CurrentPremera BluecrossPolicy N/A

Metallic (M4) Drug List — Formulary and Utilization Management

A formulary drug list describing covered generic, brand, and specialty drugs, utilization management restrictions (prior authorization, quantity limits, step therapy), and tier placement for Premera Blue Cross Metallic (M4) plans (excluding American Indian/Alaskan Native zero cost-share plans). Applies to providers and pharmacies administering or dispensing drugs to members of these plans.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Drug List — Formulary and Utilization Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2024

Next Review DateN/A

Key ActionObtain and document required prior authorization, step therapy failures, or quantity-limit justification when a product line shows PA, ST, or QL to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4tier levels

PA, QL, ST, LAutilization types

MBmedical benefit flag

QL examplesexample QLs

partialdocument scope (partial)

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.

~120+drug entries (segment)

Coverage Criteria & Scope

General Coverage Condition

Covered when consistent with the member's coverage contract and when any listed utilization management requirements are satisfied:

General Coverage Condition: Drug is included on the plan's drug list AND any specified utilization management restriction(s) shown in the Requirements/Limits column (e.g., PA, QL, ST, LA, VAC, ACA PV) are met

Member's benefit booklet and the drug list Requirements/Limits column determine specific coverage conditions; absence of required prior authorization, step-therapy documentation, or exceeding quantity limits may result in denial

This formulary applies to Premera Blue Cross Metallic (M4) plans for covered drugs when consistent with the member's coverage contract. The drug list specifically excludes American Indian/Alaskan Native eligible plans that have zero cost shares, as noted in the plan scope statement.

Within the provided document window there are no standalone clinical exclusion criteria; the content is presented as a formulary product list showing drug names, tier placement, and utilization management flags. Coverage is therefore determined by inclusion on the drug list and satisfaction of any listed requirements (e.g., PA, ST, QL) rather than by explicit clinical exclusion statements in this excerpt.

No explicit categorical exclusions are listed in these vaccine and immunology chunks; entries primarily assign drug tiers and annotate requirement flags such as VAC (vaccine benefit), PA (prior authorization), ST (step therapy), and QL (quantity limits). Coverage and any limits follow the Requirements/Limits annotations on each line.

Listed Drugs, Tiers and Coding Examples

Listed drugs and tiers (sample from document)mixed

CRESEMBA ORAL CAPSULE 186 MG	Drug Tier = 3; Requirements Limits = PA
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml	Drug Tier = 1
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg	Drug Tier = (listed)
flucytosine oral capsule 250 mg, 500 mg	Drug Tier = 3
griseofulvin microsize oral suspension 125 ml mg/5	Drug Tier = (listed)
itraconazole oral capsule 100 mg	Drug Tier = 1
ORAVIG MUCO-ADHESIVE BUCCAL TABLET 50 MG	Drug Tier = 3; Requirements Limits = PA
PAXLOVID ORAL TABLETS, DOSE PACK 150-100 MG, 300 MG	Drug Tier = 2; Requirements Limits = QL (40 per 90 days)
POWDER IN PACKET 100 MG	Requirements Limits = QL (360 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG,200 MG	Drug Tier = 4; Requirements Limits = PA; ST; LA

Quantity limits examples — common QL patterns

QL (30 per 30 days)Example quantity‑limit commonly applied to tablets or monthly supplies (shown for multiple antiviral and HIV products).

QL (60 per 30 days)Example quantity‑limit used for select oral formulations and powders (appears on INSTRESS/ISENTRESS entries).

QL (120 per 30 days)Higher monthly limit example shown for some formulations (e.g., APTIVUS QL 120 per 30 days).

QL (40 per 90 days)Example multi‑month pack limit (PAXLOVID dose pack documented as QL 40 per 90 days).

Example QL thresholds

3 per 30 daysLow recurring QL applied to controlled/limited products (example: XYREM/XYWAV QL = 3 per 30 days).

Authorization, Documentation & Provider Steps

Prior Authorization

Prior Authorization Required

Prior Authorization Requirement — Some drugs listed on the formulary require prior authorization (PA) before coverage. When PA is indicated in the Requirements/Limits column, the member’s physician or other prescribing provider must request approval from Premera prior to dispensing. Lack of required prior authorization may result in the drug not being covered or claims denied.

