CurrentPremera BluecrossPolicy N/A

Formulary Drug List (Essentials E4) — Coverage Criteria

Premera Blue Cross formulary drug list (Essentials E4) describing covered generic, brand, and specialty drugs, tiers, utilization management restrictions, and associated requirements for members and providers.

Policy Summary

PayerPremera Bluecross

PolicyFormulary Drug List (Essentials E4) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain required prior authorization and submit supporting documentation when a drug entry lists PA, QL, ST, SP, or LA to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Essentials (E4)Formulary name / tier set

Tier 1-4Medication tiers described

PA/QL/ST/SP/LACommon restrictions used

severalTier = EX (excluded) drugs

844-722-HMO1Support phone

Coverage rules and exclusions

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General coverage criteria

Coverage is plan-dependent and subject to utilization management controls.

General coverage conditions: Drug coverage is based on the member's coverage contract and the drug list attached to the plan; specific utilization management requirements (Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Specialty Pharmacy (SP), Limited Access (LA)) must be met for coverage.

Member booklet and benefit plan determine final coverage; providers may need to supply additional documentation to support requests.

Coverage with utilization management

Coverage and restrictions are specified per product line with tier and requirement flags. Coverage may require meeting one or more utilization management controls shown alongside each product.

Product-level utilization controls: Coverage for a listed drug requires satisfaction of the specific 'Requirements Limits' indicated for that product (for example: PA, QL, ST, SP, LA).

Examples in the formulary show entries with 'Requirements Limits = PA', 'PA; SP', 'PA; QL', or 'ST'.

Prior authorization (PA) required: If the product's Requirements Limits include 'PA', prior authorization must be obtained before the drug will be covered.

Examples: BELBUCA (Requirements Limits = PA); multiple narcotic analgesic entries list PA in Requirements Limits (see formulary).

Quantity limits (QL) applied: If the product's Requirements Limits include 'QL' the quantity limit shown (e.g., 18 per 30 days, 30 per 30 days, 60 per 30 days, etc.) must not be exceeded for coverage.

Quantity limits are specified per product in the formulary listing.

Step therapy (ST) applies where indicated: If the product's Requirements Limits include 'ST', required prior therapies must be tried and documented before the listed product will be covered.

Some products in the formulary are flagged 'ST' indicating step therapy requirements.

Specialty or site restrictions (SP/LA/OCh): If the product's Requirements Limits include 'SP', 'LA', or 'OCh', coverage is limited to specialty pharmacy, limited access sites, or specified channels and associated program enrollment/handling must be met.

Examples: certain oncology and specialty agents show 'PA; SP; LA' or 'PA; SP'.

Exclusions

Certain formulations are marked EX indicating exclusion from coverage.

Excluded drugs (Tier = EX): Drugs or specific formulations listed with 'Tier = EX' are excluded from coverage under this formulary extract and will not be covered by the plan.

Examples in the formulary: multiple butalbital-containing products and several diclofenac/ER analgesic formulations are marked Tier = EX.

Some drugs are designated EX (Excluded) in the Essentials formulary. When a product is marked EX, it is not covered under the formulary and the member is responsible for the full cost of the drug at the pharmacy unless otherwise specified in the member's benefit plan.

The extract includes specific products marked EX, for example PIFELTRO ORAL TABLET 100 MG and multiple erythromycin/ery‑tab suspension and delayed‑release entries that are shown as EX in the tier column.

Additional examples of items listed with Tier = EX include inhalation or specialty formulations such as BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML, DARAPRIM ORAL TABLET 25 MG, NEBUPENT INHALATION RECON SOLN 300 MG, and other antimicrobial formulations which are shown as excluded in this fragment.

The document shows several tetracycline and doxycycline presentations with exclusion designations (for example, delayed‑release and extended‑release formulations such as certain DORYX and DOXYCYCLINE products) marked EX in the tier column.

Selected analgesic and CNS product formulations appear as EX in the extract. Examples include certain butalbital‑containing products shown as excluded and topical/transdermal or specialized diclofenac preparations (e.g., transdermal patches) listed as EX.

