CurrentPremera BluecrossPolicy N/A

Metallic (M2) Formulary Drug List — Formulary Drug List (Health Savings Account qualifying plans)

This document is the Metallic (M2) Formulary Drug List describing covered generic, brand, and specialty drugs, utilization management restrictions, and tiering for Health Savings Account qualifying plans offered by Premera Blue Cross.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M2) Formulary Drug List — Formulary Drug List (HSA qualifying plans)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain required prior authorization and submit supporting clinical documentation for any drug listed with 'PA' to avoid denial of coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyP&T review

includes specialtyIncludes specialty

uses PA/QL/STUtilization management

HSA plansApplies to

multipleEntries with PA/QL/LA/ST

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.

Formulary Coverage & Product Restrictions

Formulary coverage with product-specific restrictions

Covered when the product is listed on the formulary tier and any product‑specific requirement(s) shown in the Requirements / Limits column are satisfied.

Tier assignment: Product is covered only if listed on the formulary (Tier 1 or Tier 2) for the member's plan.

See formulary line for the product's Tier assignment.

Product‑specific utilization controls: When a product line includes one or more flags in Requirements / Limits (e.g., PA; LA; ST; QL), those controls must be satisfied for coverage of that specific product.

Examples: PA (prior authorization), LA (limited access), ST (step therapy), QL (quantity limit). Refer to the product line for exact flags and numeric QL values.

Prior authorization (PA): If the Requirements / Limits column includes 'PA' for the product, prior authorization must be obtained before coverage will be approved.

Failure to obtain required PA may result in denial of coverage.

Limited access (LA) or other program checks: If the Requirements / Limits column includes 'LA', 'Och' or similar access annotations, the product is subject to additional distribution or program restrictions that must be met for coverage.

See individual product entry for specifics; examples include oncology and specialty agents listed with 'PA; Och; LA'.

Quantity limits (QL): When a product has a numeric QL (for example 'QL (1 per 30 days)', 'QL (120 per 30 days)', 'QL (3 per 30 days)'), covered quantity is limited to that amount per the stated time frame.

Prescriptions exceeding the specified QL require prior authorization or will be denied at claim adjudication.

Step therapy (ST): If 'ST' appears for a product, the member must meet the plan's step‑therapy requirement (try specified alternative(s) first or demonstrate contraindication/intolerance) before coverage of the listed product will be approved.

Specific required first‑line agents or failure criteria are defined in the plan's step therapy rules (not shown on each line).

Operational documentation: When PA, LA or QL apply, appropriate documentation supporting medical necessity, diagnosis, dosing and requested quantity should be provided with the PA or claim as required by the plan.

Refer to the plan's 'Drugs Requiring Approval' resources or PA forms for submission details.

Formulary coverage by tier with utilization controls

Coverage and utilization management follow tier placement; many Tier 2 and specialty agents require additional controls as listed.

Tier‑based coverage: Drugs listed on the formulary are covered according to their assigned Tier (e.g., Tier 1 or Tier 2). Tier placement indicates cost‑sharing and benefit pathway for the member.

Refer to each product line for its Tier assignment.

Tier 2 / specialty agent controls: Many Tier 2 and specialty products are listed with 'PA' and/or 'LA' indicating prior authorization and limited‑access processes apply to those tiers.

Examples: specialty biologics (COSENTYX, SKYRIZI, DUPIXENT) show 'PA; LA' on their product lines.

Quantity limits by tier: Where a QL is specified on the product line (e.g., QL (1 per 30 days) for QFITLIA; QL (60 per 30 days) for XARELTO; QL (120 per 30 days) for VUMERITY), coverage is limited to that quantity per the time frame regardless of Tier.

Numeric QL values are shown per product line and must be followed or authorized through PA if higher quantities are clinically required.

Drugs removed from the drug list or moved to a higher cost‑sharing tier will be communicated to affected members by letter and posted on the plan website's 'Drug list Changes' page. Coverage of any drug remains subject to the member's coverage contract and member booklet; changes in tiering or formulary status do not override the member's plan terms.

This segment of the formulary does not contain explicit exclusion statements. Product lines in the list specify tier placement and any applicable utilization controls (e.g., PA, QL, ST), but no standalone exclusions are declared in these chunks.

