Providence Health Plan formulary Coverage & PA

General formulary coverage and restrictions

Covered per formulary tier with restrictions as indicated.

Formulary coverage: Drugs listed on the Providence formulary are covered according to the member's benefit and tier placement; ACA Preventive drugs listed as 'ACA Preventive' are covered in full with zero cost share when applicable.

See Tier definitions in formulary (ACA Preventive = 0).

Utilization restrictions: Coverage may be subject to prior authorization (PA), quantity limits (QL/OL), step therapy (ST), specialty pharmacy dispensing (S), or limited access (LA) as indicated in the formulary notes.

Restriction flags and explanations are listed in the formulary 'Restrictions/Limitations' section.

Specialty drugs may be limited to a 30‑day supply and required to be dispensed through a contracted specialty pharmacy; tier placement and specialty designation determine cost share and site-of-care rules.

Preferred specialty pharmacy example: Credena Health; see 'Restrictions/Limitations' for S and LA definitions.

Generic equivalent/alternative coverage rules

Formulary coverage and member cost rules.

Generic substitution and member cost responsibility: When a generic equivalent is available, members requesting a brand‑name drug are responsible for the difference in cost between the brand and generic in addition to the brand copayment or coinsurance; that difference is not applied toward the calendar year deductible or out‑of‑pocket maximum unless the brand is authorized via a formulary exception.

Brand-versus-generic cost differentials and exception rules are described in the Generic Alternatives section.

Opioid PA and QL requirements

Utilization management for opioids and controlled analgesics.

Opioid dose and quantity limits: Opioid coverage is subject to product‑specific quantity limits and a total cumulative opioid dose limit; the formulary limits total cumulative opioid dose to 90 morphine milligram equivalents (MME) per day and applies QL entries per product (examples include fentanyl transdermal patch QL 15 units per 30 days and various per‑day QL for oral opioids).<= 90 MME/day

Multiple opioid line items list 'QL (Total cumulative opioid dose limited to 90 morphine milligram equivalent (MME) per day)' and product QLs.

General coverage by product listing

Coverage follows listed product-specific quantity limits and tiers:

Product listing governs coverage: Coverage for a listed product is consistent with the product's assigned formulary tier and any Notes (e.g., QL, PA, S, LA); providers and pharmacies must follow the specified quantity limits and authorization requirements on the formulary listing.see QL notes

Vaccine and other product entries include QL expressed as allowed units per stated time period (per day, per lifetime, per 28 days).

Formulary coverage stance by product

Coverage and utilization management is provided per drug by tier and note; where 'PA' is listed, prior authorization is required; 'QL' indicates quantity limits.

Formulary stance by product: Each drug line item in the formulary indicates tier placement and Notes that specify utilization controls. Where Notes = 'PA', prior authorization is required before coverage; where Notes include 'QL' or 'OL', quantity limits apply per the listed units/time period; 'PV', 'S', 'LA', and 'ST' are additional flags affecting coverage or site of dispensing.

See product entries for product‑specific QL values (e.g., REPATHA QL 2 mL per 28 days; PRALUENT QL 2 mL per 28 days) and PA flags.

Providence excludes certain drugs from coverage under the prescription drug benefit. Examples called out in the formulary guidance include drugs that are not approved by the Food & Drug Administration (FDA) and most drugs that are available without a prescription (over‑the‑counter drugs), unless coverage is mandated by law or the plan (for example, ACA preventive drug coverage). Members and providers should consult plan documents and follow the formulary exception process when necessary.

When a generic equivalent is available, the formulary policy requires members who request a brand‑name product to pay the difference in cost between the brand and the generic in addition to any applicable brand copayment or coinsurance. That cost difference will not apply toward the member’s calendar‑year deductible or out‑of‑pocket maximum unless the brand is authorized through a formulary exception in accordance with plan rules.

No explicit exclusion lists are provided in this portion of the formulary extract. The document shows vaccine product entries with tiering and quantity‑limit notes but does not state additional, line‑level not‑covered exclusions in these chunks.