PA = Prior Authorization required before the drug will be covered.
If PA is not obtained the claim may be denied or benefit may be reduced.

Prior Authorization

Hepatitis C Agents — PA (may include ST/LA)

Prior authorization is required for selected hepatitis C and related antiviral agents. Examples in the formulary include SOVALDI, EPCLUSA, VOSEVI, ZEPATIER and certain VIREAD formulations; many of these entries also include Step Therapy (ST), Limited Access (LA) or other special handling flags.

Drugs with Requirements/Limits = PA; ST; LA will trigger PA and may also require documentation of prior therapies or special site-of-care.
Providers should submit clinical documentation of diagnosis, prior treatment history, and relevant labs when requesting PA for hepatitis C agents.

Definitions & Acronyms

Specialty Drug (Tier 4 / MB)

DefinitionSpecialty drugs (Tier 4) are generally biologics and other targeted drugs used for complex conditions that often require special handling.

Tier assignmentTier 4 = Specialty Drug (higher tier for specialty therapies).

MB (Medical Benefit)MB indicates the medical benefit designation; drugs billed/ administered in clinic, infusion center, or via home infusion are covered under the medical benefit.

QL — Quantity limit

QL (Quantity Limit)Maximum allowed quantity per specified time period as listed on the formulary line (e.g., 'QL (30 per 30 days)').

PurposeLimits drug supply per prescription or within a defined timeframe to control utilization.

Step Therapy Lists & Notes

Statement	Requirements / Limits
ST indicator in the Requirements/Limits column denotes that step therapy applies for the listed product	When 'ST' appears next to a drug entry, the member must try specified alternative(s) before the listed drug will be covered

Products / Class	Step therapy note
Selected specialty antivirals (e.g., SOVALDI, EPCLUSA) and oral antineoplastics (e.g., ALECENSA, BOSULIF) listed in the formulary	Entries include 'ST' in Requirements/Limits indicating step therapy is required; specific step algorithms are not provided in this excerpt

Product	Step therapy note
XCOPRI (cenobamate) — maintenance and titration pack entries	Requirements/Limits show 'ST' (and PA) indicating step therapy is required prior to coverage, including the titration pack

Agents	Step therapy note
CGRP migraine agents: AMOVIG, AJOVY, EMGALITY	Each entry lists 'PA; ST' in Requirements/Limits, indicating prior authorization and step therapy apply

Products / Category	Step therapy note
Multiple opioid and specialty products (examples: ZILBRYSQ; acetaminophen-codeine formulations; fentanyl patches/lozenges; hydrocodone formulations; NUCYNTA ER)	These entries include 'ST' (often with PA and sometimes QL), indicating step therapy is required prior to coverage

Products / Examples	Step therapy note
Branded psychotropic examples: BELSOMRA; COTEMPLA XR-ODT; DESVENLAFAXINE ER; DYANAVEL XR; FETZIMA; REXULTI; SPRAVATO; SUNOSI; VYVANSE; XYREM/XYWAV	These product lines list 'ST' (with PA for many) in Requirements/Limits, indicating step therapy is required prior to coverage

Products	Step therapy note
Examples include VYVANSE; XYREM and XYWAV; DOPTELET; FRAGMIN	Each entry shows 'ST' (some with PA and QL), indicating step therapy requirements apply to these products

Products / Classes	Step therapy note
Select agents and classes: LINZESS, LIVMARLI, MOVANTIK, SKYRIZI, ILARIS, NEUPOGEN, GENOTROPIN, multiple multiple sclerosis agents (e.g., dimethyl fumarate, fingolimod, glatiramer)	Requirements/Limits include 'ST' (often alongside PA, LA, and QL), indicating step therapy is required prior to coverage

Policy expectation	Provider action
When 'ST' is listed in Requirements/Limits for a product	Documented failure or contraindication to the required prior step agents should be provided when requesting coverage

Products / Category	Step therapy note
Many biologics and specialty agents (examples in interleukins and other biologic classes: ACTEMRA, ADALIMUMAB variants, CYLTEZO, ENBREL, HUMIRA, HYRIMOZ, KEVZARA, SIMPONI, etc.)	These entries list 'ST' (commonly with PA and LA), indicating step therapy is required for many biologic and specialty agents