Within the covered sections shown here there are no formal medical‑necessity decision rules or exclusionary clinical criteria provided. Entries are organized by therapeutic category with Tier assignments and Requirements / Limits flags (for example, ACA for preventive contraceptive items), but specific medical‑necessity logic or clinical eligibility criteria are not specified in this portion of the document.

This document segment does not include any statements labeled 'Not Medically Necessary.' Coverage lines use administrative flags (such as PA, QL, ST, or LA) to denote utilization controls; explicit 'Not Medically Necessary' provisions are not present in the cited excerpts.

Coding, Identifiers & Quantity Examples

No billed codes in this segmentmixed

XL	Not an extracted billing code; no CPT/HCPCS/ICD-10 codes present in this segment

Formulary product entries (examples)NDC|brand

REBIF REBIDOSE SUBCUTANEOUS PEN 8.8MCG/0.2ML-22 MCG/0.5ML	Formulary listing; Tier 2; Requirements / Limits = PA; LA; QL (12 per 30 days or 4.2 per 30 days per entry)
teriflunomide 14 mg, 7 mg	Tier 2; Requirements / Limits = PA; LA; QL (30 per 30 days)
VUMERITY 231 MG	Tier 2; Requirements / Limits = PA; LA; QL (120 per 30 days)

Specialty or PA-required drugs (examples)brand

CABLIVI INJECTION KIT 11 MG	Tier 2; Requirements / Limits = PA
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG - 5 MG	Tier 2; Requirements / Limits = PA; LA
DOPTELET ORAL TABLET 20 MG	Tier 2; Requirements / Limits = PA; LA

NDC/strength listings (informational)NDC

No codes listed

Quantity limits examples

QL (30 per 30 days)Example quantity limit used on multiple antiviral and antiretroviral entries (e.g., COMPLERA, CIMDUO, many ART products).

QL (60 per 30 days)Common QL for several oral antivirals and chronic therapies (e.g., ISENTRESS entries show 60/30d).

QL (360 per 30 days)Example large-period QL shown for certain oral powders/pellets (e.g., NORVIR QL 360 per 30 days).

QL (40 per 365 days)Example annualized QL shown for oseltamivir capsule (40 per 365 days).

QL (20 per 365 days)Example QL for higher‑dose oseltamivir capsule strengths (45/75 mg listed as 20 per 365 days).

QL (30 per 30 days — PREZCOBIX example)

Authorization, Documentation & Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many specific drugs across the formulary. Drugs marked with "PA" (or combined indicators such as "PA; LA", "PA; Och; LA") in the Requirements/Limits column must have prior approval from Premera before the prescription will be covered. Failure to obtain required PA may result in claim denial.

Examples of single-agent PA flags: SOVALDI, EPCLUSA, VISTOGARD, XYREM/XYWAV, SUNOSI, PAXLOVID (selected presentations).
Many oncology and immunosuppressant agents show combined controls: PA plus oncology oversight ("Och") and limited access ("LA"). Examples include numerous oral antineoplastics (e.g., ALECENSA, CABOMETYX, IMBRUVICA, ICLUSIG, JAKAFI, KISQALI) and antineoplastics/immunosuppressants listed under the ANTINEOPLASTIC & IMMUNOSUPPRESSANT category.
Specialty biologics and dermatologic biologics (e.g., COSENTYX, TALTZ, SKYRIZI, DUPIXENT, TREMFYA, SILIQ, SOTYKTU) and many rheumatology/autoimmune biologics (e.g., ADALIMUMAB products, ENBREL, SIMPONI, XELJANZ, RINVOQ) require PA and often LA.

Prior Authorization

Opioid & Selected Analgesic PA

Prior authorization applies broadly to many opioid/analgesic formulations and selected controlled analgesics. Where a PA requirement exists, prescribers should submit clinical justification per the PA process; some formulations also have quantity limits (QL).

Quantity Limits (QL) — Per-Product Examples

Multiple QL examples

QL (30 per 30 days)Multiple antiretroviral and antiviral entries show QL (30 per 30 days) as a standard monthly limit.

QL (60 per 30 days)Common monthly limit for many chronic treatments (e.g., some ARV and chronic antivirals).

QL (360 per 30 days)Large-cycle QL used for oral powder/pellet formulations (NORVIR example shows QL 360/30d).

