Priority Health Medicare MPSERS Formulary (Drug List)
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This document is the Priority Health Medicare MPSERS formulary describing covered prescription drugs, coverage rules (prior authorization, step therapy, quantity limits), member protections, and how to request exceptions; it affects Priority Health Medicare MPSERS plan members and their prescribers and pharmacies.
No material clinical or coverage changes in this revision.
Coverage rules and formulary application
Standard formulary coverage
Covered when ALL of the following are met:
See Evidence of Coverage for filling rules
Formulary change and member protections
Mid‑year formulary changes and member protections — Covered when the listed member protections or notices are followed:
If an immediate change affects a member currently taking the drug, member or prescriber may request an exception to continue therapy
Members may request a formulary exception to continue their current drug under the protection rules
Members and prescribers should refer to mailed notice and Exception process
Formulary exceptions
Formulary exceptions — Decision timelines and required documentation:
Standard decision within 72 hours; expedited (24‑hour) review available when waiting could cause serious harm
If approved to cover a non‑formulary drug it will be covered at a predetermined cost‑sharing level
Temporary/transition coverage
Temporary and transition coverage rules — Covered when the transition conditions are met:
If prescription is written for fewer days, refills may be allowed to reach a 30‑day supply; coverage ends if exception/authorization not approved
Applies when access is limited or member in institutional setting
Supports continuity while a formulary decision or exception is pursued
Drug-specific coverage with PA/QL constraints
Drug‑specific coverage with PA/QL constraints — Covered when the product line entry and its Requirements/Limits are satisfied:
Examples in the formulary: VERSACLOZ (PA; QL 540 ML/30 days); OZEMPIC (PA; QL 3 ML/28 days); MOUNJARO (PA; QL 2 ML/28 days)
Examples: clozapine dispersible (PA); VERSACLOZ (PA; QL 540 ML/30 days)
Examples: JANUMET XR QL 60 EA/30 days; OZEMPIC QL 3 ML/28 days; XIFAXAN QL varies by strength
General coverage rules
General coverage rules — Coverage depends on tier and any listed requirements:
See formulary legend for tier definitions and supply restrictions
Examples: REDEMPLO (PA; QL 0.5 mL/84 days); VERQUVO (PA; QL 30 EA/30 days); REPATHA products (PA; specific QLs)
Product-level coverage controls
Product‑level coverage controls — Covered when meeting the product line's specified payer requirements:
Providers must follow PA and QL rules where present and submit required documentation
Examples of ED products are listed in the formulary; payments for ED drugs do not count toward catastrophic coverage
Contact CustomerCare for Home Infusion or Part B/Part D billing guidance
In the formulary legend ED stands for Excluded Drug. An ED-marked prescription drug is not normally covered under a Medicare Prescription Drug Plan; amounts paid for an ED drug do not count toward a member's total drug costs and do not help the member qualify for catastrophic coverage. Members who receive extra help will not receive assistance for drugs designated ED.
The formulary uses ED in the abbreviations section to identify excluded products. Entries elsewhere (for example specialty antidepressants and other therapeutic sections) reference requirements such as PA, QL, and occasionally NE (No Express Scripts), but when an item is labeled ED it indicates exclusion from coverage under the plan.
The formulary also uses the NE and ED annotations in the Requirements/Limits column. NE denotes No Express Scripts (restricted fill channel), while ED denotes an Excluded Drug. When either code appears on a drug line it signals restricted access or that the product is not covered per the formulary legend.
Within the provided excerpt there are no explicit clinical exclusion criteria (for example, no medically necessary clinical test or diagnosis listed that would bar coverage). The document instead flags products with shorthand codes (e.g., ED) and directs readers to the formulary legend for meaning.
Although the abbreviation ED is defined in the legend, these chunks do not list a comprehensive set of excluded drugs; the legend refers to ED but the specific excluded items are not exhaustively enumerated in this excerpt.
This section reiterates the ED abbreviation in the legend, but no individual excluded-drug lines are provided here. The document shows how ED would be applied, yet specific excluded drug entries are not present in these chunks.
Some formulary entries are explicitly marked ED in the drug lists. Examples in the dermatology and topical sections include items such as tretinoin (emollient) and various urea external formulations that are flagged ED in the listing.