The fragment specifically lists several butalbital‑acetaminophen formulations; for example, butalbital‑acetaminophen oral capsule 50‑300 mg and butalbital‑acetaminophen oral tablet 50‑325 mg are shown with Tier = EX for certain presentations in this extract.

Multiple diclofenac and extended‑release analgesic products are designated EX in the excerpt — examples include certain diclofenac transdermal patches and other ER or specialty analgesic formulations that are marked EX in the tier field.

A range of specific products and formulations are marked EX in the listing; examples in the extract include items such as KLOXXADO NASAL SPRAY (tier entries shown elsewhere), SUBOXONE strengths with QL/PA annotations, and other named products where particular presentations are placed in Tier = EX.

Several CNS and psychiatric agents are shown with Tier = EX for particular strengths or formulations in this extract. For instance, entries such as DORAL ORAL TABLET 15 MG and EFFEXOR XR ORAL CAPSULE, EXTENDED RELEASE are listed as EX in the tier column for the presented formulations.

Cardiovascular and antiarrhythmic listings also contain exclusions; the fragment shows that specific strengths/formulations (for example, disopyramide phosphate oral capsule 150 mg, certain NORPACE presentations, and select antihypertensives) are marked EX indicating they are not covered in those forms.

The extract identifies additional excluded items in cardiovascular and specialty therapy areas — for example, certain LOVENOX syringe presentations, some strengths of PROMACTA, and other listed products are shown with Tier = EX indicating formulary exclusion for those presentations.

Several biologic dermatology products are shown as EX or EX/PA in this portion of the formulary. Examples include multiple presentations of COSENTYX (pens and syringes) and other psoriasis biologics listed with Tier = EX in the excerpt.

The product listings in this fragment present tier assignments and requirement flags (PA, QL, SP, LA, ST), but the excerpt does not include detailed clinical prior‑authorization criteria; it primarily communicates formulary placement and exclusion status for specific presentations.

Entries shown as EX in the formulary extract imply those specific products or formulations are not covered under the Essentials formulary. The provided fragment does not supply additional clinical 'not medically necessary' criteria beyond stating exclusion in the tier column.

Formulary coding, tiers, and administrative flags

Sample formulary entriesmixedCovered

ANCOBON ORAL CAPSULE 250 MG, 500 MG	Tier = 4
BREXAFEMME ORAL TABLET 150 MG	Tier = 4; Requirements Limits = PA; QL (24 per 180 days)
NOXAFIL ORAL SUSPENSION 200 MG/5 ML	Tier = EX
VFEND ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML	Tier = 4; Requirements Limits = ST
VIVJOA ORAL CAPSULE 150 MG	Tier = 4; Requirements Limits = PA; SP
APRETUDE INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE 600	Tier = 4; Requirements Limits = PA; SP
CABENUVA INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE	Tier = 3; Requirements Limits = SP
EPCLUSA ORAL TABLET 200-50 MG	Tier = 3; Requirements Limits = PA; SP; LA
HARVONI ORAL PELLETS IN PACKET	Tier = 3; Requirements Limits = PA; SP; LA

Administrative flags and formulary tiersmixed

PA	Prior Authorization (administrative flag)
QL	Quantity Limit (administrative flag)
SP	Specialty Pharmacy (administrative flag)
LA	Limited Availability / Limited Access (administrative flag)
EX	Excluded (administrative flag)
Tier	Formulary tier indicator (numeric or EX)

Quantity limit notesmixed

QL (60 per 30 days)	Quantity limit applied to some hydrocodone ER products and others
QL (120 per 30 days)	Example QL for morphine ER (listed elsewhere)
QL (90 per 30 days)	Example QL for morphine extended-release capsules
QL (28 per 30 days)	PEMAZYRE QL example
QL (18 per 30 days)	Triptans QL example (several agents)
QL (240 per 30 days)	EVRYSDI QL example
QL (60 per 30 days)	Dalfampridine / other examples

