs, RETEVMO, ROMVIMZA, many IV biologics).

Oncology oral therapy packs and tablets often require PA + QL + NDS
IV biologics and specialty injectables commonly require PA and are NDS

Prior Authorization

Prior authorization required for selected specialty drugs

Multiple specialty medications across therapeutic areas are designated PA; many also include quantity limits and NDS designations. Examples include MS agents, pulmonary hypertension therapies, inhaled biologics, and injectable antipsychotics.

Multiple Sclerosis agents (e.g., COPAXONE, GLATOPA, KESIMPTA) = PA; QL; NDS
Pulmonary arterial hypertension agents (e.g., ADEMPAS, OPSUMIT, treprostinil) = PA; QL; NDS
Selected injectables (e.g., TOBI PODHALER, TOBRAMYCIN inhalation) = PA; NDS

Prior Authorization

PA required for specific listed products

Specific listed products require PA (and often QL/NDS) — e.g., PREVYMIS, PEGASYS, PREVYMIS, VOSEVI, and many hepatitis/antiviral regimens; cardiometabolic specialty agents (REPATHA, VASCEPA) also require PA where noted.

Antiviral/hepatitis agents flagged PA; many are NDS
REPATHA (evolocumab) = PA
Omega‑3 (omega‑3‑acid ethyl esters) = PA

Prior Authorization

Multiple products require PA

Multiple products across the formulary require prior authorization. Providers must verify the formulary line for PA before prescribing or dispensing to avoid denials. This includes many CNS, endocrine, antineoplastic, specialty, and device/supply items.

Antipsychotics and CNS agents with PA flags (e.g., NUPLAZID, quetiapine ER)
Antineoplastics and supportive agents with PA flags and QLs
Specialty injectables and biologics with PA and NDS

Prior Authorization

OMNIPOD PA and QL

OMNIPOD 5 pods and kits require prior authorization and have defined quantity limits: introductory kits are PA with a 1‑per‑365‑days limit and pods are PA with a 15‑per‑30‑days limit (verify current per‑line QL entries when requesting authorization).

OMNIPOD 5 INTRO KIT = PA; QL (1 per 365 days)
OMNIPOD 5 PODS = PA; QL (15 per 30 days)

Denial Risk

Prior authorization and non-standard restrictions

Some agents require PA plus non‑standard restrictions (NDS) and may be denied without standard Part D appeal rights if designated DP or NDS. Verify whether a product is DP (not Part D) — these have different appeal and catastrophic coverage implications.

NDS = Non‑Extended Supply; many specialty packs and injectables are NDS
DP = Not a Part D drug — different appeals rules; costs may not count toward catastrophic threshold

Documentation Required

Exception request documentation

Documentation requirements and supply limits must be included with PA requests. Prescribers should include clinical rationale, regimen notes (when applicable), and requested quantity to match formulary QL. For expedited exceptions, submit a supporting statement by fax.

Fax prescriber supporting statement for exceptions to 1‑855‑829‑2875
Include QL requested and clinical justification on PA/exception requests
Regimen or BID notes (e.g., oncology dosing, BID IV regimens) should be specified in the request

Documentation Required

Quantity limits enforceable

Quantity limits are enforced per formulary line and must be observed. Many products list exact QL windows (e.g., 30 per 30 days, 60 per 30 days, therapy‑pack counts per 90 days). When requesting PA, document the exact quantity and time window.

Examples: PAXLOVID QL entries (per 90 days), colchicine QLs (60 or 120 per 30 days)
Antipsychotic and injectable QLs (per 28/30/180 days)
Document QL on PA requests to match formulary entries

Documentation Required

Documentation of restrictions

Formulary entries combine PA, QL, ST, NDS, and DP flags. Providers must review the "Necessary actions, restrictions, or limits on use" column for each product and follow instructions when submitting prescriptions or authorization requests.

Table column codes: PA, ST, QL, BID, DP, NDS — review meanings before submitting requests
ST appears for selected formulations (e.g., BARACLUDE oral solution, dispersible tablets)

Documentation Required

Quantity limits and tier documentation

Quantity limits and tier assignments are shown per product line; requests that exceed QL or do not follow ST sequences may be denied. Confirm tier placement when counseling members about expected cost sharing.

