CurrentPresbyterian Health PlanPolicy N/A
Commercial 4-Tier Prescription Drug Formulary — Coverage Criteria
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Defines the Presbyterian Health Plan and Presbyterian Insurance Company Commercial 4-tier formulary structure, management processes (prior authorization, step therapy, quantity limits), and member/provider processes for exceptions and inquiries; applies to commercial plan members and providers in the plan's service area.
Policy Summary
PayerPresbyterian Health Plan
PolicyCommercial 4-Tier Prescription Drug Formulary — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization and submit required clinical documentation (including diagnosis validation and applicable NDC) when a product is annotated with PA or DX.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
4Formulary tiers (Tier 1-4)
72hStandard PA processing time (when complete)
24hExpedited PA processing time
$25Preferred insulin copay cap
multipleListed with PA requirement
biologicsDX / SP flags present
Coverage Criteria and Product-Level Controls
General Medical Necessity and Prior Authorization
Covered when ALL of the following are met:
Formulary coverage general criteria: Drug is a covered benefit under the member's specific plan AND prior authorization (if required) is approved based on medical necessity and appropriateness.
Medical Director or other clinical professional will review PA requests; non‑Formulary drugs require medical exception documentation.
Formulary utilization management controls
Products listed on the formulary are subject to the utilization management controls shown on each product line; coverage requires adherence to those controls.
UM flag adherence: If a formulary line includes any of the following notes, coverage requires compliance with that control: PA (Prior Authorization), DX (Diagnosis Validation), QL (Quantity Limit), AL (Age Limit), ST (Step Therapy), NDS, SP (Specialty Pharmacy), or CB (Copay Cap).
Apply per‑product as annotated in the formulary entries.
Product-specific coverage criteria (examples)
Coverage of listed formulary drugs is governed by the product-specific utilization management notes shown next to each formulation (examples):
Acetaminophen–codeine products (pediatric rules): Not covered for patients under 12 years of age; for patients age 12–18 years prior authorization is required; quantity limits apply as noted (e.g., QL 166 mL per 1 day for some solutions; QL 13 EA per 1 day for tablets).age <12 => not covered; age 12-18 => PA
See formulary product lines for exact QL and AL values.
Butalbital-containing combinations: Certain butalbital combinations require prior authorization for minors (12–18) and are not covered under 12; quantity limits (e.g., QL 6 EA per 1 day) apply per formulation.age <12 => not covered; age 12-18 => PA
Apply product-specific Notes.
Extended‑release opioid formulations: Some ER opioid products are subject to step therapy (ST) and quantity limits; Schedule II products are limited to a maximum 34‑day supply where noted.Schedule II => max 34-day supply
Follow ST and QL flags on product lines.
MOUD and buprenorphine products: Buprenorphine and related MOUD products may be flagged BH (behavioral health), have age limits and quantity limits, and may require specialty pharmacy handling (SP); coverage follows those annotations.varies by product
See specific product Notes for QL and AL.
Formulary coverage logic
Coverage is determined by formulary tier and the utilization-designation flags shown on each line item:
Formulary coverage logic: Coverage follows the assigned formulary tier; products annotated with PA require prior authorization before coverage, ST indicates step therapy edits that require documented trial/failure of prerequisite agents, QL indicates an allowable quantity per timeframe, and AL denotes minimum/maximum age restrictions. BH notes may indicate behavioral‑health zero cost‑share where applicable.
Providers must supply required documentation (PA, DX, evidence of step failure, etc.) when submitting requests.
Insulin products
Insulin products are covered according to tier, copay cap, and quantity limits as listed:
Preferred insulin coverage: Preferred formulary insulins (Tier 2 entries) are covered with a copay cap (CB) not to exceed $25.00 per 30‑day supply for eligible plans; High Deductible Health Plan members remain subject to deductible rules.CB <= $25 per 30 days
Document on claim/PA as required.
Insulin quantity limits: Insulin pen/cartridge/solution QLs are applied per product (common examples: QL 45 mL per 30 days or QL 50 mL per 30 days; select U‑500 products have distinct QLs such as 18 mL per 30 days).QL examples: 45-50 mL per 30 days
Follow the specific product QL in the formulary line.
GLP-1/GIP agents
Incretin mimetic agents (GLP‑1 and GIP) are subject to utilization controls as annotated:
GLP‑1/GIP coverage: Selected incretin mimetic agents (e.g., Mounjaro, Trulicity) require prior authorization (PA) and are subject to quantity limits (example QL 2 mL per 28 days); some entries include NDS or other plan flags.QL 2 mL per 28 days
PA required where noted on the formulary line.
Oral antidiabetics and combinations
Oral antidiabetic agents and combinations are managed with tiering and utilization edits:
Oral antidiabetic utilization: Multiple oral antidiabetic agents and combinations are assigned tiers and may require step therapy (ST) and quantity limits (examples: Steglujan marked ST with QL 30 EA per 30 days; dapagliflozin noted ST and QL 30 EA per 30 days).varies by product
Follow ST and QL flags per product line.
Supportive and specialty medications
Supportive, antidote, antiemetic, and antifungal medications have product-level UM annotations:
Supportive and specialty agents: Naloxone, naltrexone/Vivitrol, antiemetics (ondansetron, palonosetron, aprepitant/Emend/Cinvanti) and antifungals (echinocandins, Ambisome, voriconazole) are listed with tiers and may require prior authorization (PA), quantity limits (QL), or be designated MB or SP per the formulary line.varies
Refer to each product line for PA/QL/MB/SP specifics (e.g., naloxone QL 2 mL per 30 days; Vivitrol QL 1 EA per 28 days; Emend IV = PA).
Formulary utilization controls
Formulary utilization controls summarized for provider guidance:
Utilization control summary: Products annotated with PA require prior authorization; products with QL are limited to the specified quantity per timeframe; ST indicates step therapy edits requiring documented trials of prerequisite agents; AL indicates age limits; NDS and SP indicate other plan-specific handling; BH indicates behavioral health zero cost‑share may apply; STI indicates zero cost‑share when used for STI prevention/treatment per benefit rules.
Providers must follow the annotations on each formulary line when submitting claims or PA requests.
Formulary product-level coverage rules
Coverage and restrictions are listed per product — follow the product line entry for the exact combination of tier and utilization flags:
Per‑product coverage rules: Each formulary product line assigns a tier and may include notes such as PA, QL, AL, BH, DX (diagnosis validation), SP, NDS, or CB; coverage and approval depend on meeting those annotations and any documentation requirements.
See individual product entries for required documentation (e.g., DX for biologics, PA for injectables).
Contraceptives - coverage and copay notes
Contraceptive products are covered with specific supply and copay guidance:
Contraceptive coverage: Multiple contraceptive formulations (oral, transdermal, vaginal ring, IUD, injectable, emergency contraceptives) are listed with tiering; many carry a '$0 Copay per PPACA guidelines' note and 'Up to a six‑month supply' where indicated.Up to 6 months supply where noted
Apply PPACA $0 Copay notes per benefit plan rules; documentation of supply may be required.
Steroids and cough/cold - coverage notes
Selected corticosteroids and cough/cold products have quantity and age-based restrictions:
Steroids and cough/cold coverage notes: Budesonide delayed‑release capsules have an annual QL (e.g., QL 448 EA per 365 days); certain cough/cold codeine‑containing or guaifenesin‑codeine products are not covered for patients under 12 years and require prior authorization for ages 12–18.Budesonide QL 448 per 365 days; cough/cold age rules: <12 not covered; 12-18 => PA
Follow product line entry for exact QL and AL values.
Presbyterian Health Plan maintains a closed Formulary: the Formulary is a continually updated preferred drug list intended to encourage safe, effective, and cost‑efficient medication use. Non‑Formulary drugs are not routinely reimbursed and require a medical exception showing medical necessity for coverage; the medical exception process is the route to request coverage of non‑Formulary medications.