Utilization management codesmixed

PA	Prior authorization required
ST	Step therapy required
SP	Special program or specialty authorization

Formulary requirement/limit codesmixed

QL (1 per 30 days)	Quantity limit example for QFITLIA
QL (60 per 30 days)	Quantity limit example for rivaroxaban/Xarelto products
QL (120 per 30 days)	Quantity limit example for icosapent ethyl / LOVAZA-type products
PA	Prior Authorization required
SP	Specialty designation
ST	Step therapy
ACA	ACA flag (operational designation listed in document)
EX	Tier = EX (listed for many products)

inv-23: Quantity limits examples — assorted QL examples

Examples of common QLsExamples include QL (24 per 180 days); QL (30 per 30 days); QL (60 per 30 days); QL (900 per 30 days)

Formulary contextQuantity limits are specified in the Requirements/Limits column and enforced per time period (e.g., per 30 days, per 90 days)

Denial riskRequests exceeding listed QLs may be denied without prior authorization or appropriate justification

Provider actionPrescribers must document medical necessity when requesting quantities above QL

inv-24: Example quantity limit — EMTRIVA QL (30 per 30 days)

ProductEMTRIVA ORAL CAPSULE 200 MG

Quantity limitQL (30 per 30 days)

TierTier = 4

Source noteListed in Requirements/Limits column as QL (30 per 30 days)

inv-25: Annual quantity limit example — NORVIR/RELENZA/PAXLOVID examples

NORVIR (ritonavir) powderQL (360 per 30 days)

RELENZA DISKHALERQL (2 per 365 days)

PAXLOVID dose packQL (40 per 90 days)

Oseltamivir examplesQL (40 per 365 days) and QL (20 per 365 days) for specified capsule strengths

inv-26: Quantity limits — Cayston, Xifaxan, ivermectin examples

Cayston inhalation solutionQL (84 per 30 days)

Xifaxan oral tabletQL (60 per 30 days)

Stromectol / Ivermectin oral tabletQL (20 per 30 days)

Requirements flagsExamples include PA and LA alongside QL for inhalation/limited-access products

inv-27: Quantity limits examples — PEMAZYRE, QINLOCK, RETEVMO, TEPMETKO, WELIREG examples

PEMAZYRE oral tabletQL (28 per 30 days)

QINLOCK oral tabletQL (90 per 30 days)

RETEVMO oral tabletQL (60 per 30 days)

TABRECTA oral tabletQL (168 per 30 days)

WELIREG / ZEJULA / TREXALL examplesWELIREG QL (90); ZEJULA QL (30); TREXALL QL (15) per 30 days

inv-28: Selected Quantity Limits — assorted product QLs (tripans, injectables, high-cost agents)

Triptans (oral) e.g., almotriptan, eletriptan, rizatriptanQL (18 per 30 days)

Selected injectables/biologicsExamples include QL (8 per 30 days) for certain injections; QL (10 per 30 days) for select agents

EVRYSDI oral recon solutionQL (240 per 30 days)

Ormalvi (ormalvi) tabletQL (121 per 30 days)

Icosapent ethyl / LOVAZA / VASCEPAQL (120 per 30 days)

inv-29: Morphine ER QL example

Morphine oral tablet extended releaseQL (120 per 30 days)

Requirement flagListed with Requirements Limits = PA; QL as applicable

Formulary noteApplies to morphine ER tablet strengths shown in listing

inv-30: Morphine ER capsules QL example

Morphine oral capsule extended-release pelletsQL (90 per 30 days)

Associated flagsRequirements Limits include PA where indicated

Use noteSpecific strengths listed with the QL in the formulary extract

inv-31: Hydromorphone ER QL example

Hydromorphone extended-release oral tabletQL (60 per 30 days)

Requirement flagRequirements Limits = PA; QL for ER formulations as listed

Applies toExtended-release hydromorphone strengths shown in formulary

inv-32: Quantity limits examples — assorted (1/30, 60/30, 120/30)