Formulary tier examples: S0 (Tier 1), SO (Tier 2), etc.
Dispersible or specialty formulations sometimes carry ST; verify before substitution

Documentation Required

Quantity limit adherence

Adherence to specified quantity limits and step therapy requirements is required for coverage. If step therapy is indicated, the alternative(s) to be tried are noted on the formulary or in plan ST documents; exceptions may be requested with clinical justification.

Step therapy example: BARACLUDE oral solution = ST; NDS
Dispersible tablet formulations may have ST entries (e.g., risperidone dispersible)

Documentation Required

Documentation of PA and QL

PA requests for products with QL and NDS should include explicit documentation of the requested supply and clinical need. For specialty/oncology agents, include regimen details and dosing frequency (BID, PACK, therapy‑pack counts) to support the authorization.

Regimen/BID notes must be documented for many antineoplastic agents
Include therapy‑pack counts when requesting authorization for packeted antivirals or oncology packs

Documentation Required

Quantity limits and NDS annotations

Many formulary lines include QL and NDS annotations for specialty products. Pharmacy claims must match the QL and supply flags; PA requests should indicate NDS when the product is non‑extended supply to ensure appropriate processing.

NDS flagged for many specialty injectables and antivirals (e.g., EPCLUSA, HARVONI, oncology biologics)
Claims for NDS items are limited to ≤30 days supply unless otherwise noted

Documentation Required

Supply documentation to meet PA and QL

When submitting PA or exceptions, supply supporting documentation to meet PA and QL requirements: diagnosis, prior therapies tried (for ST), planned dosing/regimen, and exact quantity requested. This expedites review and reduces denial risk.

Include prior therapy history for ST cases
Provide dosing schedule and quantity to match QL entries
Attach relevant lab results or clinical notes when applicable

Documentation Required

Quantity limits and NDS handling

Pharmacy claims handling must respect QL and NDS flags; if a claim exceeds a QL or requests extended supply for an NDS product, the claim may reject and a PA will be required. Document QL values on authorization forms to align with adjudication rules.

Claims exceeding QL may be denied or redirected for PA review
NDS items should not be submitted for >30 days supply without approval
Document QL number (e.g., "60 per 30 days") on PA request forms

Documentation Required

Document QL when requesting PA

Always include the formulary quantity limit (QL) in the PA request. The plan uses the QL entry to adjudicate appropriate quantity and duration (examples across the formulary: 30/30, 60/30, 120/30, therapy‑pack per 90 days).

Document QL and time window exactly as shown on formulary line when requesting PA
Examples: INBRIJA = QL (300 per 30 days); PROTOCOL‑specific oncology QLs vary by pack

Step Therapy

Step therapy noted for specific agents

Step therapy is noted for select agents and formulations (e.g., BARACLUDE oral solution, certain dispersible tablets). In many sections there are no explicit step sequences listed — consult the plan's ST policy or clinical criteria when ST appears.

BARACLUDE oral solution = ST; NDS
Dispersible tablets (e.g., risperidone dispersible, olanzapine dispersible) may be ST
When ST is not specified in a line, no sequence is implied

Note

Regimen notes present; no step‑therapy rules in excerpt

Some lines include regimen notes (BID, therapy packs, pack counts) but do not specify broader step‑therapy sequences. For example, many antineoplastic and antiviral lines include dosing frequency or BID instructions — include these in PA requests.

Antineoplastic lines commonly list BID or regimen‑specific dosing
Therapy packs (e.g., PAXLOVID, oncology packs) list pack counts and QL windows

Note

Step therapy not specified

In many formulary entries step therapy is not specified; absence of an ST flag indicates no required step before coverage. Always check the "Necessary actions" column for ST before assuming a required sequence.

If ST is blank for a product line, no step therapy is indicated in the formulary excerpt
Confirm via plan ST policy if there is any uncertainty

Step Therapy

Step therapy for select formulations

Step therapy appears for select formulations (not all products) — dispersible and specialized oral forms are common examples where ST is used to direct initial therapy before covering alternative formulations.

Risperidone dispersible tablets = ST; QL per 30/60/90 days depending on strength
Olanzapine dispersible products = ST; QL as noted

Note

Formulary tier placements shown

Formulary tier placements (e.g., S0, SO, Tier 1/2/3) are shown per product line. Providers should use the tier level to advise members about likely cost sharing and to identify preferred alternatives when considering step therapy or exceptions.