Multiple individual products in the excerpt are labeled ED. Notable examples include tretinoin (emollient), several urea external creams/gels, and other items referenced as ED in the dermatologic and topical agent listings.
Fertility and infertility-related products are assigned a dedicated tier and some are excluded. The formulary shows ED designations for certain agents used in fertility treatment (examples include chorionic gonadotropin intramuscular, hCG injection solution reconstituted 12000 unit, and listed products such as NOVAREL, OVIDREL, and PREGNYL marked ED).
The formulary notes that Tier 5 (Specialty) drugs are limited to a 30-day supply only. This supply restriction is shown in the tier legend and reiterated across specialty listings.
Specific products are shown in the respiratory and related sections as ED and therefore will not be covered. Examples called out in the excerpt include benzonatate and certain inhalation sodium chloride/nebulization solutions marked ED.
In the chunks reviewed there are no explicit statements using the phrase 'not medically necessary.' The formulary uses coverage flags and requirements (e.g., PA, QL, ED) rather than explicit 'not medically necessary' language in these excerpts.
Abbreviations, tiers, and code legend
| B/D | Part B vs. Part D classification; may require additional information to determine coverage setting |
| EA | Each |
| ED | Excluded Drug — not normally covered in Medicare Part D |
| QL (750 ML per 30 days) | Quantity limit for diclofenac sodium external solution 1.5% |
| QL (30 EA per 30 days) | Quantity limit for mefenamic acid oral |
| QL (4 EA per 28 days) | Quantity limit for buprenorphine transdermal |
| QL (10 EA per 30 days) | Quantity limit for fentanyl transdermal patch (selected strengths) |
| QL (60 EA per 30 days) | Quantity limit for hydromorphone ER tablets (example) |
| QL (235.2 ML per 28 days) | Quantity limit for ARIKAYCE |
| QL (720 ML per 30 days) | Quantity limit for tobramycin injection solutions |
| T1-T6 | Formulary drug tier definitions: T1-Preferred generic; T2-Generic; T3-Preferred brand; T4-Non-preferred drug; T5-Specialty; T6-Infertility |
| XIFAXAN ORAL TABLET 200 MG | Drug listed with Tier 4; Requirements: PA; QL (9 EA per 30 days) |
| XIFAXAN ORAL TABLET 550 MG | Drug listed with Tier 5; Requirements: PA; QL (60 EA per 30 days) |
| DIFICID ORAL SUSPENSION RECONSTITUTED | Tier 5; Requirements: ST; QL (136 ML per 10 days) |
| DIFICID ORAL TABLET | Tier 5; Requirements: ST; QL (20 EA per 10 days) |
| VANCOMYCIN HCL INTRAVENOUS SOLUTION | Multiple IV strengths listed; Requirements: HI |
| CEFTRIAXONE SODIUM INJECTION SOLUTION | Multiple strengths listed; Requirements: HI |
| PIPERACILLIN-TAZOBACTAM INTRAVENOUS SOLUTION | Multiple strengths listed; Requirements: HI |
| BRIVARACETAM ORAL SOLUTION/TABLET | Tier 5; Requirements: PA; QL (600 ML per 30 days for solution; 60 EA per 30 days for tablets) |
| EPIDIOLEX | Tier 5; Requirements: PA; QL (500 ML per 30 days) |
| PERAMPANEL ORAL TABLET/SUSPENSION | Tier 5; Requirements: PA; QL (30 EA per 30 days for many tablet strengths; 680 ML per 28 days for suspension) |
| XCOPRI formulations | Tier 5; Requirements: PA; QL (various per-strength limits listed) |
| 100 mg | lomustine oral capsule 100 mg (listed with Tier 5) |
| 250 mg | abiraterone acetate oral tablet 250 mg (QL 120 EA per 30 days) |
| 100 mg | erlotinib HCl oral tablet 100 mg (PA; QL 30 EA per 30 days) |
| 25 mg | erlotinib HCl oral tablet 25 mg (PA; QL 90 EA per 30 days) |