Observation	Detail
No explicit step therapy algorithms provided in some document windows	The document often shows an 'ST' flag next to products but does not include the detailed step sequence or specific preferred agents within these chunks

Quantity Limits (Examples by Product)

Selected product-specific quantity limits

POWDER IN PACKET 100 MG360 per 30 days

ODEFSEY 200-25-25 MG30 per 30 days

oseltamivir 30 mg40 per 365 days

oseltamivir 45 mg/75 mg20 per 365 days

oseltamivir suspension6 per 365 days

PAXLOVID dose pack40 per 90 days

PREZCOBIX 800-150 MG30 per 30 days

oseltamivir (device) RELENZA DISKHALER

Medical Benefit & Site-of-Care Notes

Note

Formulary Governance & Miscellaneous Background

The formulary is maintained and reviewed by a Pharmacy and Therapeutics Committee composed of physicians, pharmacists, and other health care providers. The committee evaluates drugs for safety, effectiveness, and cost to inform placement on the drug list and any utilization controls shown in the Requirements/Limits column.

Biosimilars & Comparative Handling

Note

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Drug List — Formulary and Utilization Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2024

Next Review DateN/A

Key ActionObtain and document required prior authorization, step therapy failures, or quantity-limit justification when a product line shows PA, ST, or QL to avoid claim denial.

SourceLink

On This Page

360 per 30 daysHigh QL used for some powder-in-packet or dispensing formats (PROMACTA powder QL = 360 per 30 days).

180 per 30 daysAlternate PROMACTA presentation limit (PROMACTA powder/tablet variants include QL = 180 per 30 days for some forms).

60 per 30 daysMonthly QL used for numerous oral products (example shown across antiretroviral and other agents).

Quantity limits examples for selected injectables

EVENITY QLQL = 2 per 30 days for the 105 mg syringe; QL = 1 per 30 days for the 210 mg (two 105 mg) presentation (Requirements Limits = PA; ST; LA; QL).

TERIPARATIDE QLTERIPARATIDE subcutaneous pen injector 20 mcg/dose: QL = 30 per 30 days (Requirements Limits include PA; ST; QL).

ACTEMRA QLACTEMRA subcutaneous pen/syringe: QL = 2 per 30 days (Requirements Limits = PA; ST; LA; QL).

Prior Authorization

Antineoplastics — PA & Special Handling

Prior authorization is required for selected antineoplastic and oncology oral agents and may be accompanied by additional utilization controls (e.g., OCh, ST, LA, QL). Providers should expect to submit supporting clinical information.

Antineoplastics noted with PA (and often Och/OCh) include agents such as ALECENSA, BOSULIF, BALVERSA and others.
Some oral chemotherapy drugs may be covered under the member’s medical benefit; check the member booklet and indicate if medical benefit billing is intended.

Step Therapy

CGRP Agents — PA & Step Therapy

CGRP migraine agents (for example AMOVIG, AJOVY, EMGALITY) are subject to prior authorization and step therapy requirements. Coverage is conditioned on meeting step therapy criteria and any PA documentation.

Requirements/Limits = PA; ST is shown for multiple CGRP products.
Providers should document prior trial(s) of preferred therapies and clinical rationale for the selected agent when submitting PA requests.

Step Therapy

XCOPRI — PA & Step Therapy

XCOPRI products require prior authorization and step therapy. Titration packs and specialty formulations are likewise subject to PA/ST controls.

Requirements/Limits for XCOPRI entries include PA and ST; confirm which NDC/formulation is requested when initiating PA.
Document prior trial history per step therapy requirements and provide dosing/titration intent on the PA request.

Denial Risk

Opioid & Specialty Analgesics — PA/ST/QL

Prior authorization applies to many opioid and specialty analgesic agents. Numerous narcotic analgesics and some specialty opioid formulations are flagged with PA and/or ST; providers must follow these controls to avoid denials.

Many narcotic analgesic entries show Requirements/Limits = PA; ST (examples: fentanyl patches, certain codeine and combination products, NUCYNTA ER).
Quantity limits (QL) also apply to several opioid products and may require documentation for overrides.