In this segment of the formulary listing there are no explicit statements that items are categorically not covered. Products are presented with tier assignments and notes (e.g., PV, PA, QL) that describe coverage controls rather than explicit not‑covered declarations.

If a brand‑name drug is requested when a generic equivalent exists and a formulary exception is not granted, the member remains financially responsible for the brand‑generic cost difference and the plan may effectively not cover the brand except through an approved exception; providers should submit a formulary exception when clinically indicated.

Within the available excerpt there are no explicit statements labeling products as “not medically necessary.” The formulary entries in this section focus on tier assignment, preventive eligibility, and quantity‑limit notes rather than explicit not‑medically‑necessary determinations.

This portion of the formulary extract does not list specific items as not medically necessary. Coverage and any restrictions are expressed via tiering and note flags (for example, PA, QL, PV) rather than through explicit not‑medically‑necessary language in these chunks.

Authorization, Step Therapy & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs noted in the formulary. Providers must request and obtain authorization before dispensing drugs marked “PA” to avoid claim denials.

PA indicators in formulary entries require prior authorization before dispensing
Many high-cost, specialty, antiviral, antineoplastic, immune globulin, PCSK9 inhibitor, and select cardiovascular agents are annotated PA
Drugs with PA and no prior approval may be denied at claim adjudication

Prior Authorization

Prior authorization required for many formulary drugs

Numerous formulary drugs require prior authorization. Check the product Notes field for PA, ST (step therapy), QL (quantity limits), S (specialty), and LA (limited access) annotations and submit PA requests when indicated.

Many common and specialty agents in the formulary list include PA in the Notes column — review each line-item before prescribing
When ST is present, step therapy rules apply (see step-therapy callouts)
When a product is marked S or LA, pharmacy sourcing or specialty pharmacy routing may be required

Prior Authorization

Prior authorization and QL for listed specialty agents

Specialty biologics, oncology agents, and other specialty therapies frequently include both PA and quantity limits (QL). Requests for these agents should include specific dosing, frequency, and supplier details to support approval and any QL overrides.

Examples: ENBREL formulations — Notes = PA; QL (4 mL per 28 days); S
Many oral antineoplastics and biologics include Notes = PA; QL; S; LA
Provide dosing schedule, intended duration, and prior treatment history with PA requests

Prior Authorization

Prior authorization required for select antiviral agents

Select antiviral agents (HCV, CMV, HIV-related and other antivirals) are labeled PA and/or S; providers must obtain PA and adhere to listed QLs and specialty sourcing where indicated.

Hepatitis C regimens (MAVYRET, VOSEVI, ledipasvir‑sofosbuvir, sofosbuvir‑velpatasvir) are Notes = PA; S
CMV agents (PREVYMIS, VALCYTE, valganciclovir) include PA, QL, and S annotations
HIV prevention agents (DESCOVY, emtricitabine‑tenofovir) include indication-based notes — confirm diagnosis and coverage rules

Prior Authorization

Prior authorization for immune globulins

Immune globulin products are commonly annotated PA and S (and sometimes LA). Prior authorization is required and documentation should justify medical necessity and the requested dose/interval.

Examples: CUTAQUIG, GAMMAKED, GAMUNEX‑C, HIZENTRA, HYQVIA, XEMBIFY — Notes = PA; S; LA
Include diagnosis, prior therapies, weight-based dosing (if applicable), infusion/site of care, and planned administration schedule with PA request

Prior Authorization

Prior authorization required for selected high-tier products

High-tier and specialty products (e.g., PCSK9 inhibitors, omega‑3 agents, select oncology and inhaled therapies) carry PA and quantity limits. Confirm PA requirements before prescribing to avoid denials and cost-shift to the member.

PCSK9 inhibitors (REPATHA, PRALUENT) — Notes = PA; QL (mL per 28 days); S
Icosapent ethyl (VASCEPA) and some omega‑3 agents — Notes = PA
Tolvalptan (SAMSCA), tolvaptan — Notes = PA; S; LA

Step Therapy

PA required for specified agents / Step therapy applies when ST is listed

PA and step‑therapy indicators (ST) are present across therapeutic classes. When ST is listed, the preferred first‑line therapies must be tried or documented as inappropriate before the ST drug will be approved.

