Premera Bluecross formulary coverage & Prior Auth

General coverage rules

Covered drugs are listed by tier; coverage depends on the member's benefit contract and the drug's placement on the formulary.

Formulary coverage prerequisites: Drug must be on the member's plan drug list and applicable member benefit rules (deductible, out‑of‑pocket) must be met; administrative controls indicated on the formulary (PA, ST, QL, age limits, site-of-care) must be satisfied where present.

See the Requirements/Limits column for product-specific controls.

Formulary coverage with utilization management

Drugs are covered per formulary tier but may require administrative controls when restrictions apply.

Formulary coverage with administrative controls: Coverage follows the formulary tier; when a product line lists PA, SP, QL, LA, Och, ST or EX the corresponding administrative requirement must be met (for example: obtain prior authorization, dispense via specialty pharmacy, adhere to quantity limits, follow step therapy).

No additional clinical medical‑necessity algorithms are provided in this extract.

Formulary coverage with utilization management

Coverage and utilization rules apply as noted per product entry.

Formulary requirement: Each product is assigned a formulary tier and may have Restrictions/Limits that govern coverage actions (examples include PA, SP, Och, LA, QL, ST, or designation as EX). Coverage is contingent on meeting those listed requirements.

See individual product lines for exact restriction flags and QL values.

Formulary tiering and utilization management

Formulary coverage summarized by tier and restrictions

Formulary entry: Each listed product includes a Tier designation and may include one or more restriction flags (PA = prior authorization; QL = quantity limit; ST = step therapy; SP = specialty pharmacy; LA/Och = limited/oncology access; EX = excluded).

This document provides tier and restriction flags but does not include product‑specific clinical coverage algorithms in the excerpt.

Formulary coverage controls

Coverage is governed by formulary tiering and listed restriction flags (PA, QL, ST, SP, LA, EX).

Prior Authorization required: Products with 'PA' in the Restrictions/Limits field require prior authorization before coverage will be approved.

Examples in the listing include multiple neurologic, oncology and specialty agents (see product lines with PA).

Quantity limits apply: Products with 'QL' have numerical dispensing limits per time period; claims exceeding the stated QL require justification or PA and may be denied.QL values vary by product (see thresholds in formulary).

Examples: triptans and many specialty agents include QL annotations.

Step therapy required: Entries marked 'ST' require a trial of preferred alternatives before the non‑preferred agent is covered.

Examples include multiple CNS and antihypertensive entries flagged ST.

Formulary coverage notes

Coverage and requirement notes as listed on the formulary extract

General formulary stance: Products are listed with a Tier and Restrictions/Limits; coverage requires adherence to the tiering and any listed administrative controls (PA, QL, ST, SP, LA, EX).

Presence of 'EX' indicates exclusion or non‑covered tiering for that product/strength.

Formulary tiering and restriction annotations

Coverage tier and restriction flags

Formulary assignment: Each product line includes a Tier designation and a Restrictions/Limits field; these values determine required administrative actions for coverage (e.g., PA, ST, QL, SP, LA or EX).

Providers should consult the specific product entry for the exact restriction flags and any numeric QL values.

Formulary coverage controls

Formulary coverage and utilization management for listed products

Tier assignments govern cost‑sharing: Products are assigned numeric tiers (1–4) or EX; tier placement affects member cost‑share and benefit applicability.

Examples include TOPROL XL marked EX and biologic agents placed in higher tiers.

Prior authorization / specialty pharmacy: Products annotated with PA and/or SP require prior authorization and/or specialty pharmacy fill before coverage is approved.

Examples: UPTRAVI, ALHEMO PEN, HEMLIBRA and other specialty agents in this section.

Quantity limits: Some products include explicit QL values (units per 30 days) that limit dispensed quantities; claims exceeding those limits require justification or prior authorization.QL values as listed per product.

See ALHEMO, HEMLIBRA, eltrombopag, REPATHA entries for examples.

Coverage may be denied when a drug's listed administrative controls are not satisfied. Specifically, drugs annotated with PA (prior authorization) or ST (step therapy) in the "Restrictions/Limits" column require the insurer's approval or completion of required step edits before benefits will be paid; failure to obtain approval or follow step therapy may result in the drug not being covered.