Prior Authorization

Interleukin/Biologic Agents — PA, ST & LA

Many interleukin, biologic and specialty injectable agents require prior authorization and often step therapy and limited-access handling (PA; ST; LA). These utilization controls also commonly include quantity limits and site-of-care designations.

Examples include ACTEMRA, ADALIMUMAB products (and biosimilars), ENBREL, HUMIRA, SIMPONI, and others listed with PA; ST; LA; QL.
Requests lacking required PA/ST/LA documentation may be denied; providers must document disease indication, prior therapies, and rationale for biologic selection.

Note

Tier-Based Handling & Cost Share

Tier-based handling — the drug tier (e.g., Tier 1/2/3/4/MB) is shown for each product and affects member cost share and may influence utilization requirements. Some Tier 3 or Tier 4 products are more likely to carry PA/ST/QL flags.

Drug Tier indicates cost-sharing; higher tiers (e.g., Tier 3 or 4) often have additional utilization controls.
Examples: certain oral antivirals, specialty injectables, and high-cost agents are assigned Tier 3 or 4 with corresponding PA or QL flags.

Note

Utilization Flags — What They Mean

Utilization flags present — formulary entries include flags such as PA (Prior Authorization), ST (Step Therapy), LA (Limited Access), QL (Quantity Limit), OCh (Oral Chemotherapy), VAC (Vaccine), and ACA PV. These flags communicate required actions and restrictions; review the Requirements/Limits column for each drug.

PA = prior authorization required; ST = step therapy required; LA = limited access/specialty distribution; QL = quantity limit; OCh = oral chemotherapy; VAC = vaccine-specific requirements; ACA PV = preventive/vaccine program flag.

Denial Risk

PA/ST/QL — Combined Controls & Denial Risk

PA/ST flags and PA/ST/QL requirements present — Drugs that show PA and/or ST (and where applicable QL) require that providers meet both the prior authorization and step therapy conditions and comply with quantity limits. Failure to meet these requirements may lead to claim denial.

When Requirements/Limits lists PA; ST; QL, the provider must submit clinical justification for PA and evidence of attempts at required prior therapies per ST.
Quantity limits (QL) noted (for example EPIDIOLEX QL = 400 per 30 days; XYREM QL = 3 per 30 days) must be observed and documented for exception requests.

Prior Authorization

Specialty Injectables — PA, LA & QL

Prior authorization and utilization controls for specialty injectables — many specialty injectable products require PA and may be limited to specialty pharmacies or specific sites of care (LA). Examples include PROMACTA, DOPTELET, CABLIVI, HEMLIBRA, and numerous biologic injectables.

Requirements/Limits = PA; LA; QL are common for specialty injectables; confirm site-of-care and dispensing pharmacy requirements when requesting PA.
Provide supporting clinical documentation, weight/dosing and prior therapy history as applicable for specialty injectable PA submissions.

Note

ACA Preventive (ACA PV) Flags

ACA PV requirement flag — Many preventive and contraceptive products are marked ACA PV. This flag indicates program-level preventive coverage designations which may affect cost sharing and coverage rules.

Products like certain low-dose aspirin formulations and many contraceptives show Requirements/Limits = ACA PV.
Refer to the member booklet and ACA preventive coverage rules for specifics on member cost share and coverage eligibility.

Documentation Required

Documentation Required for PA/ST/LA Requests

Provider documentation expectations — When a drug’s Requirements/Limits includes PA, ST, or LA, the provider must submit sufficient clinical documentation to support the request. This may include diagnosis, prior medication trials and failures, labs, dosing/titration plans, and site-of-care justification.

Documentation for PA/ST/LA drugs should include prior therapy history, reason for discontinuation of alternatives, and relevant diagnostic test results.
Quantity limits require documentation and rationale for any request exceeding listed QLs (e.g., EPIDIOLEX QL = 400 per 30 days).

Documentation Required

Quantity Limits — Documentation & Exceptions

Quantity limits require documentation — where Quantity Limits (QL) are noted, providers should document the clinical need if requesting quantities above the limit. Examples: EPIDIOLEX QL (400 per 30 days), PROMACTA QL (various per 30 days), XYREM/XYWAV QL (3 per 30 days).

