CurrentPremera BluecrossPolicy N/A

Metallic (M4) Formulary Drug List — Formulary / Utilization Management (coverage criteria)

Lists drugs covered under the Metallic M4 plans and describes formulary development, utilization management (PA, QL, ST, LA) and site-of-care designations for members, prescribers, and pharmacies.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Formulary Drug List — Formulary / Utilization Management (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line indicates PA to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5plans

4formulary tiers

PA/QL/ST/LAutilization types

quarterlyP&T frequency

manyitems with PA noted

60/30d

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Coverage criteria and general conditions

General coverage conditions

Covered when ALL of the following are met:

Please see Requirements/Limits column on the formulary for product-level flags (PA, QL, LA, Och, ACA, MB) that indicate utilization controls and benefit assignment.

Prior Authorization

Authorization triggers and managed access

Authorization triggers and utilization controls (PA/QL/LA/Och) are present throughout the formulary and require provider attention. Use the plan's 'Drugs Requiring Approval' page to initiate PA requests and to view any required forms or submission instructions. Managed access or limited access (LA) entries (including starter kits) and medical‑benefit assigned drugs may have separate pathways and criteria.

PA/LA/QL flags on formulary entries imply documentation and prior authorization are required.
Managed access notes and limited availability (LA) items may require specific enrollment or supplier arrangements.
Step therapy requirements are applied where indicated on the formulary and must be met before alternatives are approved.
Failure to follow utilization management processes may result in claim denial or member out‑of‑pocket liability.

Prior authorization, step therapy, documentation, and provider requirements

Prior Authorization

Prior authorization required when 'PA' is listed

Obtain prior authorization when the formulary line for the drug shows 'PA' in the Requirements/Limits column; without PA the drug may not be covered.

PA is indicated in the Requirements/Limits column for specific products (e.g., EPCLUSA, HARVONI).
See the payer's 'Drugs Requiring Approval' page for submission process details.

Prior Authorization

PA/LA required for selected antiviral formulary drugs

Prescribers must secure prior authorization or limited approval for select formulary antiviral products that display 'PA' or 'LA' in the Requirements/Limits column.

Examples include SOVALDI (PA; LA), VIREAD (PA; QL), VEMLIDY (PA) as shown on the formulary lines.
Claims for these products without required PA/LA may be denied.

Prior Authorization

Formulary drug list and coding-level items

Drug list (formulary items with tiers and limits)mixed

N/A	The document lists drug names, strengths, tiers and utilization requirements; no procedure or billing CPT/HCPCS/ICD-10 codes are provided in this chunk set.

Quantity limit examples — common

30 per 30 daysCommon example quantity limit used for several antiretroviral and antiviral products (e.g., BIKTARVY, GENVOYA, ODEFSEY).

60 per 30 daysCommon monthly QL seen for multiple products including some tablet strengths and adult formulations.

360 per 30 daysHigh monthly QL example used for certain powder/packet or suspension products (e.g., NORVIR powder; some oral suspensions).

180 per 30 daysExample QL used for selected oncology oral agents (listed among common examples).

40 per 365 daysYearly/seasonal QL example (e.g., oseltamivir entries show per 365-day limits in nearby sections).

Quantity limit examples — neurology / specialty

Explicit quantity limits by product

Multiple QL examples — common aggregated

30 per 30 daysExample QL used for drugs such as BIKTARVY (QL 30 per 30 days).

60 per 30 daysExample QL used for products like ISENTRESS and other oral formulations (QL 60 per 30 days).

120 per 30 daysExample higher monthly QL noted for some formulations in the antiviral/other lists.

360 per 30 daysExample high QL used for certain powder/packet products (e.g., NORVIR powder/pellet examples in adjacent listings).

