CurrentPremera BluecrossPolicy N/A

Formulary Drug List (Essentials E1/E3)

This document is the Premera Essentials formulary drug list describing covered generic, brand, and specialty drugs, applicable utilization management restrictions, and tiering for members on E1 (HSA) and E3 (PPO) plans.

Policy Summary

PayerPremera Bluecross

PolicyFormulary Drug List (Essentials E1/E3)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' on the formulary before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

E1, E3formulary lists described

3drug tiers

multipleutilization management types

multipleitems with Prior Authorization

QL examplesQuantity limits examples

Formulary Coverage & Interpretation

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General Formulary Coverage

Covered drugs and any special requirements are indicated in the Requirements/Limits column; coverage follows the member's benefit plan and may require meeting the listed restrictions.

General coverage rule: Drug is included on the formulary and covered subject to the member's benefit plan and any listed requirements or limits (e.g., PA = prior authorization; QL = quantity limit; ST = step therapy; Age limits; SP = specialty pharmacy; LA = limited access; NF = non‑formulary).

Providers must follow the Requirements/Limits shown on the formulary; failure to obtain required prior authorization or meet other listed requirements may result in denial of coverage.

Formulary coverage entries (listing)

Drugs are listed with Drug Tier and Requirements / Limits flags; coverage is determined per the formulary and any associated PA/QL/SP flags

Formulary entries: Each listed product includes a Drug Tier and may include Requirements / Limits flags such as PA, QL, SP, OCh, LA, ACA, or NF. Coverage for the product follows the tier and any flags shown for that specific formulation/strength.

This listing shows product-level tier and Requirements/Limits indicators; clinical justification or prior authorization forms and quantity-limit details are managed per the flags shown.

Examples (illustrative entries from the list): Examples of listed products and indicated Requirements/Limits include: EDURANT (Drug Tier = 2; QL 30 per 30 days); CAYSTON (PA; SP; LA; QL 84 per 30 days); BLUJEPA (PA; QL 20 per 30 days); ZILBRYSQ (PA; SP); SUBLOCADE (SP); various opioid products with PA and/or QL designations; buprenorphine-naloxone films/tablets with QL (60–90 per 30 days); and aspirin low-dose products with ACA designation.

See the formulary line-item for the exact Tier and Requirements/Limits for each formulation and strength.

Non-Formulary (NF) drugs are medications that are not included in the formulary drug list. Per the formulary guidance, members taking an NF drug will generally be responsible for the full cost of the medication unless a formulary exception is granted. For information about requesting a formulary exception or coverage options, providers or members should contact customer service using the number on the back of the member ID card.

Within the provided document chunks there are no explicit exclusion statements (for example, no list of services or drug categories that are expressly excluded from coverage). The chunks present product listings with Drug Tier and Requirements / Limits entries but do not contain standalone exclusion language or a dedicated exclusions section.

The supplied excerpts do not contain any discrete statements labeling therapies or indications as "Not Medically Necessary". The content consists of formulary product listings with tiering and utilization flags (PA, QL, SP, LA, NF) but does not include specific 'Not Medically Necessary' determinations in these chunks.

Drug Listings, Codes & Example Limits

Sample listed drugs and tiers/requirementsmixed

ANCOBON ORAL CAPSULE 250 MG, 500 MG	Drug listed as NF
clotrimazole mucous membrane troche 10 mg	Tier 1
CRESEMBA ORAL CAPSULE 186 MG, 74.5 MG	Tier 3; PA
DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML	NF
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml	Tier 1
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg	Tier 1
flucytosine oral capsule 250 mg, 500 mg	Tier 1
griseofulvin microsize oral suspension 125 mg/5 ml	Tier 1
griseofulvin microsize oral tablet 500 mg	Tier 1
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg	Tier 3

1–10 of 33

1/4

Drug list (formulations & strengths)NDC | mixed

N/A	This section lists drug formulations and strengths (no CPT/HCPCS/ICD-10 codes present in these chunks)

