Prior authorization and quantity limits for selected anti-obesity agents

Certain obesity agents require prior authorization and have specified quantity limits.

• SAXENDA INJ 18MG/3ML — Requirements/Limits = PA; QL (5 pens every 30 days).
• WEGOVY INJ (multiple strengths) — Requirements/Limits = PA; QL (4 pens every 28 days).
• ZEPBOUND INJ (multiple strengths) — Requirements/Limits = PA; QL (4 pens every 28 days).

Opioid prior authorization, QL, and initial fill limits

Many opioid and opioid-combination products require prior authorization, are subject to quantity limits, and immediate‑release/other forms are often subject to an initial 7‑day fill limit.

• Acetaminophen with codeine solutions/tabs — PA; QL (varies by product); subject to initial 7‑day limit.
• Codeine sulfate tablets — PA; QL (42 tabs every 30 days); subject to initial 7‑day limit.
• Fentanyl lozenges — PA; QL (120 lozenges every 30 days).

OTC and contraceptive coverage notes

Over-the-counter products and contraceptives have special coverage notes; contraceptives are covered for 365 days OTC but may still be subject to an over‑the‑counter PA indicator.

• As of 4/1/19, contraceptives are covered for 365 days OTC.
• OTC products may carry an 'Over the counter PA' flag indicating prior authorization processes may apply.

Prior Authorization and Quantity Limits for opioids

Certain morphine ER strengths and other opioid products require prior authorization and have quantity limits; some high‑strength products explicitly state 'High Strength Requires PA'.

• Morphine sulfate ER caps (10–60 mg) — PA; QL (commonly 60 caps/30 days for lower strengths; 30 caps/30 days for some higher strengths).
• Morphine sulfate ER 100 mg — Requirements/Limits = PA; High Strength Requires PA.
• Morphine oral solution — PA; QL (900 mL every 30 days); subject to initial 7‑day limit.

Step Therapy and PA notes

Some opioid products are subject to step therapy and may require PA for high strengths; buprenorphine formulations also show ST and QL requirements.

• XTAMPZA ER CAP 36MG — ST; PA; QL (90 caps every 30 days); High Strength Requires Prior Auth.
• BELBUCA (multiple microgram strengths) — ST; QL (60 films every 30 days); higher strengths require PA.
• Buprenorphine sublingual tablets — QL (90 tabs every 30 days); $0 copay for certain strengths; approval required after the first 30‑day supply.

Prior Authorization and step therapy note

Prior authorization applies when a product's Requirements/Limits indicates PA and also applies if step therapy is not met per the formulary legend.

• Legend: 'Prior Authorization PA** - PA Applies if Step is Not Met'.
• PA flags on a product row indicate authorization is required prior to coverage when criteria or step therapy are not met.

Quantity limits for antiretrovirals

Quantity limits are applied to many antiretroviral products; specific QLs are listed per formulation.

• Abacavir sulfate solution 20 mg/mL — QL (900 mL every 30 days).
• Abacavir sulfate tablets 300 mg — QL (60 tabs every 30 days).
• APRETUDE suspension — QL (2 vials every 90 days).

Prior Authorization for Fidaxomicin

Fidaxomicin 200 mg tablets are listed as requiring prior authorization.

• Fidaxomicin tab 200 mg — Requirements/Limits = PA.

Prior Authorization and Quantity Limits for Hepatitis C Agents

Hepatitis C agents require prior authorization and have quantity limits; some products also require step therapy.

• EPCLUSA (multiple presentations) — PA; QL (examples: 28 pellets/tabs every 28 days; 56 pellets every 28 days depending on pack).
• HARVONI (multiple presentations) — PA; QL (28–56 pellets/tabs every 28 days).
• SOVALDI/VOSEVI — Requirements/Limits = PA; QL as listed per presentation.

High-Risk Medication PA

Nitrofurantoin products are designated high‑risk for older members and require prior authorization for members age 70 and older.

• Nitrofurantoin macrocrystalline caps 25 mg and 50 mg — Requirements/Limits = PA; High Risk Medications require PA for members age 70 and older.

PA and QL for Nucala

NUCALA injections require prior authorization and have product‑specific quantity limits that vary by strength and presentation.

• NUCALA INJ 40MG/0.4 — PA; QL (2.5 syringes every 28 days) with presentation noting 1 every 28 days.
• NUCALA INJ 100MG — PA; QL (3 vials/syringes/pens every 28 days).

Prior authorization and quantity limits for select biologic antiasthmatic agents

Several biologic antiasthmatic agents and other high‑cost injectables list prior authorization and quantity limits in their Requirements/Limits entries.

