CurrentPremera BluecrossPolicy N/A

Metallic (M4) Formulary Drug List — Coverage Criteria

List of generic, brand, and specialty drugs covered under the Metallic M4 plans and the rules, tiers, and utilization management restrictions that apply to coverage for members and providers.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Formulary Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when 'PA' is indicated on a formulary entry before dispensing or submitting a claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5plans using the Metallic M4 drug list

~120+distinct drug entries (partial)

PA, QL, STcommon utilization management restrictions

multiplequantity limit examples

1-4drug tiers present

Coverage Criteria and Changes

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.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed in the formulary. When a drug's Requirements/Limits column includes "PA" (or "PA; LA", "PA; LA; QL"), prescribers or pharmacies must obtain prior approval before the drug will be covered. Failure to obtain required PA may result in denial of coverage.

PA applies wherever annotated in the Requirements / Limits column (examples across sections: SOVALDI, EPCLUSA, multiple oncology, specialty, endocrine, gastroenterology and pain agents).
Drugs marked PA; LA require both prior authorization and limited-access handling.
Specialty biologics and many high-tier agents (e.g., REPATHA, COSENTYX, DUPIXENT, SKYRIZI, CIMZIA, ACTHAR, ONCOLOGY agents) commonly carry PA or PA; LA flags.

Prior Authorization

PA/LA Required for Specific Agents

Some specific products require PA and/or Limited Access (LA) status; these agents often also include quantity limits (QL). Prescribers should check the exact Requirements/Limits entry for product-level rules.

Examples: EPCLUSA, SOVALDI, IMBRUVICA, BOSULIF, many antineoplastic & immunosuppressant drugs = PA; LA.
Specialty multiple sclerosis agents (e.g., AVONEX, PLEGRIDY, MAYZENT, KESIMPTA) = PA; LA; QL as indicated.
ORNITRAM and other select Tier 4 agents (e.g., ORENITRAM) may be PA; LA and denied without authorization.

Prior Authorization

Prior Authorization Required for Specified Products

Numerous listed products across therapeutic classes explicitly require prior authorization. Providers must submit a PA request when applicable and ensure documentation supports medical necessity.

Examples by class: neurology (rufinamide, XCOPRI), migraine biologics (EMGALITY, NURTEC), opioids and extended-release opioids, specialty endocrine and hematology agents (DOPTELET, CABLIVI).
Many immunology/rheumatology biologics and other specialty injectables are PA; LA (e.g., ADALIMUMAB variants, SIMPONI, ACTEMRA).
When PA is listed alongside LA or QL, the PA submission should address both access restrictions and any quantity rationale.

Prior Authorization

Prior Authorization & Additional Flags Present for Selected Products

Selected drugs include multiple utilization management flags (PA, LA, QL, ST). Review the per-product Requirements/Limits entry and comply with those specific requirements when submitting claims or PA requests.

Examples: SODIUM OXYBATE ORAL SOLUTION = PA; LA; QL (3 per 30 days).
SUNOSI = PA; QL (30 per 30 days).
Specialty multiple sclerosis products and disease-modifying therapies frequently include PA; LA; QL entries.

Prior Authorization

Prior Authorization for Certain Coagulation/Hematology Agents

Certain coagulation and hematology agents require prior authorization and may have quantity limits. Ensure PA requests include indication and prior therapy history as appropriate.

Examples: DOPTELET = PA; LA. eltrombopag entries = PA; QL (strength-specific QL noted: 12.5/25 mg = QL 30/30d; 50/75 mg = QL 60/30d).
Erythropoiesis-stimulating agents and related products (ARANESP, EPOGEN, PROCRIT, RETACRIT) commonly require PA; LA.

Prior Authorization

PA and Quantity Limits for QFITLIA

Some products (e.g., QFITLIA) require both PA and have specific quantity limits (QL). Prescribers must supply documentation to justify overrides or exceptions.

QFITLIA PEN and QFITLIA solution = PA; QL (1 per 30 days).
Requests exceeding QL or lacking PA documentation may be denied.

Documentation Required

Documentation for Restricted Drugs

Documentation and supporting clinical information are required when drugs are subject to utilization management (PA, LA, QL, ST). Submit complete clinical rationale with PA requests to avoid delays or denials.