Quantity limits (QL) and specialty/limited‑access routing (SP, LA, Och) are additional triggers for denial if the specified limits or dispensing channels are not adhered to.

Within the excerpt provided there are no standalone prose statements declaring broad policy exclusions; instead, coverage status is expressed per line-item using tier assignments and restriction flags. The listing uses designation flags (for example PA, QL, ST, SP, LA, EX) to indicate administrative controls or exclusion at the product/strength level.

Because exclusions are encoded on individual entries rather than in a separate exclusion narrative, absence of an explicit exclusion paragraph in this excerpt does not change the fact that some products are effectively non‑covered as shown by their line-item flags.

This segment of the formulary does not contain discrete medical necessity rules or condition‑specific clinical criteria in narrative form. Coverage determinations in the excerpt are conveyed through the formulary tier and restriction fields rather than through explicit clinical medical‑necessity algorithms.

Providers should therefore use the listed Restrictions/Limits flags (e.g., PA, ST, QL) and the insurer's prior authorization processes to establish whether clinical documentation is required to support coverage.

Certain products are specifically designated as excluded via the formulary Tier = EX designation. Examples shown in this excerpt include BELBUCA (buccal film) and BUTRANS (transdermal patch), which are listed with Tier = EX and are not covered as listed.

When a product line is assigned Tier = EX or the Restrictions/Limits field shows EX, claims billed for those items will be treated as excluded unless a separate exception process applies.

The formulary uses Tier = EX to indicate an exclusion or non‑covered/non‑preferred placement for specific products or formulations. This flag functions as the line‑level exclusion indicator rather than a separate exclusion paragraph.

Entries marked Tier = EX are presented alongside other tiers in the formulary extract and their designation signals that the product is not covered under the standard formulary placement.

Examples of products marked with EX in the excerpt include opioid and analgesic items and multiple branded products. Specific EX‑marked entries shown are BELBUCA and BUTRANS, and other branded combinations (e.g., some opioid combination tablets) that appear with Tier = EX in the listing.

These EX examples demonstrate how exclusion status is applied at the product/strength level in the formulary lines.

The EX designation indicates a product is placed outside the standard covered tiers (1–4) and is treated as excluded or on a non‑covered specialty tier. In this extract, EX serves as the formulary's exclusion marker for specific strengths or formulations.

Providers should interpret Tier = EX as an instruction that the product will not be covered under the plan's normal pharmacy benefit unless an exception is granted.

Additional EX examples listed in the excerpt include branded combination analgesics and certain extended‑release or specialty formulations (for example, some PERCOCET and TRAMADOL ER entries are shown as EX). These line‑level EX markings indicate the product is excluded for the listed strength/formulation.

The extract shows that EX assignments are applied to a range of therapeutic areas, including analgesics, topical agents, and selected branded psychotherapeutics.

No clinical medical necessity criteria, algorithms, or condition‑specific coverage rules are provided in this excerpt. The document fragment conveys coverage stance through tier assignments and restriction flags rather than through explicit medical necessity statements.

For clinical criteria or medical necessity rules, providers must follow the payer's prior authorization pathways referenced in the Restrictions/Limits fields and supporting authorization documentation requirements.

The extract includes multiple examples of products assigned EX status across therapeutic classes (e.g., cardiovascular agents, antidepressants, and opioid/combo analgesics). Specific EX entries called out include TOPROL XL, certain statin combinations, and branded opioid/combo preparations.

These EX assignments illustrate that exclusion labeling is applied broadly and may affect commonly used branded products as well as select formulations.

Where the table shows Restrictions/Limits = EX or Tier = EX, the product is listed as excluded and will be denied/not covered if billed as listed. Several topical products in the excerpt are also designated as EX (for example, HYFTOR topical gel and various topical lotions noted as EX).

Topical and external products are specifically represented among EX‑tier items in the excerpt, confirming that EX applies to both systemic and topical formulations.

There are no statements in this excerpt that label products as not medically necessary in narrative form. Instead, coverage decisions are indicated by the restriction flags and tier assignments on each formulary line.

