Providence Health Plan prescription formulary Coverage

Formulary Tier Coverage Logic

Coverage and cost-sharing depend on tier placement and member benefit design

Tier placement rules: Drugs are assigned to tiers (ACA Preventive, Tier 1–6) which determine cost share; brand-name drugs are CAPITALIZED and generics are listed in lower-case italics in the formulary listing.

Member pays cost-share per benefit summary and may owe the difference if choosing a brand when a generic equivalent exists.

ACA Preventive: Drugs on the ACA Preventive tier (Tier 0) are covered in full with zero cost share; tier placement can change when a generic becomes available.

ACA Preventive coverage may be subject to age or condition limits as indicated in the formulary.

Specialty drugs are typically limited to a 30-day supply and are placed on higher specialty tiers (Tier 5 preferred specialty; Tier 6 other specialty) with specialty handling requirements.30-day

Preferred specialty pharmacy (e.g., Credena Health) is used for specialty fills per formulary guidance.

Generic substitution and cost responsibility

Formulary preference and member financial responsibility

Generic preference and cost responsibility: Prescribers and members should use generic equivalents or clinically appropriate generic alternatives when available; if a brand-name drug is requested or prescribed when a generic equivalent exists, the member is responsible for the cost difference in addition to the brand copay/coinsurance.

The difference in cost generally does not apply toward the Calendar Year Deductible and Out-of-Pocket Maximum unless the brand is authorized through a formulary exception while a generic equivalent exists (then the difference may apply).

Opioid PA and QL requirements

Opioid coverage notes and limits

Opioid prior authorization and quantity limits: Many opioid products are subject to prior authorization (PA) and have specified quantity limits (QL) per day or per fill; the formulary also applies a total cumulative opioid dose limit measured in morphine milligram equivalents (MME).Total cumulative opioid dose limited to 90 MME per day

Examples in the formulary include product-level QL rules (e.g., fentanyl patches QL 15 EA per 30 days; various ER opioids QL 2 EA per day; tramadol QL examples) and PA where noted.

Specialty drug coverage requirements

Specialty biologic agents

Biologic/specialty PA and QL: Many biologic and specialty agents (for example, adalimumab products, ENBREL, CIMZIA, HADLIMA, SIMLANDI, SIMPONI, ZYMFENTRA) are listed with prior authorization (PA), quantity limits (QL) and specialty (S) or limited access (LA) flags.

Tier placement for these biologics is commonly Tier 5 (preferred specialty) or Tier 6 (other specialty); QL values are specified per formulation (e.g., per 28 days) in the formulary.

Formulary coverage with PA and QL

Coverage and access rules for listed drugs as shown in formulary table

Formulary access conditions: Drugs listed with a Tier and 'Notes = PA' require prior authorization and are subject to the listed quantity limits (QL) and any specialty labeling (S) or limited access (LA) designations.

Providers must follow the payer's prior authorization process and adhere to QL measurements (EA, mL, kit/vial) when submitting requests or claims.

Formulary administrative coverage

Coverage stance for listed drugs is administrative and tied to plan controls; individual clinical criteria are not present in this fragment.

Formulary administrative controls: Formulary entries identify tier assignment and plan-level utilization controls (PA, QL, LA, S). Clinical indication-specific medical necessity criteria are not included in this excerpt.

Adjudication relies on satisfying the plan-level PA and QL requirements shown next to each product.

Coverage conditional on utilization controls

Coverage entries are product-level and subject to utilization controls; coverage is conditional on meeting PA/QL/LA/S rules as listed per drug

Formulary coverage conditions: Coverage for a listed product is conditional on the drug being on the formulary and on satisfying any noted utilization controls (prior authorization [PA], quantity limit [QL], limited access [LA], or specialty [S]).

This excerpt does not provide indication-specific medical necessity criteria; follow stated PA/QL/LA/S requirements for coverage determinations.

Formulary listing and QL/PA annotations

Coverage is indicated by tier assignment with quantity limits and notes; specific clinical necessity criteria are not present in this excerpt.