Provide diagnosis, prior therapies and responses, relevant labs or imaging, and rationale for dosing/quantity when submitting PA.
Specialty biologics and high-cost agents often require more detailed documentation (e.g., prior tumor testing, specialty monitoring, previous therapy failures).
For eltrombopag and other agents with strength-based QL, indicate why quantities above listed QL are medically necessary.

Denial Risk

Document Quantity Limits and Risk of Denial for Exceedance

Quantity limits (QL) are applied to many products; claims exceeding those limits may be denied or require additional justification. Check product-level QL and include supporting documentation for higher quantities.

Examples: oseltamivir QL entries (various formulations, e.g., 40/365, 20/365), PAXLOVID = QL (40 per 90 days), LIVMARLI formulations with differing QLs (9.5 mg/ml, 19 mg/ml, tablets).
Opioids and certain extended‑release products have QLs (e.g., morphine ER, OXYCONTIN) that may limit days supply or pill count.
When seeking an override, submit clinical justification and prior treatment history.

Step Therapy

Follow Per-Product Requirements (PA, ST, QL, ACA) and Step Therapy Rules

Follow each product's listed Requirements/Limits precisely — some entries include ACA, ST (step therapy), PA, LA, and QL. For ST entries, ensure required step edits are met before requesting coverage for the target drug.

Step therapy (ST) requires trial of specified alternative(s) before coverage of the ST-marked drug (examples: FANAPT, FETZIMA, REXULTI, VRAYLAR, TRINTELLIX; topical acne retinoids often list ST).
Some policies list ACA (Affordable Care Act) applicability — this may affect coverage and cost-sharing for preventive or women's health drugs.
Where ST is not explicitly detailed in the excerpt, standard step-edit processes still apply per plan systems; confirm with payer PA/step guidance.

Documentation Required

Submit Prior Authorization with Supporting Documentation

When submitting a prior authorization, include the required documentation and reference the per-product limits. For products with multiple flags (PA/LA/QL), explain both medical necessity and the need for quantities or limited-access handling.

Submit PA with clinical notes, prior medication history, lab/imaging as applicable, and the requested quantity and duration.
For products with strength‑dependent QL (e.g., eltrombopag), indicate which strength is prescribed and why the QL may need modification.
Missing documentation for PA/LA/QL requests is a common cause of denial—ensure completeness at submission.

Prior Authorization

PA Required for Some Ophthalmic Agents

Ophthalmic (eye) products may also be subject to PA. Check the Requirements/Limits field for ophthalmic agents and obtain PA when annotated to avoid coverage denial.

Example: BETOPTIC S and other selected ophthalmic entries may show PA; follow the annotated requirements.
Provide ocular diagnosis, prior therapies and rationale when requesting PA for eye drops or ophthalmic therapies.

Definitions and Key Flags

Drug tiers and MB

Tier definitionsTier 1: Preferred Generic; Tier 2: Preferred Brand; Tier 3: Non‑preferred; Tier 4: Specialty (generally biologics; often require special handling).

MB (Medical Benefit)MB includes drugs administered in a clinic, infusion center, or by home infusion and are covered under the medical benefit rather than the pharmacy benefit.

Actionable noteCheck Requirements/Limits column and 'Drugs Requiring Approval' page — specialty (Tier 4) and MB products often require prior authorization.

Prior Authorization (PA)

DefinitionPA = Prior Authorization; member or prescriber must obtain prior approval before the drug is covered.

Usage examplesPA appears in Requirements/Limits for many products (e.g., SOVALDI, LIVMARLI, many specialty agents).

ConsequenceFailure to obtain PA when required may result in the drug not being covered.

Och (oncology) designation

DefinitionOch = oncology designation flag used in the Requirements/Limits column to denote antineoplastic/oncology agents.

UsageOch is shown alongside PA/LA for many cancer agents (e.g., BOSULIF, IMBRUVICA) to indicate oncology-specific handling.

ImplicationEntries with Och often also include PA and/or LA — expect specialty review processes for oncology products.

Limited Access (LA)

DefinitionLA = Limited Access; indicates restricted distribution or special handling for the product in the Requirements/Limits column.

UsageLA appears with PA for multiple specialty injectables/biologics (e.g., BOSULIF, AVONEX) to denote restricted access pathways.