Absence of a distinct NMN statement in this window means that determinations about medical necessity would be handled through prior authorization reviews or exception processes as applied to the line‑level restrictions.

No explicit "not medically necessary" (NMN) language appears in the portion of the document provided. Coverage and exception determinations are signaled by the presence or absence of PA, QL, ST, SP, LA, or EX flags on each drug entry rather than by standalone NMN statements.

If clinical evaluation is required to assess medical necessity, that process will be initiated via the prior authorization workflow referenced on the formulary.

Coverage status in this extract is indicated by line‑level flags (e.g., PA, QL, ST, EX) rather than by explicit NMN determinations. In practice, products that are effectively excluded are labeled EX on the formulary lines.

Therefore, coverage control is enforced through the listed restriction codes and prior authorization processes rather than through separate "Not Medically Necessary" declarations in the excerpt.

The formulary signals coverage limitations using flags and tier assignments; where a product is not covered as listed it is flagged EX rather than accompanied by an explicit NMN paragraph. Coverage exceptions or medical necessity reviews, when applicable, are managed through the payer's prior authorization procedures.

Providers should consult the Restrictions/Limits column and follow the prior authorization/documentation pathways when an item is not covered as listed.

Certain branded combination products are shown as EX in the excerpt. Examples include PERCOCET and PRIMLEV, which are listed with Tier = EX, indicating non‑preferred or excluded status for those specific formulations.

When branded combinations or opioid combination products are marked EX, they will be treated as excluded under the standard formulary unless an exception is granted.

What providers must do (authorizations, documentation, site of care)

Prior Authorization

Prior authorization required

Many drugs on the formulary require prior authorization (PA) before coverage is approved. PA flags are common across therapeutic classes — including antivirals, neurology agents, specialty biologics, oncology and immunosuppressants, multiple sclerosis and pulmonary agents, select topical products, and numerous opioid and opioid-combination products.

PA required for many listed agents across the formulary (examples: EPCLUSA, HARVONI, SOFOSBUVIR-VELPATASVIR, many HIV agents).
Numerous neurology and migraine agents are PA-designated (examples: LAMICTAL starter kits, LYRICA, NEURONTIN, AIMOVIG, EMGALITY, UBRELVY).
Many specialty and infusion/injectable drugs require PA and specialty pharmacy (SP) routing (examples: APRETUDE, CABENUVA, ALHEMO, HEMLIBRA, DUPIXENT, COSENTYX, ORENITRAM, UPTRAVI).
Select inhaled/nebulized antibiotics and cystic fibrosis therapies are PA/SP/LA flagged (examples: TOBI inhalation solution, CAYSTON, BETHKIS).
Some topical agents and acne/dermatologic products have PA or step-therapy flags (examples: OPZELURA, adapalene topical products, imiquimod in pump forms).
Opioid and opioid-combination products commonly carry PA and/or quantity limits (examples: many hydrocodone, oxycodone, morphine formulations; SUBOXONE/ZUBSOLV quantity limits).

Documentation Required

Authorization and documentation expectations

Prior authorization and specialty/pharmacy routing often require documentation at submission. When PA, SP, LA, ST, or QL appear in the formulary restrictions, expect clinical supporting information will be requested and verify the required site-of-care or dispensing channel prior to prescribing or dispensing.

Collect clinical information pertinent to the PA (diagnosis, prior treatment history, weight/dosing where applicable, prior trial of preferred alternatives for ST).
Specialty agents (SP) may require use of an approved specialty pharmacy and/or administration in a specified site of care (LA = limited access/limited distribution).
When QL is present, confirm allowed quantity (examples: PAXLOVID QL limits; SPRITAM QL per 30/90 days; SUNLENCA QL per 365 days).
Denial is likely if PA/SP/LA requirements or QL limits are not met at time of claim adjudication.

Step Therapy

Step therapy and specialty-step pathways

Step therapy (ST) and step edits (SP/ST flags) are used across multiple drug classes. If an ST flag is present, a trial of specified alternative(s) is required before a non-preferred drug will be covered.