40 per 90 or 365 daysSeasonal/longer-interval QL examples appear for influenza antivirals (oseltamivir) and Paxlovid dose packs in the extract.

lamivudine oral solution 10 mg/mL — QL

Step therapy program indicators and affected products

Scope	Example / Notes	Coverage label
Step therapy may require trial of specified, preferred agents before coverage of non-preferred agents
ORAVIG (muco-adhesive buccal tablet 50 mg) is explicitly listed with Requirements / Limits = ST in the formulary — example of ST notation
Step therapy required

Therapeutic area	Utilization controls cited	Coverage label
Antineoplastic & immunosuppressant agents
Many entries show PA and oncology/limited-access annotations (e.g., PA; Och; LA) indicating step/authorization programs apply
Prior authorization required

Product group	Controls observed	Coverage label
Neurology / seizure and CNS agents (examples: BRIVIACT, EPIDIOLEX, XCOPRI)
Tier-based quantity limits and prior authorization are present (e.g., BRIVIACT: PA; QL 2 or 60 per 30 days; EPIDIOLEX: PA; QL 400 per 30 days). Step sequences are not explicitly detailed in these chunks.
Covered with prior authorization / QL as listed

Product	Starter / Pack designation	Coverage label
ZEPOSIA
Starter kit (28-day) listed separately with Requirements / Limits = PA; LA; QL (starter kit QL 1 per 365 days) — implies staged access or limited/starter access prior to maintenance supply
Limited access / prior authorization

Product class	Quantity limits / Step info	Coverage label
Buprenorphine-naloxone formulations (sublingual film/tablet)
Documented quantity limits (e.g., QL 60 or 90 per 30 days depending on strength); no explicit prior-step agents specified in these chunks
Covered with QL

Product	Formulation / ST note	Coverage label
DESVENLAFAXINE ER
Listed with Requirements / Limits = ST (step therapy) for specified ER formulations
Step therapy required

Product	ST annotation	Coverage label
TRINTELLIX (vortioxetine)
Requirements / Limits = ST noted for TRINTELLIX in the formulary extract
Step therapy required

Designation	Notes	Coverage label
ACA-designated agents
Some agents are annotated with 'ACA' in the Requirements / Limits column (e.g., certain preventive or contraceptive items); ACA flag shown but step therapy details are not provided in these chunks
ACA designation (coverage per ACA)

Finding	Supporting text	Coverage label
No explicit ST requirements in segment
Multiple formulary lines list PA, LA, QL but do not define step therapy sequences in these chunks — explicit ST sequences are absent in these extracts
No ST specified

Product	Notes	Coverage label
Metformin oral solution 500 mg/5 ml
Listed with Requirements / Limits = ST in the formulary extract (step therapy must be met prior to coverage)
Step therapy required

Product	Requirements / Limits	Coverage label
Dexlansoprazole oral capsule (biphasic delayed release) 30 mg, 60 mg
Formulary entry indicates Requirements / Limits = ST for dexlansoprazole
Step therapy required

Product group	Formulary flags	Coverage label
Allergy immunotherapy / sublingual tablet products (examples: ORALAIR, RAGWITEK, GRASTEK)
These products are flagged with PA in the excerpt (e.g., RAGWITEK Requirements / Limits = PA); explicit step therapy sequences are not shown in these chunks
Prior authorization required

Product set	Controls observed	Coverage label
Various oral and injectable specialty agents
Multiple lines show PA and/or LA annotations; many specialty agents list PA/LA/QL but step therapy specifics are not included in these extracts
Covered with PA/LA/QL as listed

Medical Benefit and site-of-care designations

Prior Authorization

Complete PA/LA authorization processes for MB-tier drugs

Where a drug line shows 'PA' or 'LA' the payer requires completion of the associated authorization processes; submit PA and any requested clinical documentation for those drugs.

Formulary entries include Requirements/Limits fields; 'PA' and 'LA' indicate authorization processes must be completed per payer policy.
Check the drug line and payer resources for required documentation and specialty pharmacy routing.

Note

Infusion‑administered specialty biologics: verify PA/LA and site‑of‑care

Specialty biologics and injectables listed as Tier 4 with PA/LA flags are often administered in clinic or infusion centers (MB tier); verify site‑of‑care requirements and obtain PA where indicated.

Specialty biologics (Tier 4) are designated PA and LA in many entries — site‑of‑care restrictions may apply although not explicitly stated in every line.
Coordinate authorization and scheduling with infusion/clinic services as required.

Terminology and abbreviations used in the formulary

Definitions — Utilization management abbreviations

PA — Prior AuthorizationThe prescriber must obtain approval before the drug will be covered (PA).

QL — Quantity LimitPlan limits the amount of drug covered per prescription or within a specified time frame (QL).

ST — Step TherapyRequires trial of a specified alternative drug before coverage of the requested drug (ST).