Operational noteProducts with LA may require site‑of‑care or vendor-specific procedures in addition to PA.

Quantity Limit (QL)

DefinitionQL = Quantity Limit; a maximum quantity covered per prescription or within a specified time frame (e.g., per 30 days, per 365 days).

ExampleQL (60 per 30 days) — e.g., many agents list 'QL (60 per 30 days)' as the allowable amount for a 30‑day period.

DocumentationPrescriptions exceeding listed QL may require documentation or prior authorization to be covered.

Prior Authorization (PA) — restated

Definition (concise)Prior Authorization (PA): a coverage requirement where the member or provider must obtain approval before the prescription is covered.

Where shownPA is listed in the Requirements/Limits column next to specific products (many specialty, high‑cost, or restricted drugs).

EffectClaims may be denied if PA is not obtained when indicated.

Step Therapy (ST)

DefinitionST = Step Therapy; requires trying specified alternative drugs first (a step) before the listed drug will be covered.

UsageST is indicated in Requirements/Limits for select agents (e.g., FANAPT, FETZIMA, dexlansoprazole) where step edits apply.

NoteSpecific step sequences are not listed in this extract; follow plan step‑edit rules when ST is shown.

Quantity Limit — per‑period limits

DefinitionQuantity Limit = maximum number of units allowed during a specified period (e.g., per 30 days); shown as QL (number per time period).

Per‑period exampleQL (1 per 365 days) — starter kits or single‑use packs may be limited to 1 per year (e.g., ZEPOSIA starter kit).

Provider actionPrescriptions above the QL require documentation or prior authorization and may be denied at point of sale.

Limited Access (LA) — restated

Definition (restated)LA = Limited Access; indicates special access restrictions (restricted distribution, site‑of‑care, or vendor controls) in the Requirements/Limits field.

Common pairingLA commonly appears with PA and Och for specialty/oncology agents (e.g., BOSULIF, AVONEX).

Implication for coverageLimited Access may require additional administrative steps beyond standard PA to complete authorization and dispense the drug.

PA (shorthand)

ShorthandPA = Prior Authorization (abbreviation used throughout Requirements/Limits).

Where to lookThe Requirements/Limits column shows 'PA' next to products that require prior approval prior to coverage.

Quantity Limit example

Simple exampleQL: 1 per 30 days — an example QL format showing one unit allowed per 30‑day period.

Typical displayQuantity limits are shown as 'QL (number per time period)' adjacent to the product entry in the formulary list.

Step Therapy reference (ST present)

ST referencedST (Step Therapy) is present for select agents in the Requirements/Limits column though the specific step criteria are not detailed in this excerpt.

Examples notedAgents such as FANAPT, FETZIMA, REXULTI, VRAYLAR, TRINTELLIX show 'ST' indicating step therapy applies.

Drug Tier (formulary classification)

DefinitionDrug Tier = formulary classification indicating relative cost‑sharing and coverage category (Tier 1–4 as shown in the formulary).

ExamplesTier 1 = Preferred Generic; Tier 2 = Preferred Brand; Tier 3 = Non‑preferred; Tier 4 = Specialty (often biologics).

PA / LA / QL (combined definitions)

PAPrior Authorization — requires approval prior to coverage when indicated in Requirements/Limits.

LALimited Access — denotes restricted distribution or special handling; often paired with PA.

QLQuantity Limit — numeric limit noted as 'QL (number per time period)'.

PA (restated)

Definition (concise)PA = Prior Authorization — a coverage approval required before the drug will be covered.

Displayed asShown as 'PA' in the Requirements/Limits column next to applicable drugs.

QL (restated with examples)

DefinitionQL = Quantity Limit — a maximum allowed quantity during a specified timeframe, shown as 'QL (number per time period)'.

ExamplesCommon examples include QL (8 per 30 days), QL (30 per 30 days), QL (60 per 30 days), QL (400 per 30 days).

ST (restated)

DefinitionST = Step Therapy — requires trial and failure of specified preferred alternatives before the requested drug is covered.

UsageAppears as 'ST' in Requirements/Limits for select products; specific step sequences are defined by plan rules (not in these chunks).

LA (restated)

DefinitionLA = Limited Access — a flag indicating special access restrictions or distribution controls for a product.