Formulary coverage entries: Products are listed with tier assignments (including Tier 0 ACA Preventive and Tiers 1–6) and often include quantity limits (QL) and notes such as PA or PV. No detailed clinical AND/OR criteria are provided in this portion.

Use the tier assignment, QL, and note annotations when adjudicating pharmacy claims or reviewing prior authorization requests.

Formulary product coverage (listing)

Formulary coverage by product and tier

Listed products: The formulary lists product-level entries by name, formulation and tier (examples in this excerpt include multiple contraceptives on Tier 0, isotretinoin on Tier 4, many specialty biologics on Tiers 5–6, and numerous opioid and oncology agents assigned to higher tiers).

This is a product/tier listing excerpt and does not include expanded clinical eligibility criteria beyond the product names, tier placements, and utilization notes.

Examples of formulary exclusions in this excerpt include drugs that are not approved by the Food & Drug Administration (FDA) and drugs available over-the-counter (OTC) unless a government requirement applies (for example, an ACA preventive drug that must be covered). Membership and plan documents define the full exclusion list; the formulary excerpt directs members and providers to plan materials for complete exclusion details.

When a generic equivalent becomes available, the formulary prefers the generic and the plan may change brand coverage or require a formulary exception. If a member requests the brand when a generic exists, the member is responsible for the difference in cost between the brand-name and generic drug in addition to the brand copayment or coinsurance; the difference generally does not apply toward the member’s deductible or out-of-pocket maximum unless the brand is authorized through a formulary exception.

Entries annotated with LA (limited access) or S (specialty) indicate restricted distribution or specialty handling and typically signal that dispensing will be controlled (for example, specialty-channel or limited-site distribution). These flags appear alongside high-tier biologic and specialty products and are used to indicate additional site or specialty requirements.

This formulary fragment does not include explicit clinical exclusion statements. The visible content is administrative (tier assignments and utilization controls such as PA, QL, LA, and S) rather than condition-specific clinical exclusion language.

The excerpt does not list a separate set of specifically excluded products. Instead, coverage controls are indicated by tier assignments and inline notes (e.g., PA, QL, LA, S) on each product line; those tier/notes determine restrictions or additional authorization requirements.

No explicit coverage exclusions are stated in this extract. Some products carry LA or S designations that indicate limited access or specialty handling, which may limit how and where the product is dispensed but do not themselves read as absolute coverage exclusions in this fragment.

The material presented here does not contain any explicit statements declaring a product as not medically necessary. The formulary lines show administrative controls (PA/QL/LA/S) and tiering rather than clinical 'not medically necessary' determinations.

Consistent with the fragment above, there are no specified 'not medically necessary' determinations for listed products in this portion of the formulary. Coverage entries focus on tiering and utilization management annotations rather than explicit medical necessity denials.

Coding, Identifiers, and Quantity Rules

Drug listings (no billing codes in this segment)mixed

N/A	The provided chunks list drug names, strengths, tiers, and notes but do not include CPT/HCPCS/ICD-10 or NDC codes in this segment.

Formulary product entries (no explicit CPT/HCPCS/ICD-10/NDC codes provided in excerpt)mixed

NDC-like / formulation entries

Multiple product listings with strength and volume (e.g., 40 MG/0.8 ML, 80 MG/0.8 ML, 100 MG/ML, 200 MG/ML), presented as formulary product entries rather than explicit NDC codes.

Formulary product listings (no explicit procedure or diagnosis codes)mixed

NDC-like/product entries

The document lists drug products by name, formulation, strength and tier (no explicit NDC codes in these chunks).

Formulary product entries (no explicit CPT/HCPCS/ICD codes in this fragment)mixed

NDC	Not provided in this window; product lines and strengths listed without NDCs.

Formulary dosage descriptorsmixed

10 MG/DAY

dosage description shown in line items (LENVIMA example)

Formulary product entries (no explicit billing codes)mixed

NDC or CPT not provided

The excerpt lists product names, formulations, strengths, unit sizes and tier/QL notes but does not include explicit NDC, CPT, or ICD-10 codes.