LA — Limited AccessMay require use of an in-network specialty pharmacy or reflect site/distribution restrictions (LA).

Definitions — QL / PA / LA

QL (abbreviation)Quantity Limit — specified maximum units per time period (examples: 60 per 30 days, 90 per 30 days, 120 per 30 days).

Formulary maintenance and committee oversight

The formulary is maintained by an independent Pharmacy & Therapeutics Committee that evaluates drugs for safety, effectiveness, and cost and meets regularly to review new and existing therapies. The list groups drugs by therapeutic category and indicates utilization management controls (such as PA, QL, ST, age limits, and LA) which must be met for coverage of affected products.

Additional coding and examples

Policy revision history

policy_snapshotLatest

Formulary drug list published as the Metallic (M4) Formulary Drug List with utilization management flags (PA, QL, ST, LA) and medical benefit (MB) designations; updates are posted during the year and members notified of removals or tier changes.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Formulary Drug List — Formulary / Utilization Management (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line indicates PA to avoid coverage denial.

SourceLink

On This Page

Prior authorization required for oral oncology and specialty agents

Many oral oncology and specialty oral agents are designated 'PA' (often with Och and/or LA) and require prior authorization before coverage.

Examples: abiraterone, ALECENSA, CABOMETYX and other targeted oral antineoplastics are listed with Requirements/Limits = PA; Och; LA.
Obtain PA per plan rules prior to dispensing or administration.

Prior Authorization

Neurology drugs: PA and QL requirements (e.g., BRIVIACT, EPIDIOLEX)

Selected neurology agents show utilization controls — obtain PA and document quantity limits where indicated for neurologic therapies.

BRIVIACT: Requirements/Limits = PA; QL (2 per 30 days for solution; 60 per 30 days for tablets).
EPIDIOLEX: Requirements/Limits = PA; LA; QL (400 per 30 days).

Prior Authorization

PA required for specific neurologic/specialty products (EPIDIOLEX etc.)

Obtain prior authorization for specific listed products when the formulary shows 'PA' in Requirements/Limits (examples include EPIDIOLEX and several rufinamide/XCOPRI/NUEDEXTA entries).

EPIDIOLEX ORAL SOLUTION = PA; LA; QL (400 per 30 days).
XCOPRI maintenance and titration packs are listed with Requirements/Limits = PA.

Prior Authorization

PA required for many opioid and narcotic products

Prior authorization is required for multiple narcotic and opioid products listed with 'PA' in Requirements/Limits; obtain PA before dispensing to avoid denial.

Hydrocodone and hydromorphone products are marked 'PA'.
Some extended‑release opioid products additionally carry QL entries (e.g., morphine ER QL 120 per 30 days).

Prior Authorization

Prescriber must obtain PA where indicated on the drug line

When a drug line shows 'PA' the prescriber must obtain prior authorization from the plan before the drug will be covered.

Examples spanning CNS and specialty sections show numerous products with 'PA' noted (e.g., AVONEX, SUNOSI, multiple ADHD and sleep agents).
Submit PA per payer instructions for affected products.

Prior Authorization

PA required for specified specialty injectable and oral agents

Prior authorization is required for many injectable and specialty oral agents; check the Requirements/Limits field for PA/LA/QL and submit PA documentation as required.

MS therapies (AVONEX, BETASERON, glatiramer, fingolimod, dimethyl fumarate) are listed with PA; LA; QL entries.
Follow plan PA submission process for injectable specialty agents.

Prior Authorization

PA and additional restrictions for high‑tier/specialty drugs

High‑tier and specialty drugs frequently carry 'PA' and sometimes 'LA' annotations; obtain required prior authorization and adhere to any quantity limits noted.

Specialty biologics and other Tier 4 agents commonly require PA and may also have LA or QL.
Examples include REPATHA, COSENTYX, DUPIXENT and similar agents.

Prior Authorization

PA required for selected specialty/high‑tier drugs

Obtain prior authorization for listed specialty/high‑tier drugs where the formulary indicates 'PA'; many examples are shown in the extract.

Examples in the extract include carglumic acid, deferasirox, deferiprone and other orphan/high‑cost agents with PA noted.
Coverage may be denied without completed PA.