Common contextOften used with PA and Och for specialty and oncology products (e.g., BOSULIF, AVONEX).

ACA designation

ACA designationACA indicates an Affordable Care Act preventive coverage annotation used for certain contraceptives and related devices in the formulary.

EffectProducts marked ACA may be subject to preventive coverage rules (no member cost‑sharing where applicable).

PA (duplicate mapping)

Definition duplicatePA = Prior Authorization; indicates prior approval requirement before coverage.

Where seenPA is repeatedly used across Requirements/Limits for many specialty and high‑cost drugs.

LA (duplicate mapping)

Definition duplicateLA = Limited Access — indicates restricted distribution or handling; often accompanies PA.

ExamplesSeen with oncology and specialty products (e.g., BOSULIF, AVONEX).

QL (duplicate mapping)

Definition duplicateQL = Quantity Limit — numeric limit per specified timeframe, shown as 'QL (number per time period)'.

Typical formatExamples include QL (40 per 365 days), QL (60 per 30 days), QL (1 per 365 days).

ACA — contraceptive coverage annotation example

ACA exampleACA annotated for many contraceptive devices and products (e.g., IUDs, rings, oral contraceptives) indicating ACA‑related coverage treatment.

ImplicationACA entries may be covered without member cost‑sharing where plan and regulatory criteria apply.

ACA — preventive coverage designation

Preventive coverage noteACA = Affordable Care Act preventive coverage designation — applied to many contraceptives and related devices (no member cost‑sharing where applicable).

Where shownDisplayed in the Requirements/Limits column for applicable OB/GYN products and devices.

QL — per 30 days example

QL per 30 days exampleQL (30 per 30 days) — common QL format used for many tablet products (e.g., TIVICAY QL (60 per 30 days) illustrates per‑period notation).

InterpretationThe first number is the allowed quantity and the time unit follows (per 30 days, per 90 days, per 365 days).

PA; LA (combined definition)

Combined flagsPA; LA — entries with both flags require prior authorization and have limited access controls (common for specialty injectables).

Operational impactProviders must follow PA procedures and any LA‑specific distribution/site‑of‑care steps before claims will be approved.

Requirements / Limits = ACA

Requirements/Limits = ACAA plan‑specific designation applied to many products indicating they are subject to ACA‑related requirements and coverage handling.

ExamplesOften applied to contraceptives, some bowel prep products; consult plan documentation for operational details.

Step Therapy Listings and Notes

Scope	Summary
Formulary entries annotated with 'ST' (Step Therapy)	Step therapy may require trial of specified alternative drugs listed where 'ST' appears in the Requirements / Limits column; prescribers must follow plan step edits when ST is indicated.
[{"text":"Examples / evidence in document","status":""},{"text":"Document guidance explains ST and lists individual products with Requirements / Limits = ST (see product-level entries).","status":""}

Scope	Summary
Oncology / antineoplastic agents	Certain antineoplastic agents are listed with 'Och' and 'PA' (and sometimes 'LA'), indicating oncology‑specific managed pathways; these flags accompany utilization management but explicit ST sequences are not provided in the excerpt.
[{"text":"Examples / evidence in document","status":""},{"text":"Multiple oncology agents show Requirements / Limits = PA; Och; LA (e.g., ALECENSA, abiraterone), indicating oncology-specific handling alongside authorization requirements.","status":""}

Scope	Summary
General step therapy coverage note	Many products in the formulary require Prior Authorization (PA) or Limited Access (LA) as the primary utilization control; step‑therapy sequences are not specified for these items in the provided excerpts.
[{"text":"Examples / evidence in document","status":""},{"text":"Numerous specialty and biologic products are annotated with PA and/or LA in the Requirements / Limits column (see multiple entries), while ST sequences are not detailed in these segments.","status":""}

Scope	Summary
Specialty injectable / biologic items	In this segment PA and LA are the predominant controls for specialty injectables and biologics; explicit step therapy sequences are not provided in the excerpt.
[{"text":"Examples / evidence in document","status":""},{"text":"Entries such as ACTEMRA, ADALIMUMAB biosimilars, SIMPONI, and TYENNE are shown with Requirements / Limits = PA; LA, with no ST algorithm listed here.","status":""}

Drug / Class	Step Therapy status
DESVENLAFAXINE (extended release oral tablet) — psychotherapeutics	ST — Step Therapy indicated in Requirements / Limits for select psychotherapeutic agents.
FANAPT (iloperidone) — antipsychotic (tablets and titration packs)	ST — Requirements / Limits = ST for FANAPT and titration packs.