Identifiersmixed

NDC/HCPCS not listed

No explicit NDC, CPT, HCPCS, or ICD-10 codes provided in this extract; only product names, strengths, and tier/notes are listed.

NDC / codes not specifiedNDC

No codes listed

NDC/CPT/HCPCS not listed in this segmentmixed

No codes listed

Formulary product identifiersmixed

NDC (not listed explicitly)

No NDCs provided in these chunks; product listings are by brand/generic and strength.

Formulary items (no procedure/diagnosis codes in excerpt)mixed

No codes listed

Total cumulative opioid dose limit — 90 MME per day

ThresholdTotal cumulative opioid dose limited to 90 MME per day

Applies toAll opioid product listings annotated with 'Total cumulative opioid dose limited to 90 morphine milligram equivalent (MME) per day'

Examples in formulary notesfentanyl transdermal patch, hydrocodone ER, methadone, morphine, oxycodone and tramadol lines reference the 90 MME/day cap

Quantity limits examples — assorted per-day and per-period examples

Biologic per-28-day examplesHadlima: QL 1.6 mL per 28 days; Simlandi: QL 2 EA per 28 days; Simponi: QL 1 ML per 28 days

Oral solution per-day examplesXeljanz oral solution: QL 10 ML per 1 day; methadone solutions: QL (4 ML per 1 day) or higher depending on concentration

Small-volume injectablesAdalimumab presentations show QL like 2 EA per 28 days or 1 EA per 28 days depending on kit strength

Quantity limits shown in notes — examples like 12 EA per 30 days, 36 ML per 1 day, 60 EA per 365 days

12 EA per 30 daysExamples in notes: QL (12 EA per 30 days) — e.g., praziquantel and emverm entries

36 ML per 1 dayValganciclovir oral recon solution 50 mg/ml notes: QL (36 ML per 1 day)

60 EA per 365 daysOTEZLA starter or dose-pack notes include QL (1 clm per 365 days) or other yearly caps (example: 60 EA per 365 days shown for select antineoplastics)

Quantity limits — exact per-product QL values (example IBRANCE)

IBRANCEQL (21 EA per 28 days) — IBRANCE (palbociclib) capsules/tablets

FOTIVDAQL (21 EA per 28 days) — FOTIVDA noted with similar per-28-day QL

MEKINIST recon solutionMEKINIST ORAL RECON SOLN notes show QL (40 ML per 1 day) for solution presentations

Quantity limits examples — e.g., 21 EA per 28 days, 8 EA per 28 days, 1 EA per 1 day

21 EA per 28 daysIBRANCE (capsules/tablets) — QL (21 EA per 28 days)

8 EA per 28 daysExamples: select antineoplastic lines (e.g., some BRAFTOVI/TAFINLAR notes) list QL values such as 8 EA per 28 days

1 EA per 1 dayMultiple oral oncology agents and others show per-day QL (e.g., many drugs annotated QL (1 EA per 1 day))

Quantity limits examples for vaccines — doses per day/lifetime/years

0.5 mL per 1 dayExample vaccine notes: QL (1 DOSE (0.5 ML) per 1 day)

3 DOSES per lifetime (1.5 mL total)VAXELIS/GARDASIL style entries: QL (3 DOSES (1.5 ML) per lifetime)

1 mL per 10 yearsTENIVAC and similar vaccines: QL (1 DOSE (1 ML) per 10 years)