Include dosing schedule, patient weight (if dosing is weight-based), and clinical rationale when requesting QL exceptions.
Claims should reflect approved quantity and PA reference number where applicable to avoid denials.

Billing Rule

Limited Access (LA) Drugs

LA flag present — Limited Access (LA) indicates products that are restricted to specialty pharmacies, have restricted distribution, or require special handling, patient education, or provider coordination. Requests for LA drugs typically require PA and specific dispensing channels.

LA-designated drugs cannot routinely be filled at a network retail pharmacy; confirm specialty pharmacy network and prior authorization routing.
Provide documentation of patient education or handling needs if requested by the PA reviewer.

Documentation Required

Specialty Product Documentation

Documentation for specialty products — High-tier and specialty drugs (for example ORENITRAM ER, DOPTELET, CABLIVI, PROMACTA, HEMLIBRA, FRAGMIN, many biologics) list utilization controls requiring supporting clinical documentation to justify coverage.

Include relevant specialty prescribing notes (e.g., hematology/oncology consult notes), lab values, and prior medication history in PA submissions.
Where medical benefit coverage may apply (e.g., some oral chemotherapies), indicate intent to bill to medical benefit rather than pharmacy when submitting requests.

Documentation Required

Vaccine Documentation (VAC)

Vaccine documentation — Items designated VAC indicate vaccine-specific requirements. Providers should document indication, administration date, and any supporting clinical information required by immunization program rules or the plan.

VAC-flagged products (e.g., certain intramuscular vaccine preparations) require appropriate vaccine administration documentation.
Follow billing and coding guidance for vaccines and include required clinical justification when VAC is tied to utilization controls.

Documentation Required

Allergy Immunotherapies — PA & ST Documentation

Documentation for allergy immunotherapies — Some sublingual/tablet allergy immunotherapies (for example RAGWITEK, ORALAIR, GRASTEK) are marked PA; ST indicating documentation of prior attempts, contraindications, or trial of preferred therapies may be necessary.

Submit history of prior therapies and clinical rationale when requesting PA for allergy immunotherapy agents.
Step therapy may require trial of alternative treatments before coverage of the listed product is approved.

Note

Check Product-Level Flags Before Prescribing

Product-level utilization flags documented — The formulary displays utilization flags and quantity limits alongside each product. Verify the Requirements/Limits column for each NDC/formulation to determine PA, ST, LA, QL, VAC, or ACA PV applicability before prescribing or dispensing.

Always check the specific NDC/formulation entry in the formulary for the correct Requirements/Limits.
If multiple flags apply (e.g., PA; ST; LA; QL), ensure all required documentation elements are included with the PA request.

Documentation Required

Provider Actions — Submit Complete PA Documentation

Physician/provider actions — The prescribing physician or healthcare provider may need to provide additional information about the member’s medical condition, prior treatment history, and other clinical data to obtain coverage for drugs subject to utilization controls. PA requests should include complete supporting documentation to expedite review.

Information on the PA process and required documentation is available on Premera’s 'Drugs Requiring Approval' webpage.
Incomplete PA requests or missing documentation may delay decisions or lead to denials.

Step Therapy

Step Therapy (ST) — When It Applies

Step therapy — Some drugs are subject to step therapy (ST); members must try specified alternative(s) first. Step therapy is applied across therapy classes including certain specialty antivirals, antineoplastics, biologics, narcotic analgesics and multiple psychotherapeutic agents.

ST markers are shown in the Requirements/Limits column for affected products (e.g., many hepatitis C agents, select antineoplastics, CGRP agents, ZILBRYSQ, and multiple biologics).
Providers should document prior trials and clinical rationale when requesting an exception to ST requirements.

Step Therapy

Step Therapy for Biologics

Step therapy for specialty biologics — Many disease-modifying biologics and specialty agents list ST in combination with PA and LA. Requests for these agents require documentation of prior therapies and justification for progression to the requested biologic.

Biologic entries such as ACTEMRA, ADALIMUMAB variants, ENBREL, HUMIRA and biosimilars include PA; ST; LA.
Provide trial history of conventional therapies and reasons for failure/intolerance when requesting PA for biologics.

DocumentationQuantity limits should be documented on the claim or prior authorization request when applicable.