| No codes listed |
| 60 EA per 30 days | Quantity limit example for TRADJENTA (from chunk 126) |
| 2 ML per 28 days | Quantity limit for TRULICITY (from chunk 127) |
| 620 ML per 30 days | Quantity limit for XARELTO oral suspension (from chunk 137) |
| 60 ML per 30 days | Quantity limit for enoxaparin prefilled syringes (100 mg/ml,150 mg/ml) (from chunk 135) |
| ENTRESTO ORAL CAPSULE SPRINKLE | Formulary entry; Tier 3; QL (240 EA per 30 days) |
| REDEMPLO | Tier 5; Requirements/Limits = PA; QL (0.5 ML per 84 days) |
| TRYNGOLZA | Tier 5; Requirements/Limits = PA; QL (0.8 ML per 30 days) |
| VERQUVO | Tier 4; Requirements/Limits = PA; QL (30 EA per 30 days) |
| REPATHA | Tier 3; Requirements/Limits = PA; QL (2 ML per 28 days) |
| REPATHA PUSHTRONEX SYSTEM | Tier 3; Requirements/Limits = PA; QL (3.5 ML per 30 days) |
| REPATHA SURECLICK | Tier 3; Requirements/Limits = PA; QL (2 ML per 28 days) |
| NEXLETOL | Tier 4; Requirements/Limits = PA; QL (30 EA per 30 days) |
| NEXLIZET | Tier 4; Requirements/Limits = PA; QL (30 EA per 30 days) |
| KERENDIA | Tier 4; Requirements/Limits = PA; QL (30 EA per 30 days) |
| OTEZLA ORAL TABLET 30 MG | Drug listed with Tier 5; Requirements: PA; QL (60 EA per 30 days) |
| clotrimazole-betamethasone external cream | Tier 2; Requirements/Limits = ST |
| clotrimazole-betamethasone external lotion | Tier 4; Requirements/Limits = QL (120 ML per 30 days) |
| fluorouracil external cream 5% | Tier 2; Requirements/Limits = QL (40 GM per 30 days) |
| imiquimod external cream 5% | Tier 4; Requirements/Limits = (none listed) |
| PANRETIN | Tier 5; Requirements/Limits = PA; QL (60 GM per 30 days) |
| SANTYL | Tier 4; Requirements/Limits = QL (60 GM per 30 days) |
| carglumic acid oral tablet soluble | Tier 5; Requirements/Limits = PA; LA |
| KLOR-CON products | Tier 2; Requirements/Limits = (none listed) |
| magnesium sulfate injection solution 50% | Tier 4; Requirements/Limits = (none listed) |
| No codes listed |
| nda020503 | albuterol sulfate HFA inhalation aerosol solution (specific NDA) |
| nda020983 | albuterol sulfate HFA inhalation aerosol solution (specific NDA) |
What prescribers and pharmacies must do
Prior authorization required — check formulary Requirements/Limits
Check the Requirements/Limits column in the formulary (beginning on page 12) for any drug listed with 'PA' — prior authorization must be obtained from Priority Health Medicare before filling those prescriptions; failure to obtain PA may result in the plan not covering the drug.
- Look up the drug on the formulary and confirm 'PA' in the Requirements/Limits column before dispensing.
- If PA is required, submit the prescriber’s request and supporting documentation per the plan process prior to fill.
PA required for specified medications (e.g., lidocaine patch, ARIKAYCE, colistimethate, daptomycin)
Obtain prior authorization for specific listed products that show 'PA' (examples in the formulary include lidocaine patch products, ARIKAYCE, colistimethate, and daptomycin) before dispensing or billing.
- Lidocaine 5% external patch entries are marked PA; verify and secure authorization before fill.
- ARIKAYCE is listed with PA; follow PA process and note any QL/HI annotations.
XIFAXAN requires PA and strength-specific quantity limits
XIFAXAN (rifaximin) oral tablets require prior authorization and are subject to quantity limits — confirm strength-specific QL when submitting a PA.
- XIFAXAN 200 mg: PA; QL 9 EA per 30 days.
- XIFAXAN 550 mg: PA; QL 60 EA per 30 days.