Prior Authorization

PA required for select labeled endocrine/insulin products

Prior authorization is required for multiple branded insulin and specialty diabetes products when 'PA' is shown on the formulary line; obtain PA before coverage is applied.

INSULIN ASPART 70/30 (pen/solution) entries show Requirements/Limits = PA.
Other diabetes and endocrine specialty products in the extract also list PA.

Prior Authorization

PA required for select specialty/biologic drugs

Several biologic and specialty products are designated with PA or LA on the formulary; prescribers must submit PA per the plan for these agents.

Examples: CHOLBAM (PA), CIMZIA (PA; LA), OMVOH (PA; LA).
Follow plan PA requirements for coverage decisions.

Prior Authorization

PA required for selected formulations (endocrine, vaccines)

Many specialty endocrine formulations and certain vaccines/immunologics list 'PA' (and sometimes 'LA'); obtain prior authorization for those formulations when noted.

ARANESP injection presentations are listed with Requirements/Limits = PA; LA.
Check each formulation's Requirements/Limits before prescribing or administering.

Prior Authorization

PA or LA required for selected specialty biologics

Numerous specialty biologic agents and some oral specialty therapies are marked 'PA' or 'LA' and require prior authorization or limited‑access handling before coverage.

Examples include ACTEMRA, ADALIMUMAB products, ENBREL, and other rheumatology biologics with PA; LA noted.
Submit PA and utilize specialty distribution channels when LA is specified.

Note

Formulary shows PA flag; consult payer for specific PA criteria

Formulary lines show tier and Requirements/Limits but this extract does not include detailed PA clinical criteria — when PA is indicated, follow the payer's prior authorization process for required documentation.

This extract lists PA flags but specific criterion text is not provided here.
Refer to the payer's full policy or 'Drugs Requiring Approval' resources for clinical criteria and submission forms.

Step Therapy

Step therapy enforcement when 'ST' is listed

When a product is marked 'ST' in Requirements/Limits the prescriber must follow step therapy — a specified alternative must be tried first before the requested drug will be covered.

Example: ORAVIG is noted in the formulary as ST (step therapy).
Other agents labeled 'ST' (DESVENLAFAXINE ER, FANAPT, TRINTELLIX, VRAYLAR, EDARBI/EDARBYCLOR, QBRELIS) require prior-step trials as listed.

Step Therapy

Step/other utilization management for select specialty (oncology) drugs

Some antineoplastic and immunosuppressant agents reference PA and program codes such as 'Och' or 'LA' indicating step or other utilization management steps may apply; obtain PA and follow any oncology program requirements.

Examples: many oral targeted oncology agents include Requirements/Limits = PA; Och; LA.
Contact payer for oncology-specific authorization processes.

Note

Limited access / starter kit: follow LA and starter‑kit rules

Certain products carry 'LA' or starter‑kit designations (starter kit example: ZEPOSIA starter kit) — obtain any required limited‑access authorizations and document starter‑kit use per plan instructions.

ZEPOSIA STARTER KIT = Requirements/Limits: PA; LA; QL (1 per 365 days) and maintenance pack QL (30 per 30 days).
LA may indicate limited distribution or specialty pharmacy use.

Step Therapy

Step therapy required for specified products (examples listed)

Multiple products are marked 'ST' indicating step therapy is required; ensure documented failure or contraindication to the required first‑line agent before requesting coverage for the step agent.

Examples of ST entries: DESVENLAFAXINE ER (ST), FANAPT products (ST), FETZIMA dose packs (ST).
Submit clinical evidence of prior therapy trials when requesting PA where ST applies.

Step Therapy

Step therapy applies to select CNS/psychiatric agents (TRINTELLIX, VRAYLAR)

Step therapy applies to several CNS and psychiatric agents marked 'ST' (e.g., TRINTELLIX, VRAYLAR) — document prior trial history per plan rules when requesting coverage.

TRINTELLIX and VRAYLAR are listed with Requirements/Limits = ST.
Provide records of prior treatments or intolerances when submitting authorization requests.

Note

Managed access / LA notes — follow limited‑access processes

The appearance of 'LA' alongside 'PA' for some agents indicates managed or lifecycle/limited access; follow plan direction for specialty distribution or site‑of‑care requirements when LA is present.

Examples include DOPTELET, REPATHA, and JUXTAPID which show PA and LA annotations.
LA may reflect limited availability or specialty pharmacy channel requirements.