QL (40 per 365 days)Annualized QL example used for seasonal antiviral capsule formulations (oseltamivir capsule listed 40/365d).

oseltamivir oral suspension for reconstitution 6 mg/ml

Productoseltamivir oral suspension for reconstitution 6 mg/ml

Medical Benefit & Administration Site

Billing Rule

Coordinate PA and authorization for MB (infusion/clinic/home) drugs

Drugs administered in clinic or infusion settings are covered under the medical benefit (MB); specialty biologics often fall under the MB and are typically managed with PA and limited‑access pathways.

If a product line is MB, coordinate medical‑benefit authorization and infusion scheduling per plan requirements.

Billing Rule

Specialty biologics (infusion/clinic) require PA and site‑of‑care coordination

Specialty biologics administered in infusion centers or clinic settings are typically managed under PA and may require limited access processes; obtain necessary authorization for medical‑benefit administered biologics.

For specialty biologics (e.g., COSENTYX, TREMFYA) with PA; LA, confirm site‑of‑care authorization and PA prior to infusion or dispensing.

Biosimilars & Reference Product Preferencing

Billing Rule

Check PA/LA for adalimumab reference products and biosimilars

Multiple adalimumab reference and biosimilar products are listed with mixed tiering and PA/LA requirements; review the specific product line for PA/LA designations when preparing authorization or billing.

Adalimumab biosimilars (ADALIMUMAB‑ADAZ, ADALIMUMAB‑ADBM, ADALIMUMAB‑RYVK) list PA and in some cases LA — obtain PA and follow any limited access instructions.

Definitions & Flags

Key definitions

PAPrior Authorization — the member or provider must obtain approval before the drug is covered.

QLQuantity Limit — the amount of drug covered per prescription or within a specified time frame.

STStep Therapy — requires trying specified alternative drug(s) before coverage of the listed drug is provided.

MBMedical Benefit — drugs administered in clinic/infusion or via home infusion are covered under the medical benefit.

ACAAffordable Care Act preventive medication designation; denotes ACA coverage provisions for applicable products.

QL — Quantity Limit definition & examples

Step Therapy Listings & Flags

Product	Requirement / Limit
ORAVIG muco-adhesive buccal tablet 50 mg
Requirements / Limits = ST

Product	Requirement / Limit
Avidoxy oral tablet 100 mg
Requirements / Limits = ST

Product	Requirement / Limit
FANAPT oral tablet (various strengths) and FANAPT titration packs
Requirements / Limits = ST
Desvenlafaxine (examples shown in psychotherapeutic listing)
Requirements / Limits = ST (desvenlafaxine indicated in step therapy listings)

Product	Requirement / Limit
FANAPT (tablets and titration packs)
Requirements / Limits = ST
FETZIMA oral capsules (multiple strengths and dose packs)
Requirements / Limits = ST
TRINTELLIX (listed among psychotherapeutics)
Requirement / Limits = (psychotherapeutic section indicates ST for select agents like these)
VRAYLAR oral capsule (various strengths)
Requirements / Limits = ST

Product	Requirement / Limit
EDARBI (azilsartan medoxomil) formulations
Requirements / Limits = ST
EDARBYCLOR (combination) formulations
Requirements / Limits = ST

Product	Requirement / Limit
QBRELIS oral solution 1 mg/mL
Requirements / Limits = ST

Product	Requirement / Limit
Adapalene topical cream/gel/lotions (various formulations)
Requirements / Limits = ST
AZELEX topical cream 20% and related acne/topical agents
Requirements / Limits = ST (where shown)
Claravis (isotretinoin) — listed in acne therapy
Requirements / Limits = (acne section includes ST for select topical/oral agents)

Product	Requirement / Limit
INSULIN ASP PRT - Insulin aspart 70/30 subcutaneous solution
Requirements / Limits = PA
SOLIQUA 100/33 subcutaneous insulin pen (insulin/GLP-1 combo)
Requirements / Limits = PA (as listed)

Product	Requirement / Limit
Various biologic/self-injectable products (examples: ADALIMUMAB-RYVK, ENBREL, CYLTEZO)
Requirements / Limits = PA; LA (indicating limited access/managed distribution)
RINVOQ LQ oral solution and RINVOQ ER tablets
Requirements / Limits = PA; LA (managed access indicated)

Product	Requirement / Limit
Adalimumab reference and biosimilar products (e.g., ADALIMUMAB-RYVK and other adalimumab listings)
Requirements / Limits = PA; LA (many biologics show PA/LA and tier differences)
SIMLANDI (CF) autoinjector and SIMPONI subcutaneous pen/syringe
Requirements / Limits = PA; LA (prior authorization with limited access)