Benefit exclusion designations identify drugs that are not a covered benefit under the plan and therefore are not eligible for reimbursement regardless of clinical justification unless otherwise specified by separate benefit language.
Within the extracted formulary segments there are no additional, explicit categorical exclusions listed; instead coverage is governed at the product level by tiering and utilization management notes (e.g., PA, QL, ST, AL) shown on individual line items.
Certain codeine‑, tramadol‑, and related combination cough/cold and analgesic products are explicitly not covered for patients under 12 years of age. For patients aged 12–18 years these products require prior authorization (PA) before coverage; consult the individual product line note for the specific PA and quantity limit (QL) that applies.
Formulary entries include the product’s tier and an associated Notes field; Notes commonly indicate utilization controls such as PA (prior authorization), ST (step therapy), QL (quantity limits), AL (age limits), and benefit flags (e.g., BH, $0, MB).
Preferred insulin products carry a copay cap (CB) of $25 per 30‑day supply when noted as the preferred formulary insulin; many insulin and specialty lines also list specific QLs (for example, common insulin QLs of 45 mL or 50 mL per 30 days) which must be followed and documented on claims or prior authorization submissions.
Formulary Entries, Codes, and Quantity Limit Examples
Formulary drug entries (selected)mixed
| palonosetron hcl intravenous solution 0.25 mg/2ml | palonosetron hcl IV solution 0.25 mg/2ml — Tier = MB; Notes = QL (2 ML per 5 days). |
| caspofungin acetate intravenous solution reconstituted 50 mg | caspofungin acetate IV solution reconstituted 50 mg — Tier = MB; Notes = listed under ECHINOCANDINS. |
| caspofungin acetate intravenous solution reconstituted 70 mg | caspofungin acetate IV solution reconstituted 70 mg — Tier = MB; Notes = listed under ECHINOCANDINS. |
| promethazine hcl injection | promethazine hcl injection — formulary entry (injectable) with corresponding notes where applicable. |
| promethazine hcl oral | promethazine hcl oral formulations (tablet/syrup) — formulary entry where applicable. |
| promethazine hcl rectal | promethazine hcl rectal formulation (suppository) — formulary entry where applicable. |
| REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML | REPATHA subcutaneous solution prefilled syringe 140 mg/mL — product-level entry (ensure covered NDCs / PA/QL per biologic section where applicable). |
| amlodipine benazepril combination | amlodipine benazepril combination products — ACE/ARB combination entries included in formulary (ensure corresponding tier/QL if present). |
| ACE/ARB/HCTZ combinations | ACE/ARB/HCTZ combination products — combination antihypertensive entries included in formulary. |
| vancomycin hcl IV reconstituted 500 mg | vancomycin hcl IV reconstituted 500 mg — IV formulation entry (parenteral). |
1–10 of 15
1/2
Covered biologic NDC examplesNDCCovered
| AMJEVITA 40 MG/0.4ML auto-injector | Covered NDCs: 55513-0482-01, 55513-0482-02; QL (1.6 ML per 28 days). |
| AMJEVITA 40 MG/0.8ML auto-injector | Covered NDCs: 72511-0400-01, 72511-0400-02; QL (3.2 EA per 28 days). |
| AMJEVITA 80 MG/0.8ML | Covered NDCs: 55513-0481-01, 55513-0481-02; QL (1.6 ML per 28 days). |
| AMJEVITA 40 MG/0.4ML prefilled syringe | Covered NDCs: 55513-0479-01, 55513-0479-02; QL (1.6 ML per 28 days). |
| HUMIRA (2 PEN) 40 MG/0.4ML | Covered per listed NDCs where applicable; QL (2 EA per 28 days). |
| KEVZARA 150 MG/1.14ML prefilled syringe | Covered examples with QL (2.28 ML per 28 days). |
| REPATHA 140 MG/ML prefilled syringe | REPATHA (evolocumab) prefilled syringe 140 mg/mL — ensure covered NDCs referenced in product list where applicable. |
Regulatory scheduling notemixed
| Schedule II supply limit | Schedule II medications are limited to a 34 day supply maximum (as noted on morphine sulfate ER entries). |
Quantity Limits and Notes examplesmixed
| QL (30 EA per 30 days) | Multiple stimulant entries (e.g., amphetamine-dextroamphetamine) — QL (30 EA per 30 days) and variations present. |
| QL (60 EA per 30 days) | Various formulations show QL (60 EA per 30 days) per line. |
| QL (90 EA per 30 days) | Some agents list QL (90 EA per 30 days). |
| QL (120 EA per 30 days) | Higher QL examples (e.g., lamotrigine ER lines). |
| QL (50 ML per 30 days) | Insulin/solution ML-based QL examples (e.g., HUMALOG QL 50 ML per 30 days). |
| QL (45 ML per 30 days) | Insulin QL examples (45 ML per 30 days) as listed for several insulin pens/solutions. |
| QL (2 ML per 5 days) | Palonosetron IV QL example: QL (2 ML per 5 days). |
| QL (1.6 ML per 28 days) | Biologic ML-based QL examples for AMJEVITA and others. |
| QL (3.2 EA per 28 days) | Biologic EA-based QL examples (AMJEVITA 0.8 mL autoinjector). |
| QL (448 EA per 365 days) | Example QL (448 EA per 365 days) appears with budesonide oral capsule entry and is included here. |
1–10 of 15
1/2
No procedure or billing codesmixed
| No codes listed |
Formulary drug lines (no billing codes in excerpt)mixed
| metformin entries | Metformin ER and regular tablet lines included under BIGUANIDES. |
| insulin product entries | Humalog, Humulin, Lantus and others with CB copay cap notes and QL (45-50 ML per 30 days) present. |
Formulary product entries (partial)mixed
| ondansetron oral dispersible 4 mg/8 mg | ondansetron oral tablet dispersible 4 mg, 8 mg — QL (90 EA per 30 days). |
| palonosetron hcl IV 0.25 mg/2ml | palonosetron hcl IV 0.25 mg/2ml — Tier = MB; QL (2 ML per 5 days). |
| aprepitant oral capsule | aprepitant oral capsule 125 mg, 40 mg — PA; QL (1 EA per 30 days). |
Selected urinary/antimalarial entriesmixed
| nitrofurantoin products | Nitrofurantoin macrocrystal and monohydrate forms included; oral suspension QL noted. |
| chloroquine phosphate 250/500 mg | Chloroquine phosphate oral tablet 250 mg, 500 mg included. |
| hydroxychloroquine sulfate 200 mg | Hydroxychloroquine oral tablet 200 mg included. |
Selected antineoplastic/targeted therapy entriesmixed
| REPATHA 140 mg/mL | REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML noted among biologic entries — ensure PA/coverage per policy where applicable. |
| various antineoplastics | Multiple antineoplastic agents listed with PA/QL/DX requirements (e.g., ALECENSA, ALUNBRIG, KEYTRUDA QLEX). |
Diagnosis codes referencedICD-10
| DX (Diagnosis Validation Required) | Many biologic and antineoplastic entries require diagnosis validation at point of sale or prior authorization. |
Quantity-limit statements (formulary lines)mixed
| QL examples | Consolidated QL statements preserved (30/60/90 per 30 days, ML per 28/30 days, EA per 365 days such as 448 EA per 365 days). |
Quantity limits — examplesmixed
| QL (2 ML per 5 days) | palonosetron IV QL example preserved. |
| QL (448 EA per 365 days) | Budesonide oral capsule QL example preserved. |
| QL (50 ML per 30 days) | Insulin copay cap QL examples preserved (50 ML/HUMALOG etc.). |
Prior Authorization, Step Therapy, Documentation, and Denial Risks
Prior Authorization
Prior Authorization Required
Prior authorization (PA) is required for many specific formulary products including select biologics, specialty and oncology agents, certain antivirals/hepatitis agents, select opioids and cough/cold preparations for pediatric ages, and other listed drugs. When a drug entry includes a PA note or PA flag, prescribers must submit a Prior Authorization request and supporting clinical documentation. PA requests are reviewed by a Medical Director or other clinical professional to determine medical necessity and benefit coverage; PA approval does not guarantee payment if coverage ends before service delivery.