PA — Prior authorization

PA (Prior Authorization)Prior authorization required before coverage is approved; indicated by 'PA' in the Requirements/Limits column.

When usedApplied to select high‑cost, specialty, or restricted products (examples include many hepatitis C agents and biologics).

ConsequenceLack of required PA may result in the drug not being covered or claim denial.

ST — Step therapy

ST (Step therapy)Requires trial and documented failure or contraindication to specified preferred therapies before coverage for the listed drug is provided (flagged as 'ST').

ScopeApplied to many therapeutic classes including CGRP agents, certain psychotropics, opioids, and biologics as indicated by 'ST'.

Provider actionProviders must document prior step therapy trials or rationale when requesting coverage for ST‑flagged drugs.

LA — Limited access

LA (Limited Access)Usage restrictions or special program required for coverage; may limit distribution to specialty pharmacies or specific administration sites.

ExamplesUsed for drugs with restricted distribution, special handling, or site‑of‑care limitations (LA appears with many biologics and injectables).

Provider implicationClaims or PA requests may require site‑of‑care justification when LA is present.

MB — Medical benefit

MB (Medical benefit)Indicates the drug is covered under the medical benefit rather than the pharmacy benefit; typically for clinic/infusion‑administered products.

BillingMB drugs and associated services are billed to the medical benefit; check member booklet and medical policies for coverage details.

Site of careMB designation often correlates with administration in infusion center, office, or home infusion settings.

ACA PV — ACA preventive

ACA PVACA preventive designation aligned with Affordable Care Act preventive requirements (used for certain contraceptives and preventive products).

ImplicationProducts marked 'ACA PV' may have different cost‑sharing or coverage handling per plan rules.

PlacementCommonly applied to select contraceptives and preventive therapies in the formulary listing.

VAC — Vaccine-specific requirements

VAC (Vaccine designation)Indicates vaccine‑specific requirements or controls apply; listed on vaccine lines as 'VAC'.

DocumentationVAC entries may require administration documentation and adhere to vaccine benefit rules.

Coverage contextApplied to immunizations and vaccines listed in the Vaccines & Immunology section of the formulary.

PA; ST; LA; QL — Benefit control flags

PAPrior authorization required — flagged when PA appears in Requirements/Limits.

STStep therapy required — flagged when ST appears in Requirements/Limits.

LALimited access or site/location restrictions — flagged when LA appears.

QLQuantity limit — flagged when QL appears specifying allowed quantity over time.

Utilization flags — PA; ST; LA

PAPrior authorization (PA) — many entries include PA to indicate pre‑approval is required before coverage is granted.

STStep therapy (ST) — indicates required trial/failure of preferred agents prior to coverage for the listed drug.

LALimited access (LA) — indicates restricted distribution or site‑of‑care requirements for certain products.

REYATAZ powder 50 MG150 per 30 days

ritonavir 100 mg360 per 30 days

tenofovir disoproxil fumarate 300 mg30 per 30 days

TIVICAY 50 MG60 per 30 days

TRIUMEQ 600-50-300 MG30 per 30 days

VIRACEPT 250 MG90 per 30 days

VIRACEPT 625 MG60 per 30 days

CAYSTON inhalation solution 75 MG/ML90 per 30 days

SIVEXTRO 200 MG6 per 30 days

XIFAXAN 200/550 MG60 per 30 days

ALECENSA 150 MG240 per 30 days

anastrozole30 per 30 days

BOSULIF ORAL CAPSULE 50 MG30 per 30 days

ZYKADIA 150 MGQL (90 per 30 days)

EPIDIOLEX ORAL SOLUTION 100 MG/MLQL (400 per 30 days)

almotriptan malateQL (18 per 30 days)

NURTEC ODT 75 mgQL (8 per 30 days)

sumatriptan productsQL (8 or 18 per 30 days depending on formulation)

NUDEXTA 20-10 MGQL (60 per 30 days)

ZEPOSIA 0.92 MGQL (30 per 30 days); starter kit QL (1 per 365 days)