Quantity limits examples — 2 EA per 1 day; 1.2 ML per 28 days; 4 ML per 28 days

2 EA per 1 dayUPTRAVI notes include QL (2 EA per 1 day) for select dose strengths

1.2 ML per 28 daysANDEMBRY autoinjector: QL (1.2 ML per 28 days)

4 ML per 28 daysTAKHZYRO (certain presentations) and other injectables note QL (4 ML per 28 days)

Quantity limit examples — assorted ML/EA per 30 days examples

4 ML per 30 daysSumatriptan subcutaneous pen/solution notes: QL (4 ML per 30 days)

12 EA per 30 daysZolmitriptan nasal/oral forms: QL (12 EA per 30 days)

540 ML per 30 daysSodium oxybate / XYWAV: QL (540 ML per 30 days)

Actions Required by Prescribers and Providers

Prior Authorization

Prior Authorization Required

Many drugs listed in the formulary are subject to prior authorization (PA). Drugs marked "PA" in the formulary require prior approval from Providence Health Plan before the drug will be covered. Providers must submit a completed prior authorization request on behalf of the member when PA is indicated; without an approved PA the claim may be denied.

Drugs marked "PA" require prior authorization before dispensing.
Specialty agents (marked "S") frequently also require PA and must be obtained through a contracted specialty pharmacy when indicated.
Many high-tier, specialty, oncology, antiviral, biologic, and select neurologic/migraine agents in the formulary show "PA" in the Notes column (examples: PREVYMIS, MAVYRET, VOSEVI, VENCLEXTA, IBRANCE, KERENDIA, REYVOW, AUSTEDO, WAKIX, sodium oxybate products).
PA is enforced in combination with other utilization controls such as QL (quantity limits), LA (limited access), ST (step therapy) and S (specialty). Missing PA, exceeding QL, or failing other requirements can result in coverage denial.

Step Therapy

Step Therapy (ST) — When Required

Step therapy (ST) is a form of prior authorization used for select products; when ST is indicated the member is expected to have tried clinically preferred first-line options before the ST drug will be approved. ST flags appear on some agents (for example: XCOPRI, TRINTELLIX, certain anticonvulsants and antidepressants). If step drugs have been tried previously and documented, the ST drug may be approved automatically; otherwise providers should submit a PA with documentation explaining why step therapy cannot be met.

ST may be enforced for both oral and specialty agents.
When ST is listed (Notes = ST) provide clinical history documenting prior trials or rationale for exception.
If member is new to the plan and prescription history is unavailable, PA is required to establish prior therapy.

Documentation Required

Quantity Limits, Specialty, Provider Verification, and Limited Access

Quantity limits (QL), limited access (LA), provider verification (PV), and specialty pharmacy (S) indicators accompany many PA requirements and must be adhered to in coverage requests. Providers must document indication, dose, dispensing quantity and frequency when submitting PA/QL requests; failure to provide required documentation may cause denial or delay.

Follow the QL limits shown in the Notes (examples: IBRANCE, FOTIVDA, vaccine dosing limits, ANNOVERA, PYRAZINES).
Provider verification (PV) flags require verification steps documented in the request.
Limited access (LA) drugs may only be filled at specific pharmacies per manufacturer distribution — document pharmacy choice.
Specialty (S) drugs often require dispensing via a contracted specialty pharmacy (e.g., Credena Health).

Billing Rule

Brand vs. Generic — Member Cost Responsibility

Brand vs. generic: when a generic equivalent or clinically acceptable generic alternative exists, the formulary prefers the generic. If a brand drug is requested when a generic is available, the member is responsible for the cost difference and that difference may not apply to the deductible/OOP maximum unless a formulary exception is approved and the plan specifies otherwise. Coverage and tier placement for brand drugs may change when generics become available.

If provider prescribes brand when generic exists, member pays difference in cost between brand and generic in addition to copay/coinsurance.
If a formulary exception authorizes brand despite a listed generic, cost-difference rules and how the difference counts toward the deductible/OOP are described in plan language.

Denial Risk

Documentation Requirements and Denial Risk

Documentation expectations and risk of denial: prescribers must supply clinical justification and supporting records when PA, ST, QL, LA, PV or S flags appear. The plan will review submitted documentation against the utilization management criteria; lack of adequate documentation or failure to obtain PA before dispensing may result in claim denial.