- PA required when 'PA' appears in formulary Notes for the product.
- Many biologics/specialty agents require both PA and diagnosis validation (DX) and may restrict to covered NDCs — provide NDC when requested.
- PA applies to numerous oncology and antineoplastic agents; diagnosis validation (DX) is commonly required at PA or point of sale.
- Select antiviral/hepatitis agents (e.g., MAVYRET, sofosbuvir-velpatasvir, entecavir, valganciclovir) require PA and may have QL/NDS/SP flags.
- Some injectables/long-acting therapies (e.g., ABILIFY MAINTENA, CABENUVA, SPRAVATO) require PA and have quantity and age limits.
- Select opioids and codeine-containing cough/cold products are subject to PA and pediatric age-based coverage limits (not covered under certain ages; PA required for adolescents).
- Schedule II controlled medications are limited to a 34-day supply maximum where noted.
- PA approvals may require prescriber-supplied clinical information, diagnosis codes, prior trials (for step therapy), and covered NDCs for product-specific coverage.
- If required PA, DX, QL, ST, BH, CB or AL notes are not followed or documentation is missing, requests may be denied.
- Expedited PA requests are processed within 24 hours when delay could jeopardize health; standard requests processed within 72 hours when complete.
Step Therapy
Step Therapy Applies — Prescribe/Document Prerequisite Trials
Step therapy (ST) applies to numerous formulary items. Where a product is noted with 'ST' or step edits, coverage requires prior use of prerequisite FDA‑approved drugs (the plan does not publish a specific algorithm in this document). Prescribers should document prior therapies tried and reasons for failure or intolerance to meet step therapy requirements. Common examples include DPP‑4 combinations, certain inhaled asthma products (DULERA), anticonvulsants and some antidiabetic combinations and insulins where ST is indicated.
- Step therapy applies when the formulary Notes include 'ST' or list prerequisite agents.
- No explicit step therapy algorithm is provided here; prescribers must document prior trials or request a medical exception.
- Step therapy examples: JANUMET XR (ST), DULERA (ST), saxagliptin‑metformin er (PA/QL) and certain SGLT2/DPP4 combinations.
Documentation Required
Documentation Required for PA / Medical Exceptions
Provide complete clinical documentation with PA or medical exception requests. This includes diagnosis validation (DX) when required, relevant patient history, prior therapy trials and failures, NDCs for product‑specific coverage, and any supporting labs or notes. Missing or incomplete information is a common denial trigger.
- Prescribers must provide clinical rationale and documentation to support PA/medical exceptions.
- When DX is required in the Notes, include the diagnosis code and any requested clinical validation.
- Provide the NDC when coverage is limited to approved products or NDCs are listed.
- Follow all Notes flags: PA, ST, QL, BH, CB, AL, DX, NDS, SP as applicable to avoid denials.
Billing Rule
Benefit-Based Coverage Controls and Flags
Benefit‑based coverage controls (BH, CB, QL, AL, NDS, SP) are applied across the Formulary and impact PA decisions and point-of-sale coverage. Providers must follow note flags and stated limits; exceeding QLs or missing PA/ST can result in claim denial or request for additional information.
- BH indicates behavioral‑health related coverage rules (may include zero cost‑share in some plans).
- CB indicates copay cap rules (e.g., insulin $25 cap) and must be documented where applicable.
- QL (quantity limits) and AL (age limits) must be adhered to; requests exceeding these require justification via PA.
- NDS (non‑standard dispensing/special handling) and SP (specialty) flags denote specialty or non-routine distribution requirements.
Denial Risk
PA and Quantity Limit (QL) Triggers
PA and QL triggers — many products are subject to quantity limits and PA; exceeding QL or bypassing PA may prompt utilization review or denial. Copay cap (CB) documentation also applies for insulins and must be considered when processing claims.
- Quantity Limits (QL) are specified per product (daily, per 30 days, per year); observe and document any requests exceeding those limits.
- Copay cap (CB) for preferred insulins must be applied and documented per plan rules.
- Requests that present PA+QL conflicts require prescriber justification and may be subject to denial without adequate documentation.
Prior Authorization
Prior Authorization and Age-Based Limits
PA for age‑specific use: Several products include age limits (AL) or are not covered under certain ages. Examples include codeine- and opioid-containing cough/cold products, tramadol (pediatric age restrictions), and many behavioral health agents requiring PA for patients under defined ages. Prescribers must confirm patient age and include age‑appropriate justification when requesting PA.
- Not covered for patients under specified ages — do not submit PA unless plan Notes permit (e.g., some codeine products not covered <12 years).
- PA required for adolescent age group (e.g., 12–18) for certain opioid/cough products — include age in the request.
- Some long‑acting injectables and intramuscular products have minimum age requirements (AL) listed; verify prior to submission.
Prior Authorization
PA for Specialty and Oncology Drugs — DX and NDCs Required
Specialty and oncology agents frequently require PA plus diagnosis validation and may be limited to specific covered products/NDCs. Prescribers should supply diagnosis, staging or indication details, requested regimen, prior therapies, and NDCs when the Notes require coverage only for approved products.
- Many antineoplastics list PA and DX (Diagnosis Validation Required) — include clinical oncology documentation.
- Coverage often limited to approved NDCs; see product Notes (e.g., AMJEVITA covered NDCs).
- Specialty flags (SP) and non‑standard dispensing (NDS) may necessitate specialty pharmacy routing.
Denial Risk
Denial Risk — Follow PA/ST/DX and Documentation Requirements
Denial risk if PA/ST/DX/documentation missing: Requests that do not meet PA, step therapy, quantity, age, diagnosis validation, or required documentation criteria will be denied. Ensure full adherence to formulary Notes and submit all requested information to reduce adverse determinations.
- Denials are common when prior authorization is not obtained for PA‑flagged drugs or when step therapy prerequisites are unmet.
- Incomplete clinical information, missing DX, or not providing required NDCs can trigger adverse determinations.
- Expedite requests only when medically necessary — otherwise follow standard 72‑hour processing timelines.
Initiation and Pediatric Initiation Controls
Pediatric initiation constraints
Pediatric initiation constraints for certain opioid‑containing and related products:
Acetaminophen‑codeine and codeine‑containing products (pediatrics): Not covered for patients under 12 years of age. For patients aged 12–18 years, prior authorization is required for initiation of therapy; quantity limits and minimum age annotations apply per product line.age <12 => not covered; age 12-18 => PA
Examples and exact QLs are listed on product lines (see acetaminophen‑codeine solution/tablet entries).
Initiation controls
Initiation controls captured in formulary notes govern access at start of therapy:
Initial therapy PA/ST requirements: Certain agents require prior authorization at initiation (PA) and some agents or classes require step therapy (ST) — prescribers must document trials of prerequisite agents or provide clinical justification per the ST/PA requirements shown on the formulary line.
Examples: selected GLP‑1/GIP agents require PA and QL (e.g., QL 2 mL per 28 days); select oral antidiabetics and combinations are marked ST with specified QLs.