Tier examples: SO (Tier 1), S0 (Tier 2), etc.
Tier placement and PA/QL flags together determine coverage path and member cost share

Step Therapy Rules and Examples

Step therapy rule	Notes / example(s)
Member must try specified first-line drugs before later options
Exceptions can be requested if prescriber documents first‑line therapy was ineffective or inappropriate (see exception process); source explains step therapy concept and that exceptions are allowed.

Step therapy rule	Notes / example(s)
Step therapy (ST) may require trying another drug before this formulary drug will be approved
Document defines ST as requiring a member to try an alternative drug first; check per‑line formulary entries for 'ST' notation.

Step therapy rule	Notes / example(s)
No explicit step therapy algorithm specified in these entries
Formulary lines in the cited chunks instead show utilization controls such as PA, QL, DP and BID; review per‑drug rows for any 'ST' flags.

Step therapy rule	Notes / example(s)
BARACLUDE oral solution is noted with ST (step therapy)
Chunk shows: 'BARACLUDE ORAL SOLUTION 0.05 MG/ML ... NECESSARY ACTIONS = ST; NDS' indicating step therapy applies to this formulation.

Step therapy rule	Notes / example(s)
No explicit multi‑step therapy sequencing provided for these antineoplastic agents
Several IV/oral oncology agents include 'BID' dosing and 'NDS' flags (e.g., bendamustine, carboplatin, cisplatin entries) but the excerpt does not define step sequence requirements.

Step therapy rule	Notes / example(s)
Prior authorization (PA) required before coverage for the listed drugs
Multiple oncology and specialty oral agents are annotated 'PA' (e.g., dasatinib, VENCLEXTA) indicating PA is required prior to coverage.

Tier example	Implication
SO (Tier 1) vs SO (Tier 2) examples shown in formulary rows
Tier placement (Tier 1 vs Tier 2) implies preferred vs non‑preferred agents on the formulary; chunk 163 lists ENTRESTO and others with Tier and QL info.

Tier designation	Implication / example
SO Tier 1 / SO Tier 2 designations present
Multiple‑sclerosis and specialty agent lines display S0/SO tier codes indicating formulary placement; explicit step sequences are not detailed.

Step therapy / PA rule	Notes / example(s)
Prior authorization (PA) required before coverage for selected agents (example: droxidopa)
Chunk 183 shows droxidopa entries with 'PA; QL (90 per 30 days); NDS' indicating PA is required prior to coverage for this agent.

Step therapy rule	Notes / example(s)
No explicit step therapy steps listed in these chunks
Entries show tiering, QL and NDS flags for injectable/LAI antipsychotics (e.g., ABILIFY MAINTENA with QL/NDS) rather than ST sequencing.

Step therapy rule	Notes / example(s)
Step therapy required for certain dispersible tablet formulations
Chunk 218/221 show olanzapine and risperidone dispersible tablets annotated 'ST' with accompanying QL values (e.g., olanzapine dispersible ST; QL 60 per 30 days).

Step therapy / PA rule	Notes / example(s)
Some specialty and multiple sclerosis agents are subject to PA and QL; explicit step‑therapy sequences are not provided
Chunks 252–253 list MS agents (COPAXONE, BETASERON, KESIMPTA) with PA and specific QL values; ST sequencing is not shown for these lines.

Step therapy rule	Notes / example(s)
Formulary tier indicators (S0, SO) present but explicit step‑therapy sequences not provided
Chunks include many lines with S0/SO tier codes and PA/QL/NDS annotations; the excerpt does not provide multi‑step sequencing details for these entries.

Quantity Limits (QL) — Product Examples and Values

Quantity limits — plan observation

Plan may set QLsThe plan may set quantity limits for listed drugs as indicated in the formulary rows (QL).

QLs enforceable per entryQuantity limits are specified per product and must be followed for dispensing and claims processing.

QL timeframesLimits are expressed with a quantity and time period (e.g., per 30 days, per 90 days, per 365 days).