Formulary product entries (no billing codes provided)mixed

No codes listed

Utilization management flags and example quantity limitsmixed

PA	Prior Authorization flag
SP	Specialty designation
LA	Limited Access
QL (60 per 30 days)	Quantity limit example shown

No explicit billing/CPT/HCPCS/ICD codes in this excerptmixed

No codes listed

inv-11: EDURANT PED quantity limit — key/value: 180 per 30 days

EDURANT PED (suspension)Quantity limit: 180 per 30 days

Drug TierTier = 2 (as listed)

Requirements / Limits fieldShown as QL (180 per 30 days)

inv-12: EDURANT quantity limit — key/value: 30 per 30 days

EDURANT (oral tablet 25 mg)Quantity limit: 30 per 30 days

Drug TierTier = 2 (as listed)

Requirements / Limits fieldShown as QL (30 per 30 days)

inv-13: Specialty drug supply — general note about month supply limitation for specialty drugs

Specialty drug supply noteSpecialty drugs are generally limited to a month supply on dispense

Dispensing channelMay require dispensing at an in‑network specialty pharmacy (SP) or limited distribution (LA)

Clinical supportSpecialty drugs may require enhanced clinical support, provider coordination, or patient education

inv-14: Examples of Quantity Limits — illustrative QL examples

High example QLQL (240 per 30 days) — e.g., ALECENSA 150 mg shown with QL 240 per 30 days

Mid-range example QLQL (60 per 30 days) — e.g., REVUFORJ 160 mg with QL 60 per 30 days

Other example QLQL (120 per 30 days) — e.g., BAFIERTAM 95 mg with QL 120 per 30 days

inv-15: EPIDIOLEX quantity limit — QL 400 per 30 days

EPIDIOLEXQuantity limit: 400 per 30 days (PA; SP; LA indicated)

FormulationEPIDIOLEX listed as oral solution 100 mg/mL with Requirements = PA; SP; LA; QL (400 per 30 days)

Enforcement noteSpecified QL will be enforced and documentation may be required for amounts exceeding the limit

inv-16: Example QLs — assorted examples across chunks

Common QLs (examples)30 per 30 days; 21 per 30 days; 14 per 30 days; 60 per 30 days; 90 per 30 days; 120 per 30 days; 168 per 30 days

ContextExamples drawn from multiple adjunctive and oncology agents listed with QL in Requirements / Limits

Provider actionClaims exceeding these limits may require documentation or prior authorization per the formulary notes

inv-17: Quantity limits examples — 60/90/120 per 30 days examples

Opioid/buprenorphine QL examplesExamples include QL 60 per 30 days, QL 90 per 30 days, QL 120 per 30 days

Specific productsMorphine ER and other opioid formulations show QL entries (60/90/120 per 30 days depending on product)

EnforcementQuantity limits for these products are noted in Requirements / Limits and may trigger PA or denial if exceeded

inv-18: Quantity limits examples — 1/30/120/1 per 90 days examples

Mixed QL examplesExamples include QL (1 per 30 days); QL (30 per 30 days); QL (120 per 30 days); QL (1 per 90 days)

Products referencedExamples drawn from varied product listings (e.g., REDEMPLO QL 1 per 90 days; SOFDRA QL 1 per 30 days)

Note on starter kitsSome starter packs or single‑use products list 1 per period (e.g., ZEPOSIA starter kit QL 1 per 365 days)

Prior Authorization, Documentation & Denial Risk

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed in the formulary. When a product row includes a PA flag, the provider or member must obtain prior approval from Premera before the prescription will be covered; without an approved PA the claim may be denied.

PA flag present on numerous agents across therapeutic classes (examples below).
Failure to obtain required prior authorization may result in the drug not being covered.

Prior Authorization

Prior Authorization for Selected Specialty/High‑Tier Agents

Selected specialty and high‑tier agents commonly require prior authorization and are frequently routed through a specialty pharmacy or have limited access designations. Examples include ARIKAYCE (PA; SP), VIVJOA (PA; SP), Apretude (PA; SP), and many antineoplastic / immunosuppressant agents (e.g., abiraterone, AKEEGA) which show PA; SP; OCh; LA.