Step edits present for oral antipsychotics and select CNS agents (examples: INVEGA, LATUDA, REXULTI, RISPERDAL).
ST used for some topical and tetracycline-class antibiotics (examples: adapalene topical, DORYX).
Follow the plan’s step-therapy pathway and document prior trials and reasons for failure/intolerance when requesting an exception via PA.

Denial Risk

Quantity limits, restriction flags, and denial risk

Quantity limits, formulary tier designations, and other restriction flags (PA, SP, LA, QL, ST, EX) are active denial triggers. Providers should verify allowable quantities and tier limitations before prescribing; exceedance or missing required approvals can lead to claim denial.

Document quantity limits when submitting PA requests (examples: LAMICTAL QL 150 per 30 days; SPRITAM QL varying per strength; SUBOXONE QL 60/90 per 30 days).
Formulary designations that may trigger denial: EX = excluded (no coverage), PA = prior authorization required, SP = specialty pharmacy, LA = limited access, ST = step therapy, QL = quantity limit.
Examples of quantity-limit enforcement: ALHEMO/HEMLIBRA QL noted; SUNLENCA QL limits per 365 days; SABRIL SP/LA/PA restrictions for limited-access agents.

Prior Authorization

Provider action checklist to avoid denials

Operational step: before prescribing or dispensing, verify formulary status and required processes — obtain PA, route to specialty pharmacy if required, supply requested clinical documentation, and confirm quantity and site-of-care limits to reduce denial risk.

Check the payer’s online "Drugs Requiring Approval" page for PA forms, required documentation, and specialty pharmacy routing.
When submitting a PA, include diagnosis, prior therapy trials and durations, rationale for agent selection, dosing details, and any relevant lab or imaging information.
For drugs flagged SP/LA, confirm the designated specialty pharmacy and any channel restrictions prior to dispensing.
If a product is marked EX (excluded), the plan will not cover it — consider therapeutic alternatives or pursue an exception if clinically justified.

Step therapy requirements and tables

Coverage label	Policy summary
ST (Step therapy)	Member must try preferred agent(s) listed by the plan before a non-preferred agent will be covered. See Requirements/Limits column for ST designation.
Evidence	Step therapy is indicated by the 'ST' flag in the Restrictions/Limits column; coverage requires trial of preferred alternatives prior to non-preferred agents.

Coverage label	Policy summary
ST (Step therapy)	No explicit step therapy sequences or numbered steps are specified in the provided formulary excerpt; entries show ST as a requirement but not step-by-step sequences.
Evidence	Document notes 'No explicit step therapy rules are listed in this excerpt' and ST is used as a flag without detailed sequences.

Coverage label	Policy summary
ST (Step therapy)	Certain tetracycline-class agents and select oral specialty antibiotics are labeled 'ST', indicating they are subject to step therapy controls; specific alternative agents/steps are not provided.
Evidence	Examples include tetracycline-class listings (DORYX, DOXYCYCLINE, tetracycline) and products like SEYSARA annotated with Restrictions = ST.

Coverage label	Policy summary
SP / PA (Specialty/Step Routing)	Entries annotated with 'SP' and/or 'PA' indicate specialty pharmacy routing and/or step edits may apply prior to coverage; follow payer's specialty and step edit processes when present.
[{"text":"Evidence","status":""},{"text":"Formulary lines show 'PA; SP; LA' for several agents (e.g., EPCLUSA) and guidance that 'SP' indicates specialty pharmacy dispensing or step edits.
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Coverage label	Policy summary
SP / PA (Step/limited access)	High-tier agents such as SABRIL (vigabatrin) are annotated with PA; SP; LA indicating step edits, specialty pharmacy, or limited-access routing apply before coverage.
Evidence	SABRIL oral tablet listed with 'Restrictions Limits = PA; SP; LA' showing step/limited access controls for selected high-tier agents.

Coverage label	Policy summary
ST (Step therapy)	ST designation indicates a required trial of preferred therapies prior to coverage of the non-preferred product; examples in neurologic/muscular sections reference ST flags (e.g., AMRIX noted as ST in document commentary).
Evidence	Formulary definitions explain ST as step therapy requirement; entries in the neurological section note products flagged ST (document references step therapy for certain products).