ST entries (e.g., certain anticonvulsants and anticonvulsant formulations) require prior trial of specified agents or documented intolerance
If prior medication history is unavailable (new patient), PA is required to document medical necessity
Possible step edits and preference indicators (PV) may influence prior authorization outcomes

Documentation Required

Prior authorization flags, QL presence, and documentation requirements

Formulary notes include PA and QL flags that will trigger utilization management. Providers must follow the Notes field and supply documentation (clinical indication, prior therapies, dosing, quantity and frequency, and site of care) to support PA and any QL exceptions.

Quantity limits are enforced (examples: ENBREL QL (4 mL per 28 days); sumatriptan injections QL (4 mL per 30 days))
Opioid entries show cumulative MME limits (Total cumulative opioid dose limited to 90 MME per day) — exceeding limits may cause denial
Brand requests when a generic exists may require a formulary exception and member pays the cost difference; exception approvals should be documented

Denial Risk

Prior authorization and step therapy triggers / Denial risk from unmet PA/QL

Failure to obtain required PA or to adhere to QL/ST rules can result in claim denials or member financial liability. Providers should verify coverage, obtain PA prior to dispensing, and include supporting documentation to reduce denial risk.

Denial risk if PA or QL conditions are not met (examples across antipsychotics, migraine injectables, anticonvulsants)
Brand vs generic: member responsible for cost difference unless a formulary exception is granted
Opioid MME and QL overages — prescriptions exceeding specified MME or QL may be denied

Documentation Required

Documentation for non-formulary or restricted drugs

When a drug is not on the formulary or is restricted, submit either a prior authorization request or a formulary exception with clinical rationale. Include relevant clinical records, prior medication trials, and any specialty‑pharmacy routing information.

Formulary exception requests must document why formulary alternatives are unsuitable
For non‑formulary or limited‑access drugs provide supporting clinical notes, diagnosis, and prior treatment history
Contact Customer Service or the plan’s PA vendor for submission instructions and specialty pharmacy requirements

Specified Quantity Limits (selected examples)

inv-146: example (sumatriptan) — 9 tablets

Example—sumatriptan (oral)9 tablets per 30 days

Example—sumatriptan (injectable pen/cartridge)QL (4 mL per 30 days) for STATDOSE pen/cartridge

Source contextQuantity limits used to limit frequency and volume of triptan therapy

inv-147: fentanyl transdermal patch — 15

Fentanyl transdermal patch (example)15 (QL = 15 EA per 30 days)

Formulation examples72-hour transdermal patches across multiple mcg/hr strengths

Utilization noteNotes = PA; QL and cumulative opioid MME limit apply

inv-148: buprenorphine transdermal patch — 4

Buprenorphine transdermal patch (example)4 (QL = 4 EA per 28 days)

Formulation examplesWeekly buprenorphine patches listed at multiple mcg/hr strengths

Utilization noteNotes = PA; QL and cumulative opioid MME limit apply

inv-149: methadone oral solution/concentrate — varies by formulation (e.g., 4 mL/day, 20 mL/day, 40 mL/day)

Methadone oral solutions/concentratesQuantity limits vary by formulation (examples: 4 mL/day; 20 mL/day; 40 mL/day)

Formulation examplesMethadone oral concentrate 10 mg/mL (QL 4 mL/day); methadone oral solution 10 mg/ mL (QL 20 mL/day); 5 mg/5 mL (QL 40 mL/day)

NotesEntries reference total cumulative opioid MME limit as well as formulation-specific QLs

inv-150: ENBREL formulations — 4 ML

ENBREL formulations QL4 mL per 28 days

Formulations referencedENBREL mini cartridge, solution, syringe, SureClick pen (dose volumes noted) — all with QL 4 mL/28 days