Provide indication, prior therapy, dosing, expected duration, and relevant clinical records with PA requests.
PA denial risk is heightened for specialty and high-cost agents if PA/QL/ST requirements are not satisfied.
Providers may request formulary exceptions or submit PA requests on behalf of members; contact Customer Service for assistance.

Quantity Limits and Examples

unspecified examples (e.g., sumatriptan) — example 9 tablets per 30 days

Sumatriptan tablets exampleQuantity limit example in guidance: sumatriptan tablets limited to 9 tablets every 30 days (member-facing example)

Sumatriptan injectableFormulary entry notes QL (4 ML per 30 days) for sumatriptan succinate subcutaneous pen/solution

Reason for QLQuantity limits are used to ensure safe and effective use (example provided in Restrictions/Limitations section)

Various listed opioids and biologics — per-day and per-28-day examples

Opioid per-day examplesMany opioid lines include per-day QL entries such as QL (1 EA per 1 day), QL (2 EA per 1 day), QL (10 EA per 1 day) depending on product

Total opioid capNotes across opioid listings reference Total cumulative opioid dose limited to 90 MME per day

Biologics per-28-day examplesSeveral biologic/DMARD entries show per-28-day QL (e.g., 1.6 mL per 28 days; 2 EA per 28 days; 0.8 mL per 28 days)

Multiple specialty biologics and DMARDs — assorted per-28-day QL examples

HadlimaHadlima autoinjector/syringe notes: PA; QL (1.6 mL per 28 days or 0.8 mL per 28 days for CF presentations); S

SimlandiSimlandi autoinjector/syringe notes: PA; QL (2 EA per 28 days or 2 mL per 28 days depending on kit); S

Adalimumab biosimilarsAdalimumab-AATY/ADAZ entries show PA; QL (2 EA per 28 days or per-syringe limits) and S designation

Examples in notes — 12 EA per 30 days; 36 ML per 1 day; 60 EA per 365 days

12 EA per 30 daysemverm / praziquantel lines show QL (12 EA per 30 days)

36 ML per 1 dayValganciclovir oral recon solution 50 mg/ml notes: QL (36 ML per 1 day)

4 EA per 1 dayMultiple antiviral/antifungal entries indicate per-day EA limits (e.g., valganciclovir 450 mg QL 4 EA per 1 day)