Range of sample QLsExamples in the formulary include QL values such as 1 per 365 days, 60 per 30 days, 120 per 30 days, and 18 per 30 days

Common QL sizesTypical QLs shown: 1/365 days (annual), 30/30, 60/30, 120/30

EnforcementQLs are enforced via the Requirements/Limits column and may be combined with PA or SP flags

What providers must do (authorizations, documentation, and risks)

Prior Authorization

Prior authorization and other utilization management requirements

Many drugs on the formulary include utilization-management tags that require action by the prescriber before the drug will be covered. Common requirement tags and what they mean: PA = Prior Authorization (a written or electronic authorization is required before dispensing; without PA the claim may be denied); QL = Quantity Limit (coverage limited to a specified amount per time period); ST = Step Therapy (an alternative drug must be tried first); SP = Specialty pharmacy (must be dispensed by the plan’s specialty pharmacy or vendor); LA/OCh = Limited access / site-of-care or oncology site restrictions; VAC = Vaccine program requirements; EX = Excluded/not covered. Failure to obtain required PA or to adhere to QL/ST/SP/LA flags may result in claim denial or non-coverage.

Prior authorization (PA) is required for many formulary products — including oral oncology, specialty biologics, neurology agents, and select CNS/migraine biologics.
Specialty (SP) and limited-access (LA) flags indicate dispensing or site-of-care restrictions and may require program enrollment or use of a designated pharmacy or infusion site.
Quantity limits (QL) are specified per product (for example: zolmitriptan 18 per 30 days; many triptans QL = 18 per 30 days; various agents list QL per 30/90/365 days).
Step therapy (ST) applies when noted — the member must trial and fail the required agent(s) before the requested drug is covered.
Documentation: prescribers must submit clinical information to support medical necessity when requesting PA or program enrollment; missing or inadequate documentation can trigger denial.
Denial risk: claims submitted without required PA, that exceed QL, that ignore SP/LA dispensing/site requirements, or that do not follow ST sequences may be denied.
Examples of drugs and product groups commonly requiring PA/SP/LA/QL (non‑exhaustive): Cayston (PA; LA; QL), Emverm (PA), Impavido (PA), VIVJOA (PA; SP), EPCLUSA (PA; SP; LA), HARVONI (PA; SP; LA), TECFIDERA/TECFIDERA 240 mg (PA; SP; LA; QL), many antineoplastics and immunosuppressants (PA; SP; OCh; LA), specialty biologics (Dupixent, Repatha, Tryngolza, QFITLIA, etc. show PA; SP; LA; QL where listed), migraine biologics and CR therapies (Aimovig, Ajovy, Emgality, Emgality pens/syringes — PA), numerous neurology agents (Avonex, Betaseron, Copaxone, Tecfidera, Vumerity — PA; SP; LA; QL), and many CNS products (triptans, levetiracetam entries with PA; QL).

Documentation Required

Documentation and submission requirements

What providers must submit and watch for when requesting coverage: supply clinical documentation consistent with the product’s Requirements/Limits field (diagnosis, prior therapies and outcomes, dosing, intended duration). For specialty and site‑of‑care drugs, include program enrollment forms or infusion/administration site information if required. When quantity limits or time-based QLs apply, indicate the intended dosing schedule and quantity to justify exceptions.

Documentation should show trial and failure (or contraindication) of ST agents when a Step Therapy (ST) flag exists.
For PA requests include relevant supporting labs, prior treatment history, and rationale for the requested agent.
If a product is marked SP or LA, confirm dispensing pharmacy/site acceptance and any required specialty program enrollment.
When requesting exceptions to QL, provide clinical rationale and expected duration of therapy.
Keep copies of approvals/authorizations; dispensing without required PA risks retrospective denial or member liability.

Denial Risk

Administrative requirements, flags, and denial risk

Administrative handling notes and denial triggers: claims may be rejected or denied if requirements are not met. Review the Requirements/Limits column on the formulary for tags (PA; SP; LA; QL; ST; EX) and follow the corresponding operational steps before dispensing.