Step Therapy Rules and Examples
| Step therapy definition | Notes |
|---|---|
| Step therapy requires prior use of one or more FDA‑approved prerequisite drugs that treat the same condition before covering a step‑therapy medication. | Prerequisite drugs are specified by the plan; prescribers must document trial and failure or contraindication to those agents when submitting requests. |
| Step therapy promotes use of equally effective lower‑cost formulary drugs first; coverage of the requested drug is contingent on meeting ST requirements. | ST is applied as noted on formulary product lines; when ST applies, documentation of prior drug trials is required for approval. |
| Presence of explicit algorithm | Notes |
|---|---|
| No explicit multi‑step algorithm is specified in the extracted formulary chunks. | Many products instead rely on prior authorization (PA), diagnosis validation (DX), quantity limits (QL), age limits (AL), or specialty pharmacy (SP) flags as the primary utilization controls. |
| When an explicit ST sequence is not provided, PA and DX requirements should be followed as indicated in the product Notes. | Absence of a detailed algorithm means prescribers must follow product‑level Notes and contact the plan for required prerequisite agents if unclear. |
| Class / examples | Notes |
|---|---|
| Certain extended‑release (ER) opioid products (e.g., morphine ER, oxymorphone ER) | Formulary Notes indicate ST applies to some ER opioid formulations; Schedule II products also have a 34‑day supply maximum. |
| Selected ER opioids listed with 'ST' in product Notes | Where ST applies, prior use of prerequisite opioid therapy as defined by the plan is required; PA and QL also commonly apply. |
| Example product | ST / Notes |
|---|---|
| DULERA inhalation aerosol | Notes = ST; QL (13 GM per 30 days). |
| XOLAIR (example in doc) | Listed with utilization controls; ST flag appears on multiple agents in this class. |
| clobazam (oral suspension and tablets) | Notes = ST; QL (8 mL per 1 day for suspension; 2 EA per 1 day for tablets). |
| diazepam rectal gel | Notes = ST; BH; QL (5 EA per 30 days); AL. |
| NAYZILAM nasal solution | Notes = QL (10 Delivery Systems per 30 days); ST flag appears on related anticonvulsant entries. |
| VALTOCO nasal liquid / therapy packs | Notes = ST; QL (10 EA per 30 days or 5 packs per 30 days depending on strength); AL (Min 2 Years). |
| Products annotated 'ST' | Specific step therapy requirement (summary) |
|---|---|
| clobazam (oral suspension, tablets) | Notes indicate ST; prescriber must document trial/failure of prerequisite agents; QL specified (suspension 8 mL/day; tablets 2 EA/day). |
| diazepam rectal gel | Annotated ST; documentation of prior trials required; QL 5 EA per 30 days; BH note present. |
| lacosamide oral solution | Notes = ST; QL (1200 mL per 30 days) for solution formulation. |
| VALTOCO (various strengths/packs) | Notes = ST; QL varies by formulation (10 EA or 5 packs per 30 days); minimum age requirements apply. |
| Other anticonvulsants referenced with ST | When ST is annotated, plan requires trial of specified prerequisite agent(s) before covering the ST drug. |
| DPP‑4 / combinations | ST / Notes |
|---|---|
| JANUMET XR (sitagliptin‑metformin XR) / alogliptin‑metformin combinations | Notes = ST (JANUMET XR = ST; alogliptin‑pioglitazone combos = ST); QL examples (JANUMET XR QL 60 EA per 30 days). |
| saxagliptin‑metformin ER combinations | Notes = PA; some DPP‑4 inhibitors and combinations are annotated ST or PA per formulary lines. |
| Oral antidiabetics / antiemetics | ST / Notes |
|---|---|
| Steglujan, dapagliflozin, Steglatro, Segluromet | Notes = ST on multiple oral antidiabetic combinations; QL commonly 30 EA per 30 days (Steglujan, dapagliflozin examples). |
| Granisetron / ondansetron / aprepitant (antiemetics) | Some antiemetics (e.g., granisetron noted elsewhere) and aprepitant entries show ST or PA; ondansetron noted with QL (90 EA per 30 days). |
| ST enforcement | Supporting note |
|---|---|
| Where product Notes include 'ST', step therapy edits are enforced at claim/authorization processing. | Prescribers must document prior use/failure of required prerequisite agents or provide justification for medical exception. |
| If ST is absent but PA/DX flags present, PA/DX remain primary controls. | No universal step sequence specified in this extract; follow product‑level Notes for required prerequisites. |
| Oral oncology agents | ST / Notes |
|---|---|
| Some oral oncology agents (examples: VENCLEXTA, erivedge, daurisimo) note PA and DX; QLs are listed per product. | No explicit multi‑step ST algorithm is present for oral oncology agents in these chunks; PA and DX are the primary utilization controls. |
| Specialty handling flags (NDS, SP) and QL often accompany PA/DX for oral oncology agents. | When step edits are needed, the plan will specify them on the product line; none are detailed here. |
| Specialty oncology agents | Implication |
|---|---|
| Multiple specialty oncology agents are marked with PA, DX, NDS, and SP (e.g., LENVIMA, INLYTA, ALECENSA). | These flags imply specialty pathways and required documentation but do not provide explicit step therapy sequencing in this excerpt. |
| Prescribers must submit diagnosis validation and follow PA requirements for approval. | Quantity limits and specialty pharmacy handling are common controls for these agents. |
| sacubitril‑valsartan (Entresto) | ST / QL |
|---|---|
| sacubitril‑valsartan oral tablet | Notes = ST; QL (60 EA per 30 days). ENTRESTO sprinkle noted as PA; sacubitril‑valsartan explicitly annotated 'ST' indicating step therapy applies. |
| Guaifenesin‑codeine / cough products | Coverage / PA / Age limits |
|---|---|
| guaifenesin‑codeine oral solution / G Tussin AC / guaiatussin AC | Notes = PA; Not covered for patients under 12 years of age. Prior authorization required for patients 12–18; AL Min 12 Years specified. |
| Guaifenesin‑codeine oral solution (100‑10 mg/5 mL) examples | Coverage requires prior authorization for ages 12–18 and is not covered for <12 years. Documentation must support PA per formulary Notes. |
Quantity Limits and Per-Product Examples
inv-179: Multiple individual formulary drugs — examples: 30 EA/30 days; 60 EA/30 days; 120 EA/30 days; 14 EA/7 days; 1 EA/day
30 EA / 30 daysExample common QL: 30 EA per 30 days
60 EA / 30 daysExample common QL: 60 EA per 30 days
120 EA / 30 daysExample common QL: 120 EA per 30 days
14 EA / 7 daysExample short-interval QL: 14 EA per 7 days
1 EA per dayDaily unit limit example: 1 EA per day (e.g., certain anorexiants/phentermine)
inv-180: Preferred formulary insulin — $25 copay cap
Preferred formulary insulin copay capPreferred formulary insulin: copay not to exceed $25 per 30-day supply
Applies across insulin brands/formsCopay cap noted on multiple insulin product lines (pens/cartridges/solutions)
HDHP applicationHigh Deductible Health Plan members subject to deductible first though cap remains in language
inv-181: AMJEVITA subcutaneous solution — QL (1.6 ML per 28 days)
AMJEVITA QL (auto-injector 0.4 mL)QL 1.6 mL per 28 days for AMJEVITA 40 mg/0.4 mL presentations
AMJEVITA covered NDCsCoverage applies to approved products only; specific covered NDCs are listed on formulary (see product line)