NotesEntries list Notes = PA; QL (4 ML per 28 days)

inv-151: adalimumab-aaty 40 mg/0.4 ml — 2 EA

adalimumab-aaty 40 mg/0.4 mL QL2 each per 28 days

FormulationSubcutaneous auto-injector kit 40 mg/0.4 mL — Notes = PA; QL (2 EA per 28 days)

Related entryMatches other adalimumab-aaty listings with similar QL per 28 days

inv-152: adalimumab-aaty 80 mg/0.8 ml — 1 EA

adalimumab-aaty 80 mg/0.8 mL QL1 each per 28 days

FormulationSubcutaneous auto-injector kit 80 mg/0.8 mL — Notes = PA; QL (1 EA per 28 days)

NotesListed with specialty flags (S) and PA

inv-153: RINVOQ oral solution — 12 ML

RINVOQ oral solution QL12 mL per 1 day

RINVOQ tablet QLQL (1 EA per 1 day) for oral tablets

NotesEntries include Notes = PA; QL and S; LA flags for some formulations

inv-154: benznidazole; ALINIA; TIVICAY PD — specified in notes

Benznidazole QL (pediatric example)60 each per 365 days for ages 2-12

ALINIA QL180 mL per 30 days or 6 each per 30 days (tablet vs suspension entries)

TIVICAY PD noteListed with product-specific QL entries in Notes (e.g., QL 6 EA per 1 day for some formulations)

inv-155: maraviroc (SELZENTRY) — QL (2 EA per 1 day) for some formulations

Maraviroc (SELZENTRY) QLQL (2 each per 1 day) for some formulations

Formulations referencedSELZENTRY oral tablets and oral solution listed; 150 mg tablet Notes = QL (2 EA per 1 day)

NotesEntries may include specialty flags; check Notes for PA/QL

inv-156: VALCYTE oral recon solution 50 mg/mL — 36 mL

VALCYTE oral recon solution QL36 mL per 1 day

StrengthVALCYTE oral recon solution 50 mg/mL — Notes = QL (36 mL per 1 day); S

Clinical noteHigh-volume antiviral oral solutions have daily mL QLs enforced

inv-157: PREVYMIS oral pellets/tablet — 4

PREVYMIS QL4 each per 1 day

FormulationPREVYMIS oral pellets/tablet — Notes = PA; QL (4 EA per 1 day); S; LA

Utilization notePrior authorization applies and QL enforced per day

inv-158: XIFAXAN oral tablet — 3

XIFAXAN QL3 each per 1 day

FormulationXIFAXAN oral tablet 200 mg, 550 mg — Notes = PA; QL (3 EA per 1 day)

Coverage notePA noted for some antibacterial/antiparasitic agents; follow Notes

inv-159: IBRANCE — 21

IBRANCE QL21 each per 28 days

FormulationIBRANCE (palbociclib) 75/100/125 mg — Notes = PA; QL (21 EA per 28 days); S; LA

Administrative noteQuantity limits apply to dosing cycles; follow Notes for PA/QL

inv-160: lapatinib — 6

Lapatinib QL6 each per 1 day

FormulationLapatinib oral tablet 250 mg — Notes = PA; QL (6 EA per 1 day)

NotesPA and QL apply for antineoplastic TKIs

inv-161: VENCLEXTA STARTING PACK — 42

VENCLEXTA starting pack QL42 each per 28 days

FormulationVENCLEXTA starting pack (venetoclax dose pack) — Notes = PA; QL (42 EA per 28 days); S; LA

Use noteStarting-pack QL reflects starter dosing regimen; follow PA guidance

inv-162: PEMAZYRE — 14

PEMAZYRE QL14 each per 21 days

FormulationPEMAZYRE oral tablet 13.5/9/4.5 mg — Notes = PA; QL (14 EA per 21 days); S; LA

NotesQuantity limit specified per 21-day period

inv-163: ORGOVYX — 32

ORGOVYX QL32 each per 30 days

FormulationORGOVYX oral tablet 120 mg — Notes = PA; QL (32 EA per 30 days); S; LA