DIFICID: prior authorization, step therapy, and quantity limits
DIFICID (fidaxomicin) oral tablet and suspension require step therapy and prior authorization and are quantity‑limited; submit documentation showing ST criteria met and request PA referencing the listed QL.
- DIFICID oral tablet: ST; QL 20 EA per 10 days.
- DIFICID oral suspension (reconstituted): ST; QL 136 ML per 10 days.
Anticonvulsant products require PA and have quantity limits
Selected anticonvulsant and specialty neurology products are listed with PA and QL; providers must request prior authorization and include any required clinical documentation to support the requested quantity.
- Brivaracetam oral solution: PA; QL 600 ML per 30 days.
- Brivaracetam tablets: PA; QL 60 EA per 30 days.
- EPIDIOLEX: PA; QL 500 ML per 30 days; FINTEPLA and perampanel formulations also show PA and QL as specified.
PA required for specified anticonvulsant drugs (e.g., eslicarbazepine acetate, rufinamide)
Obtain prior authorization for the listed anticonvulsant agents (examples include eslicarbazepine acetate and rufinamide) when the formulary entry shows 'PA'; include quantity-limit justification if requesting amounts above the QL.
- Eslicarbazepine acetate 200/400 mg: PA; QL 30 EA per 30 days.
- Eslicarbazepine acetate 600/800 mg: PA; QL 60 EA per 30 days.
- Rufinamide oral suspension/tablet entries are marked PA.
Prior authorization and quantity/availability limits for many specialty oncology drugs
Many specialty oncology oral agents require prior authorization and have product‑specific quantity limits or limited‑availability flags; include diagnosis and planned dosing when requesting PA.
- Examples: ABIRTEGA (abiraterone) QL 120 EA per 30 days; KISQALI entries show PA and QL as listed.
- Follow the Requirements/Limits column for PA, QL, and LA annotations on each oncology agent.
PA required for many specialty drugs — confirm PA and QL
Numerous specialty drugs are designated 'PA' in the formulary; providers must obtain prior authorization before coverage — many of these specialty items also have quantity limits that must be observed.
- Example specialty entries show PA plus specific QLs (e.g., PIQRAY PA; QL 56 EA per 28 days).
- Confirm both PA and QL per the drug line before dispensing.
PA required for listed high‑cost/specialty agents (examples: VERSACLOZ, LIVTENCITY, PREVYMIS, MOUNJARO, OZEMPIC)
Certain high‑cost or specialty agents (examples include VERSACLOZ, LIVTENCITY, PREVYMIS, MOUNJARO, OZEMPIC) require prior authorization; include clinical rationale and requested quantity per the product QL when submitting PA requests.
- VERSACLOZ: PA; QL 540 ML per 30 days.
- MOUNJARO and OZEMPIC entries: PA with specified QLs (e.g., OZEMPIC QL 3 ML per 28 days).
PA required for certain devices/supplies (e.g., TRULICITY auto‑injector, pen needles)
Prior authorization is required for certain device and supply items noted as 'PA' in the formulary (examples include TRULICITY auto‑injector and specified pen needles); obtain PA before dispensing supplies or devices.
- TRULICITY auto‑injector: PA; QL 2 ML per 28 days.
- Various pen needles and insulin syringe supplies are listed with PA in Requirements/Limits.
PA required for specialty/high‑cost medications — submit clinical info and dosing
Specialty/high‑cost medications listed with 'PA' require prior authorization before coverage; review each Requirements/Limits entry and submit PA with the member’s clinical information and dosing to avoid claim denials.
- Examples: REDEMPLO, TRYNGOLZA, VERQUVO, REPATHA products, NEXLETOL/NEXLIZET are all listed with PA and sometimes QL.
- Submit supporting clinical documentation and follow the formulary QL when requesting authorization.
PA required for listed PA drugs (e.g., NEXLETOL, NEXLIZET, REPATHA variants)
Prior authorization is required for the listed agents (examples include NEXLETOL, NEXLIZET, REPATHA and its presentations); confirm PA and the product‑specific quantity limits before dispensing.
- REPATHA: PA; QL 2 ML per 28 days (PushtROnex and SureClick variations have their own QLs).
- NEXLETOL/NEXLIZET: PA; QL 30 EA per 30 days.