Note

Step therapy not specified in these listings — verify full policy

Some formulary segments show no explicit step therapy sequences — when 'ST' is not present, step edits do not apply based on this extract, but always verify the full PA criteria for the product.

Several chunks in the extract contain no ST annotation; absence here does not preclude other utilization controls.
Refer to the full policy for product‑specific step therapy details.

Step Therapy

Metformin oral solution: step therapy applies

Metformin oral solution in this extract is marked 'ST' — ensure required prior steps are met before coverage is approved for that formulation.

metformin oral solution 500 mg/5 ml = Requirements/Limits: ST.
Document prior trials per step therapy rules when seeking coverage.

Step Therapy

Step therapy noted for dexlansoprazole

Dexlansoprazole is listed with Requirements/Limits = ST — obtain or document adherence to the step therapy sequence before coverage.

DEXLANSOPRAZOLE ORAL CAPSULE 30/60 mg = Requirements/Limits: ST.
Provide documentation of prior therapy trials or contraindications when submitting authorization.

Prior Authorization

PA on allergy immunotherapy/tablet products (ORALAIR, GRASTEK, RAGWITEK)

Allergy immunotherapy sublingual/tablet products such as ORALAIR, GRASTEK and RAGWITEK are marked 'PA' — obtain prior authorization and document clinical rationale; explicit step sequences are not provided in the extract.

Entries show PA for these sublingual immunotherapy products; contact payer for documentation requirements.
Step therapy sequences are not specified in this extract.

Documentation Required

Provide supporting clinical information with PA requests

When a drug line shows 'PA', prescribers should include supporting clinical information (diagnosis, prior treatments, dosing rationale) with the PA request to demonstrate medical necessity.

The formulary notes that physicians may need to provide additional information on the member's condition for drugs subject to utilization management.
Documentation should align with the drug's labeled dosing and any QL or ST requirements.

Documentation Required

Submit PA with required documentation and QL justification

Formulary entries that show 'PA', 'LA' or 'QL' require submission of prior authorization and supporting documentation as indicated on the drug line; include quantity rationale when requesting amounts above QL.

EPIDIOLEX is annotated 'PA; LA; QL (400 per 30 days)' — include dosing and quantity rationale in the PA submission.
For QL items (e.g., JOENJA QL 60 per 30 days), document the requested quantity on the PA or claim.

Billing Rule

Document quantity limits (QL) on PA/claims to avoid denials

When a formulary line includes quantity limits (QL), document the allowed units on the prior authorization or claim; exceeding QL without authorization may lead to denial.

Quantity examples include QL (60 per 30 days, 90 per 30 days, 120 per 30 days).
Aprepitant entries show QL 1 per 30 days or 2 per 30 days depending on strength — document appropriately.

Documentation Required

Follow PA/LA processes and specialty distribution requirements

For drugs labeled with PA or LA, follow the payer's prior authorization process — submit required clinical documentation and use the specified specialty or distribution channel if LA is indicated.

Examples: ARANESP and many biologics list PA; LA — these may require specialty pharmacy dispensing or site‑of‑care restrictions.
Contact the payer or review the 'Drugs Requiring Approval' resource for submission instructions.

Documentation Required

PA submissions must reflect LA and QL when annotated

Products annotated with 'PA; LA; QL' (e.g., EPIDIOLEX, AVONEX, glatiramer products) require PA submission that addresses limited access and quantity limits per the formulary entries.

AVONEX entries: PA; LA; QL (1 per 30 days).
Glatiramer and other MS therapies show PA; LA; QL values that must be documented.

Denial Risk

Denial risk if PA is not obtained

Failure to obtain required prior authorization when a drug is flagged 'PA' may result in the drug not being covered or the claim being denied.

The formulary states PA is required and coverage may be denied without prior approval.
Confirm PA status before dispensing or administering the drug.

Denial Risk

PA/LA required for select high‑cost antivirals — denial risk without PA

High‑cost antivirals and hepatitis C agents (e.g., SOVALDI, EPCLUSA, VEMLIDY, ZEPATIER) are subject to PA and/or LA; submit required prior authorization or limited‑approval documentation to avoid claim denial.