DX and specialty flagsAMJEVITA entries include DX (Diagnosis Validation Required) and SP/NDS flags
inv-182: HUMIRA various presentations — QL (2 EA per 28 days) or as listed
HUMIRA QLHUMIRA presentations: QL 2 EA per 28 days (or as listed by presentation)
PA and DXHUMIRA lines include PA and DX (Diagnosis Validation Required) and flags for NDS and SP
Presentation-specific QLsSome HUMIRA kits/pens list alternative QLs (e.g., 1 kit per 28 days) per presentation
inv-183: TYENNE — QL (3.6 ML per 28 days)
TYENNE QLTYENNE subcutaneous presentations: QL 3.6 mL per 28 days
PA/DX/SP flagsTYENNE entries include PA; DX (Diagnosis Validation Required); SP/NDS as applicable
IV formulations notedTYENNE IV presentations listed (MB tier) with PA/DX flags per product
inv-184: OTEZLA 30 mg — QL (60 EA per 30 days)
OTEZLA QLOTEZLA (apremilast) 30 mg oral tablet: QL 60 EA per 30 days
PA and DXOTEZLA line notes include PA and DX (Diagnosis Validation Required); NDS and SP flags
Therapy packOTEZLA therapy pack entries reference same QL (60 EA per 30 days)
inv-185: Stimulant agent QLs — range 30–120 EA per 30 days depending on formulation
Stimulant QL rangeStimulant agents (e.g., armodafinil, methylphenidate) show QLs ranging from 30 to 120 EA per 30 days depending on formulation
Age limits and PAMany stimulant entries include AL (minimum age) and PA notes for select formulations
Formulation-specific QLsExamples across entries: QL 30 EA/30 days; QL 60 EA/30 days; QL 120 EA/30 days
inv-189: Morphine sulfate ER beads/capsules — QL (30)
Morphine sulfate ER QLMorphine sulfate ER beads/capsules: QL 30 (EA per 30 days) noted for selected formulations
ST and Schedule II notesMorphine ER entries include ST; Schedule II formulary lines reference the 34-day supply maximum
Various strengths listedMultiple strengths/formulations of morphine ER appear with corresponding QLs
inv-190: Schedule II medications — 34 day supply maximum
Schedule II maximum days' supplySchedule II medications are limited to a 34 day supply maximum
Opioid examplesSchedule II notation appears with various ER opioid entries (e.g., morphine, oxymorphone) in product notes
Documentation requirementPrescribers should document prescription schedule and days' supply to comply with the limit
inv-191: Multiple QL examples as listed across product groups (e.g., 135 EA/30 days, 120 EA/30 days, 90 EA/30 days)
Multiple QL examplesExamples across product groups include QL 135 EA/30 days, 120 EA/30 days, 90 EA/30 days (benzodiazepines, antiepileptics, others)
Inhaler/gram QLsSome respiratory agents use gram limits (e.g., QL 20.4 GM per 30 days; QL 8 GM per 30 days)
Starter packsStarter/therapy packs use time-based QLs (e.g., QL 74 EA per 365 days for certain starter packs)
inv-192: clobazam oral suspension — 8 ML
Clobazam oral suspension QLClobazam oral suspension 2.5 mg/mL: QL 8 mL per 1 day
Clobazam oral tablet QLClobazam oral tablet 10/20 mg: QL 2 EA per 1 day
Highlight — clobazam suspension limitClobazam oral suspension QL 8 mL per day (noted on formulary)
inv-193: clobazam oral tablet — 2 EA
Clobazam tablet QLClobazam oral tablet (10 mg, 20 mg): QL 2 EA per 1 day
ST/notesClobazam tablet entries include ST and QL flags as indicated on product lines
Behavioral health noteMany clobazam entries include BH notation (behavioral health) where applicable
inv-194: diazepam rectal gel — 5 EA
Diazepam rectal gel QLDiazepam rectal gel: QL 5 EA per 30 days
ST/BH notesDiazepam rectal gel line includes ST and BH flags where applicable
Pediatric/age limitsSome rectal gel entries include AL notes in formulary lines
inv-195: NAYZILAM nasal solution — 10 delivery systems
NAYZILAM QLNAYZILAM nasal solution 5 mg/0.1 mL: QL 10 delivery systems per 30 days
Indications/notesNAYZILAM entries include BH and ST notes as applicable
Packaging-specific QLQL referenced as delivery systems per 30 days (product-specific)
inv-196: VALTOCO — 10 EA or 5 packs depending on strength
VALTOCO QL (single doses)VALTOCO 10 mg dose nasal liquid: QL 10 EA per 30 days
VALTOCO therapy pack QLVALTOCO therapy packs (e.g., 2x7.5 mg) QL 5 packs per 30 days depending on strength
Highlight — VALTOCO dose/pack limitsVALTOCO: QL 10 EA or 5 packs per 30 days depending on strength (AL Min 2 Years noted)
inv-197: lacosamide oral solution — 1200 ML
Lacosamide oral solution QLLacosamide oral solution 10 mg/mL: QL 1200 mL per 30 days
ST noteLacosamide oral solution entry includes ST flag where noted
Tablet QL comparisonLacosamide tablets: QL 60 EA per 30 days (formulation-dependent)
inv-198: levetiracetam ER oral tablet — 120 EA
Levetiracetam ER QLLevetiracetam ER oral tablet: QL 120 EA per 30 days
Formulation noteDifferent levetiracetam formulations carry specific QLs (tablets vs solution)
Behavioral health noteSome anticonvulsant entries include BH notation as applicable
inv-199: pregabalin oral capsule — 60 EA
Pregabalin QLPregabalin oral capsule: QL 60 EA per 30 days
BH notationPregabalin entries include BH notation for behavioral health where applicable
Multiple strengthsQL applies across multiple strengths/formulations listed
inv-200: felbamate oral suspension — 900 ML
Felbamate suspension QLFelbamate oral suspension: QL 900 mL per 30 days
Tablet QLFelbamate tablets show QLs (e.g., 90–180 EA per 30 days depending on strength)
Formulation distinctionDifferent felbamate forms (suspension vs tablet) have distinct QLs noted
inv-201: paroxetine hcl oral tablet — 30 EA per 30 days (example)
Paroxetine tablet QLParoxetine HCl oral tablet (some strengths): QL 30 EA per 30 days (example)
Paroxetine suspension PAParoxetine oral suspension: PA noted for some presentations
Formulation notesParoxetine QLs vary by formulation/strength as listed in formulary
inv-202: venlafaxine hcl er — 2 EA per day (example)
Venlafaxine ER dosing QLVenlafaxine HCl ER oral capsule: example QL 2 EA per day
SNRIs class QLsSNRIs entries include QLs such as 60 EA per 30 days for some venlafaxine products
BH notationMany SNRI entries include BH notes where applicable
inv-203: Insulin product examples and QLs (Humalog, Humulin, insulin aspart, insulin glargine-yfgn, insulin lispro)
Insulin product QL examplesInsulin examples include QL 45 mL per 30 days; QL 50 mL per 30 days; QL 18 mL per 30 days for U-500 Kwikpen
Products citedExamples include Humalog, Humulin, insulin aspart, insulin glargine-yfgn, insulin lispro among others
Copay cap referenceThese insulin product lines also reference the preferred insulin copay cap (CB) of $25/30 days
inv-204: desvenlafaxine succinate ER — QL 30 EA per 30 days
Desvenlafaxine QLDesvenlafaxine succinate ER: QL 30 EA per 30 days
BH noteEntry includes BH notation where applicable
TieringDesvenlafaxine appears in formulary with tier and QL indicated
inv-205: JANUMET / alogliptin-metformin combos — QL 60 EA per 30 days (example)
JANUMET / alogliptin-metformin QLJANUMET (alogliptin‑metformin combos) example QL 60 EA per 30 days
ST/PA notesSome DPP‑4/metformin combination lines include ST or PA flags as annotated
Formulary exampleQL shown as example for combination oral antidiabetics (60 EA per 30 days)
inv-206: Various insulins (pen/cartridge/solution) — 45 mL or 50 mL per 30 days
Insulin pen/cartridge/solution QLsCommon QLs for pen/cartridge/solution insulins: 45 mL or 50 mL per 30 days (product-dependent)