Utilization notePA and QL apply for hormonal antineoplastic agents

inv-164: JAKAFI — 2 EA

JAKAFI QL2 each per 1 day

FormulationJAKAFI oral tablet (multiple strengths) — Notes = PA; QL (2 EA per 1 day); S; LA

NotesQuantity limit applies per day for febrile/antineoplastic indications as listed

inv-165: OJJAARA — 1 EA

OJJAARA QL1 each per 1 day

FormulationOJJAARA oral tablet 100/150/200 mg — Notes = PA; QL (1 EA per 1 day); S; LA

Administrative noteDaily QL listed in Notes — follow PA for coverage

inv-166: COTELLIC — 63 EA

COTELLIC QL63 each per 28 days

FormulationCOTELLIC oral tablet 20 mg — Notes = PA; QL (63 EA per 28 days); S; LA

NotesHigh QL reflects chronic dosing; PA applies

inv-167: XPOVIO — 8 EA

XPOVIO QL (example range)8 each per 28 days (other QLs vary by strength: 4, 24, 32 per 28 days)

FormulationXPOVIO oral tablet (various dosing patterns) — Notes = PA; QL (8 EA per 28 days typical listing)

Coverage noteQL varies by strength/dosing; consult Notes for specific strength

inv-168: HAVRIX / VAQTA / ENGERIX-B / RECOMBIVAX HB (examples) — 1 dose per day; 2-3 doses per lifetime

Vaccine dose limits (examples)1 dose per day; 2-3 doses per lifetime depending on vaccine

ExamplesHAVRIX/VAQTA/ENGERIX-B/RECOMBIVAX HB entries list QL per day and per lifetime (2–3 doses) as applicable

Provider actionObserve per-dose and lifetime QLs when administering vaccines

inv-169: PROQUAD / ROTARIX / ROTATEQ — per-day and per-lifetime limits

ROTARIX / ROTATEQ per-day/lifetime limitsROTARIX example: 1 mL per day; 2 mL per lifetime (per listing)

PROQUAD limitsPROQUAD QL (1 DOSE/1 VIAL per 1 day); lifetime vial limits noted in table

Clinical noteVaccines include both per-administration and lifetime QLs as listed

inv-170: PROQUAD (PF) and other listed products — 1 DOSE (1 VIAL) per 1 day

PROQUAD (PF) per-day QL1 dose (1 vial) per 1 day

Other product QLsSome products in vaccine group list QL as 1 EA per 1 day or per-lifetime limits

Provider noteFollow vaccine-specific Notes for dose and lifetime limits

inv-171: REPATHA (pens/syringe/wearable), PRALUENT — QL per 28 days

REPATHA pens/syringes QL2 mL per 28 days (pens/syringes)

REPATHA wearable QL3.5 mL per 28 days (wearable injector)

PRALUENT QL2 mL per 28 days

inv-172: Epinephrine auto-injector (EPIPEN/EPIPEN JR) — QL 2 pens per 30 days

Epinephrine auto-injector QL2 pens per 30 days

Products referencedEPIPEN / EPIPEN JR (auto-injectors) — Notes = QL (2 PENS per 30 days)

Provider notePer-month limit applied to anaphylaxis therapy auto-injectors

inv-173: FIRAZYR / icatibant — QL 18 mL per 30 days

FIRAZYR / icatibant QL18 mL per 30 days

FormulationFIRAZYR subcutaneous syringe 30 mg/3 mL — Notes = PA; QL (18 mL per 30 days); S; LA

Coverage notePA and QL apply for bradykinin receptor antagonists

inv-174: CAMZYOS — QL 1 each per 1 day

CAMZYOS QL1 each per 1 day

FormulationCAMZYOS oral capsule 10/5 mg — Notes = PA; QL (1 EA per 1 day); S; LA

Provider noteDaily QL with PA for cardiac myosin inhibitor

inv-175: TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML — 4 ML

TAKHZYRO solution QL4 mL per 28 days

TAKHZYRO syringe QL2 mL per 28 days (150 mg/mL syringe)