Colchicine capsule QL

Colchicine capsule 0.6 mgQL 60 per 30 days

Source lineFormulary entry: colchicine oral capsule 0.6 mg — QL (60 per 30 days)

Colchicine tablet QL

Colchicine tablet 0.6 mgQL 120 per 30 days

Source lineFormulary entry: colchicine oral tablet 0.6 mg — QL (120 per 30 days)

MITIGARE QL

MITIGARE oral capsule 0.6 mgQL 60 per 30 days

Source lineFormulary entry: MITIGARE ORAL CAPSULE 0.6 MG — QL (60 per 30 days)

Assorted QL examples (NSAIDs and analgesics)

Celecoxib (100/200/50 mg)QL 60 per 30 days

Diclofenac potassium 50 mgQL 120 per 30 days

Naproxen DR 500 mgQL 90 per 30 days

Vancomycin 125 mg QL

Vancomycin HCl oral capsule 125 mgQL 80 per 180 days

Source lineFormulary: vancomycin HCl oral capsule 125 mg — QL (80 per 180 days)

Vancomycin 250 mg QL

Vancomycin HCl oral capsule 250 mgQL 160 per 180 days

Source lineFormulary: vancomycin HCl oral capsule 250 mg — QL (160 per 180 days)

PREZISTA QLs

PREZISTA oral suspension (100 mg/mL)QL 400 per 30 days

PREZISTA oral tablet 150 mgQL 240 per 30 days

PREZISTA oral tablet 75 mgQL 480 per 30 days

PREZISTA 150 mg QL

PREZISTA 150 mg tabletQL 240 per 30 days

Source lineFormulary entry shows QL (240 per 30 days)

PREZISTA 75 mg QL

PREZISTA 75 mg tabletQL 480 per 30 days

Source lineFormulary entry shows QL (480 per 30 days)

LIVTENCITY 200 mg QL

LIVTENCITY oral tablet 200 mgQL 336 per 28 days

Source lineFormulary: LIVTENCITY — PA; QL (336 per 28 days); NDS

PAXLOVID (10x150 & 10x100) QL

PAXLOVID therapy pack (10 x 150 mg & 10 x 100 mg)QL 40 per 90 days

Source lineFormulary entry specifies QL (40 per 90 days)

PAXLOVID (6x150 & 5x100) QL

PAXLOVID therapy pack (6 x 150 mg & 5 x 100 mg)QL 22 per 90 days

Source lineFormulary entry specifies QL (22 per 90 days)

PAXLOVID (20x150 & 10x100) QL

PAXLOVID therapy pack (20 x 150 mg & 10 x 100 mg)QL 60 per 90 days

Source lineFormulary entry specifies QL (60 per 90 days)

PREVYMIS QL

PREVYMIS oral tablet (240/480 mg)PA; QL 28 per 28 days; NDS

Source lineFormulary: PREVYMIS — PA; QL (28 per 28 days); NDS

Oseltamivir QLs

Oseltamivir phosphate capsules (30 mg)QL 168 per 365 days

Oseltamivir (45/75 mg)QL 84 per 365 days

Oseltamivir suspensionQL 1080 per 365 days

RELENZA Diskhaler QL

RELENZA DiskhalerQL 120 per 365 days

Source lineFormulary: RELENZA DISKHALER — QL (120 per 365 days)

Paxlovid duplicate QL (10x150 & 10x100)

Paxlovid (10 x 150 mg & 10 x 100 mg) — duplicate listingQL 40 per 90 days

NoteSame QL value appears elsewhere in document for this pack size

Paxlovid duplicate QL (6x150 & 5x100)

Paxlovid (6 x 150 mg & 5 x 100 mg) — duplicate listingQL 22 per 90 days

NoteSame QL value appears elsewhere in document for this pack size

Paxlovid duplicate QL (20x150 & 10x100)

Paxlovid (20 x 150 mg & 10 x 100 mg) — duplicate listingQL 60 per 90 days

NoteSame QL value appears elsewhere in document for this pack size

Prevymis duplicate QL

Prevymis — duplicate listingQL 28 per 28 days; PA; NDS

NotePrevymis appears with PA/QL/NDS in multiple lines

Xofluza dose pack QL

Xofluza dose pack (40/80 mg)QL 1 per 180 days

Source lineFormulary: XOFLUZA therapy packs — QL (1 per 180 days)