If a drug is EX (excluded) the plan will not cover it — do not submit for routine coverage.
PA must be obtained prior to dispensing for PA‑designated drugs; retrospective requests may be denied except where allowed by plan policy.
Exceeding a product’s QL without an approved override may result in denial at claim adjudication.
Specialty drugs often require prior authorization plus use of the plan’s specialty pharmacy; verify specialty pharmacy routing before prescribing.
Site/program controls (OCh, LA) for antineoplastics and infusible agents require coordination with the plan’s designated administration sites/programs.
Common administrative flags to check on the formulary: PA; SP; LA; OCh; QL; ST; VAC; EX.

Prior Authorization

Examples of products that typically require PA and other limits

Practical examples to help identify actions needed for specific products (representative, not exhaustive): if a listed product includes PA or PA; SP; LA; QL then prior authorization and any listed program/site or quantity controls must be satisfied before coverage is approved.

Infectious disease/specialty antivirals: EPCLUSA and HARVONI — PA; SP; LA often required.
Antineoplastics & immunosuppressants: many oral and IV oncology agents (abiraterone, ALECENSA, ALUNBRIG, PEMAZYRE, TABRECTA, etc.) list PA; SP; OCh; LA and may have QL limits.
Neurology and MS agents: Avonex, Betaseron, Copaxone, Tecfidera, Vumerity — PA; SP; LA; QL frequently apply.
CNS/migraine biologics: Aimovig, Ajovy, Emgality, Emgality pens/syringes — PA required.
Other specialty products: Dupixent, Repatha, QFITLIA, Tryngolza, SKYRIZI, SPEVIGO, and similar biologics — PA; SP; LA; QL as listed.
Selected oral agents with PA and QL examples: levetiracetam formulations (PA; QL 360 per 30 days), oxcarbazepine ER (PA; QL 120–240 per 30 days), trokendI/TrokendI XR (PA; QL), topiramate (PA; QL 240 per 30 days).

Note

Provider action checklist and operational guidance

Operational tips: check the formulary Requirements/Limits column for each drug prior to prescribing or dispensing; when in doubt, contact the plan’s pharmacy services or prior authorization unit. Keep in mind that some products require multiple controls (PA + SP + LA + QL) and that step therapy (ST) may apply even if not explicitly detailed in a short description — follow the ST flag procedures when present.

Confirm whether Step Therapy (ST) applies; if ST is listed, document trials of the required first‑line agents before requesting the next‑line drug.
For products with multiple tags (e.g., PA; SP; LA; QL), ensure each program or site requirement is met and documented.
If a PA is denied, review the denial reason, provide any additional supporting documentation, and consider an appeals process per plan guidance.

Quantity limits by product

inv-143: Multiple listed drugs with QLs — aggregated examples

Aggregate examplesFormulary shows many drugs with QLs including 24 per 180 days; 30 per 30 days; 60 per 30 days; 900 per 30 days

Combined flagsMany of these QLs appear with PA, SP, or LA flags indicating additional controls

Provider implicationProviders should check Requirements/Limits for each product prior to prescribing

inv-144: EMTRIVA ORAL CAPSULE 200 MG QL (30 per 30 days)

ProductEMTRIVA ORAL CAPSULE 200 MG

Quantity limitQL (30 per 30 days)

TierTier = 4

inv-145: NORVIR ORAL POWDER IN PACKET 100 MG QL (360 per 30 days)

ProductNORVIR ORAL POWDER IN PACKET 100 MG

Quantity limitQL (360 per 30 days)

TierTier = 2

inv-146: RELENZA DISKHALER QL (2 per 365 days)

ProductRELENZA DISKHALER

Quantity limitQL (2 per 365 days)

TierTier = 4

inv-147: PAXLOVID ORAL TABLETS, DOSE PACK QL (40 per 90 days)

ProductPAXLOVID ORAL TABLETS, DOSE PACK

Quantity limitQL (40 per 90 days)