NotesEntries list PA; QL; S; LA for TAKHZYRO formulations

inv-176: TAKHZYRO SUBCUTANEOUS SYRINGE 150 MG/ML — 2 ML

TAKHZYRO syringe QL2 mL per 28 days

FormulationTAKHZYRO subcutaneous syringe 150 mg/mL — Notes = PA; QL (2 ML per 28 days)

Administration noteFollow PA and QL for syringe presentations

inv-177: UPTRAVI ORAL TABLET — 2 EA

UPTRAVI QL2 each per 1 day

FormulationUPTRAVI oral tablet — Notes = PA; QL (2 EA per 1 day); S; LA

Clinical noteDaily QL listed for pulmonary antihypertensive prostacyclin agents

inv-178: TYVASO products — unspecified QL entries present (product-specific)

TYVASO QL entriesProduct-specific QLs present (see product Notes)

Formulations referencedTYVASO inhalation solution and starter/refill kits — Notes = PA; S; LA; QL varies by kit/product

Provider noteConsult product-specific Notes for exact QL values

inv-179: EMGALITY SYRINGE; APTIOM — EMGALITY QL (3 ML per 28 days); APTIOM QL (2 EA per 1 day or per 2 days depending on strength)

EMGALITY syringe/pen QLEMGALITY QL 1 mL per 28 days (pen/syringe entries show 1 mL/28 days; some listings show 3 mL per 28 days for other formats)

APTIOM QLAPTIOM QL 2 each per 1 day (or QL 2 EA per 2 days for some strengths)

NotesEntries include PA; QL and strength-dependent limits — consult Notes for exact QL by presentation

inv-180: multiple entries — examples provided inline

Representative multiple QL examplesExamples in listing include QL (2 EA per 1 day); QL (20 mL per 1 day); QL (10 EA per 1 day)

ContextVarious therapeutic classes list per-day or per-period QLs in Notes

Provider actionFollow product Notes for the specific QL applicable to the dispensed formulation

inv-181: Multiple (see line items) — Various QL entries

Representative QL patternsExamples: QL (1 EA per 1 day); QL (10 EA per 1 day); QL (2 EA per 1 day); QL (1 EA per 365 days)

ApplicabilityUsed across many formulary line items (acute, chronic, and lifetime limits)

GuidanceClaims exceeding these limits may be denied without PA or supporting documentation

inv-182: methylphenidate transdermal patch 24 hour — 1 EA

Methylphenidate transdermal patch QL1 each per 1 day

Formulation examples24-hour methylphenidate transdermal patch at multiple strengths — Notes = QL (1 EA per 1 day)

Provider noteDaily QL applies to stimulant transdermal patches

inv-183: RELEXXII ORAL TABLET EXTENDED RELEASE 24HR — 1 EA

RELEXXII QL1 each per 1 day

FormulationRELEXXII oral tablet extended release 24 hr — Notes = QL (1 EA per 1 day)

NotesDaily QL applied to extended-release stimulant formulations

inv-184: AJOVY AUTOINJECTOR 225 MG/1.5 ML — 1.5 ML

AJOVY autoinjector QL1.5 mL per 28 days

FormulationAJOVY autoinjector 225 mg/1.5 mL — Notes = PA; QL (1.5 mL per 28 days)

Provider noteMonthly QL applies to CGRP mAb autoinjectors

inv-185: EMGALITY PEN/ SYRINGE 120 MG/ML — 1 ML

EMGALITY pen/syringe QL1 mL per 28 days (pen/syringe entries)

FormulationEMGALITY pen/syringe 120 mg/mL — Notes = PA; QL (1 ML per 28 days)

NotesPA and QL apply for migraine CGRP mAbs

inv-186: AIMOVIG AUTOINJECTOR 140/70 MG — 1 ML

AIMOVIG autoinjector QL1 mL per 28 days

FormulationAIMOVIG autoinjector 140/70 mg — Notes = PA; QL (1 ML per 28 days)