Nuzyra 150 mg QL

Nuzyra oral tablet 150 mgQL 30 (per 14 days)

Source lineFormulary: Nuzyra 150 mg — QL (30)

RELENZA duplicate QL

Relenza Diskhaler — duplicateQL 120 per 365 days

NoteAppears in multiple antiviral listings with same QL

Dasatinib 20 mg QL

Dasatinib oral tablet 20 mgQL 90 per 30 days

Dasatinib oral tablet 100 mgQL 30 per 30 days

Dasatinib 100 mg QL

Dasatinib oral tablet 100 mgQL 30 per 30 days

Source lineFormulary: dasatinib 100 mg — PA; QL (30 per 30 days); NDS

MEKINIST oral solution QL

MEKINIST oral solution reconstituted 0.05 mg/mLQL 1260 per 30 days

Source lineFormulary: MEKINIST ORAL SOLUTION RECONSTITUTED — QL (1260 per 30 days)

IMBRUVICA oral suspension QL

IMBRUVICA oral suspension 70 mg/mLQL 216 per 27 days

Source lineFormulary: IMBRUVICA ORAL SUSPENSION 70 MG/ML — QL (216 per 27 days)

LUMAKRAS 120 mg QL

LUMAKRAS oral tablet 120 mgQL 240 per 30 days

Source lineFormulary: LUMAKRAS 120 mg — QL (240 per 30 days)

RETEVMO (80/120/160 mg) QL

RETEVMO oral tablet 80/120/160 mgQL 60 per 30 days

RETEVMO 40 mgQL 90 per 30 days

RETEVMO 40 mg QL

RETEVMO oral tablet 40 mgQL 90 per 30 days

Source lineFormulary: RETEVMO 40 mg — QL (90 per 30 days)

VENCLEXTA starting pack QL

VENCLEXTA starting pack (10/50/100 mg) therapy packQL 42 per 28 days

Source lineFormulary: VENCLEXTA STARTING PACK — QL (42 per 28 days); PA; NDS

VITRAKVI oral solution QL

VITRAKVI oral solution 20 mg/mLQL 300 per 30 days

Source lineFormulary: VITRAKVI ORAL SOLUTION 20 MG/ML — QL (300 per 30 days)

Amlodipine-valsartan QL

Amlodipine-valsartan oral tablet (combo)QL 30 per 30 days

Source lineFormulary: amlodipine besylate-valsartan — QL (30 per 30 days)

ENTRESTO capsule sprinkle QL

ENTRESTO oral capsule sprinkleQL 240 per 30 days

Source lineFormulary: ENTRESTO capsule sprinkle — QL (240 per 30 days)

Atorvastatin QL

Atorvastatin oral tabletQL 30 per 30 days

Source lineFormulary: atorvastatin — QL (30 per 30 days)

Digoxin & ivabradine QLs

Digoxin oral tabletQL 30 per 30 days

Ivabradine oral tabletQL 60 per 30 days

Ivabradine QL

IvabradineQL 60 per 30 days

Source lineFormulary: ivabradine — QL (60 per 30 days)

ADEMPAS & sildenafil QLs

ADEMPAS (riociguat)QL 90 per 30 days

Sildenafil citrate 20 mgQL 360 per 30 days

Sildenafil 20 mg QL

Sildenafil citrate 20 mgQL 360 per 30 days

Source lineFormulary: sildenafil citrate 20 mg — PA; QL (360 per 30 days)

Treprostinil injection QL note

Treprostinil injectionPA; NDS (no numeric QL shown in inventory chunk)

Source noteFormulary line lists PA and NDS for treprostinil; numeric QL not present in that chunk

MARPLAN 10 mg QL

MARPLAN oral tablet 10 mgQL 180 per 30 days

Source lineFormulary: MARPLAN — QL (180 per 30 days)

Paroxetine suspension QL

Paroxetine HCl oral suspension 10 mg/mLQL 900 per 30 days

Source lineFormulary: paroxetine suspension — PA; QL (900 per 30 days)

TRINTELLIX QL

TRINTELLIX oral tabletQL 30 per 30 days (PA noted)

Source lineFormulary: TRINTELLIX — PA; QL (30 per 30 days)