• NUCALA formulations — PA; QL as specified by presentation (see NUCALA entries).
• Key biologic injectables (examples in document) are flagged with PA and QL where applicable.

Prior authorization and QL for antineoplastic agents

Multiple antineoplastic agents require prior authorization and have specified quantity limits for particular strengths or presentations.

• VENCLEXTA tabs (10/50/100 mg and start pack) — PA; QL (120–180 tabs every 30 days depending on strength or start pack).
• Various chemotherapy and targeted therapy products (e.g., temozolomide, dasatinib) — Requirements/Limits = PA; QL as listed.

Utilization control definitions (legend)

The formulary legend defines utilization control abbreviations and clarifies that prior authorization applies if step therapy is not met.

• PA** or PA — Prior Authorization; 'PA Applies if Step is Not Met' is noted in the legend.
• QL — Quantity Limits; ST — Step Therapy.

Denial risk without PA for specified biologics/oncologics

Some injectable oncology and biologic agents explicitly list prior authorization; coverage may be denied without PA for these products.

• ERBITUX INJ 100MG/200MG — Requirements/Limits = PA.
• KADCYLA and KEYTRUDA injections — Requirements/Limits = PA.

Prior Authorization requirement summary

Prior authorization is required for many products noted with PA in the Requirements/Limits column and applies when step therapy is not met.

• Products marked 'Requirements/Limits = PA' require an approved prior authorization before coverage.
• PA flags include PA** indicating PA applies if the step therapy requirement is not satisfied.

Step Therapy and Quantity Limits notes

Step therapy (ST) and quantity limits (QL) are commonly applied; OTC contraceptives are noted and may carry an OTC PA indicator.

• GLP‑1 and incretin agents — ST; PA**; QL (e.g., liraglutide 3 pens every 30 days; MOUNJARO 4 pens every 28 days).
• Insulins and pen products — ST; QL commonly 4 pens every 28 days.

Utilization control abbreviations

Utilization control abbreviations used throughout the formulary: PA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy.

• PA applies when step therapy is not met (PA**).
• QL indicates maximum allowed quantity in a time period (e.g., per 28/30 days).

PA example

An example product listing showing PA: KERENDIA (finerenone) tablets are listed with Requirements/Limits = PA.

• KERENDIA TAB 10/20/40 mg — Drug Tier = Tier 4; Requirements/Limits = PA.

PA for specific formulations

Certain injectable or specialty formulations are flagged as requiring prior authorization in their Requirements/Limits entries.

• Lidocaine (cardiac) IV pref syr 100 mg/5 ml — flagged in Requirements/Limits entries.
• Other specialty injectable presentations display PA indicators in the formulary.

Utilization controls noted

Utilization controls are annotated across the formulary: PA applies if step not met; Over the counter PA is indicated for OTC items; PA** appears alongside ST and QL annotations.

• PA**, ST, and QL flags appear together on many product rows to indicate combined controls.
• OTC products may still show an 'Over the counter PA' annotation.

Prior authorization and quantity limits for select specialty drugs

Select specialty drugs commonly require prior authorization and have quantity limits specified per product.

• Ambrisentan — PA; QL (30 tabs every 30 days).
• Bosentan — PA; QL (112 tabs every 28 days for suspension; other strengths QL as listed).
• Sildenafil (PAH) — PA; QL (360 tabs every 30 days).

Step therapy and PA cross-reference

Products subject to step therapy will require prior authorization if the step is not met (PA** annotation is used to indicate this cross‑reference).

• Ranolazine ER — ST; PA** (PA applies if step not met).
• Other agents listed with ST; PA** indicate PA is required when step therapy is not satisfied.

OTC contraceptive coverage note

Over‑the‑counter contraceptives are covered for 365 days OTC as of 4/1/19; an 'Over the counter PA' indicator may still appear for OTC products.

• Contraceptives covered 365 days OTC effective 4/1/19.
• OTC products may be annotated with 'Over the counter PA' in the formulary.

Prior authorization and quantity-limit indicators

Many product rows include PA and/or QL indicators in their Requirements/Limits text; these flags denote that prior authorization or quantity limits apply to specific strengths or presentations.

• Examples include entries showing 'PA =', 'PA = QL', or 'Requirements/Limits = PA'.
• Providers should check the product‑level row for the exact PA/QL annotations.

Examples of PA-applicable products

Specific products explicitly list 'Requirements/Limits = PA' or note high‑strength PA requirements for older members.

• EMSAM transdermal patches — Requirements/Limits = PA.
• Certain high‑strength imipramine formulations require PA for members age 65 and older.