U-500 QL exampleU-500 Kwikpen: QL 18 mL per 30 days (specific high-concentration insulin example)
Copay cap cross-referenceThese product lines reference the preferred insulin copay cap (CB $25/30 days)
inv-207: Example GLP-1s (Mounjaro, Trulicity) — QL 2 mL
GLP-1 example QLGLP‑1 agents (e.g., Mounjaro, Trulicity): QL 2 mL per 28 days
PA noteEntries for these incretin mimetic agents include PA and NDS flags as indicated
Product examplesMounjaro and Trulicity listed with QL 2 mL per 28 days in formulary
inv-208: Vivitrol — 1 EA
Vivitrol QLVivitrol (naltrexone long‑acting injection): QL 1 EA (per dosing interval)
PA/administration notesVivitrol entries include site/administration and QL notes as applicable
Formulary tieringVivitrol appears with tier and QL indicated in formulary list
inv-209: Ondansetron — 90 EA
Ondansetron QLOndansetron oral dispersible tablets (4 mg, 8 mg): QL 90 EA per 30 days
Palonosetron IV QLPalonosetron IV 0.25 mg/2 mL: QL 2 mL per 5 days
Emend oral suspension QLEMEND oral suspension reconstituted 125 mg/5 mL: QL 6 EA per 28 days
inv-211: EMEND oral suspension reconstituted — 6 EA
EMEND oral suspension QLEMEND oral suspension reconstituted 125 mg/5 mL: QL 6 EA per 28 days
EMEND IV noteEMEND IV is Tier MB and requires PA
NK1 antagonist packagingAprepitant entries include PA and QL (1–3 EA per 30 days depending on pack)
inv-212: palonosetron IV 0.25 mg/2ml — 2
Palonosetron IV QLPalonosetron HCl IV 0.25 mg/2 mL: QL 2 (ML per 5 days)
MB tierPalonosetron IV listed as MB tier with QL specified
CINV agent notesAnti‑emetic IV agents often require PA and have defined QLs per treatment course
inv-213: atorvastatin calcium oral tablet — 30
Atorvastatin QLAtorvastatin calcium oral tablet: QL 30 EA per 30 days
$0 tier noteAtorvastatin listed at $0 tier in formulary where applicable
Common cholesterol QLStatin entries commonly use QL 30 EA per 30 days for maintenance fills
inv-214: XIFAXAN 200 mg — 9
XIFAXAN 200 mg QLXIFAXAN 200 mg oral tablet: QL 9 EA per 30 days
XIFAXAN 550 mg QLXIFAXAN 550 mg oral tablet: QL 60 EA per 30 days
Indication-specific packsQ L varies by indication/strength — e.g., hepatic encephalopathy vs IBS-D dosing
inv-215: XIFAXAN 550 mg — 60
XIFAXAN 550 mg QLXIFAXAN 550 mg: QL 60 EA per 30 days
PA/ST notesCertain XIFAXAN entries may include PA depending on indication
Treatment-course QLsDifferent strengths reflect differing QLs aligned to typical treatment courses
inv-216: vancomycin 125 mg capsule — 56
Vancomycin 125 mg QLVancomycin HCl oral capsule 125 mg: QL 56 (per 14 days)
Vancomycin 250 mg QLVancomycin HCl oral capsule 250 mg: QL 80 EA per 30 days
Vancomycin solution QLVancomycin oral solution (25/50 mg/mL): QL 300 mL per 14 days
inv-217: vancomycin 250 mg capsule — 80
Vancomycin 250 mg QLVancomycin HCl oral capsule 250 mg: QL 80 EA per 30 days
PA noteSome vancomycin capsule entries include PA per formulary notes
Oral solution QLOral solution QL 300 mL per 14 days for reconstituted formulations
inv-218: vancomycin oral solution — 300 mL
Vancomycin oral solution QLVancomycin oral solution reconstituted 25/50 mg/mL: QL 300 mL per 14 days
Use-case noteSolution QL reflects pediatric/weight‑based preparations and reconstitution volumes
Formulary tieringSolution may be tiered differently (MB/2/3) depending on product line
inv-219: abiraterone acetate 250 mg — QL 120 EA per 30 days
Abiraterone QLAbiraterone acetate 250 mg oral tablet: QL 120 EA per 30 days
PA/DX flagsEntry includes QL and may be subject to PA/DX as oncology agent
Specialty handlingOncology agents often include SP/NDS indications alongside QL
inv-220: ALECENSA 150 mg — QL 240 EA per 30 days
ALECENSA QLALECENSA (alectinib) 150 mg oral capsule: QL 240 EA per 30 days
PA/DX/LA flagsALECENSA entry includes PA, LA, DX and other specialty flags
NDS/Specialty noteTherapy packs and specialty oncology entries may list NDS/SP alongside QL
inv-221: VENCLEXTA various strengths — QL 30-120 EA per 30 days depending on strength
VENCLEXTA QL rangeVENCLEXTA (venetoclax) QL varies by strength/pack: QL 30–120 EA per 30 days depending on strength
PA/DX/LA notesVENCLEXTA entries include PA, DX and potentially LA (limited access) flags
Oncology packaging impactPack/strength determines monthly QL (varies by treatment regimen)
inv-222: DAURISMO 100 mg — 30 EA
DAURISMO 100 mg QLDAURISMO 100 mg oral tablet: QL 30 EA per 30 days
DAURISMO 25 mg QLDAURISMO 25 mg oral tablet: QL 60 EA per 30 days
PA/DX/SPDAURISMO includes PA, DX and SP flags as oncology agent
inv-223: DAURISMO 25 mg — 60 EA
DAURISMO 25 mg QLDAURISMO 25 mg: QL 60 EA per 30 days
Oncology PA/DXDAURISMO entries include PA and DX requirements and SP where applicable
Treatment pack noteQLs reflect typical dosing schedules per indication
inv-224: ERIVEDGE 150 mg — 30 EA
ERIVEDGE QLERIVEDGE 150 mg oral capsule: QL 30 EA per 30 days
PA/DX/SP notesERIVEDGE includes PA, DX and SP flags as oncology agent
Formulation/pack noteQL aligns with standard monthly treatment quantities
inv-225: ZOLINZA 100 mg — 120 EA
ZOLINZA QLZOLINZA 100 mg oral capsule: QL 120 EA per 30 days
PA/DX flagZOLINZA listing includes PA and DX as oncology/dermatology agent
Specialty noteMay require specialty handling (SP/NDS) per formulary line
inv-226: pomalidomide — 21 EA
Pomalidomide QLPomalidomide oral capsule: QL 21 EA per 28 days
PA/NDS/SPPomalidomide entries include PA, NDS and SP flags as required
Regimen-based QLQL structured to align with cycle-based oncology regimens (28‑day cycles)
inv-227: KRAZATI 200 mg — 180 EA
KRAZATI QLKRAZATI 200 mg oral tablet: QL 180 EA per 30 days
PA/LA/DX flagsEntry includes PA, LA and DX requirements and NDS where indicated
Specialty handlingOncology agent may be managed via specialty pharmacy (SP)
inv-228: LUMAKRAS 120 mg — 240 EA
LUMAKRAS 120 mg QLLUMAKRAS 120 mg oral tablet: QL 240 EA per 30 days
LUMAKRAS 320 mg QLLUMAKRAS 320 mg oral tablet: QL 3 EA (per 1 day) — pack/strength dependent
PA/DX/SP notesLUMAKRAS lines include PA, DX and SP flags per formulary
inv-229: LUMAKRAS 320 mg — 3 EA
LUMAKRAS 320 mg QLLUMAKRAS 320 mg: QL 3 EA per 1 day (specific high‑strength pack limit)
PA/DX requirementPA and DX required for high‑cost oncology agents as noted
Pack-based QLHigh‑strength tablets often have very low QLs reflecting single‑use dosing
inv-230: MEKINIST 0.5 mg — 90 EA
MEKINIST 0.5 mg QLMEKINIST 0.5 mg oral tablet: QL 90 EA per 30 days
MEKINIST 2 mg QLMEKINIST 2 mg oral tablet: QL 30 EA per 30 days
PA/DX/SPMEKINIST entries include PA, DX and SP flags as oncology agent
inv-231: MEKINIST 2 mg — 30 EA
MEKINIST 2 mg QLMEKINIST 2 mg: QL 30 EA per 30 days
Therapy pack noteDifferent strengths/packings result in differing QLs per 30 days
Oncology PA/DXPA and DX frequently required for MEKINIST formulations
inv-232: CABOMETYX — 30 EA
CABOMETYX QLCABOMETYX oral tablet: QL 30 EA per 30 days
PA/DX/SPCABOMETYX listing includes PA, DX and SP flags as oncology agent
Dose-pack notesTherapy pack options influence monthly QL as indicated in product lines
inv-233: CAPRELSA 100 mg — 60 EA
CAPRELSA QLCAPRELSA (vandetanib) 100 mg oral tablet: QL 60 EA per 30 days
PA/LA/DX flagsCAPRELSA includes PA, LA and DX requirements in formulary notes
NDS/Specialty noteMay be managed via specialty pharmacy; pack/therapy flags indicated