Coverage label	Policy summary
Tiering / QL implying ST	Opioid-dependence products (buprenorphine formulations, SUBOXONE/SUBLOCADE) have tiering and quantity limits that may be part of utilization management pathways and imply step or dispensing controls; they are subject to QL and sometimes PA.
Evidence	Buprenorphine-naloxone films/tablets have QL entries (60–90 per 30 days) and SUBLOCADE is listed among controlled products; the formulary associates QL/PA with utilization controls for these agents.

Coverage label	Policy summary
ST (Step therapy)	Multiple products across psychotropic and neurology classes are labeled 'ST', indicating step therapy requirements apply per the formulary rules; specific step details are not provided in the excerpt.
Evidence	Examples include CLOZARIL, INVEGA oral ER, LATUDA and other entries annotated with 'Restrictions Limits = ST' in the formulary listing.

Coverage label	Policy summary
ST (Step therapy)	Products annotated with 'ST' require step therapy per formulary rules before coverage of the listed product; specific step sequences are not shown in this extract.
Evidence	Formulary entries list multiple drugs with 'ST' flags (document notes that ST-marked entries require trial of preferred therapies).

Coverage label	Policy summary
ST (Step therapy)	Examples of products flagged ST include VERSACLOZ, ARBLI, CONJUPRI, and CONSENSI — these entries indicate step therapy is required before coverage of the listed formulation.
Evidence	VERSACLOZ is listed with 'Restrictions Limits = ST'; ARBLI and several combination agents are shown with ST and associated QL information in the formulary excerpt.

Coverage label	Policy summary
ST (Step therapy)	Multiple antihypertensive combination agents are annotated with 'ST', indicating step therapy applies to these branded combination products per the formulary.
Evidence	Examples include ARBLI, TRIBENZOR, DIOSVAN/EXFORGE HCT and other combination antihypertensives listed with 'Restrictions Limits = ST' in the cardiovascular listings.

Coverage label	Policy summary
ST (Step therapy)	The excerpt does not include explicit step-by-step sequences; ST is applied as a flag to indicate a required trial of preferred agents but the detailed sequences are not present in this segment.
Evidence	Document notes 'No explicit step therapy rules are listed in this excerpt' while also showing ST flags on multiple entries, demonstrating absence of detailed sequences in the extract.

Coverage label	Policy summary
SP / PA (Specialty/Step pathway)	Presence of 'SP' together with 'PA' suggests specialty pharmacy dispensing and/or step-therapy pathways may be required prior to coverage; follow specialty channel and PA processes when indicated.
Evidence	Formulary entries show combinations like 'PA; SP; LA' (e.g., EPCLUSA) and other specialty agents annotated with SP, indicating specialty routing and prior authorization requirements.

Coverage label	Policy summary
ST (Step therapy)	Topical products such as adapalene topical 0.1% and certain metronidazole topical formulations are listed with 'Restrictions Limits = ST', indicating step therapy applies to selected topical therapies.
[{"text":"Evidence","status":""},{"text":"Adapalene topical 0.1% and adapalene topical 0.3% gel are shown with 'Restrictions Limits = ST' in the topical/dermatological listings; some topical gels are Tier = EX or have ST flags as noted.
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Quantity limits (QL) by product

inv-169: zolmitriptan (example QL)

Zolmitriptan (oral tablets)QL 18 per 30 days (documented example for oral zolmitriptan)

Sumatriptan subcutaneous solutionQL 8 per 30 days (example shown)

UBRELVYQL 10 per 30 days

inv-170: EDURANT — QL 30 per 30 days

EDURANT — adult tabletQL 30 per 30 days

TierListed as Tier 2 in formulary extract

Provider noteQuantity limits noted in Restrictions Limits column — exceedance requires documentation

inv-171: EDURANT ORAL TABLET 25 MG — QL 30

EDURANT ORAL TABLET 25 MGQL 30 per 30 days

Formulary tierTier = 2 (as listed)