EPCLUSA entries show Requirements/Limits = PA; LA.
SOVALDI entries show Requirements/Limits = PA; LA — claims without PA/LA may be denied.

Denial Risk

Utilization-control flags (PA/LA/QL/Och) can lead to denial if unmet

PA, LA, and QL flags on the formulary indicate utilization controls that can trigger claim denial if the listed requirements are not met; verify and meet these controls before submission.

Utilization controls shown as PA, LA, QL, and Och must be satisfied for coverage.
Check each drug's Requirements/Limits column and follow payer processes.

Denial Risk

PA required for many opioids — risk of denial without PA

Many opioid and opioid‑ER products require prior authorization; dispensing without PA may result in denial of coverage.

Hydrocodone, hydromorphone, morphine, oxycodone and related formulations are commonly marked PA.
Confirm PA before filling opioid ER prescriptions to prevent claim denials.

Denial Risk

Quantity limits enforced — denial risk for exceedance

Quantity limits indicated on the formulary (e.g., 60/30d, 90/30d, 120/30d) are enforced — claims exceeding the listed QL without authorization or exception documentation may be denied or partially paid.

Examples: morphine ER QL 120 per 30 days; oxycodone ER QL 90 or 120 per 30 days depending on strength.
Document medical necessity for quantities exceeding QL when submitting PA.

Denial Risk

PA/LA/QL triggers for specialty biologics — risk of denial if unmet

Specialty injectable and oral disease‑modifying agents are commonly subject to PA, LA and QL; failure to complete authorization and site/distribution requirements may lead to claim denial.

Examples include a wide range of rheumatology and biologic products listed with PA; LA flags (e.g., ACTEMRA, ENBREL, ADALIMUMAB products).
Follow specialty PA and limited‑access procedures to secure coverage.

BRIVIACT (oral solution)QL 2 per 30 days (BRIVIACT oral solution).

BRIVIACT (tablets)QL 60 per 30 days (BRIVIACT tablets).

EPIDIOLEX (oral solution)PA; LA; QL (400 per 30 days).

NERLYNXQL 180 per 30 days (noted among oncology/targeted agents).

QINLOCKQL 90 per 30 days (listed for targeted oncology agent).

Quantity limit examples — numeric

60 per 30 daysCommon QL for multiple controlled or specialty oral formulations (e.g., various ER opioids, certain antivirals).

90 per 30 daysObserved QL for selected extended-release opioid products and other agents.

120 per 30 daysObserved QL for some high-limit products (e.g., morphine ER lines).

20 per 5 daysKetorolac oral tablet 10 mg: QL 20 per 5 days (short-duration analgesic limit).

Lamivudine oral solution 10 mg/mLQuantity limit = 900 per 30 days (QL 900 per 30 days).

lamivudine oral tablets — QL

Lamivudine oral tablets 150 mg, 300 mgQuantity limit = 60 per 30 days (QL 60 per 30 days).

PAXLOVID dose pack — QL

PAXLOVID dose packQuantity limit = 40 per 90 days (QL 40 per 90 days).

STRIBILD oral tablet — QL

STRIBILD oral tabletQuantity limit = 30 per 30 days (QL 30 per 30 days).

CAYSTON inhalation solution — QL

CAYSTON inhalation solution 75 mg/mLQuantity limit = 84 per 30 days (QL 84 per 30 days).

NORVIR oral powder in packet — QL

NORVIR oral powder in packet 100 mgQuantity limit = 360 per 30 days (QL 360 per 30 days).

Various QL examples — aggregated

Examples of assorted QLsAggregated examples include 30/30d, 60/30d, 84/30d, 120/30d, 240/30d, 360/30d, 400/30d depending on product and formulation.

Product typesExamples span antivirals, neurology agents, inhalation solutions, oncology oral agents, and specialty biologics.

Annotation usageQL values appear in the Requirements / Limits column and are paired with PA/LA flags for many specialty products.

subvenite and starter kits — QL

Subvenite starter kitsQuantity limit = 120 per 30 days (QL 120 per 30 days) for starter kits and dose packs noted.

Starter kit variantsMultiple starter kit colors/packs (blue/green/orange) each list QL 120 per 30 days in the extract.

dihydroergotamine nasal spray — QL

Dihydroergotamine nasal sprayQuantity limit = 8 per 30 days (QL 8 per 30 days).