Observation	Implication
No explicit step therapy sequencing or step-failure criteria are listed in the provided formulary fragments
Many products are still indicated with 'PA' or other flags (PA; LA; QL) — prior authorization is required where shown and may trigger denial if not obtained

Formulary Development & Scope

The formulary is developed and maintained by an independent Pharmacy & Therapeutics Committee composed of physicians and pharmacists who review safety, effectiveness, and cost. The committee meets regularly (at least quarterly) to place new drugs and reassess existing placements; the formulary organizes drugs by condition categories and provides line‑level tiering and utilization management flags for each product.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M2) Formulary Drug List — Formulary Drug List (HSA qualifying plans)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain required prior authorization and submit supporting clinical documentation for any drug listed with 'PA' to avoid denial of coverage.

SourceLink

On This Page

PA as common Tier 2 control: Prior authorization is commonly required for Tier 2 specialty and many non‑routine agents; absence of explicit clinical decision steps in the formulary means PA criteria are handled through the plan's PA process.

Examples in the formulary include QFITLIA, DUPIXENT, COSENTYX and multiple MS agents indicated with 'PA' and QL values.

No additional clinical decision trees in this segment: This formulary segment specifies tier placement and per‑line utilization flags but does not include detailed clinical AND/OR criteria or stepwise failure logic for PA decisions.

Providers should submit clinical information per the plan's PA documentation requirements when requesting exceptions or quantities beyond stated QLs.

A 30 per 30 days QL appears on select protease inhibitor entries (PREZCOBIX listed QL 30/30d).

Sample quantity limits

QL (40 per 365 days)oseltamivir oral capsule entry example shows QL (40 per 365 days).

QL (360 per 365 days)oseltamivir oral suspension for reconstitution 6 mg/ml shown as QL (360 per 365 days).

QL (40 per 90 days)PAXLOVID oral tablets dose pack listed as QL (40 per 90 days) in the antiviral section examples.

Opioids and related analgesics with PA: fentanyl transdermal patches, hydrocodone ER and immediate-release formulations, hydromorphone (oral and rectal), morphine (multiple formulations), oxycodone products, methadone, meperidine.
Many of these agents also include QL entries (e.g., hydrocodone with QL 60 per 30 days, hydromorphone ER QL, morphine ER QL, OXYCONTIN QL).
Some non-narcotic analgesics and adjuncts also require PA or have QLs (e.g., butorphanol nasal spray PA; buprenorphine-naloxone QLs for MAT).

Documentation Required

PA plus Other Oversight (LA, Och, QL)

PA frequently accompanies additional utilization controls such as quantity limits (QL), limited access (LA), and specialty program/oncology oversight (Och). The Requirements/Limits field lists the exact flags and any numeric QLs you must follow.

When Requirements/Limits shows multiple flags (e.g., "PA; Och; LA; QL (60 per 30 days)"), both prior authorization and adherence to the listed limits/programs are required for coverage.
Examples of PA plus LA: SOVALDI (PA; LA), EPCLUSA (PA; LA), many MS and biologic agents (PA; LA; QL).
Examples of PA with QL: JAKAFI (PA; Och; LA; QL 60 per 30 days); sodium oxybate (XYREM/XYWAV) is PA; LA; QL (3 per 30 days).

Denial Risk

Authorization & Documentation Expectations

PA and other utilization designations (PA, ST, QL, LA, Och, ACA) are shown in the Requirements/Limits column. For any PA, providers must follow Premera's PA submission process and may need to supply supporting clinical documentation; absence of required documentation can cause denial.

Administrative designations present: PA (Prior Authorization), ST (Step Therapy), QL (Quantity Limit), LA (Limited Access), Och (Oncology oversight), ACA (Affordable Care Act preventive).
Information and forms for PA requests are available on Premera's "Drugs Requiring Approval" web page; providers should submit clinical rationale, prior therapies tried (when ST applies), relevant labs or diagnoses, and quantity/usage justification.
Denial triggers: claims may be denied if PA, ST, or QL requirements are not satisfied or if required supporting documentation is not provided.

Step Therapy

Step Therapy Requirements

Step therapy (ST) applies to selected agents across therapeutic classes. When a drug is marked "ST" the plan requires trials of specified preferred alternatives before the requested agent will be covered. Some entries do not specify step logic on the drug list — consult the PA/step therapy criteria for details.