Drug / Class	Step Therapy status
FANAPT (iloperidone) — oral tablets and titration packs	Requirements / Limits = ST (step therapy) — plan step edits apply; prescribers must follow step rules.
FETZIMA (levomilnacipran) — extended‑release capsule	Requirements / Limits = ST — step therapy indicated for this agent.
REXULTI (brexpiprazole) — oral tablets	Requirements / Limits = ST — listed with ST in the formulary entries.
VRAYLAR (cariprazine) — oral capsules	Requirements / Limits = ST — ST annotation present in product entry.
TRINTELLIX (vortioxetine) — oral tablets	Requirements / Limits = ST — step therapy noted for this antidepressant.

Drug / Class	Step Therapy status
EDARBI (azilsartan) / EDARBYCLOR (azilsartan/chlorthalidone)	Requirements / Limits = ST — entries show ST annotation, but specific step details are not included in the excerpt.

Drug / Class	Step Therapy status
Adapalene topical formulations (cream, gel, lotion, swab) — acne topical retinoids	Requirements / Limits = ST — multiple adapalene products are designated ST, indicating a step edit applies before coverage.
AZELEX topical cream (azelaic acid) — acne topical agent	Requirements / Limits = ST — AZELEX is listed with ST in Requirements / Limits.

Drug / Class	Step/Authorization
Insulin combinations and select insulin products (e.g., INSULIN ASPART 70-30, SOLIQUA, TOUJEO MAX) — insulin therapy	Many insulin combination products are annotated with Requirements / Limits = PA; some products in the insulin class have utilization management flags including PA (and may have ST implications per plan edits).

Drug / Class	Step Therapy status
Metformin oral solution — antidiabetic (oral solution)	Requirements / Limits = ST — metformin oral solution is listed with ST in the Requirements / Limits field.
CORTIFOAM (hydrocortisone) rectal foam and select topical/rectal products	Requirements / Limits = ST — certain topical/rectal products show ST annotation in the document.

Drug / Class	Step Therapy status
Dexlansoprazole oral capsule 30 mg, 60 mg — proton pump inhibitor / ulcer therapy	Requirements / Limits = ST — dexlansoprazole is specifically marked ST in the formulary entry.

Scope	Summary
General excerpt — PA/LA primary	This segment shows many formulary entries primarily annotated with Prior Authorization (PA), Limited Access (LA), and Quantity Limits (QL); explicit step therapy sequences are generally not provided in these chunks.

Scope	Summary
Specialty injectable / biologic products	Many specialty injectable and biologic products are listed with Requirements / Limits = PA and often LA; step therapy sequences are not specified in the provided excerpts — PA is the primary utilization control.
Examples / evidence in document	Entries such as ACTEMRA, SIMPONI, ADALIMUMAB biosimilars, and ARANESP show PA (and LA for some), indicating prior authorization and limited access apply for specialty injectables.

Quantity Limits (QL) — Per-Product Values

Various QL examples

OverviewSee Requirements/Limits column for per‑drug QL values; examples include QL (8 per 30 days), QL (30 per 30 days), QL (4 per 30 days).

PurposeQuantity limits control supply dispensed and help manage utilization; exceeding them may require PA or documentation.

oseltamivir 30 mg QL

Drugoseltamivir oral capsule 30 mg — QL (40 per 365 days).

Period40 per 365 days (yearly limit).

oseltamivir 45/75 mg QL

Drugoseltamivir oral capsule 45 mg, 75 mg — QL (20 per 365 days).

Period20 per 365 days (yearly limit).

oseltamivir suspension QL

Drugoseltamivir oral suspension for reconstitution 6 mg/ml — QL (360 per 365 days).

Period360 per 365 days (yearly limit).

PAXLOVID QL

DrugPAXLOVID ORAL TABLETS (dose pack) — QL (40 per 90 days).

Period40 per 90 days.

RELENZA QL

DrugRELENZA DISKHALER (5 mg/actuation) — QL (2 per 365 days).