TierTier = 2

inv-148: Cayston/Xifaxan/Ivermectin QLs examples

CAYSTON inhalation solutionQL (84 per 30 days)

XIFAXAN oral tabletQL (60 per 30 days)

STROMECTOL / IVERMECTINQL (20 per 30 days)

inv-149: AROMASIN QL (30 per 30 days)

Aromasin (exemestane) 25 mgQL (30 per 30 days)

TierTier = 4

RequirementsPA; OCh may be listed where applicable

inv-150: IBTROZI QL (90 per 30 days)

Ibtrozi oral capsule 200 mgQL (90 per 30 days)

TierTier = 4

RequirementsRequirements Limits include PA; SP; OCh as listed per product

inv-151: PEMAZYRE QL (28 per 30 days)

Pemazyre oral tabletQL (28 per 30 days)

Numeric QL28

Requirement flagsPA; SP; OCh

inv-152: PEMAZYRE numeric QL example (28)

PEMAZYRE QL numeric28 per 30 days

Requirement flagsPA; SP; OCh

TierTier = 4

inv-153: QINLOCK QL (90)

QINLOCK oral tabletQL (90 per 30 days)

Requirement flagsPA; SP; OCh

TierTier = 3

inv-154: RETEVMO QL (60)

RETEVMO oral tabletQL (60 per 30 days)

Requirement flagsPA; OCh (as listed)

TierTier = 4

inv-155: TABRECTA QL (168)

TABRECTA oral tabletQL (168 per 30 days)

Requirement flagsPA; SP; OCh; LA

TierTier = 4

inv-156: ZEJULA QL (30)

ZEJULA oral tabletQL (30 per 30 days)

Requirement flagsPA; SP; OCh; LA

TierTier = 4

inv-157: TREXALL QL (15)

TREXALL oral tabletQL (15 per 30 days)

TierTier indicated in listing

Requirement notePA; SP; OCh flags may apply depending on product entry

inv-158: EPIDIOLEX QL (400)

EPIDIOLEX oral solution 100 mg/mLQL (400 per 30 days)

Requirement flagsPA; SP; LA

TierTier = 4

inv-159: levetiracetam QL (360)

Levetiracetam (tablets/ER/suspension)QL (360 per 30 days)

RequirementsPA where indicated; QL enforced per 30 days

Use noteSpecified across formulations in the formulary extract

inv-160: oxcarbazepine ER 150 mg QL (480)

Oxcarbazepine ER 150 mgQL (480 per 30 days)

Requirement flagsPA; QL as listed

Formulary contextApplies to extended-release 24 hr 150 mg entry

inv-161: topiramate QL (240)

Topiramate oral tabletQL (240 per 30 days)

RequirementsPA; QL as listed for tablet formulations

TierVaries by formulation

inv-162: Triptans QL (18 per 30 days) examples

Oral triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan)QL (18 per 30 days)

Certain non-oral products (pens/injectables/Nurtec/Reyvow/Ubrevly etc.)Various QLs (8, 10, or other per 30 days) as specified per product

Provider noteCheck product line for exact per-30-day QL and PA requirements

inv-163: Injectable and other migraine meds QLs (various)

Sumatriptan pen/syringe and select migraine injectablesQL examples include 8 or 10 per 30 days depending on product

NURTEC ODT and similarQL (8 per 30 days) for NURTEC ODT noted in listing

Various device/biologic QLsDifferent QLs apply to pens, injectables, and ODTs as specified in Requirements/Limits

inv-164: EVRYSDI QL (240 per 30 days)

EVRYSDI oral recon solutionQL (240 per 30 days)

DalfampridineQL (60 per 30 days)

OrmalviQL (121 per 30 days)

ContextThese high-volume QLs commonly apply to oral solutions or chronic-dose tablets

inv-165: dalfampridine QL (60 per 30 days)

Dalfampridine (extended release 10 mg)QL (60 per 30 days)