Examples of ST-marked products: FANAPT (and FANAPT titration packs), FETZIMA, REXULTI, TRINTELLIX, VRAYLAR, QBRELIS.
Step therapy not specified: some formulary rows show the ST flag without full step logic on the list; providers should reference the plan's PA/step criteria or contact Premera for required trial agents.
Step/therapeutic preference: biosimilar vs brand tiering and tier-based preferred agents may create implied step preference; check clinical criteria when prescribing specialty biologics.

Quantity limitQL (360 per 365 days)

Section/SourceAntivirals — antiviral entries listing (oseltamivir suspension)

RELENZA DISKHALER INHALATION blister 5 mg/actuation

ProductRELENZA DISKHALER INHALATION blister 5 mg/actuation

Quantity limitQL (2 per 365 days)

Section/SourceInfluenza antivirals — RELENZA entry showing 2/365d limit

PAXLOVID ORAL TABLETS, dose pack

ProductPAXLOVID ORAL TABLETS, dose pack

Quantity limitQL (40 per 90 days)

Section/SourceAntivirals — PAXLOVID dose pack listing

REYATAZ oral powder in packet 50 mg

ProductREYATAZ oral powder in packet 50 mg

Quantity limitQL (150 per 30 days)

Section/SourceAntivirals — REYATAZ entry

Multiple documented per-line examples

Common monthly examplesQL (60 per 30 days); QL (90 per 30 days); QL (180 per 30 days); QL (240 per 30 days); QL (400 per 30 days)

ContextThese per-line examples appear across specialty and oncology/neurology product listings where different dosing regimens require distinct QLs.

ActionVerify the product line for the exact QL value when authorizing or adjudicating claims.

hydrocodone bitartrate examples

Product classhydrocodone bitartrate (ER and other formulations)

Quantity limitQL (60 per 30 days)

NotesListed under opioid analgesics with PA and QL applied to ER and select formulations.

morphine oral capsule (ER)

Productmorphine oral capsule (ER, extended-release pellets)

Quantity limitQL (90 per 30 days)

Section/SourceOpioid analgesics listings showing PA; QL on ER capsule formulations.

morphine oral tablet extended release

Productmorphine oral tablet extended release

Quantity limitQL (120 per 30 days)

NotesExtended‑release tablet strengths show higher monthly QLs as noted in opioid section.

OXYCONTIN extended release

ProductOXYCONTIN (oral tablet extended release)

Quantity limitQL (90 per 30 days) and QL (120 per 30 days) depending on strength

NotesLower strengths listed as QL 90/30d; higher strengths listed QL 120/30d as shown in OXYCONTIN entries.

buprenorphine-naloxone products

Product groupbuprenorphine‑naloxone products (films, tablets)

Quantity limitsQL (60 per 30 days) and QL (90 per 30 days) depending on formulation

ContextDifferent formulations (sublingual film vs tablet) carry distinct QLs in the non‑narcotic analgesics section.

butorphanol nasal spray

Productbutorphanol nasal spray, non-aerosol 10 mg/ml

Quantity limitQL (2 per 30 days)

NotesListed with PA; QL (2 per 30 days) in non‑narcotic analgesics section.

ketorolac oral tablet

Productketorolac oral tablet 10 mg

Quantity limitQL (20 per 5 days)

NotesShort-duration NSAID with a 5‑day QL window as listed in non‑narcotic analgesics.

NUCYNTA ER and other ER opioids

Product examplesNUCYNTA ER and other ER opioids

Quantity limitExamples include QL (60 per 30 days) for NUCYNTA ER and similar ER opioids

ContextER opioid entries frequently pair PA with monthly QLs to manage chronic dispensing.

Sodium oxybate (XYREM/XYWAV) and select MS agents

Product groupSodium oxybate (XYREM / XYWAV) and select MS agents

Quantity limitsExamples include QL (3 per 30 days) for sodium oxybate; various MS products show QL ranges from 1 to 120 per 30 days or per 365 days

NotesThese specialty agents carry PA and often LA plus specific QLs per product line.

SUNOSI

ProductSUNOSI oral tablet (150 mg and 75 mg)

Quantity limitsQL (30 per 30 days) for 150 mg; QL (60 per 30 days) for 75 mg

NotesSUNOSI entries show strength‑dependent QLs in the non‑narcotic/sleep disorder section.