INBRIJA 42 mg QL

INBRIJA inhalation capsule 42 mgQL 300 per 30 days; PA; NDS

Source lineFormulary: INBRIJA — PA; QL (300 per 30 days); NDS

Aripiprazole oral solution QL

Aripiprazole oral solutionQL 900 per 30 days

Source lineFormulary: aripiprazole oral solution — QL (900 per 30 days)

Clozapine formulations QLs

Clozapine (various tablets/dispersible)QL varies by strength (examples: 270; 120; 180 per 30 days)

Source lineFormulary: multiple clozapine strengths with specific QLs per strength

INVEGA QL variations

INVEGA products (SUSTENNA/TRINZA/HAFYERA)QLs vary by product (examples: 0.75 per 28 days; 1 per 28 days; 1.75 per 90 days; 2.63 per 90 days; multi‑month caps)

Source lineFormulary entries list per-syringe QLs and NDS annotations

INVEGA TRINZA 546 mg QL

INVEGA TRINZA 546 mg prefilled syringeQL 1.75 per 90 days

Source lineFormulary: INVEGA TRINZA 546 MG — QL (1.75 per 90 days)

INVEGA TRINZA 819 mg QL

INVEGA TRINZA 819 mg prefilled syringeQL 2.63 per 90 days

Source lineFormulary: INVEGA TRINZA 819 MG — QL (2.63 per 90 days)

Lurasidone QLs

Lurasidone (various strengths)QL 30 per 30 days or 60 per 30 days depending on strength

Source lineFormulary: lurasidone — QL (30 or 60 per 30 days depending on strength)

VERSACLOZ & EPIDIOLEX QLs

VERSACLOZ oral suspension 50 mg/mLQL 600 per 30 days

EPIDIOLEX oral solution 100 mg/mLQL 600 per 30 days

EPIDIOLEX & rufinamide QLs

EPIDIOLEX oral solution 100 mg/mLQL 600 per 30 days

Rufinamide oral suspension 40 mg/mLQL 2400 per 30 days

Rufinamide & lacosamide QLs

Rufinamide oral suspension 40 mg/mLQL 2400 per 30 days

Lacosamide oral solutionQL 1200 per 30 days

Lacosamide & levetiracetam QLs

Lacosamide oral solutionQL 1200 per 30 days

Levetiracetam ODT 250 mgQL 360 per 30 days

Levetiracetam ODT 250 mg QL

Levetiracetam ODT 250 mgQL 360 per 30 days

Source lineFormulary: levetiracetam ODT 250 mg — QL (360 per 30 days)

Pregabalin QL ranges

Pregabalin (capsules, various strengths)QL examples: 120 per 30 days; 90 per 30 days; 60 per 30 days depending on strength

Source lineFormulary: pregabalin entries with PA and strength‑dependent QLs

SPRITAM QL

SPRITAM disintegrating tablet (250–1000 mg)QL 90–360 per 30 days depending on strength

Source lineFormulary: SPRITAM QLs vary by strength (90–360 per 30 days)

VALTOCO QL

VALTOCO nasal dosesQL 10 per 30 days

Source lineFormulary: VALTOCO — QL (10 per 30 days)

XCOPRI QLs

XCOPRI oral tablet and therapy packsQL 28–60 per 28–30 days depending on pack

Source lineFormulary: XCOPRI therapy packs list QL values (28–60 per 28–30 days)

AIMOVIG / EMGALITY QLs

AIMOVIG (auto-injector)QL 1 per 30 days; PA noted

EMGALITY (various presentations)QL 2–3 per 30 days depending on presentation; PA noted

EMGALITY examples

EMGALITY (300 mg dose syringe)QL 3 per 30 days

EMGALITY (120 mg presentations)QL 2 per 30 days

Multiple sclerosis agents QLs

Multiple sclerosis agents (COPAXONE, BETASERON, BAFIERTAM, fingolimod)QLs vary by product (examples: COPAXONE 20 mg/mL QL 30 per 30 days; COPAXONE 40 mg/mL QL 12 per 28 days; BETASERON QL 14 per 28 days)