Provider noteMonthly QL for AIMOVIG autoinjector presentations

inv-187: NURTEC ODT 75 MG — 8 EA

NURTEC ODT QL8 each per 30 days

FormulationNURTEC ODT 75 mg — Notes = PA; QL (8 EA per 30 days)

Utilization notePer-30-day limit applied to gepant acute migraine therapy

inv-188: sumatriptan oral tablet — 9 EA

Sumatriptan oral tablet QL9 each per 30 days

FormulationSumatriptan succinate oral tablet 100/25/50 mg — Notes = QL (9 EA per 30 days)

Related QLSumatriptan injectable pen/cartridge QL (4 mL per 30 days) listed separately

inv-189: zolmitriptan oral/nasal formulations — 6-12 EA

Zolmitriptan QL range6–12 each per 30 days depending on formulation

FormulationsZolmitriptan oral and nasal presentations show QL (6–12 EA per 30 days) in Notes

Provider noteQL varies by route — consult product Notes

inv-190: IMITREX STATDOSE PEN (sumatriptan) and refills — 4 ML

IMITREX STATDOSE pen/cartridge QL4 mL per 30 days

FormulationIMITREX STATDOSE pen and refills — Notes = QL (4 ML per 30 days)

Related entryMatches sumatriptan injectable QL entries

inv-191: MAXALT (rizatriptan) tablets / disintegrating — 12

MAXALT (rizatriptan) QL12 each per 30 days

FormulationMAXALT oral tablet/disintegrating 10 mg — Notes = QL (12 EA per 30 days)

Provider notePer-30-day limit for rizatriptan formulations

inv-192: sodium oxybate / XYREM / XYWAV — 540

Sodium oxybate (XYREM/XYWAV) QL540 mL per 30 days

FormulationXYREM oral solution 500 mg/mL — Notes = PA; QL (540 ML per 30 days); S; LA

Utilization noteHigh-volume QL with PA for controlled narcolepsy agent

Step Therapy Overview & Flags

Requirement	Notes
Trial of first-line therapies before coverage of ST-designated drug
If first-line alternatives have not been tried or cannot be tried, prior authorization is required before the ST-designated drug will be approved

Flag	Implication
S (Specialty) or LA (Limited Access)
Indicates specialty biologics and select anti-inflammatory agents may have restricted distribution or site requirements and may be subject to additional management steps (e.g., specialty pharmacy, limited access); utilization controls such as PA/QL often accompany these flags

Annotation	Meaning in formulary
S (appears in Notes)
Denotes specialty/step edits may apply prior to coverage; specific step sequences are not provided in this document excerpt

Product group	Coverage note
Antiretroviral and PrEP products (e.g., DESCOVY, emtricitabine-tenofovir)
Some products include indication-based notes (e.g., covered in full for PrEP with specific diagnosis) — coverage may be condition-specific before full benefit applies

Hepatitis C agents	Utilization control
MAVYRET, VOSEVI, ledipasvir–sofosbuvir, sofosbuvir–velpatasvir
Noted with PA in formulary notes — prior authorization is required for these hepatitis C agents

Marker	Effect on coverage
S annotation on agents
Indicates step therapy requirements apply before coverage; prescribers should follow step therapy requirements when requesting coverage

Control	Role in utilization management
PA (Prior Authorization)
Requires submission of prior authorization request; used as a utilization control in lieu of explicit multi-step sequences in this excerpt

Agent examples	Notation / implication
NEXLETOL (bempedoic acid), VASCEPA (icosapent ethyl)
Listed with Notes = PA indicating prior authorization (or step/authorization requirement) is required prior to coverage

Summary	Observation
Formulary listings in this portion use note flags (PA, QL, S) rather than explicit step sequences
No detailed step therapy step sequence is specified in the excerpt; items are annotated with PA/QL/S/LA as utilization controls