NURTEC ODT — QL

NURTEC ODTQuantity limit = 8 per 30 days (PA; QL 8 per 30 days).

rizatriptan / zolmitriptan / related triptans — QL

Rizatriptan / Zolmitriptan oral formsQuantity limit = 18 per 30 days for oral formulations (QL 18 per 30 days).

Sumatriptan/other formulationsCertain sumatriptan formulations list QL 8 per 30 days for injectables/pen/cartridge forms.

NUEDEXTA — QL

NUEDEXTAQuantity limit = 60 per 30 days (QL 60 per 30 days).

dalfampridine — QL

DalfampridineQuantity limit = 60 per 30 days (PA; LA; QL 60 per 30 days).

ZEPOSIA starter kit / maintenance — QL

ZEPOSIA starter kitStarter kit QL = 1 per 365 days (QL 1 per 365 days).

ZEPOSIA maintenanceMaintenance QL = 30 per 30 days (QL 30 per 30 days).

sumatriptan (various forms) — QL

Sumatriptan various formsQuantity limits vary by formulation: QL 8 per 30 days for injectable/pen forms; QL 18 per 30 days for many oral formulations.

UBRELVY — QL

UBRELVYQuantity limit = 10 per 30 days (PA; QL 10 per 30 days).

hydrocodone ER and similar — QL

Hydrocodone ER and related productsMany hydrocodone ER products carry Prior Authorization; representative QL noted = 60 per 30 days where specified.

hydromorphone & morphine ER family — QL

Hydromorphone ER / Morphine ER / OXYCONTIN / Oxymorphone ERQuantity limits vary by product: examples include 60 per 30 days, 90 per 30 days, and 120 per 30 days depending on formulation and strength.

ketorolac 10 mg — QL

Ketorolac oral tablet 10 mgQuantity limit = 20 per 5 days (QL 20 per 5 days).

buprenorphine–naloxone — QL

Buprenorphine–naloxone sublingual film/tabletQuantity limit = 60 or 90 per 30 days depending on strength/formulation (QL 60 or 90 per 30 days).

SODIUM OXYBATE ORAL SOLUTION — QL

Sodium oxybate oral solutionQuantity limit = 3 per 30 days (QL 3 per 30 days).

SUNOSI tablets — QL

SUNOSI oral tablet 150 mgQuantity limit = 30 per 30 days (QL 30 per 30 days).

SUNOSI oral tablet 75 mgQuantity limit = 60 per 30 days (QL 60 per 30 days).

AVONEX pen/syringe kit — QL

AVONEX intramuscular pen/syringe kitQuantity limit = 1 per 30 days (PA; LA; QL 1 per 30 days).

BAFIERTAM — QL

BAFIERTAM oral capsule 95 mgQuantity limit = 120 per 30 days (PA; LA; QL 120 per 30 days).

BETASERON kit — QL

BETASERON subcutaneous kit 0.3 mgQuantity limit = 14 per 30 days (PA; LA; QL 14 per 30 days).

dimethyl fumarate — QL variants

Dimethyl fumarate formulationsQuantity limits vary by listing: examples include QL 14 per 365 days, QL 1 per 365 days (starter), and QL 60 per 30 days for maintenance strengths.

fingolimod / glatiramer — QL

Fingolimod 0.5 mgQuantity limit = 30 per 30 days (PA; LA; QL 30 per 30 days).

Glatiramer 20/40 mg syringesQuantity limit = 30 per 30 days (PA; LA; QL 30 per 30 days).

AVONEX / glatopa — QL

AVONEX intramuscular 30 mcg/0.5 mLQuantity limit = 1 per 30 days (PA; LA; QL 1 per 30 days).

Glatopa 20 mg syringeQuantity limit = 30 per 30 days (PA; LA; QL 30 per 30 days).

teriflunomide — QL

Teriflunomide 7 mg, 14 mgQuantity limit = 30 per 30 days (PA; LA; QL 30 per 30 days).

rivaroxaban / XARELTO — QL

Rivaroxaban 2.5 mgQuantity limit = 60 per 30 days (QL 60 per 30 days).

XARELTO (various strengths and suspension)Quantity limit = 60 per 30 days for tablets and reconstitution suspension (QL 60 per 30 days).