Prior authorization required for listed drugs (e.g., OTEZLA, PANRETIN, RELISTOR, FASENRA, GATTEX)
Specific drugs in the formulary (e.g., OTEZLA 30 mg, PANRETIN, RELISTOR, FASENRA, GATTEX) are designated 'PA' — obtain prior authorization and document indication and dosing to meet coverage requirements.
- OTEZLA 30 mg: PA; QL 60 EA per 30 days.
- PANRETIN: PA; QL 60 GM per 30 days.
- RELISTOR oral: PA; QL 90 EA per 30 days; RELISTOR subcutaneous: PA.
PA required for listed specialty/non‑preferred drugs (examples: AMVUTTRA, ENDARI, NULIBRY, PROLASTIN‑C, VYNDAMAX)
Many specialty or non‑preferred drugs (e.g., AMVUTTRA, ENDARI, NULIBRY, PROLASTIN‑C, VYNDAMAX, testosterone/growth hormone products) are marked 'PA' — request PA and include the clinical justification and, if applicable, limited‑availability documentation.
- AMVUTTRA: PA; QL 0.5 ML per 90 days.
- ENDARI: PA; QL 180 EA per 30 days.
- PROLASTIN‑C intravenous solution: PA; LA (limited availability).
Prior Authorization required for numerous specialty agents (e.g., LUPRON DEPOT, COSENTYX, DUPIXENT)
Numerous specialty and biologic agents (examples include LUPRON DEPOT, SIGNIFOR, SOMAVERT, COSENTYX, DUPIXENT) are listed with PA; obtain prior authorization and include dosing/indication to support coverage.
- LUPRON DEPOT 1‑month and 3‑month kits: PA required.
- DUPIXENT presentations: PA; QLs vary by presentation (e.g., 3.42 ML per 30 days for 200 mg auto‑injector).
PA required for selected specialty/high‑cost agents (e.g., BILPREVDA, EVENITY, OXERVATE, XDEMVY)
Selected specialty/high‑cost agents (e.g., BILPREVDA, EVENITY, OXERVATE, XDEMVY) require prior authorization; follow the Requirements/Limits entry and supply PA with clinical rationale and requested quantity.
- EVENITY: PA; QL 2.34 ML per 30 days.
- OXERVATE: PA; QL 28 ML per 30 days.
- BILPREVDA: PA.
PA required for many respiratory/pulmonary specialty drugs — confirm PA, QL, and B/D
Respiratory and pulmonary specialty drugs are often designated 'PA' and may have QL or LA flags — obtain prior authorization and confirm Part B/Part D (B/D) billing designation where shown.
- CAYSTON, KALYDECO, ORKAMBI, TRIKAFTA entries show PA and various QLs; some CF agents are B/D or LA.
- Pulmonary antihypertensives (ADEMPAS, ambrisentan, bosentan, OPSUMIT) list PA; QL and LA vary by product.
Step therapy requirement — trial of preferred agents required when 'ST' applies
Where the formulary flags 'ST' (Step Therapy) on a drug entry, a trial of preferred agent(s) is required before coverage of the listed drug; consult the formulary entry and submit evidence of step completion or justification when requesting PA or an exception.
- Step therapy may require trying Drug A (preferred) before Drug B (non‑preferred) will be covered.
- Providers should document prior trials and clinical response when submitting PA or exception requests.
Step Therapy flag — follow ST when indicated on drug entry
Step Therapy (ST) is used as a requirement on specific drug lines; if 'ST' is indicated for a product, the prescriber must show trial and failure of preferred agent(s) or request an exception.
- ST is an abbreviation in the formulary legend; follow the product line for whether ST applies.
- If ST is present, include documentation of prior trials when seeking approval.
DIFICID requires step therapy plus prior authorization and QL adherence
DIFICID products are subject to step therapy in addition to quantity limits; include documentation that step‑therapy criteria are met when submitting an authorization request for fidaxomicin products.
- DIFICID oral tablet and suspension: ST; QLs listed (20 EA/10 days for tablets; 136 ML/10 days for suspension).