Period2 per 365 days.

REYATAZ QL

DrugREYATAZ ORAL POWDER 50 mg — QL (150 per 30 days).

Period150 per 30 days.

TIVICAY QL

DrugTIVICAY 50 mg — QL (60 per 30 days).

Period60 per 30 days.

STRIBILD QL

DrugSTRIBILD — QL (30 per 30 days).

Period30 per 30 days.

ritonavir 100 mg QL

Drugritonavir 100 mg — QL (360 per 30 days).

Period360 per 30 days.

zidovudine 100 mg QL

Drugzidovudine 100 mg capsule — QL (60 per 30 days).

Period60 per 30 days.

zidovudine syrup QL

Drugzidovudine oral syrup 10 mg/ml — QL (960 per 30 days).

Period960 per 30 days.

ivermectin 3 mg QL

Drugivermectin 3 mg — QL (20 per 30 days).

ContextListed with Requirements/Limits indicating QL for oral tablet form.

CAYSTON QL

DrugCAYSTON inhalation solution — QL (84 per 30 days).

Period84 per 30 days.

XIFAXAN QL

DrugXIFAXAN 200/550 mg — QL (60 per 30 days).

Period60 per 30 days.

VIRACEPT QLs

DrugVIRACEPT 250 mg — QL (90 per 30 days); VIRACEPT 625 mg — QL (60 per 30 days).

ContextPer‑strength QL values shown in Requirements/Limits.

JAKAFI QL

DrugJAKAFI — QL (60 per 30 days).

ContextListed with PA; Och; LA and QL in the Requirements/Limits field.

lapatinib QL

Druglapatinib — QL (180 per 30 days).

ContextListed with PA; Och; LA; QL (180 per 30 days).

RETEVMO / REVUFORJ QLs

DrugRETEVMO — QL (60 per 30 days); REVUFORJ — QL (240 per 30 days).

ContextShown with PA; Och; LA and specifed QL values.

EPIDIOLEX QL

DrugEPIDIOLEX oral solution 100 mg/mL — QL (400 per 30 days) and PA; LA indicated.

Period400 per 30 days.

subvenite QL

Drugsubvenite oral tablet — QL (120 per 30 days).

Period120 per 30 days.

Triptans QL examples

Drug class exampleTriptans (almotriptan, eletriptan, rizatriptan, frovatriptan, naratriptan, zolmitriptan, sumatriptan) — QL (18 per 30 days).

FormsSpecific agents and forms vary; several triptans show QL 18/30 days.

dihydroergotamine nasal spray QL

Drugdihydroergotamine nasal spray — QL (8 per 30 days).

Period8 per 30 days.

sumatriptan subcutaneous QL

Drugsumatriptan subcutaneous/cartridge/pen — QL (8 per 30 days).

FormsSubcutaneous forms limited to 8 per 30 days.

NURTEC ODT QL

DrugNURTEC ODT — QL (8 per 30 days).

Period8 per 30 days.

UBRELVY QL

DrugUBRELVY — QL (10 per 30 days).

Period10 per 30 days.

ZAVZPRET QL

DrugZAVZPRET nasal spray — QL (8 per 30 days).

Period8 per 30 days.

dalfampridine ER QL

Drugdalfampridine ER — QL (60 per 30 days).

Period60 per 30 days.

NUEDEXTA QL

DrugNUEDEXTA — QL (60 per 30 days).

Period60 per 30 days.

ZEPOSIA starter pack QL

DrugZEPOSIA starter pack — QL (1 per 365 days).

Period1 per 365 days.

Opioid QL examples

Opioid exampleshydrocodone ER and some hydromorphone ER — QL (60 per 30 days) where specified; morphine ER pellets QL (90); morphine ER tablets QL (120).

Typical effectOpioid ER products frequently have QL and PA annotations to manage dispensing.

ketorolac QL

Drugketorolac oral tablet — QL (20 per 5 days).

Period20 per 5 days (short‑course analgesic limitation).

MS injectables QL example

Specialty injectables/biologicsAVONEX and similar MS injectables — QL (1 per 30 days) and often PA; LA; many MS agents have PA/LA/QL annotations.

ImplicationThese products are typically managed with PA and limited access controls at the plan level.