Examples of utilization controls

The formulary lists examples of utilization controls—Step Therapy, Prior Authorization, and Quantity Limits—applied to specific products.

• TRINTELLIX — ST; PA**.
• APOKYN INJ 10MG/ML — ST; PA; QL (20 cartridges every 30 days).

Product-specific prior authorization / quantity limits

Certain product entries show product‑specific prior authorization and quantity limits—for example, INBRIJA and ONGENTYS are annotated with PA and QL where applicable.

• INBRIJA CAP 42MG — PA; QL (300 caps every 30 days).
• ONGENTYS CAP 25MG — Requirements/Limits entry indicates PA.

Prior authorization and step therapy note

Prior authorization applies when step therapy is not met (PA**); over‑the‑counter PA may apply to OTC products as annotated in the formulary.

• PA** indicates PA applies if the step is not met.
• Providers should request PA when step therapy alternatives have not been attempted or when the product row shows PA.

Product-level ST and PA examples

Product rows provide examples where step therapy and prior authorization both apply (ST with accompanying PA** annotation).

• VRAYLAR CAP 1.5/3/4.5 mg — Requirements/Limits = ST; PA**.
• Pregabalin products — Requirements/Limits = ST; PA** (see pregabalin entries).

Pregabalin utilization management

Pregabalin products list step therapy and PA** annotations; prior authorization applies when the step requirement is not met.

• Pregabalin caps (25–225 mg) — Requirements/Limits = ST; PA**.

Prior Authorization and PA notes

Prior authorization applies where noted; PA applies if step therapy is not met; OTC PA is referenced for some OTC items and contraceptives.

• Providers must obtain PA for products flagged 'PA' or 'PA**' when step therapy criteria are unmet.
• Check OTC PA annotations for OTC contraceptives and other OTC items.

Step therapy and PA examples

Examples in the formulary show several products designated as requiring step therapy and/or prior authorization; check item rows for ST, PA** and QL annotations.

• SAVELLA and BELSOMRA — ST; PA**; QL as listed.
• AIMOVIG, EMGALITY, and other migraine monoclonal antibodies — ST; PA**; QL limits specified.

Authorization notes

Authorization notes reiterate that PA applies if step therapy is not met and that an 'Over the counter PA' annotation may appear for OTC items.

• PA** indicates prior authorization is required if step therapy is not met.
• Over the counter PA indicates PA processes can apply to OTC entries.

High risk med PA for older members

High‑risk medications require prior authorization for older members (e.g., members age 70 and older) as noted in product rows.

• Muscle relaxants and other listed high‑risk meds — PA; QL (typically 60 tabs every 30 days) for members age 70+.

Buprenorphine approval requirement

Certain buprenorphine formulations have $0 copay and quantity limits and require approval after the first 30‑day supply for some strengths.

• Buprenorphine SL tablets 2 mg and 8 mg — QL (90 tabs every 30 days); $0 copay; must obtain approval after the first 30‑day supply for specified strengths.
• Buprenorphine/naloxone SL film formulations — QL (90 units every 30 days) as listed.

PA and QL for select specialty injectables

Select specialty injectables require prior authorization and have quantity limits expressed in mL or injections per period.

• Octreotide acetate injectable formulations — PA; QL (examples: 90 mL every 30 days; 225 mL every 30 days for higher concentrations).
• Somatuline and similar specialty injectables — PA; QL (1 injection every 28 days or mL limits as listed).

Step therapy and prior authorization for GLP-1 and related agents

Multiple GLP‑1 and related incretin agents list step therapy, PA** and quantity limits; examples show pens per 28–30 days limits.

• Liraglutide pen‑injector 18 mg/3 mL — ST; PA**; QL (3 pens every 30 days).
• MOUNJARO and OZEMPIC presentations — ST; PA**; QL (MOUNJARO QL 4 pens every 28 days; OZEMPIC QL per presentation).

Insulin utilization controls

Insulin and pen products commonly show step therapy and quantity limits, with many entries noting QL of 4 pens every 28 days.

• Insulin pen products (e.g., BASAGLAR, FIASP) — ST; QL (4 pens every 28 days); may show PA** where indicated.

OTC coverage and limits

OTC products and contraceptives are noted as OTC with limited treatment cycles for some products; contraceptives are covered for 365 days OTC as of 4/1/19.

• Many OTC symptomatic/respiratory products — $0 copay and limited to two treatment cycles per year.
• Contraceptives covered 365 days OTC effective 4/1/19; OTC entries may still show an OTC PA annotation.