Step therapy applies to select agents (e.g., FETZIMA, TRINTELLIX, vilazodone)
Some antidepressants and other agents are marked 'ST' in the formulary (examples include FETZIMA, TRINTELLIX, and vilazodone); if ST applies, document trials of preferred agents before requesting coverage for the ST‑flagged product.
- FETZIMA: ST; QL 30 EA per 30 days.
- Vilazodone entries list ST and QL as applicable.
Step Therapy noted in legend — follow product‑level ST flags
The formulary legend defines 'ST' (Step Therapy) as a possible requirement; where an individual drug line is flagged 'ST', follow that requirement and supply documentation of prior trials when seeking approval or exceptions.
- ST is an abbreviation in the legend—specific ST sequences are not detailed in the drug list; use clinical documentation to support exception or PA requests.
Prior Authorization Denial Risk — failure to obtain PA may lead to denial
Not obtaining required prior authorization may result in the drug not being covered by Priority Health Medicare; providers should check the formulary and obtain PA before dispensing specialty or PA‑flagged drugs.
- Claims submitted without required PA may be denied.
- For specialty/Tier 5 drugs, verify PA and QL before billing to avoid coverage denial.
XIFAXAN PA/QL — PA required and quantity limits enforced
Requests for XIFAXAN require prior authorization and are subject to strength‑specific quantity limits; ensure PA submission includes intended dose and requested quantity per the QL.
- XIFAXAN 200 mg: PA; QL 9 EA per 30 days.
- XIFAXAN 550 mg: PA; QL 60 EA per 30 days.
DIFICID ST/QL — step therapy plus quantity limits and PA required
DIFICID products are subject to step therapy and quantity limits; if prescribing fidaxomicin, include documentation of ST criteria and request PA with the QL‑specified quantity.
- DIFICID tablet: ST; QL 20 EA per 10 days.
- DIFICID suspension: ST; QL 136 ML per 10 days.
Anticonvulsant PA/QL — obtain PA and adhere to QLs for specialty neurology drugs
Multiple anticonvulsant specialty products (e.g., brivaracetam, EPIDIOLEX, FINTEPLA, perampanel formulations) require prior authorization and have quantity limits; submit PA with dosing and quantity details consistent with the formulary.
- Brivaracetam solution: PA; QL 600 ML per 30 days.
- EPIDIOLEX: PA; QL 500 ML per 30 days.
- Perampanel suspension/tablets: PA; QL as listed (e.g., 680 ML per 28 days for suspension; 30 EA per 30 days for many tablets).
PA/QL triggers — PA or QL flags require authorization or adherence to limits
Presence of 'PA' or 'QL' in the Requirements/Limits column is a trigger for prior authorization or quantity‑limit review; submit supporting clinical documentation and ensure dispensed quantities do not exceed listed QLs to avoid denials.
- Examples: eslicarbazepine acetate entries show PA with QLs of 30 or 60 EA per 30 days depending on strength.
- Providers should document indication and planned dosing in PA submissions.
Prior Authorization required for many Tier 5/specialty drugs — verify before dispensing
Prior authorization is required for many Tier 5 (specialty) drugs listed; absence of a PA may lead to claim denial — verify PA requirements before prescribing or dispensing specialty agents.
- Tier 5 drugs are specialty and limited to 30‑day supply; many have PA flags.
- Confirm PA and QL for specialty entries (e.g., oncology, biologics) to prevent coverage issues.
Prior authorization requirement — claims may be denied without PA
Claims for drugs marked 'PA' may be denied if prior authorization is not obtained; follow the formulary Requirements/Limits and obtain PA to prevent coverage denial.
- When 'PA' appears on the drug line, do not dispense assuming coverage without approval.
- Submit PA requests with clinical rationale and necessary supporting documents.
PA and QL noncompliance may lead to denial or restricted coverage
Coverage may be denied or restricted if prior authorization or specified quantity limits are not met for listed drugs (the formulary provides examples such as VERSACLOZ with QL and PA); ensure both PA approval and QL compliance.
- VERSACLOZ: PA; QL 540 ML per 30 days — lack of PA or exceeding QL may prompt denial.
- Follow both PA and QL requirements in the drug entry when submitting claims.
PA required (general) — obtain prior authorization to avoid denial
Items shown with 'PA' in the formulary will require prior authorization; failure to obtain PA may lead to denial of coverage by Priority Health Medicare.