valganciclovir oral recon soln 50 mg/ml — 36 ML

Productvalganciclovir oral recon solution 50 mg/ml

Quantity limit36 ML per 1 day

NotesListed with QL and 'S' specialty flag in formulary

valganciclovir oral tablet 450 mg — 4 EA

Productvalganciclovir oral tablet 450 mg

Quantity limit4 EA per 1 day

NotesListed with QL and 'S' specialty flag in formulary

PREVYMIS oral pellets 120 mg, 20 mg — 4 EA

ProductPREVYMIS oral pellets 120 mg, 20 mg

Quantity limit4 EA per 1 day

NotesPA; QL; S — multiple formulations have per-day EA limits

PREVYMIS oral tablet 240 mg — 2 EA

ProductPREVYMIS oral tablet 240 mg

Quantity limit2 EA per 1 day

NotesPA; QL; S

PREVYMIS oral tablet 480 mg — 1 EA

ProductPREVYMIS oral tablet 480 mg

Quantity limit1 EA per 1 day

NotesPA; QL; S

DIFICID oral suspension 40 mg/ml — 136 ML

ProductDIFICID oral suspension 40 mg/ml

Quantity limit136 ML per 30 days

NotesFormulary lists QL (136 ML) for suspension presentations

fidaxomicin oral tablet 200 mg — 20 EA

Productfidaxomicin oral tablet 200 mg

Quantity limit20 EA per 30 days

NotesQL indicated in formulary for tablet presentation

lapatinib oral tablet 250 mg — 6 EA

Productlapatinib oral tablet 250 mg

Quantity limit6 EA per 1 day

NotesPer-product QL listed in formulary

LONSURF 15-6.14 MG — 10 EA per 1 day

ProductLONSURF 15-6.14 MG

Quantity limit10 EA per 1 day

NotesFormulary entry lists PA; QL (10 EA per 1 day); LA; S

LONSURF 20-8.19 MG — 8 EA per 1 day

ProductLONSURF 20-8.19 MG

Quantity limit8 EA per 1 day

NotesFormulary entry lists PA; QL (8 EA per 1 day); LA; S

VENCLEXTA STARTING PACK — 42 EA per 28 days

ProductVENCLEXTA STARTING PACK

Quantity limit42 EA per 28 days

NotesListed with PA; QL (42 EA per 28 days); LA; S

IBRANCE (capsules/tablets) — 21 EA per 28 days

ProductIBRANCE (capsules/tablets)

Quantity limit21 EA per 28 days

NotesFormulary entry lists QL (21 EA per 28 days)

MEKINIST oral reconstruction solution — 40 ML per 1 day

ProductMEKINIST oral recon solution

Quantity limit40 ML per 1 day

NotesFormulary notes show PA; QL (40 ML per 1 day) for solution presentations

BOSULIF oral tablet 400 mg, 500 mg — 4 EA per 1 day

ProductBOSULIF oral tablet 400 mg, 500 mg

Quantity limit4 EA per 1 day

NotesListed with PA; QL (4 EA per 1 day); LA; S

BRUKINSA oral tablet 160 mg — 2 EA per 1 day

ProductBRUKINSA oral tablet 160 mg

Quantity limit2 EA per 1 day

NotesListed with PA; QL (2 EA per 1 day); S

LENVIMA various dosing lines — 1-3 EA per 1 day depending on dosing

ProductLENVIMA (various dosing lines)

Quantity limit1–3 EA per 1 day depending on dosing line

NotesFormulary shows dose-dependent per-day EA limits (PA; QL; LA; S)

ROZLYTREK oral capsule 100 mg — 5 EA per 1 day

ProductROZLYTREK oral capsule 100 mg

Quantity limit5 EA per 1 day

NotesFormulary lists PA; QL (5 EA per 1 day); LA; S

Leucovorin calcium oral tablet 10/15/5 mg — 3 EA per 1 day

ProductLeucovorin calcium oral tablet (10/15/5 mg)

Quantity limit3 EA per 1 day

NotesListed with ST; QL (3 EA per 1 day)

HYQVIA (immune globulin) — per-pack limits listed per product

ProductHYQVIA (immune globulin)

Quantity limitVarious per-pack limits listed per product (see formulary entries)

NotesHYQVIA and other IG products marked PA; LA; S with pack-specific limits

Multiple vaccines — examples include 0.5 mL per day, 3 doses per lifetime, 1 mL per 10 years

ExamplesVaccines such as QUADRACEL, VAXELIS, PNEUMOVAX-23, PREVNAR 20, GARDASIL 9, SHINGRIX list QL like 0.5 mL per day; 3 doses per lifetime; 1 mL per 10 years

Dose-per-intervalMany vaccine entries specify '1 DOSE (0.5 ML) per 1 day' and lifetime or multi-year caps

Claims noteQL statements accompany vaccine entries and must be followed when adjudicating claims

KERENDIA — QL (1 EA per 1 day)

ProductKERENDIA (finerenone) oral tablet

Quantity limitQL (1 EA per 1 day)

NotesListed with PA; QL (1 EA per 1 day)

telmisartan-hydrochlorothiazid — QL (1 EA per 1 day)

Producttelmisartan-hydrochlorothiazid oral tablet

Quantity limitQL (1 EA per 1 day)

NotesFormulary notes show QL (1 EA per 1 day)

PRALUENT; REPATHA; TAKHZYRO; UPTRAVI and others — assorted QL examples

ExamplesPRALUENT/REPATHA entries: QL (2 mL per 28 days); icatibant: QL (18 ML per 30 days); TAKHZYRO: QL 2 ML per 28 days or 4 ML per 28 days depending on presentation