REPATHA — QL note

REPATHA (all presentations)REPATHA entries include PA flag; QL value not specified in extract.

DUPIXENT / QFITLIA — QL

DUPIXENT (pen/syringe)Quantity limit = 4 per 30 days (PA; LA; QL 4 per 30 days).

QFITLIA (pen/solution)Quantity limit = 1 per 30 days (PA; QL 1 per 30 days).

eltrombopag — QL

Eltrombopag oral tablet 50/75 mgQuantity limit = 60 per 30 days (PA; QL 60 per 30 days).

Eltrombopag powder/packet 12.5/25 mgQuantity limit = 30 per 30 days (PA; QL 30 per 30 days).

Non-narcotic analgesics unit/gram — QL

Non-narcotic analgesics unit/gramQuantity limit = 6 per 30 days (QL 6 per 30 days).

Assorted specialty QL examples

JOENJA 70 mgQuantity limit = 60 per 30 days (PA; QL 60 per 30 days).

Trientine oral capsule 250 mgQuantity limit = 240 per 30 days (PA; QL 240 per 30 days).

CRENESSITY (100 mg)Quantity limit = 120 per 30 days (PA; QL 120 per 30 days).

CRENESSITY solutionQuantity limit = 240 per 30 days (PA; QL 240 per 30 days).

MYALEPTQuantity limit = 27 per 30 days (QL 27 per 30 days).

icosapent ethyl / JUXTAPID — QL

Icosapent ethylQuantity limit = 120 per 30 days (PA; QL 120 per 30 days).

JUXTAPIDQuantity limit = 30 per 30 days (PA; LA; QL 30 per 30 days).

tolvaptan / testosterone gels — QL

TolvaptanQuantity limit = 60 per 30 days (PA; LA; QL 60 per 30 days).

Testosterone transdermal gel (various forms)Quantity limits vary by formulation (examples: QL 60, 150, 300 per 30 days; QL 2 per 30 days for metered pump form).

Antiemetic and related QLs

Aprepitant oral capsuleQuantity limits = 1 per 30 days (125 mg/40 mg) or 2 per 30 days (80 mg) depending on strength (QL 1 or 2 per 30 days).

Ondansetron oral solutionQuantity limit = 2 per 30 days (QL 2 per 30 days).

SUCRAID oral solutionQuantity limit = 236 per 30 days (PA; QL 236 per 30 days).

Misc endocrine / GI / OB-GYN QLs

CTEXLI oral tabletQuantity limit = 120 per 30 days (QL 120 per 30 days).

LIVMARLI oral solution/tabletQuantity limits vary by formulation (examples: QL 60, 90, 30 per 30 days).

EVAMIST spray / estradiol gelQuantity limits specified per product (examples in extract show QL 2 per 30 days for EVAMIST).

OPILL oral tablet 0.075 mgQuantity limit = 28 per 28 days (ACA; QL 28 per 28 days).

Transdermal / contraceptive / estrogen product QLs

LyLlana transdermal patchQuantity limit = 8 per 30 days (QL 8 per 30 days).

OPILLQuantity limit = 28 per 28 days (ACA; QL 28 per 28 days).

PREMARIN / estrogen productsQuantity limits specified per formulation (examples provided in extract).

Documentation Required

LA with PA for injectables — confirm site‑of‑care and specialty routing

For injectables where 'LA' appears with 'PA' (e.g., ACTHAR, CORTROPHIN), treat LA as a likely site‑of‑care or limited‑access designation and obtain both PA and any specialty routing instructions before administration.

ACTHAR and CORTROPHIN entries list Requirements/Limits = PA; LA — this implies limited availability or site‑related handling.
Confirm payer instructions for site of administration and specialty pharmacy requirements.

PA (abbreviation)Prior Authorization — an approval required from the payer before coverage will be provided.

LA (abbreviation)Limited Access — indicates distribution or site-of-care restriction, often noted alongside PA for specialty products.

Definitions — Tier and requirements

Drug TierFormulary benefit tier (1–4) used for member cost-sharing; tiers appear on each drug line in the formulary extract.

Requirements / Limits columnShows utilization annotations such as PA, QL, ST, LA; these determine prior authorization, quantity limits, and step requirements.

Coverage depends on contractCoverage of a specific drug is subject to the member's coverage contract and the formulary's utilization management requirements.