FlagsPA; SP; LA may apply as indicated

TierTier = 4 for specified entries

inv-166: ormalvi QL (121 per 30 days)

Ormalvi oral tablet 50 mgQL (121 per 30 days)

RequirementsPA; SP where indicated

Use noteLarge numeric QL appropriate for repack/tablet dosing regimens

inv-167: hydrocodone ER QL (60)

Hydrocodone ER oral capsule (various strengths)QL (60 per 30 days)

Requirement flagPA; QL listed for ER formulations

Provider guidanceDocumentation may be required for quantities above the QL

inv-168: hydromorphone ER QL (60)

Hydromorphone ER oral tablet extended-releaseQL (60 per 30 days)

RequirementsPA; QL for ER forms as listed

Formulation noteApplies to extended-release tablet strengths shown in listing

inv-169: morphine ER QL (120)

Morphine oral tablet extended releaseQL (120 per 30 days)

Associated pellet formulationMorphine ER capsule pellets have separate QL (90 per 30 days)

RequirementsPA; QL enforced per formulary

inv-170: morphine ER capsule pellets QL (90)

Morphine oral capsule extended-release pelletsQL (90 per 30 days)

RequirementsPA; QL indicated in listing

RelationSeparate QL from morphine ER tablets (120 per 30 days)

inv-171: buprenorphine-naloxone sublingual film QLs (60/90)

Buprenorphine‑naloxone sublingual film (some strengths)QL (60 per 30 days)

Other strengthsQL (90 per 30 days) for other strengths as listed

Requirement flagsPA or SP may apply depending on product entry

inv-172: SUBOXONE / ZUBSOLV QLs by strength

SUBOXONE sublingual film 12-3 mgQL (60 per 30 days)

SUBOXONE sublingual film 2-0.5 mgQL (90 per 30 days)

ZUBSOLV sublingual tabletQL varies by strength: 90 per 30 days; 60 per 30 days; 30 per 30 days

inv-173: SUBOXONE QLs by strength (60; 90 per 30 days)

SUBOXONE sublingual film60 per 30 days (12-3 mg); 90 per 30 days (2-0.5 mg)

TierTier = 4

Requirement noteRequirements Limits show QL per strength

inv-174: ZUBSOLV QLs by strength

ZUBSOLV sublingual tabletQL (90 per 30 days) for some strengths; QL (60 per 30 days) for 8.6-2.1 mg; QL (30 per 30 days) for 11.4-2.9 mg

TierVaries by strength

RequirementsCheck Requirements/Limits for exact QL per strength

inv-175: LUMRYZ QL (30)

LUMRYZ oral extended‑release granulesQL (30 per 30 days)

Requirement flagsPA; SP; LA; QL (30 per 30 days)

Starter packStarter pack QL listed separately (1 per 365 days)

inv-176: LUMRYZ STARTER PACK QL (1)

LUMRYZ starter packQL (1 per 365 days)

Associated productStarter pack listed separately from ongoing LUMRYZ QL

RequirementsPA; SP; LA noted for starter pack entry

inv-177: SODIUM OXYBATE QL (3)

Sodium oxybate oral solution 500 mg/mLQL (3 per 30 days)

Requirement flagsPA; SP; LA; QL indicated

TierTier = 4

inv-178: SPRAVATO QL (4)

SPRAVATO nasal sprayQL (4 per 30 days)

RequirementsPA; SP; QL as listed

TierVaries by entry

inv-179: BAFIERTAM QL (120)

BAFIERTAM oral capsule (DR/ER)QL (120 per 30 days)

RequirementsPA; SP; LA may be listed

TierTier = 4 in listing

inv-180: PLEGRIDY QL (2)

PLEGRIDY subcutaneous pen/syringeQL (2 per 30 days) or QL (1 per 365 days) depending on presentation

RequirementsPA; SP; LA noted for pen and syringe entries

TierTier = 3

inv-181: TECFIDERA 240 MG QL (60)

TECFIDERA oral capsule 240 mgQL (60 per 30 days)