Anticonvulsant examples	Formulary note
FYCOMPA, APTIOM, eslicarbazepine formulations, BRIVIACT, XCOPRI
Marked 'ST' in Notes indicating step therapy requirements apply before coverage of these products

Flag	Detail
ST present on entries
ST flag indicates step therapy applies, but specific prior steps are not detailed in these chunks

Entry indicator	Coverage implication
Entries marked 'ST' (various CNS and movement disorder medications)
Step therapy requirements apply for products marked 'ST'; prescribers must document trials of required alternatives or obtain prior authorization if trials cannot be documented

Observation	Formulary behavior
This excerpt contains PA and QL controls but does not list multi-step therapy sequences
Utilization management is applied via PA/QL/S/LA/PV flags rather than explicit multi-step algorithms in the provided segments

Examples	Notes
Selected products flagged 'PA' and 'S' (e.g., AUSTEDO, tetrabenazine, REYVOW)
Indicates prior authorization is required and specialty/limited-access steps may apply prior to coverage

fentanyl transdermal patch 72 hr 12 mcg/hr	Fentanyl transdermal patch 72 hour 12 mcg/hr — PA; QL 15 EA per 30 days; total cumulative opioid dose limited to 90 MME/day
fentanyl transdermal patch 72 hr 25 mcg/hr	Fentanyl transdermal patch 72 hour 25 mcg/hr — PA; QL 15 EA per 30 days; total cumulative opioid dose limited to 90 MME/day
fentanyl transdermal patch 72 hr 50 mcg/hr	Fentanyl transdermal patch 72 hour 50 mcg/hr — PA; QL 15 EA per 30 days; total cumulative opioid dose limited to 90 MME/day
fentanyl transdermal patch 72 hr 75 mcg/hr	Fentanyl transdermal patch 72 hour 75 mcg/hr — PA; QL 15 EA per 30 days; total cumulative opioid dose limited to 90 MME/day
fentanyl transdermal patch 72 hr 100 mcg/hr	Fentanyl transdermal patch 72 hour 100 mcg/hr — PA; QL 15 EA per 30 days; total cumulative opioid dose limited to 90 MME/day

midazolam (pf) injection solution 1 mg/mL; 5 mg/mL	Midazolam injection solution 1 mg/mL and 5 mg/mL — listed (tier/notes as provided)
midazolam (pf) injection syringe 2 mg/2 mL (1 mg/mL), 5 mg/mL	Midazolam prefilled injection/syringe presentations — listed
midazolam intravenous syringe 150 mg/30 mL (5 mg/mL)	Midazolam IV syringe presentation — listed

AJOVY AUTOINJECTOR 225 MG/1.5 ML	AJOVY (fremanezumab) autoinjector/syringe 225 mg/1.5 mL — PA; QL (1.5 mL per 28 days)
EMGALITY PEN 120 MG/mL	EMGALITY (galcanezumab) pen/syringe 120 mg/mL — PA; QL (1 mL per 28 days)
AIMOVIG AUTOINJECTOR 140/70 MG/mL	AIMOVIG (erenumab) autoinjector 140 mg/mL and 70 mg/mL — PA; QL (1 mL per 28 days)
NURTEC ODT 75 MG	NURTEC ODT (rimegepant) oral disintegrating tablet 75 mg — PA; QL (8 EA per 30 days)

Total cumulative opioid dose	<= 90 MME per day applies across many opioid entries
Fentanyl patch quantity limit	QL: 15 EA per 30 days for fentanyl transdermal patches (72 hr)
Buprenorphine patch quantity limit	QL: 4 EA per 28 days for weekly buprenorphine transdermal patches

OpenPayer

Prescription Drug Formulary (2026) — 6-Tier

Formulary Coverage & Restrictions

Representative Product Entries & Coding Examples

Authorization, Step Therapy & Documentation Requirements

Specified Quantity Limits (selected examples)

Specialty Pharmacy & Site-of-Care Notes

Key Terms & Abbreviations

Initiation Controls (Excerpt)

Step Therapy Overview & Flags

Formulary Purpose & Scope