inv-234: RYDAPT for AML — 120 EA
RYDAPT QL for AMLRYDAPT (midostaurin) for AML: QL 120 EA per 30 days
Multiple indication QLsRYDAPT QL differs for other indications (e.g., ASM, SM, AHN, MCL up to 240/30) — see product notes
PA/DX requirementPA and DX required for antineoplastic agents as indicated
inv-235: XPOVIO therapy pack — 8 EA
XPOVIO therapy pack QLXPOVIO 100 mg once‑weekly therapy pack: QL 8 EA per 28 days
Other XPOVIO pack QLsOther weekly/dose packs: QL examples include 4 packs per 28 days for some schedules
PA/LA/DXXPOVIO entries include PA, LA, DX and NDS flags per therapy pack
inv-236: XPOVIO various weekly/dose packs — 4 packs
XPOVIO weekly pack QLsVarious XPOVIO weekly/dose packs: examples include QL 4 packs per 28 days depending on schedule/strength
Regimen-specific limitsPack QLs reflect dosing schedules (weekly, twice-weekly) and are listed per pack type
Utilization flagsPA/LA/DX and NDS flags accompany pack listings as noted
inv-237: INLYTA — 120 EA
INLYTA QLINLYTA (axitinib) oral tablet: QL 120 EA per 30 days
PA/DX/SPINLYTA listing includes PA, DX and SP flags as oncology agent
Pack/therapy noteTherapy packs and dosing schedules influence QLs for multikinase inhibitors
inv-238: LENVIMA therapy pack — 30-90 EA
LENVIMA therapy pack QLsLENVIMA therapy packs: QLs vary by pack/strength (examples: 30–90 EA per 30 days)
PA/DX/SP flagsLENVIMA entries include PA, DX, NDS and SP notes as applicable
Dose-dependent QLsPack strength determines monthly QL (30, 60, 90 EA per 30 days depending on pack)
inv-239: INVEGA SUSTENNA/TRINZA — per product-specific mL per dosing interval
INVEGA SUSTENNA/TRINZA QLsINVEGA SUSTENNA/TRINZA: QLs stated per product-specific mL per dosing interval (e.g., 0.75 mL per 28 days; 1.75 mL per 84 days)
BH/AL notesSome long‑acting injectables include BH and AL flags (minimum age) alongside QLs
NDS/SPNDS and SP flags may apply per product line for injection formulations
inv-240: CAPLYTA — 30 EA
CAPLYTA QLCAPLYTA oral capsule: QL 30 EA per 30 days
PA/AL notesCAPLYTA has PA and AL (Min 18 Years) flags noted in formulary
Use-caseQL aligns with chronic maintenance dosing as indicated
inv-241: risperidone oral solution — 480 mL
Risperidone oral solution QLRisperidone oral solution: QL 480 mL per 30 days
PA/AL notesPA required for patients younger than certain ages; AL Min 5 Years noted for some formulations
BH designationMany risperidone lines include BH zero-cost-share notation where applicable
inv-242: ABILIFY MAINTENA — 3 EA per 84 days
ABILIFY MAINTENA QLABILIFY MAINTENA IM prefilled syringe: QL 3 EA per 84 days
PA/BH/AL notesABILIFY MAINTENA requires PA and includes BH and AL (Min 18 Years) flags
Long‑acting injectable handlingLong‑acting injectables list QLs per dosing interval (e.g., per 84 days) and may require PA
inv-243: aripiprazole oral solution — 750 mL per 30 days
Aripiprazole oral solution QLAripiprazole oral solution: QL 750 mL per 30 days
PA/AL notesSome aripiprazole lines require PA for young children and include AL minimum ages
BH notationEntries include BH zero-cost-share notes where applicable
inv-244: various antiretroviral tablet examples — commonly 30 EA per 30 days
Antiretroviral tablets QLVarious antiretroviral tablets (e.g., Descovy, Biktarvy, Genvoya, Triumeq): common QL 30 EA per 30 days where noted
STI/$0 copay noteMany antiretroviral entries include STI notation indicating coverage at $0 copay for STI/PrEP indications
PA for new startsSome entries require PA for new starts and DX validation for PrEP indications
inv-245: Selzentry oral solution — 900 mL per 30 days
Selzentry solution QLSelzentry oral solution: QL 900 mL per 30 days
STI/$0 tierSelzentry listed at $0 tier with STI zero-cost-share notation where used for STI indications
Formulation-specific QLSolution QLs reflect liquid formulations (mL per 30 days)
inv-246: Isentress — 60/120 (examples)
Isentress QLsIsentress: QL examples include 60 EA and chewable/tablet 120 EA per 30 days depending on presentation
$0 tier/STIIsentress entries include STI zero-cost-share notes where applicable
Pack/presentation differencesQL differs by packet/tablet/chewable form (e.g., 60 vs 120 EA per 30 days)
inv-247: Tivicay 50 mg — 30
Tivicay QLTivicay (dolutegravir) 50 mg: QL 30 EA per 30 days
PD soluble QLPD soluble formulation has QL 180 EA per 30 days for pediatric/PD dosing
$0 tier/STITivicay listed at $0 tier with STI zero-cost-share notes where applicable
inv-248: Prezista oral suspension — 360
Prezista suspension QLPrezista oral suspension: QL 360 mL per 30 days
Prezista tablet QLPrezista tablets: QL examples include 60 EA per 30 days
$0 tier/STIMany Prezista entries list $0 tier/STI zero-cost-share where applicable
inv-249: Viread oral powder — 225
Viread powder QLViread oral powder: QL 225 GM per 30 days
Viread tablet QLsViread tablets listed at $0 tier for STI indications; QLs vary by formulation
STI zero-cost-shareViread entries include STI zero-cost-share language for prevention/treatment uses
inv-250: PAXLOVID therapy pack — 40; 60
PAXLOVID therapy pack QLsPAXLOVID therapy packs: QL 40 EA per 365 days (10x150/10x100 pack) and 60 EA per 365 days for alternate pack
TieringPAXLOVID listed as Tier 3 with pack‑based QLs
Pack‑specific limitsQLs based on pack size and annual limits per formulary notes
inv-251: oseltamivir capsules/suspension — various QLs depending on strength
Oseltamivir QLsOseltamivir capsules/suspension: QLs vary by strength (examples: 10–20 EA; suspension 180 mL per 180 days)
Seasonal/stock QLsDifferent QLs reflect prophylactic vs treatment pack sizes and timeframes (180‑day examples present)
Formulary examplesCapsule QL 10 EA per 180 days for some strengths; suspension QL 180 mL per 180 days
inv-252: verapamil ER 180 mg — QL 60 EA per 30 days
Verapamil ER QLVerapamil HCl ER 180 mg: QL 60 EA per 30 days
ER product QLsExtended‑release cardiovascular agents show monthly QLs (e.g., 60 EA per 30 days)
Formulary contextQL aligns with chronic therapy maintenance fills for ER cardiac drugs
inv-253: ENTRESTO sprinkle — QL 60 EA per 30 days
ENTRESTO sprinkle QLENTRESTO oral capsule sprinkle: QL 60 EA per 30 days (Notes = PA)
sacubitril-valsartan QLSacubitril‑valsartan oral tablet: QL 60 EA per 30 days (ST noted for some entries)
PA/ST flagsEntries include PA or ST flags as indicated (ENTRESTO = PA; sacubitril‑valsartan = ST)
inv-254: sacubitril-valsartan — QL 60 EA per 30 days
Sacubitril‑valsartan QLSacubitril‑valsartan: QL 60 EA per 30 days; some listings marked ST (step therapy)
ENTRESTO sprinkle PAENTRESTO sprinkle entry specifically notes PA requirement
Formulary applicationST/PA flags indicate utilization controls that must be followed for coverage
inv-255: ambrisentan — QL 30 EA per 30 days
Ambrisentan QLAmbrisentan oral tablet: QL 30 EA per 30 days
PA/NDS/SPAmbrisentan entry includes PA, NDS and SP flags in formulary notes
Pulmonary hypertension contextQL aligns with chronic dosing schedules for PAH agents
inv-256: sildenafil citrate — QL 90 EA per 30 days
Sildenafil QLSildenafil citrate oral tablet: QL 90 EA per 30 days
PA noteSome sildenafil entries may include PA for certain indications
Pack/month supplyQL consistent with monthly supply limits for chronic PDE5 therapies
inv-257: amlodipine-atorvastatin — QL 30 EA per 30 days