- Check the Requirements/Limits column for 'PA' and submit prescriber documentation to obtain authorization before fill.
Prior authorization triggers for selected agents — submit PA with clinical dosing
Drugs listed with 'PA' (for example REDEMPLO, TRYNGOLZA, VERQUVO, REPATHA products) may require prior authorization before coverage; submit a PA request with clinical information and planned dosing to meet requirements.
- REDEMPLO: PA; QL 0.5 ML per 84 days.
- TRYNGOLZA: PA; QL 0.8 ML per 30 days.
- VERQUVO: PA; QL 30 EA per 30 days.
Prior authorization risk for specialty drugs — verify PA for Tier 5 agents
Coverage for many specialty Tier 5 agents may be denied or require prior authorization — verify the PA flag on each specialty product and obtain authorization before dispensing.
- Specialty agents across sections are frequently flagged PA; ensure PA is in place for coverage.
- Contact CustomerCare or follow PA submission instructions in the plan materials.
Triggers for prior authorization or denial — follow PA/QL/ED/HI/LA/ST flags
Entries listing PA, QL, ED, HI, LA or ST are triggers for prior authorization or potential denial — when any of these flags appear, follow the Requirements/Limits instructions and submit required documentation to avoid coverage denial.
- ED (Excluded Drug) entries will be denied if billed.
- HI indicates home infusion requirement and may affect benefit/coverage channel.
Denial triggers in list — PA, ED, NE flags require action
When a listed drug has a PA requirement or is marked ED/NE, coverage may be denied or require further review — obtain PA or confirm exclusion status prior to ordering or billing.
- Drugs like CAYSTON, KALYDECO, ORKAMBI, TRIKAFTA have 'PA' in Requirements/Limits; claims without PA may be denied.
- ED entries (excluded drugs) will not be covered.
Prior authorization / quantity limit risk — claims may be denied without PA or if QL exceeded
Presence of 'PA' or 'QL' on a drug entry indicates claims may be denied without prior authorization or if quantity limits are exceeded; follow the formulary entry and include documentation when submitting PA or billing.
- If a PA is required, obtain approval before dispensing to prevent denial.
- If QL applies, ensure dispensed amount does not exceed the listed QL or document medical necessity when requesting an override.
PA/QL triggers — ensure authorization and correct B/D billing to avoid denials
Coverage may be denied or subject to review when a drug is labeled with 'PA' or 'QL' without documented authorization or when Part B/Part D (B/D) billing indicators are not met; verify benefit channel and include setting-of‑use information for B/D items.
- For B/D entries, submit clinical information describing the setting of use to determine correct billing channel.
- Ensure PA approvals are in place for PA‑flagged drugs and that QL adherence is documented at claim submission.
Excluded drugs — items marked ED will be denied if billed
Some products are marked 'ED' (Excluded Drug) and will be denied if billed; check the formulary for ED entries (examples include benzonatate and certain sodium chloride inhalation solutions) before dispensing.
- Benzonatate is listed as ED — not normally covered in this Medicare drug plan.
- Excluded items will not count toward drug cost thresholds and are not covered.
Prior authorization required for listed specialty respiratory and related drugs (examples)
Drugs with 'PA' in Requirements/Limits (examples: CAYSTON, KALYDECO, ORKAMBI, TRIKAFTA, ADEMPAS, ambrisentan, bosentan, OPSUMIT) require prior authorization — obtain PA prior to dispensing to avoid claim denials.
- CAYSTON, KALYDECO, ORKAMBI, TRIKAFTA: PA and QL as shown per product line.
- Pulmonary antihypertensives and CF agents frequently carry PA and LA flags.