Alternate entrySome Tecfidera delayed‑release strengths listed with QL (1 per 365 days)

Requirement flagsPA; SP; LA as indicated

Step therapy flags and presence

Product / example	Step therapy (ST) flag
ANAPROX DS oral tablet 550 mg	Requirements Limits = ST
Diclofenac submicroized capsule (example)	Requirements Limits = ST

Observation	Implication
No explicit step therapy sequences provided in this excerpt	Only utilization flags (PA, SP, LA, QL) are shown — no ST sequencing details
Formulary defines ST conceptually in abbreviations section	ST applies when listed but specific prior-step drugs are not enumerated here

Product / group	Notes (specialty / oncology handling)
Abiraterone oral tablet (250 mg, 500 mg)	Requirements Limits = PA; SP; OCh; LA — specialty/oncology channel handling indicated; may be part of management program
VISTOGARD oral granules in packet 10 gram	Requirements Limits = PA; SP — specialty handling indicated for oncology-related agents

Observation	Detail
Step therapy specifics not provided	Entries show PA/SP/OCh/LA/QL flags but do not list the required prior agents or sequences
Administrative flags present	These flags imply controls but not the clinical step order or exceptions in this excerpt

Product / indicator	Designation
AUSTEDO XR oral tablet extended release	Requirements Limits = PA; SP; LA — specialty/limited access designation (SP/LA) without step details
EVRYSDI oral recon soln	Requirements Limits = PA; SP; LA; QL (240 per 30 days) — SP/LA markers present; no ST specifics

Product	Requirements Limits / ST present
ANAPROX DS oral tablet 550 mg	Requirements Limits = ST
Diclofenac (various formulations) — examples in fragment	Multiple diclofenac entries noted elsewhere with EX or ST flags; ST flagged where specified

Product	ST flag (if listed)
NAPROSYN suspension (example in document)	Requirements Limits = ST (noted in related entries)
CAPLYTA (AUVELITY referenced similarly) — AUVELITY entry	AUVELITY Requirements Limits = ST (document shows ST for similar agents)

Product	Requirements Limits
FANAPT oral tablet (multiple strengths)	Requirements Limits = ST
PAXIL CR; LEXAPRO (examples of antidepressant listings)	Entries shown with Requirements Limits = ST for specified formulations

Flag	Meaning / action
ST (Step Therapy)	Before coverage for the listed drug, a specified alternative must be tried first as defined by the plan (ST explanation in abbreviations)
Entries marked 'ST' in Requirements Limits	Indicate step therapy applies; exact prior-step agents/sequences are not detailed in this excerpt

Product	Requirements Limits / ST
Accupril oral tablet (various strengths)	Requirements Limits = ST
Cardizem CD / Cardizem LA (extended release formulations)	Requirements Limits = ST

Product / group	ST flag present
Assorted CNS and analgesic products (fragment examples)	Multiple entries include 'ST' flags among other requirement flags in the listing
LOTENSIN HCT and other antihypertensives (listed in fragments)	Some entries indicate 'ST' in Requirements Limits implying step edits apply

Product	ST / other flags
Ranolazine oral tablet extended release	Requirements Limits = ST (document lists ranolazine with ST)
Niacin / certain lipid agents (examples)	Some niacin/related entries noted with ST in this section (PRALUENT / ranolazine context)

Product	ST flag / note
PRAMOSONE topical formulations (examples in dermatology section)	Requirements Limits = ST for select topical forms (document notes PRAMOSONE ST)
DAPSONE topical gel 7.5%	Requirements Limits = ST (DAPSONE topical gel 7.5% listed with ST)

OpenPayer

Formulary Drug List (Essentials E4) — Coverage Criteria

Coverage rules and exclusions

Formulary coding, tiers, and administrative flags

What providers must do (authorizations, documentation, and risks)

Quantity limits by product

Specialty pharmacy, infusion, and channel requirements

Abbreviations and terms used

Step therapy flags and presence

Formulary background and scope