ActionClaims beyond QL require justification or prior authorization

inv-172: EDURANT PED ORAL TABLET — QL 180

EDURANT PED ORAL TABLETQL 180 per 30 days

PopulationPediatric formulation — higher QL applied per listing

Provider noteVerify pediatric dosing and QL when submitting claims

inv-173: PAXLOVID ORAL TABLETS (dose pack) — QL 40

PAXLOVID dose pack (specified pack)QL 40 per 30 days (document shows QL 40 per 90 days for one pack variant and QL 40 per 30 days for another)

PAXLOVID other packQL 40 (pack-specific) — check Restrictions Limits for exact time window

Claim riskExceeding QL may lead to denial without justification

inv-174: PAXLOVID ORAL TABLETS (other pack) — QL 40

PAXLOVID (other pack variant)QL 40 (document lists QL 40 for other pack variant)

Provider actionFollow pack-specific QL timing as shown in Restrictions Limits

Denial riskRequests exceeding the pack QL require prior authorization or may be denied

inv-175: SUNLENCA ORAL TABLET 300 MG — QL 2

SUNLENCA oral tablet 300 mgQL 2 per 365 days

SUNLENCA subcutaneous solutionQL 6 per 365 days

NoteThese QLs are annual limits as shown in the formulary extract

inv-176: SUNLENCA SUBCUTANEOUS SOLUTION 309 MG/ML — QL 6

SUNLENCA subcutaneous solution 309 mg/mLQL 6 per 365 days

YEZTUGO subcutaneous solution 309QL 1 per 136 days

Provider noteCheck exact days window in Restrictions Limits when requesting exceptions

inv-177: YEZTUGO SUBCUTANEOUS SOLUTION 309 — QL 1

YEZTUGO subcutaneous solution 309QL 1 per 136 days

Channel restrictionsListed with PA and QL in Restrictions Limits — may require specialty handling

ActionRequests beyond QL require documentation/PA

inv-178: Examples: CAYSTON; XIFAXAN; STROMECTOL; ORLYNVAH; AVMAPKI-FAKZYNJA; ARIMIDEX — QLs listed

CAYSTONQL 84 per 30 days

XIFAXANQL 60 per 30 days

ORLYNVAHQL 2 per 30 days

inv-179: ARIMIDEX (anastrozole) — QL 30

ARIMIDEX (anastrozole)QL 30 per 30 days

RestrictionsAlso annotated with PA and Och in formulary extract

Provider noteQL expressed as per 30 days in Restrictions Limits column

inv-180: ENSACOVE oral capsule 100 mg — QL 60

ENSACOVE oral capsule 100 mgQL 60 per 30 days (example shown)

RestrictionsListed with PA; SP; Och in formulary extract

ActionFollow PA/SP processes for oncology agents when submitting requests

inv-181: GAVRETO oral capsule 100 mg — QL 120

GAVRETO oral capsule 100 mgQL 120 per 30 days (example shown)

RestrictionsListed with PA; SP; Och in formulary extract

Provider noteOncology QLs often accompany PA/SP/LA flags

inv-182: PEMAZYRE — QL 28 per 30 days

PEMAZYREQL 28 per 30 days

RestrictionsPA; SP; Och; QL noted in Restrictions Limits

Provider actionAdhere to QL when dispensing or request PA for exceptions

inv-183: TEPMETKO — QL 60 per 30 days

TEPMETKOQL 60 per 30 days

TABRECTAQL 168 per 30 days

TUKYSAQL 120 per 30 days

inv-184: TABRECTA — QL 168 per 30 days

TABRECTAQL 168 per 30 days

TUKYSAQL 120 per 30 days

TYKERBQL 180 per 30 days

inv-185: TUKYSA — QL 120 per 30 days

TUKYSAQL 120 per 30 days

ZEJULAQL 30 per 30 days

EPIDIOLEXQL 400 per 30 days

inv-186: ZEJULA — QL 30 per 30 days

ZEJULAQL 30 per 30 days

EPIDIOLEXQL 400 per 30 days

TREXALLQL 15 per 30 days

inv-187: EPIDIOLEX — QL 400 per 30 days

EPIDIOLEX oral solution 100 mg/mLQL 400 per 30 days

RestrictionsPA; SP; LA accompany QL for this agent

Provider noteEPIDIOLEX is a specialty product requiring PA and documentation for QL exceptions

inv-188: TREXALL — QL 15 per 30 days

TREXALL oral tabletQL 15 per 30 days

Therapeutic classAntineoplastic/chemo-adjunct in listing

Provider actionAdhere to QL or submit PA for exceptions

inv-189: Lamotrigine — QL examples (150 per 30 days; XR starter packs 60 per 30 days)