Examples: ARIKAYCE (PA; SP); VIVJOA (PA; SP); APRETUDE (PA; SP); abiraterone (PA; SP; OCh; LA).
Specialty (SP) and Limited Access (LA) flags often mean fill must occur via an in‑network specialty pharmacy or distribution channel.

Prior Authorization

Prior Authorization for Select CNS Agents

Some products — including certain CNS agents, sodium oxybate, SPRAVATO, and NUPLAZID — require prior authorization and may also require specialty pharmacy routing and limited access. These flags indicate additional coverage controls and coordination requirements.

NUPLAZID: Requirements = PA; SP; LA.
Sodium oxybate (XYREM/XYWAV): Requirements = PA; SP; LA.
SPRAVATO: Requirements = PA; SP (certified administration setting may be required).

Prior Authorization

Prior Authorization, Specialty Pharmacy & Limited Access for MS Agents

Many multiple sclerosis (MS) disease‑modifying therapies and related products are annotated with PA, SP, and LA flags. Providers must obtain prior authorization and use the designated specialty channel when indicated; program requirements (starter packs, dose‑pack limits) must be followed.

Examples: AVONEX, GILENYA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF show PA; SP; LA.
Mayzent starter packs and other starter packs have QL and PA requirements — documentation needed to request exceptions.

Prior Authorization

Prior Authorization and Utilization Flags

PA, SP, LA, QL and ST are utilization flags used throughout the formulary. When any PA/SP/LA flag appears, providers should follow the payer’s prior authorization and specialty routing processes and supply required clinical documentation to avoid delays or denials.

PA = prior authorization required. SP = specialty pharmacy routing. LA = limited access (in‑network specialty only). QL = quantity limits (numeric examples appear next to some products).
Providers may need to submit clinical justification, prior therapy history, and supporting documentation per the PA form.

Denial Risk

Obtain Prior Authorization When PA Flag Present

When a drug is annotated with PA (or combinations like PA; SP; LA), the provider must obtain prior authorization before the drug is billed or dispensed. Not following these listed requirements may result in coverage denial or claim rejection.

PA flags are present across many product lists — from anti‑infectives to oncology and specialty biologics.
Noncompliance with PA/SP/LA/QL/ST flags may lead to denial of coverage.

Prior Authorization

Prior Authorization or Specialty Channel May Be Required

Specific products carry clear PA expectations and will trigger specialty routing or special program review. Examples include REPATHA, TRYNGOLZA, UPTRAVI, and many oncology biologics — all list PA or PA; SP or PA; SP; LA in their Requirements/Limits.

REPATHA products: Requirements = PA (multiple device forms).
TRYNGOLZA: Requirements = PA; SP. UPTRAVI: Requirements = PA; SP; LA.

Documentation Required

Supporting Documentation for Prior Authorization

Providers are expected to supply supporting clinical documentation to justify PA, specialty dispensing, or exceptions to quantity limits. Documentation examples include prior therapy trials (for step therapy), clinical diagnosis, dosing rationale, and prescriber specialty.

Supporting documentation is routinely requested for PA and SP approvals.
Examples: oncology and MS agents often require staging, prior lines of therapy, or weight/dosing details.
Quantity limit exception requests should include clinical rationale and duration of therapy needed.

Documentation Required

Quantity Limits Documented

Quantity limits (QL) are documented next to many agents and must be adhered to for coverage. Numeric examples include QL (84 per 30 days) for CAYSTON, QL (240 per 30 days) for VENCLEXTA starter packs, QL (120 per 30 days) for several opioids and morphine ER formulations, and QL (1 per 90 days) for REDEMPLO.

CAYSTON inhalation solution = QL (84 per 30 days).
Morphine ER and other opioids: multiple QL annotations (e.g., 60–120 per 30 days depending on product).
REDEMPLO subcutaneous syringe = QL (1 per 90 days).