Legend: tiers, abbreviations, and terms
Protections for members already receiving therapy
Continuation of therapy protections
Continuation of therapy protections — Covered when the member was taking the drug at the start of the coverage year and protections apply:
Significant changes that do affect coverage will prompt mailed notice; members may request exceptions to continue therapy
Step therapy flags and examples
| Requirement | Description |
|---|---|
| Must try specified first-line drugs before coverage of alternative drugs | |
| Some drugs require trial of one or more preferred drugs (step therapy) before coverage of alternative drugs is allowed; consult the formulary for specific step therapy requirements. |
| When ST Appears | Action |
|---|---|
| When a drug entry includes the 'ST' flag in the Requirements/Limits column | |
| Follow Step Therapy: the member must try the preferred agent(s) indicated by the plan before the non-preferred alternative will be covered. If the preferred drug does not work, the plan will cover the alternative. |
| Product | Step Therapy Note |
|---|---|
| DIFICID oral suspension (reconstituted) | |
| Requires Step Therapy (ST) and has a quantity limit of 136 mL per 10 days; ST must be met prior to coverage. | |
| DIFICID oral tablet | |
| Requires Step Therapy (ST) and has a quantity limit of 20 EA per 10 days; ST must be met prior to coverage. |
| Example Products Marked ST | Formulary Entry / Requirement |
|---|---|
| FETZIMA | |
| Listed with Requirements/Limits = ST; QL (30 EA per 30 days) — Step Therapy required where ST is indicated. | |
| TRINTELLIX | |
| Listed with Requirements/Limits = ST; QL (30 EA per 30 days) — Step Therapy required where ST is indicated. | |
| vilazodone | |
| Listed with Requirements/Limits = ST where marked — Step Therapy required prior to coverage. | |
| eletriptan (and some triptans) | |
| Certain migraine agents are noted ST where marked; follow Step Therapy when ST appears on the drug line. |
| Reference | What the legend states | Notes |
|---|---|---|
| Abbreviation legend (ST) | ||
| ST = Step Therapy | ||
| The formulary defines 'ST - Step Therapy' as a possible requirement in the legend, but specific step sequences or detailed rules are not provided in these chunks; consult the formulary entries for product-level ST details. |
| Product Group / Formulation | Step Therapy Indicator |
|---|---|
| Paliperidone ER (extended-release) formulations | |
| Entries for paliperidone ER list 'ST' in Requirements/Limits (e.g., paliperidone ER 1.5/3/6/9 mg) — Step Therapy applies to these products. |
| Context | Implication |
|---|---|
| Formulary legend includes ST | |
| Step Therapy is referenced in the legend as 'ST', but no specific step edits or sequences are listed in these chunks — product lines must be checked for any ST requirement. |
| Observation | Interpretation |
|---|---|
| ST flag appears in formulary segments | |
| The ST flag is used as an indicator in the formulary legend; however, some segments show the flag without detailed step rules in these excerpts. |
| Section | Detail |
|---|---|
| Formulary marking of ST | |
| ST marks where applicable per the legend; detailed step therapy rules are not present in the provided chunks — check specific drug lines for ST requirements. |
| Product Example | Requirement |
|---|---|
| calcitriol external | |
| Flagged with ST in the formulary excerpt — indicates Step Therapy applies for the external calcitriol entry where shown. |
| Product Example | Requirement |
|---|---|
| clotrimazole-betamethasone (example topical entries) | |
| At least one clotrimazole-betamethasone external entry is noted with ST; follow Step Therapy when ST is listed on the product line. |
| Reference | Finding |
|---|---|
| Abbreviations and legend referencing ST | |
| ST is referenced but the provided chunks do not show the step sequences or trials required — product-level entries may contain details. |
| Formulary Legend | Meaning |
|---|---|
| ST - Step Therapy | |
| Formulary references 'ST - Step Therapy' as a possible requirement in the legend; specific step therapy rules are not included in these excerpted chunks. |
| Ophthalmic Agents | Step Therapy Notes |
|---|---|
| difluprednate (ophthalmic) | |
| Designated 'ST' in the ophthalmic section; step therapy must be met prior to coverage where ST is indicated. | |
| loteprednol products (ophthalmic gel/suspension) | |
| Some loteprednol formulations are designated 'ST' — follow Step Therapy when ST appears on these lines. |
| Legend Reference | Content |
|---|---|
| ST in the formulary legend | |
| Step Therapy is listed as 'ST' in the abbreviation legend; the provided chunks do not include full step therapy sequences for products. |
Numerical dispensing limits by product
Home infusion and billing channel notes
Biologic and biosimilar handling
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