Lamotrigine (Lamictal) formulationsQL 150 per 30 days for many formulations; XR starter packs QL 60 per 30 days

Lamotrigine starter kitsStarter kits and dose packs carry QL values noted per 30 days

Provider notePA and QL flags present — follow PA/Ql documentation guidance

inv-190: Levetiracetam — QL 360 per 30 days

Levetiracetam (tablets/solution)QL 360 per 30 days

RestrictionsPA plus QL noted for multiple levetiracetam formulations

Provider actionDocument dosing when requesting exceptions to QL

inv-191: Onfi (clobazam) — QL 60 per 30 days

ONFI (clobazam)QL 60 per 30 days

RestrictionsPA and QL listed for oral suspension and tablets

Provider noteRequests exceeding QL require justification/PA

inv-192: Sabril and vigabatrin — PA; SP; LA (special restrictions)

Sabril / vigabatrin formulationsDesignated with PA; SP; LA (special restrictions) rather than a numeric QL

ImplicationSpecial restrictions indicate limited access and specialty handling — prior authorization required

Provider actionFollow PA/SP/LA processes for coverage requests

inv-193: Multiple neurology/migraine products — QL varies (8/30, 10/30, 18/30, 60/30, 120/30, 240/30)

Migraine & neurology QL rangeQuantity limits vary across neurologic/migraine products: examples include 8/30, 10/30, 18/30, 60/30, 120/30, 240/30 depending on product

ExamplesNURTEC/REYVOW/UBRELVY/ZEMBRACE/TRUDHESA and CGRP mAbs show product-specific QLs

Provider noteCheck each product line Restrictions Limits for the exact QL value before prescribing

inv-194: hydromorphone ER — QL 60

Hydromorphone ER (oral tablet)QL 60 per 30 days

Morphine capsule ext.rel pelletsQL 90 per 30 days

Morphine tablet ext.relQL 120 per 30 days

inv-195: morphine capsule ext.rel — QL 90

Morphine capsule extended-release (pellets)QL 90 per 30 days

RestrictionsPA and QL noted in formulary extract

Provider actionAdhere to QL or submit PA justification

inv-196: morphine tablet ext.rel — QL 120

Morphine tablet extended-releaseQL 120 per 30 days

Formulary notePA and QL indicated for extended-release morphine formulations

Provider actionRequests above QL require documentation/PA

inv-197: buprenorphine-naloxone formulations — QL 60-90

Buprenorphine‑naloxone (sublingual film/tablet)QL range 60–90 per 30 days depending on strength/formulation

SUBOXONE 12‑3 mg filmQL 60 per 30 days

SUBOXONE lower-strength films/tabletsQL 90 per 30 days for 2-0.5/4-1/8-2 mg film variants

inv-198: SUBOXONE SUBLINGUAL FILM 12-3 MG — QL 60

SUBOXONE sublingual film 12‑3 mgQL 60 per 30 days

RestrictionListed with QL in Restrictions Limits — may require PA or specialty handling per plan

Provider actionVerify dispensing quantity against QL when prescribing

inv-199: SUBOXONE variants — QL 90

SUBOXONE film (multiple strengths)Some film strengths show QL 90 per 30 days (e.g., 2-0.5/4-1/8-2 mg)

ZUBSOLV optionsZUBSOLV sublingual tablets: QL 30 or 60 per 30 days depending on strength

Provider noteConfirm strength-specific QL before dispensing

inv-200: ZUBSOLV SUBLINGUAL TABLETS — QL 30 or 60

ZUBSOLV sublingual tabletsQL 30 or 60 per 30 days depending on strength

TierListed as Tier 3 in extract

ActionFollow QL and PA/ST processes if applicable

inv-201: Lumryz ER granules — QL 30

Lumryz (oral ER granules)QL 30 per 30 days

Lumryz starter packQL 1 per 365 days (starter pack) — annual limit

Provider noteStarter pack has distinct yearly QL separate from monthly QL

inv-202: Lumryz starter pack — QL 1 per 365 days

Lumryz starter packQL 1 per 365 days (documented starter pack limit)