Documentation Required

Quantity Limit Adherence and Follow‑Through

Adherence to listed quantity limits and utilization requirements is the provider’s responsibility. To obtain coverage when a QL or PA would otherwise limit dispensing, submit supporting clinical documentation and a PA request per Premera’s processes.

Follow numeric QLs exactly or request an exception with clinical justification.
Examples where QL and PA intersect: JORNAY PM (PA), MAYZENT starter (PA; QL), ROMVIMZA (QL per 28 days + PA).

Step Therapy

Step Therapy Requirements

Step therapy (ST) rules require trying specified alternatives before coverage of the requested drug. Step edits and program routing may apply especially for anticonvulsants, certain antidepressants/ADHD agents, and selected topicals; documentation of prior trials may be required to satisfy ST.

Examples: BRIVIACT and related anticonvulsants marked ST; AUVELITY marked ST for depression.
PRAMOSONE topical lotion flagged ST among topicals.
Program‑specific flags (OCh, SP, LA) can create routing/step edits for oncology and specialty programs.

Prior Authorization

Specialty Routing and Step Implications

Specialty routing and step implications: SP indicates specialty pharmacy routing and often pairs with PA and LA; these flags together mean a drug will be managed through specialty channels with program‑specific authorization steps.

When SP is present, use the in‑network specialty pharmacy designated by Premera.
PA + SP + LA combinations are common for biologics, MS agents, and many oncology drugs — follow the payer’s routing instructions.

Abbreviations & Key Terms

inv-75: PA — Prior Authorization definition

Prior Authorization (PA)Prior Authorization — member or physician must obtain prior approval before the drug is covered

Effect of no PAWithout prior approval, the drug may not be covered (coverage denial risk)

Where shownPA appears as 'PA' in the Requirements / Limits column for specific products

inv-76: QL — Quantity Limit definition

Quantity Limit (QL)Quantity Limit — the plan limits the amount of this drug that is covered per prescription or within a specific time frame (e.g., 30 per 30 days)

PresentationShown as QL (numeric value and time period) in the Requirements / Limits column

EnforcementSpecified QLs are enforced and requests exceeding them may require documentation or prior authorization

inv-77: ST — Step Therapy definition

Step Therapy (ST)Step Therapy — must try specified alternative drugs first before coverage of the listed drug; indicated as 'ST' in Requirements / Limits

DocumentationCoverage may be contingent on documented trial/failure of step drugs per the formulary

Where shownST flags appear next to specific products (e.g., select anticonvulsants, AUVELITY)

inv-78: SP / LA / NF — Specialty, Limited Access, Non-Formulary abbreviations

SP / LA / NF abbreviationsSP = Specialty Pharmacy; LA = Limited Access; NF = Non-Formulary

ImplicationsSP may require dispensing via specialty pharmacy; LA indicates restricted distribution or special handling; NF indicates not on formulary and member may be responsible for full cost

ReferenceThese abbreviations appear in the Requirements / Limits and other special requirements sections

inv-79: PA — duplicate/alternate PA definition observed in other chunks

Alternate PA wordingPA — approval required before coverage (alternate/duplicate phrasing seen in other sections)

ExamplesMultiple chunks reiterate PA as 'approval required before coverage' for listed agents

Denial riskRequests for PA‑flagged drugs may be denied without required approval

inv-80: SP — Specialty Pharmacy definition

Specialty Pharmacy (SP) definitionSpecialty Pharmacy — drugs typically used to treat chronic, complex, or rare conditions and may require enhanced clinical support; may require dispensing at specialty pharmacy

Month supply noteSpecialty Drugs are generally limited to a month supply on dispense

Associated flagsSP often appears with PA, LA, or OCh for specialty products

inv-81: OCh — Oncology Channel definition

Oncology Channel (OCh)OCh = Oral Chemo / Oncology Channel — denotes oral chemotherapy or oncology channel routing as noted in Requirements / Limits