Amlodipine‑atorvastatin QLAmlodipine‑atorvastatin oral tablet: QL 30 EA per 30 days
Combination product noteCombination cardiovascular agents follow standard monthly QLs for maintenance therapy
Formulary listingQL 30 per 30 days cited for combination antihypertensive/statin products
inv-258: Budesonide 3 mg — 448 EA per 365 days
Budesonide DR annual QLBudesonide oral capsule delayed release particles 3 mg: QL 448 EA per 365 days
Yearly limit contextAnnual QL specified for chronic corticosteroid product (per 365 days)
Formulary tierBudesonide DR listed with tier and annual QL for supply control
Site of Care and Specialty Pharmacy Handling
Note
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Key Terms and Abbreviations
inv-125: Formulary / Closed Formulary definition
Formulary definitionFormulary: a continually updated list of medications supported by evidence-based medicine; closed formulary means non‑Formulary drugs are not routinely reimbursed without a medical exception
Closed formulary implicationNon‑Formulary drugs require medical exception/prior authorization to be reimbursed
PurposeDesigned to encourage safe, effective, and cost‑efficient medication use
inv-126: Prior Authorization definition
Prior Authorization definitionPrior authorization: clinical evaluation process to determine medical necessity and coverage before services are provided
ReviewersRequests reviewed by Medical Director or other clinical professional for medical necessity
Applies to many formulary drugsPA noted on numerous product lines and is required before coverage when indicated
inv-127: Step Therapy definition
Step Therapy definitionStep therapy: requires prior use of one or more FDA‑approved prerequisite drugs that treat the same condition before covering the step‑therapy medication
PurposePromotes use of equally effective lower‑cost formulary drugs first
Prerequisite specificationPrerequisite drugs are FDA‑approved and specified by the plan
inv-128: Quantity Limit definition
Quantity Limit definitionQuantity limits: limits on maximum daily dose or number of units over a defined period to promote safe and appropriate use
TypesIncludes Maximum Daily Dose (per day) and Quantity Limits Over Time (e.g., EA per 30 days)
BasisLimits set using medical guidelines and FDA‑approved recommendations
inv-129: DX (Diagnosis Validation Required)
DX meaningDX (Diagnosis Validation Required): payer requires documentation of the covered diagnosis to approve the drug
ApplicationDX commonly applied to biologics, oncology, and select specialty agents (e.g., AMJEVITA, HUMIRA, oncology agents)
Submission contextDiagnosis validation required at prior authorization or point of sale where noted
inv-130: QL (Quantity Limit)
QL meaningQL (Quantity Limit): maximum quantity allowed per specified time period (e.g., EA per 30 days or mL per 28 days)
FormatsExpressed as EA per 30 days, ML per 28/30 days, GM per 30 days, or per dosing interval
EnforcementProducts exceeding stated QLs are subject to utilization review and may be denied without PA or exception
inv-131: AL (Age Limit)
AL meaningAL (Age Limit): minimum and/or maximum age restrictions applied to coverage for the drug
ExamplesFormulary entries include AL Min 2 Years (VALTOCO), Min 5 Years (risperidone), Min 18 Years (CAPLYTA), etc.
Pediatric implicationsCertain products not covered under 12 years or require PA for ages 12–18 as specified
inv-133: SP (Specialty Pharmacy)
SP meaningSP (Specialty Pharmacy): indicates the product is managed through specialty pharmacy processes
ApplicationMany biologics, oncology, and specialty agents flagged SP require specialty acquisition and handling
Site implicationsSP flag often accompanies PA, DX, QL and NDS on product lines
inv-134: ST (Step Therapy)
ST meaningST (Step Therapy): indicates a step‑therapy requirement as noted on product lines
ExamplesST appears on select ER opioids and other agents (e.g., morphine ER lines include ST; sacubitril‑valsartan noted ST)
Provider actionPrescribers must document trial/failure of prerequisite agents per ST rules when required
inv-145: CB (Copay cap/benefit) — preferred formulary insulin copay cap note
CB (Copay cap) meaningCB indicates copay cap/benefit (e.g., preferred formulary insulin copay not to exceed $25 per 30‑day supply)
Insulin applicationCB used on multiple insulin product lines to denote the $25/30‑day cap
HDHP noteHigh Deductible Health Plan copays/coinsurance apply to deductible first; CB cap language still present
inv-163: PPACA $0 Copay — preventive contraceptives $0 copay note
PPACA $0 Copay for contraceptivesMany contraceptive entries note '$0 Copay per PPACA guidelines' and 'Up to a six‑month supply'
Supply allowanceFormulary lines commonly allow up to a six‑month supply for contraceptives where PPACA applies
DocumentationDocumentation should support supply and PPACA eligibility as noted in formulary guidance
inv-151: DX (Diagnosis Validation) — definition and application for oncology agents
DX for oncology agentsDiagnosis Validation (DX) required: payer requires submission/validation of appropriate diagnosis for many oncology agents (e.g., VENCLEXTA, ALECENSA)
Application at PA/point of saleDX may be required at prior authorization or at point of sale per product note
Denial riskFailure to provide DX may result in denial of coverage for product lines requiring DX
inv-155: MB (Medical Benefit) — definition
MB definitionMB (Medical Benefit): drug administered by a healthcare professional, typically billed under the medical benefit and given in settings such as home, provider office, infusion suite, or outpatient facility
ImplicationMB‑tier products may require prior authorization and specialty pharmacy acquisition; site of care influences billing
ExamplesIV/infusion agents and some long‑acting injectables are listed as MB in the formulary (e.g., palonosetron IV, ABILIFY MAINTENA entries reference MB handling)
Formulary Purpose and Policy Scope
A Formulary is a preferred drug list maintained to encourage safe, effective, and cost‑efficient medication use. The plan manages utilization through tools such as prior authorization, step therapy, and quantity limits, applied per product line as indicated by formulary notes and tier assignments.
Presbyterian operates a closed Formulary, meaning non‑Formulary drugs require a documented medical exception to be reimbursed; reviewers (Medical Director or clinical professional) evaluate medical necessity when exceptions or prior authorization requests are submitted.
The extracted formulary lines are presented as product entries that show tier, notes, and any quantity or age limits. These segments do not provide separate, standalone medical necessity criteria; instead coverage decisions rely on adherence to the per‑product Notes (for example, PA, ST, QL, AL, and benefit flags) and on documentation submitted with authorization requests.
Biosimilar Coverage Notes
Note
Policy Summary
PayerPresbyterian Health Plan
PolicyCommercial 4-Tier Prescription Drug Formulary — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization and submit required clinical documentation (including diagnosis validation and applicable NDC) when a product is annotated with PA or DX.
SourceLink
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