ImplicationStarter pack is limited to one per year per Restrictions Limits

Provider actionRequest PA for exceptions if clinically indicated

inv-203: Nuvigil — QL 30

Nuvigil (armodafinil)QL 30 per 30 days

Tier/RestrictionsListed with PA; QL in neurologic section

Provider noteFollow PA and QL when prescribing for wakefulness indications

inv-204: Sodium oxybate — QL 3 per 30 days

Sodium oxybate (XYREM/XYWAV)QL 3 per 30 days (document lists Sodium oxybate QL 3/30d)

SUNOSI 150 mgQL 30 per 30 days

SUNOSI 75 mgQL 60 per 30 days

inv-205: Sunosi 150 mg — QL 30

Sunosi 150 mgQL 30 per 30 days

Sunosi 75 mgQL 60 per 30 days

RestrictionsPA flagged along with QL for both strengths

inv-207: BAFIERTAM / TECFIDERA / VUMERITY — QL examples

BAFIERTAM / TECFIDERA / VUMERITY examplesQL examples include 120 per 30 days; 14 per 365 days; 60 per 30 days depending on product formulation

RestrictionsThese MS agents commonly carry PA; SP; LA flags with accompanying QLs

Provider actionFollow PA/SP documentation for QL exceptions

inv-208: WAKIX — QL 60

WAKIXQL 60 per 30 days

XYREM / XYWAVQL 3 per 30 days

Provider noteSodium oxybate products (XYREM/XYWAV) limited to 3 per 30 days with PA/SP/LA restrictions

inv-209: XYREM / XYWAV — QL 3

XYREM / XYWAVQL 3 per 30 days

RestrictionsPA; SP; LA listed for sodium oxybate products

Provider actionSpecialty processes and documentation required for coverage

inv-210: INZIRQO oral suspension — QL 300

INZIRQO oral suspension 10 mg/mLQL 300 per 30 days

Formulary placementListed with product-specific QL in Restrictions Limits

Provider noteRespect QL when submitting claims or request PA for higher quantities

inv-211: ALHEMO PEN — QL 4

ALHEMO PENQL 4 per 30 days

RestrictionsPA; SP; LA indicated alongside QL

Provider actionSpecialty/limited access channel likely required for dispensing

inv-212: HEMLIBRA — QL 2

HEMLIBRA subcutaneous solutionQL 2 per 30 days

RestrictionsPA; SP; LA accompany the QL in the formulary listing

Provider noteCoverage and dispensing via specialty channel and PA required

inv-213: eltrombopag packets/tablets — QL 30

Eltrombopag (packets/tablets)QL 30 per 30 days (packets/tablets examples)

RestrictionsPA and SP often accompany eltrombopag entries

Provider actionFollow PA and QL requirements when requesting supply

inv-214: XARELTO — QL 60

XARELTO (various forms)QL 60 per 30 days for many listed forms

Dose packs/suspensionsDose pack and suspension forms also show QL 60 per 30 days

Provider noteObserve QL for chronic anticoagulant treatment fills

inv-215: DUPIXENT — QL 4

DUPIXENT subcutaneous pen/syringeQL 4 per 30 days

FILSPARIQL 30 per 30 days

Provider actionThese specialty biologics require PA/SP and have explicit QLs—adhere to limits or submit PA

inv-216: FILSPARI — QL 30

FILSPARI oral tabletQL 30 per 30 days

RestrictionsListed with PA; QL in Restrictions Limits

Provider noteFollow PA and QL processes for requests exceeding the QL

OpenPayer

Formulary Drug List (Preferred C4) — Premera

Coverage rules and formulary controls

Formulary entries and coding tables

What providers must do (authorizations, documentation, site of care)

Initial therapy and controls

Step therapy requirements and tables

Quantity limits (QL) by product

Specialty, limited access, and infusion/channel requirements

Abbreviations and tier definitions

Policy background