ImplicationMay indicate coverage under medical plan or specific program routing/administration requirements

Where shownOCh appears for multiple antineoplastic agents in the adjunctive agents section

inv-82: ACA — ACA appears as a Requirements/Limits flag (not defined in these chunks)

ACA flag noteACA — appears as a Requirements/Limits flag (e.g., for preventive medications); not explicitly defined in these chunks

ExampleAdult aspirin regimen noted with Requirements = ACA in the formulary excerpts

ActionACA flags may indicate preventive coverage rules under the Affordable Care Act

inv-83: PA / ST / QL / SP / LA / NF — consolidated list of abbreviations observed

Common requirement flagsPA; ST; QL; SP; LA; NF — abbreviations used in Requirements / Limits to indicate utilization controls

Meaning summaryPA = prior authorization; ST = step therapy; QL = quantity limit; SP = specialty pharmacy; LA = limited access; NF = non‑formulary

Where usedThese flags appear alongside drug listings and determine coverage controls and provider actions

inv-84: PA; SP; LA; QL — short form expansions

Short form expansionsPA = Prior Authorization; SP = Specialty; LA = Limited Access; QL = Quantity Limit

UsageShown in the Requirements / Limits column for many listed products (e.g., KERENDIA PA; QL)

Provider implicationPresence of these flags may require PA or specialty enrollment before dispensing

inv-85: Formulary requirement flags — PA, SP, QL, LA, ACA definitions summary

Formulary requirement flags summaryPA = prior authorization; SP = specialty pharmacy; QL = quantity limit; LA = limited access; ACA = administrative/clinical criteria applied

FunctionThese flags indicate utilization management controls shown in the Requirements / Limits column

EnforcementProviders must follow the indicated PA/QL/ST/SP/LA rules when submitting claims

Step Therapy Rules & Examples

Rule	Applies when	Provider action
Step therapy required (ST)
Formulary entry lists Requirements / Limits = ST next to the product
Provider must document trial and failure or intolerance of required first-line agent(s) per plan before coverage of the ST-listed product

Example antineoplastic / immunosuppressant	Requirements / Limits shown	Implication
abiraterone oral tablet (250 mg)
PA; SP; OCh; LA
May require prior authorization plus specialty/oncology channel routing and limited-access handling for initiation or coverage

Product (example)	Flags present	Action required
VISTOGARD oral granules 10 gram
PA; SP
Obtain prior authorization; dispense via specialty pharmacy per requirements

Drug	Requirements / Limits	Notes
brivaracetam (BRIVIACT) oral tablet / solution
ST; QL (60 per 30 days) for tablets; ST; QL (2 per 30 days) for solution
Step therapy required prior to coverage; quantity limits apply as listed

Statement	Support in document	Notes
No explicit step therapy sequences provided in this document segment
Many entries show PA/SP/QL flags but do not list step-by-step sequences
When ST is not shown, follow listed PA/QL/SP requirements; clinical criteria elsewhere in full policy may define sequences

Product / Program	Requirements / Limits	Program handling
SUBLOCADE (buprenorphine subcutaneous)
SP (special program) listed
May require specialty program routing or site-specific handling per SP designation

Product	Requirements / Limits	Implication
AUVELITY oral tablet (IR and ER) 45-105 mg
ST
Step therapy required prior to coverage of AUVELITY as indicated on formulary

General rule	Indicator	Consequence
Products marked 'ST' require step therapy prior to coverage
Requirements / Limits column shows ST for affected formulations
Coverage contingent on documented trial/failure of specified first-line agent(s); provider must supply supporting clinical information

Product	Requirements / Limits	Note
Zoloft (sertraline) oral tablet 50 mg
ST
Step therapy applies for this strength as indicated in the formulary listing

Example product	Flags (example)	Program implication
DOPTELET oral tablet 20 mg
PA; SP; LA
Prior authorization required; specialty pharmacy handling and limited access/distribution may apply