POWDER IN PACKET 100 MG

POWDER IN PACKET 100 MG — QL360

ODEFSEY 200-25-25 MG

ODEFSEY 200-25-25 MG — QL30

oseltamivir 30 mg

oseltamivir 30 mg — QL40

oseltamivir 45 mg, 75 mg

oseltamivir 45 mg / 75 mg — QL20

oseltamivir suspension

oseltamivir suspension — QL6

PAXLOVID dose pack

PAXLOVID dose pack — QL40

PREZCOBIX 800-150 MG

PREZCOBIX 800-150 MG — QL30

RELENZA DISKHALER

RELENZA DISKHALER — QL2

REYATAZ powder 50 MG

REYATAZ powder 50 MG — QL150

ritonavir 100 mg

ritonavir 100 mg — QL360

tenofovir disoproxil fumarate 300 mg

tenofovir disoproxil fumarate 300 mg — QL30

TIVICAY 50 MG

TIVICAY 50 MG — QL60

TRIUMEQ 600-50-300 MG

TRIUMEQ 600-50-300 MG — QL30

VIRACEPT 250 MG

VIRACEPT 250 MG — QL90

VIRACEPT 625 MG

VIRACEPT 625 MG — QL60

CAYSTON inhalation solution 75 MG/ML

CAYSTON inhalation solution 75 MG/ML — QL90

SIVEXTRO 200 MG

SIVEXTRO 200 MG — QL6

XIFAXAN 200/550 MG

XIFAXAN 200/550 MG — QL60

ALECENSA 150 MG

ALECENSA 150 MG — QL240

anastrozole

anastrozole — QL30

BOSULIF ORAL CAPSULE 50 MG

BOSULIF ORAL CAPSULE 50 MG — QL30

ZYKADIA ORAL TABLET 150 MG

ZYKADIA ORAL TABLET 150 MG — QL90 per 30 days

EPIDIOLEX ORAL SOLUTION 100 MG/ML

EPIDIOLEX ORAL SOLUTION 100 MG/ML — QL400 per 30 days

Triptan QLs (examples)

almotriptan malate oral tablet — QL18 per 30 days

NURTEC ODT 75 mg — QL8 per 30 days

sumatriptan products (various)

sumatriptan products — QL8 or 18 per 30 days depending on formulation

NUDEXTA ORAL CAPSULE 20-10 MG

NUDEXTA ORAL CAPSULE 20-10 MG — QL60 per 30 days

ZEPOSIA ORAL CAPSULE 0.92 MG

ZEPOSIA ORAL CAPSULE 0.92 MG — QL30 per 30 days (starter kit QL = 1 per 365 days)

Selected opioid quantity limits

hydrocodone (selected formulations) — QL60 per 30 days

morphine ER capsules — QL90 per 30 days

morphine ER tablets — QL120 per 30 days

Selected controlled/substance QLs

NUCYNTA ER — QL60 per 30 days

buprenorphine-naloxone sublingual film — QL60-90 per 30 days

SUNOSI QLs

SUNOSI 150 mg — QL30 per 30 days

SUNOSI 75 mg — QL60 per 30 days

XYREM / XYWAV quantity limits

XYREM — QL3 per 30 days

XYWAV — QL3 per 30 days

PROMACTA and quinidine QLs

Quinidine sulfate 200 mg — QL60 per 30 days

PROMACTA oral powder/tablet — QL360 (powder) / 180 (tablet) / 360 (tablet 12.5 mg) per 30 days

Selected GI and hepatology QLs

LIVMARLI ORAL SOLUTION 19 MG/ML — QL2 per 30 days

LIVMARLI ORAL SOLUTION 9.5 MG/ML — QL3 per 30 days

ondansetron oral tablet (disintegrating) — QL9 per 30 days

Selected biologic injection QLs

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML — QL1 per 90 days

AVONEX INTRAMUSCULAR PEN INJECTOR 30 MCG/0.5 ML — QL1 per 30 days

Selected musculoskeletal/osteoporosis injectable QLs

EVENITY 105 mg syringe — QL2 per 30 days

EVENITY 210 mg (two 105 mg) — QL1 per 30 days

TERIPARATIDE pen injector 20 mcg/dose — QL30 per 30 days

ACTEMRA — QL2 per 30 days

Transdermal/patch quantity limits

estradiol transdermal (packets/patch) — QLQL 30 per 30 days or QL 8 per 30 days depending on formulation

lyllana / dotti transdermal patches — QL8 per 30 days