KESIMPTAQL 6.4 per 365 days

NUEDEXTA QL

NUEDEXTA (20–10 mg)QL 60 per 30 days

Source lineFormulary: NUEDEXTA — PA; QL (60 per 30 days); NDS

Tetrabenazine QLs

Tetrabenazine 12.5 mgQL 90 per 30 days

Tetrabenazine 25 mgQL 120 per 30 days

BETASERON / COPAXONE QLs

BETASERON subcutaneous kit 0.3 mgQL 14 per 28 days

COPAXONE 20 mg/mLQL 30 per 30 days

COPAXONE 40 mg/mL & KESIMPTA QLs

COPAXONE 40 mg/mLQL 12 per 28 days

KESIMPTAQL 6.4 per 365 days

Musculoskeletal agent QLs (carisoprodol, methocarbamol)

Carisoprodol 350 mgQL 120 per 30 days

Methocarbamol 500 mgQL 360 per 30 days

Methocarbamol 750 mgQL 240 per 30 days

Armodafinil / modafinil QLs

Armodafinil (150/200/250 mg)QL 30 per 30 days

Armodafinil 50 mgQL 60 per 30 days

Modafinil 100 mg / 200 mgQL 30 / 60 per 30 days respectively

Sodium oxybate QL

Sodium oxybate 500 mg/mLQL 540 per 30 days

Source lineFormulary: sodium oxybate — PA; QL (540 per 30 days); NDS

Buprenorphine formulations QLs

Buprenorphine sublingual tabletQL 90 per 30 days

Buprenorphine/naloxone film 12-3 mgQL 60 per 30 days

Buprenorphine/naloxone films QL

Buprenorphine/naloxone films (2-0.5; 4-1; 8-2 mg)QL 90 per 30 days

Source lineFormulary lists QL 90 per 30 days for certain film strengths

Varenicline QLs

Varenicline starter packQL 106 per 365 days

Varenicline 56‑packQL 56 per 28 days

Androgen/testosterone QLs

Methyltestosterone 10 mgQL 600 per 30 days

Testosterone transdermal gel (some strengths)QL range 150–300 per 30 days

Cequr Simplicity device QLs

Cequr Simplicity 2U deviceQL 10 per 30 days

Cequr Simplicity inserterQL 8 per 24 days (alternate line QL 2 per 365 days)

OMNIPOD 5 kit/pods QLs

OMNIPOD 5 kitQL 1 per 365 days; PA required

OMNIPOD 5 podsQL 15 per 30 days; PA required

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600-10000 MG-UNTISML	drug product and presentation as listed
HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG	drug product and presentation as listed
KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG	drug product and presentation as listed

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG	drug product and presentation as listed
OJEMDA ORAL SUSPENSION RECONSTITUTED 25 MGIML	drug product and presentation as listed

PHENYTEK ORAL CAPSULE 200 MG, 300 MG	Formulary entry with Tier 1
phenytoin oral suspension 125 mg/5ml	Formulary entry Tier 1
pregabalin oral capsule 100 mg,150 mg,25 mg,50 mg,75 mg,200 mg,225 mg,300 mg	Various strengths with PA and QL as noted
rufinamide oral suspension 40 mg/ml; tablet 200 mg; tablet 400 mg	Rufinamide entries with PA and QL
SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000/750/500/250 MG	Spritam entries with QL limits
SYMPAZAN ORAL FILM 5/10/20 MG	Requires PA; QL
topiramate oral solution 25 mg/ml; tablet/capsule strengths	Solution requires PA; QL
VALTOCO nasal liquid 5/10/15/20 mg dose packs	QL (10 per 30 days)
vigabatrin oral packet/tablet 500 mg; VIGAFYDE/VIGADRONE/VIGPODER variants	PA; QL; NDS
XCOPRI oral tablets and therapy packs (various strengths)	QL; NDS

OpenPayer

Neighborhood INTEGRITY 2025 List of Covered Drugs (Formulary)

Coverage Criteria and Formulary Rules

Formulary Codes, Action Codes, and Examples

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Initial Therapy and Start-of-Care Rules

Step Therapy Rules and Examples

Quantity Limits (QL) — Product Examples and Values

Site of Care and Administration Notes

Biosimilar and Biological Product Substitution

Definitions and Key Terms

Policy Background and Scope

PA	Prior authorization (approval) required
ST	Step therapy required
QL	Quantity limit
BID	May be covered under Medicare Part B or D
DP	This drug is not a Part D drug
NDS	Non-Extended Supply (not available for more than a 30-day supply)