Flag	Meaning (per document)	How it may function like ST
ACA (administrative/clinical criteria) listed for some agents
ACA denotes administrative/clinical criteria in Requirements / Limits column
ACA may impose clinical/administrative steps or criteria that act like step therapy prior to coverage

Product	Requirements / Limits	Step therapy status
PRAMOSONE topical lotion 2.5-1%
ST
Topical formulation flagged ST — step therapy required as listed

Quantity Limit Table & Key Values

inv-98: EDURANT — QL value 30 (per 30 days)

EDURANT QL (per brief)Quantity limit: 30 per 30 days (EDURANT oral tablet 25 mg)

Source lineFormulary entry lists 'EDURANT ORAL TABLET 25 MG... Requirements / Limits = QL (30 per 30 days)'

TierTier = 2 as listed in the formulary excerpt

inv-99: EDURANT PED (suspension) — QL value 180

EDURANT PED QL (per brief)Quantity limit: 180 per 30 days (EDURANT PED suspension)

Source lineFormulary entry lists 'EDURANT PED ORAL TABLET FOR SUSPENSION 2.5 MG... Requirements / Limits = QL (180 per 30 days)'

TierTier = 2 as listed

inv-100: Smoking cessation aids (e.g., nicotine patches) — QL example 180

Smoking cessation aids exampleLimited to 180 days per year (example: nicotine patches) as preventive coverage under ACA PV rules

SourceOTHER SPECIAL REQUIREMENTS FOR COVERAGE notes smoking cessation aids limited to 180 days per year

ApplicabilityApplies when covered in full as preventive medication per ACA PV guidance

inv-101: CAYSTON inhalation solution — QL 84 per 30 days

CAYSTONQuantity limit: 84 per 30 days (CAYSTON inhalation solution for nebulization 75 mg/mL) — Requirements = PA; SP; LA; QL (84 per 30 days)

TierDrug Tier = 3 as listed

Provider actionPA and specialty handling required per the listing

inv-102: XIFAXAN oral tablet — QL 60 per 30 days

XIFAXANQuantity limit: 60 per 30 days (XIFAXAN oral tablet) — shown as QL (60 per 30 days)

TierDrug Tier as listed in the formulary excerpt

RequirementsRequirements / Limits column indicates QL enforcement

inv-103: BLUJEPA 750 mg — QL 20 per 30 days

BLUJEPA 750 mgQuantity limit: 20 per 30 days (BLUJEPA oral tablet 750 mg) — Requirements = PA; QL (20 per 30 days)

TierDrug Tier = 3 as listed

Provider actionPrior authorization required per listing

inv-104: ALECENSA 150 mg — QL 240 per 30 days

ALECENSA 150 mgQuantity limit: 240 per 30 days (Requirements = PA; SP; OCh; LA; QL 240 per 30 days)

TierDrug Tier = 2 as listed

Provider actionPA and specialty/oncology channel routing indicated

inv-105: ALUNBRIG 90/180 mg — QL 30 per 30 days

ALUNBRIG 90/180 mgQuantity limit: 30 per 30 days (some dose presentations) — Requirements include PA; SP; OCh; QL (30 per 30 days)

Alternate packDose pack entries show QL 60 per 30 days for certain pack sizes as listed

Provider actionPA and specialty/oncology routing required per listing

inv-106: lapatinib 250 mg — QL 180 per 30 days

lapatinib 250 mgQuantity limit: 180 per 30 days (Requirements = PA; SP; OCh; LA; QL 180 per 30 days)

TierDrug Tier = 3 as listed

Provider actionPA and specialty/oncology handling indicated

inv-107: ODOMZO — QL 30

ODOMZOQuantity limit: 30 per 30 days (ODOMZO oral capsule 200 mg) — Requirements = PA; SP; OCh; LA; QL (30 per 30 days)