REBIF REBIDOSE / REBIF TITRATION PACK

ProductREBIF REBIDOSE / REBIF TITRATION PACK

Quantity limitsQL (12 per 30 days) for standard pens; QL (4.2 per 30 days) for titration pen entries

NotesMultiple REBIF formats have distinct per‑month QLs as listed in MS agent entries.

teriflunomide

Productteriflunomide oral tablet (7 mg, 14 mg)

Quantity limitQL (30 per 30 days)

NotesListed under Multiple Sclerosis Agents with PA; LA; QL (30/30d).

VUMERITY 231 MG

ProductVUMERITY oral capsule 231 mg

Quantity limitQL (120 per 30 days)

NotesMS agent VUMERITY listed with PA; LA; QL 120/30d.

eltrombopag olamine

Producteltrombopag olamine (packets/tablets)

Quantity limitsQL (30 per 30 days) for 12.5/25 mg; QL (60 per 30 days) for 50/75 mg

NotesEltrombopag entries pair PA and QL values by strength/formulation.

QFITLIA

ProductQFITLIA (pen and solution)

Quantity limitQL (1 per 30 days)

NotesListed QFITLIA entries show a single‑unit monthly QL in the hematology/anticoagulant grouping.

XARELTO tablets and suspension

ProductXARELTO (rivaroxaban) tablets and suspension

Quantity limitQL (60 per 30 days)

NotesBoth tablets and oral suspension forms are shown with QL 60/30d in the antithrombotic section.

icosapent ethyl

Producticosapent ethyl (omega-3 acid ethyl esters)

Quantity limitQL (120 per 30 days)

NotesListed under lipid agents with PA; QL 120/30d for icosapent ethyl.

JUXTAPID

ProductJUXTAPID (lomitapide) oral capsule

Quantity limitQL (30 per 30 days)

NotesListed with PA; LA; QL (30/30d) under lipid‑lowering specialty agents.

DUPIXENT

ProductDUPIXENT (subcutaneous injector/syringe)

Quantity limitQL (4 per 30 days)

NotesDupixent entries show PA; LA; QL (4/30d) in dermatologic biologics.

CRENESSITY

ProductCRENESSITY (various formulations)

Quantity limitsQL (120 per 30 days for 100 mg); QL (60 per 30 days for 25/50 mg); QL (240 per 30 days for oral solution)

NotesCRENESSITY entries show strength/formulation‑dependent QLs and require PA.

MYALEPT

ProductMYALEPT (subcutaneous recon solution)

Quantity limitQL (27 per 30 days)

NotesMYALEPT listed with PA; LA; QL 27/30d under specialty endocrine/rare disease agents.

CRENESSITY ORAL CAPSULE 100 MG

ProductCRENESSITY ORAL CAPSULE 100 MG

Quantity limitQL (120 per 30 days)

NotesSpecific CRENESSITY 100 mg capsule QL as listed in endocrine/diabetes specialty agents.

CRENESSITY ORAL CAPSULE 25 MG, 50 MG

ProductCRENESSITY ORAL CAPSULE 25 MG, 50 MG

Quantity limitQL (60 per 30 days)

NotesLower‑strength CRENESSITY capsules listed with QL 60/30d.

CRENESSITY ORAL SOLUTION 50 MG/ML

ProductCRENESSITY ORAL SOLUTION 50 MG/ML

Quantity limitQL (240 per 30 days)

NotesOral solution formulation shows a larger monthly QL (240/30d) in the formulary.

MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML

ProductMYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML

Quantity limitQL (27 per 30 days)

NotesParallels the MYALEPT listing showing PA; LA; QL (27/30d).

tolvaptan (various)

Producttolvaptan (various)

Quantity limitQL (60 per 30 days)

NotesTolvaptan entries (PKD indications) list PA; LA; QL (60/30d).

testosterone transdermal gel 50 mg/5 gram

Producttestosterone transdermal gel 50 mg/5 gram

Quantity limitQL (60 per 30 days)

NotesListed in endocrine section with QL 60/30d for the 50 mg/5 g gel packets.

CTEXLI ORAL TABLET 250 MG

ProductCTEXLI oral tablet 250 mg

Quantity limitQL (120 per 30 days)

NotesListed under endocrine/diabetes specialty agents with a 120/30d QL.