SUNOSI QL

SUNOSISUNOSI — QL 30 (150 mg) or 60 (75 mg) per 30 days; Requirements/Limits = PA; QL.

Period30 or 60 per 30 days depending on strength.

eltrombopag QLs

eltrombopagEltrombopag 12.5/25 mg — QL (30 per 30 days); 50/75 mg — QL (60 per 30 days); Requirements/Limits = PA; QL.

Strength dependenceQL varies by strength as shown in the Requirements/Limits field.

QFITLIA QL

QFITLIAQFITLIA products (pen and solution) — Requirements/Limits = PA; QL (1 per 30 days).

Period1 per 30 days (device/pen limit).

rivaroxaban / XARELTO QL

rivaroxaban / XARELTOrivaroxaban 2.5 mg and XARELTO formulations — QL (60 per 30 days).

Period60 per 30 days.

icosapent ethyl QL

icosapent ethylicosapent ethyl — QL (120 per 30 days); Requirements/Limits = PA; QL.

Period120 per 30 days.

JUXTAPID QL

JUXTAPIDJUXTAPID — QL (30 per 30 days); Requirements/Limits = PA; LA; QL.

Period30 per 30 days.

DUPIXENT QL

DUPIXENTDUPIXENT subcutaneous pen/syringe — QL (4 per 30 days); Requirements/Limits = PA; LA; QL.

Period4 per 30 days.

NITRO-DUR QL

NITRO-DUR patchNITRO-DUR transdermal patch — QL (30 per 30 days).

Period30 per 30 days.

CRENESSITY / MYALEPT QLs

CRENESSITYCRENESSITY oral capsule — QL (120 per 30 days) for some strengths; other strengths QL (60 per 30 days); Requirements/Limits = PA; QL.

MYALEPTMYALEPT subcutaneous recon soln — QL (27 per 30 days); Requirements/Limits = PA; LA; QL.

Testosterone QL variations

testosterone formatsTestosterone transdermal gel formats have varying QLs: e.g., 60 per 30 days (50 mg/5 g), 2 per 30 days (metered pump 10 mg/0.5 g), 300 per 30 days (12.5 mg pump), 150 per 30 days (20.25 mg pump).

InterpretationQL depends on product format and strength as listed in Requirements/Limits.

tolvaptan QL

tolvaptantolvaptan — QL (60 per 30 days); Requirements/Limits = PA; LA; QL.

Period60 per 30 days.

aprepitant QLs

aprepitantaprepitant 125 mg — QL (1 per 30 days); aprepitant 80 mg — QL (2 per 30 days).

PeriodPer 30 days as listed in Requirements/Limits.

LIVMARLI QL(s)

LIVMARLILIVMARLI oral solution/tablet — QL varies by formulation/strength (examples: QL 30, 60, 90 per 30 days); Requirements/Limits = PA; QL.

Operational noteCheck specific strength/formulation entry for the exact QL for a prescription.

ondansetron / SUCRAID QLs

ondansetronondansetron oral solution — QL (2 per 30 days); ondansetron tablets/disintegrating — QL (9 per 30 days).

SUCRAIDSUCRAID oral solution — QL (236 per 30 days); Requirements/Limits = PA; QL.

teriparatide and biologic QLs

teriparatideteriparatide subcutaneous pen injector — QL (1 per 30 days); Requirements/Limits = PA; LA; QL.

Biologic injectablesMany biologic injectables list PA and LA and have QLs (e.g., PROLIA, SIMPONI) — follow per‑product limits.

Transdermal / estradiol QLs

transdermal/patch QLsdotti patch — QL (8 per 30 days); estradiol transdermal patch weekly — QL (4 per 30 days); estradiol gel packets — QL (30 per 30 days) or Evamist QL (2 per 30 days).

ContextTopical/transdermal formulations commonly show per‑30‑day QLs in Requirements/Limits.

OpenPayer

Metallic (M4) Formulary Drug List — Coverage Criteria

Coverage Criteria and Changes

Provider Requirements, Prior Authorization, and Documentation

Formulary Background

Definitions and Key Flags

Per-Product Initial Requirements (Examples)

Step Therapy Listings and Notes

Quantity Limits (QL) — Per-Product Values

Medical Benefit / Site-of-Care Notes