TierDrug Tier = 3 as listed

Provider actionPA and specialty/oncology routing required

inv-108: ONUREG 200 mg — QL 21; ONUREG 300 mg — QL 14

ONUREG 200 mgQuantity limit: 21 per 30 days (ONUREG 200 mg) — Requirements = PA; SP; OCh; LA; QL (21 per 30 days)

ONUREG 300 mgQuantity limit: 14 per 30 days (ONUREG 300 mg) — Requirements = PA; SP; OCh; LA; QL (14 per 30 days)

Provider actionPA and specialty/oncology routing indicated for both strengths

inv-110: REVUFORJ 25 mg — QL 240

REVUFORJ 25 mgQuantity limit: 240 per 30 days (REVUFORJ 25 mg) — Requirements = PA; SP; OCh; QL (240 per 30 days)

Alternate strengthREVUFORJ 160 mg noted with QL (60 per 30 days) in other entries

Provider actionPA and specialty/oncology routing required

inv-111: TABRECTA — QL 168

TABRECTAQuantity limit: 168 per 30 days (TABRECTA oral tablet 150/200 mg) — Requirements = PA; SP; OCh; LA; QL (168 per 30 days)

TierDrug Tier = 3 as listed

Provider actionPA and specialty/oncology routing required

inv-112: REVUFORJ 110 mg — QL 120

REVUFORJ 110 mgQuantity limit: 120 per 30 days (REVUFORJ 110 mg) — Requirements = PA; SP; OCh; QL (120 per 30 days)

TierDrug Tier = 3/2 depending on listing

Provider actionPA and specialty/oncology routing required

inv-113: WELIREG — QL 90

WELIREGQuantity limit: 90 per 30 days (WELIREG oral tablet 40 mg) — Requirements = PA; SP; OCh; QL (90 per 30 days)

TierDrug Tier = 3 as listed

Provider actionPA and specialty/oncology routing indicated

inv-114: EPIDIOLEX — QL 400

EPIDIOLEXQuantity limit: 400 per 30 days (EPIDIOLEX oral solution 100 mg/mL) — Requirements = PA; SP; LA; QL (400 per 30 days)

TierDrug Tier = 3 as listed

Provider actionPA and specialty/limited access handling required

inv-115: AIMOVIG / EMGALITY / dihydroergotamine — assorted QLs

AIMOVIGQuantity limit: 1 per 30 days (AIMOVIG) — Requirements = PA; QL (1 per 30 days)

EMGALITY (300 mg)Quantity limit: 3 per 30 days for the 300 mg syringe set (Requirements = PA; QL 3 per 30 days)

Dihydroergotamine nasal sprayQuantity limit: 8 per 30 days (QL 8 per 30 days)

inv-116: sumatriptan / triptans — QL examples

Sumatriptan subcutaneous pen/solutionQuantity limit: 8 per 30 days (QL 8 per 30 days)

Triptans (oral/nasal) and similar acute agentsQuantity limit: 18 per 30 days (QL 18 per 30 days)

Provider actionQLs for acute migraine agents are specified and enforced per the formulary

inv-118: ormalvi / ZEPOSIA starter / WAINUA — QL examples

ormalviQuantity limit: 121 per 30 days (listed as QL 121 per 30 days)

ZEPOSIA starter packStarter kit QL: 1 per 365 days (ZEPOSIA starter kit entries show QL 1 per 365 days)

WAINUAQuantity limit: 30 per 30 days (auto-injectors) as listed

inv-123: opioid and buprenorphine-naloxone QL examples — 60/90/120 per 30 days

Opioid and buprenorphine-naloxone examplesExamples include QL 60 per 30 days, QL 90 per 30 days, QL 120 per 30 days for various opioid and buprenorphine-naloxone products

Specific buprenorphine-naloxone filmBuprenorphine-naloxone sublingual film strengths show QL (90 per 30 days) in one entry and varied QLs by strength elsewhere

Provider actionPA and QL controls applied to many opioid formulations; exceedance may prompt review/denial

inv-124: buprenorphine-naloxone sublingual film 12-3 mg — QL 60 per 30 days

buprenorphine-naloxone sublingual film 12-3 mgQuantity limit: QL (60 per 30 days) as an example entry