LIVMARLI ORAL SOLUTION 19 MG/ML

ProductLIVMARLI oral solution 19 mg/ml

Quantity limitQL (60 per 30 days)

NotesLIVMARLI solution listed with PA; QL 60/30d.

LIVMARLI ORAL SOLUTION 9.5 MG/ML

ProductLIVMARLI oral solution 9.5 mg/ml

Quantity limitQL (90 per 30 days)

NotesAlternate LIVMARLI solution concentration listed with QL 90/30d.

LIVMARLI ORAL TABLET

ProductLIVMARLI oral tablet

Quantity limitQL (30 per 30 days)

NotesTablet formulation shown with QL 30/30d in the formulary listing.

teriparatide subcutaneous pen injector 20 mcg/dose

Productteriparatide subcutaneous pen injector 20 mcg/dose

Quantity limitQL (1 per 30 days)

NotesListed under musculoskeletal/rheumatology with PA; LA; QL (1/30d).

dotti transdermal patch

Productdotti transdermal patch (various strengths)

Quantity limitQL (8 per 30 days)

NotesTransdermal patch QL example shown in endocrine/contraceptive listings.

estradiol transdermal gel in packet

Productestradiol transdermal gel in packet

Quantity limitQL (30 per 30 days)

NotesListed with QL 30/30d for gel packet formulations.

estradiol transdermal patch (semiweekly)

Productestradiol transdermal patch (semiweekly)

Quantity limitQL (8 per 30 days)

NotesSemiweekly patch QL 8/30d as listed in endocrine therapies.

EVAMIST transdermal spray

ProductEVAMIST transdermal spray

Quantity limitQL (2 per 30 days)

NotesSpray formulation shown with a 2 per 30 days QL in hormone therapy listings.

estradiol transdermal patch (weekly)

Productestradiol transdermal patch (weekly)

Quantity limitQL (4 per 30 days)

NotesWeekly patch QL 4/30d as indicated in the formulary.

OPILL oral tablet

ProductOPILL oral tablet 0.075 mg

Quantity limitQL (28 per 28 days)

NotesOral contraceptive OPILL shown with ACA designation and QL 28 per 28 days.

QL — definition and examples

Quantity Limit (QL): we limit the amount covered per prescription or within a time frame (examples in document include QL (60 per 30 days), QL (90 per 30 days), QL (120 per 30 days); QL (40 per 365 days); QL (360 per 365 days)).

UsageQL values appear per product line and must be verified on the specific formulary entry when processing claims or PA requests.

DocumentationWhen PA and QL are both listed (e.g., PA; LA; QL), documentation supporting dosing interval and quantity may be required for authorization.

PA — Prior Authorization definition

PA — definitionPrior Authorization (PA): you (or your physician) are required to get prior authorization before the prescription is filled; without prior approval, the drug may not be covered.

ImplicationEntries marked 'PA' in Requirements / Limits indicate claims may be denied if PA is not obtained.

Common pairingPA often appears with LA (limited access), QL (quantity limits), or Och (oncology checks) for specialty and oncology agents.

ST — Step Therapy definition

ST — definitionStep Therapy (ST): before coverage for the listed drug, the member must first try another specified drug; listed on some product lines (e.g., ORAVIG, FANAPT titration packs).

Operational noteST is indicated in the Requirements / Limits column — confirm required prior agents when submitting an authorization.

ScopeAppears across therapeutic areas including psychotherapeutics, acne/topical agents, and some antihypertensives.

MB — Medical Benefit definition

MB — definitionMedical Benefit (MB): drugs normally administered in a clinic, infusion center, or via home infusion are covered under the medical benefit rather than the pharmacy benefit.

ImplicationMB entries may require facility billing and PA processes distinct from pharmacy claims.

ReferenceSee 'Drugs Requiring Approval' page for PA details for MB drugs.

Requirement flags used in Requirements / Limits

Requirement flagsCommon flags in Requirements / Limits column: PA = Prior Authorization; LA = Limited Access; Och = Oncology checks; ACA = Affordable Care Act preventive designation; ST = Step Therapy.

ActionInterpret each product line's Requirements / Limits field to determine needed documentation, PA submission, or claim adjudication rules.

ExampleEntries like 'PA; LA; QL (1 per 30 days)' denote combined requirements that must be satisfied for coverage.