ContextBuprenorphine-naloxone products show varied QLs by formulation and strength in the formulary listings

Provider actionAdhere to QL when submitting claims; documentation may be required for exceptions

inv-125: JOURNAVX / ketorolac / ZUBSOLV — assorted QL examples

JOURNAVX 50 mgQuantity limit: QL (29 per 42 days) — listed as a 42-day course limit

ketorolac 10 mgQuantity limit: QL (20 per 5 days) — short-course limit specified

ZUBSOLVQuantity limits vary by strength: QL (90 / 30 / 60 per 30 days) depending on strength

inv-128: lisdexamfetamine / LUMRYZ — QL 30; starter pack 1

lisdexamfetamineQuantity limit: 30 per 30 days (QL 30 per 30 days)

LUMRYZQuantity limit: 30 per 30 days (QL 30 per 30 days); starter pack QL 1 per 365 days

Provider actionPA/SP/LA flags may apply for LUMRYZ; follow Requirements / Limits when submitting claims

inv-131: SUNOSI / BAFIERTAM / XYREM — assorted QLs

SUNOSI 150 mgQuantity limit: 30 per 30 days (SUNOSI 150 mg) — Requirements = PA; QL (30 per 30 days)

BAFIERTAM 95 mgQuantity limit: 120 per 30 days (BAFIERTAM QL 120 per 30 days)

XYREM/XYWAVQuantity limit: 3 per 30 days (XYREM/XYWAV oral solution) — Requirements = PA; SP; LA; QL (3 per 30 days)

inv-136: Example QLs consolidated across chunks

Selected QL highlightsExamples across the formulary include QL 1 (starter packs), QL 3, QL 7 per 365 days, QL 21, QL 30, QL 60, QL 90, QL 120, QL 168, QL 240, QL 400 — see product listings for specific values

Provider implicationQuantity limits vary by product and strength; providers must follow the numeric QL and obtain PA or provide documentation when required

ReferenceMultiple chunks in the document list these QLs in the Requirements / Limits column for named products

Specialty Pharmacy, Infusion & Administration Routing

Billing Rule

Specialty pharmacy / limited distribution required

Some specialty drugs require dispensing at an in‑network specialty pharmacy or have limited distribution; providers must route prescriptions to the required specialty channel when 'SP' or 'LA' is indicated.

SP = Specialty Pharmacy (may require in‑network specialty dispensing)
LA = Limited Access (restricted distribution/special handling)

Billing Rule

SP designation implies specialty dispensing

The 'SP' designation on injectables and oral specialty drugs implies specialty pharmacy distribution requirements and routing must follow the SP designation.

Billing Rule

Infusion/oncology channel routing may be required

Certain injectable agents require specialty administration routing (infusion/oncology channel) as indicated by OCh, SP or LA flags; follow site-of-care routing when these flags are present.

Billing Rule

OCh/LA imply site/provider administration limits

Where OCh or LA flags appear (notably for oncology/antineoplastic agents), administration may be limited to infusion centers or program‑specific sites — follow the channel indicated.

Billing Rule

SP/LA indicate distribution or administration channel

SP and LA designations indicate specialty distribution or limited access and imply that administration or dispensing may be restricted to specific sites (infusion center, specialty pharmacy, outpatient) as listed.

Billing Rule

PA/SP/LA indicate site/provider limitations

PA; SP; LA flags on products often indicate site/provider limitations for administration or dispensing and providers should follow the channel noted to avoid coverage issues.

OpenPayer

Formulary Drug List (Essentials E1/E3)

Formulary Coverage & Interpretation

Drug Listings, Codes & Example Limits

Prior Authorization, Documentation & Denial Risk

Formulary Background & Scope

Abbreviations & Key Terms

Step Therapy Rules & Examples

Quantity Limit Table & Key Values

Specialty Pharmacy, Infusion & Administration Routing

Document Changes & Review