FormatsQL values presented as mL per 28 days or EA per day depending on product presentation

Specialty flagsMany of these products include PA and S/LA flags alongside QL

ANDEMBRY autoinjector — 1.2 ML per 28 days

ProductANDEMBRY autoinjector 200 mg/1.2 mL

Quantity limit1.2 ML per 28 days

NotesListed with PA; QL (1.2 ML per 28 days); LA; S

TAKHZYRO — 2 ML per 28 days (150 mg/ml) or 4 ML per 28 days (300 mg/2 ml)

ProductTAKHZYRO subcutaneous syringe 150 mg/ml or 300 mg/2 mL

Quantity limit2 ML per 28 days (150 mg/ml) or 4 ML per 28 days (300 mg/2 mL)

NotesEntries include PA; QL; LA; S

EKTERLY — 4 EA per 30 days

ProductEKTERLY oral tablet 300 mg

Quantity limit4 EA per 30 days

NotesListed with PA; QL (4 EA per 30 days); LA; S

EMGALITY — 3 ML per 28 days

ProductEMGALITY (galcanezumab) pen/syringe 120 mg/mL

Quantity limit3 ML per 28 days (pen 1 mL per 28 days for some presentations; note: EMGALITY also listed as 1 ML per 28 days in some lines)

NotesEntries show PA; QL; S for CGRP mAbs

pregabalin oral solution — 30 ML per 1 day

Productpregabalin oral solution 20 mg/mL

Quantity limit30 ML per 1 day

NotesFormulary lists QL (30 ML per 1 day) for solution presentation

DIACOMIT ORAL POWDER IN PACKET 500 MG — 6

ProductDIACOMIT oral powder in packet 500 mg

Quantity limit6 EA (per day)

NotesListed with PA; QL (6 EA per 1 day); LA; S

FINTEPLA ORAL SOLUTION 2.2 MG/ML — 12

ProductFINTEPLA oral solution 2.2 mg/mL

Quantity limit12 (per day)

NotesFormulary lists QL (12) for solution presentation

XCOPRI ORAL TABLET 200 MG — 2

ProductXCOPRI oral tablet 200 mg

Quantity limit2 (per day)

NotesXCOPRI maintenance/titration packs shown with ST and QL (1–28 EA per period depending on pack)

XCOPRI TITRATION PACK (various) — 28

ProductXCOPRI titration pack (various)

Quantity limit28 (per 365 days for some packs)

NotesTitration pack entries list QL (28 EA per 365 days or 1 pack per 365 days depending on pack)

Desvenlafaxine ER 100 mg — 4

ProductDesvenlafaxine ER 100 mg

Quantity limit4 (per day)

NotesFormulary QL indicated for extended-release strengths

Milnacipran — 2

ProductMilnacipran

Quantity limit2 (per day)

NotesListed with PA; QL (2 EA per 1 day) for some presentations

INBRIJA INHALATION CAPSULE — 10

ProductINBRIJA inhalation capsule

Quantity limit10 (per day)

NotesListed with QL (10 EA per 1 day); LA

Quetiapine ER (selected strengths) — 1-2

ProductQuetiapine ER (selected strengths)

Quantity limit1–2 (per day depending on strength)

NotesFormulary shows QL (1–2 EA per 1 day) for extended-release strengths

COBENFY — 2

ProductCOBENFY

Quantity limit2 (per day)

NotesListed with PA; QL (2 EA per 1 day)

REXULTI, VRAYLAR, LYBALVI, CAPLYTA — 1

ProductsREXULTI, VRAYLAR, LYBALVI, CAPLYTA

Quantity limit1 (per day) for each listed antipsychotic

NotesFormulary entries show PA/Q L as applicable

Dexmethylphenidate ER biphasic — 1

ProductDexmethylphenidate ER biphasic

Quantity limit1 (per day)

NotesQL noted in formulary for stimulant ER biphasic formulation

REXULTI (brexpiprazole) — 1

ProductREXULTI (brexpiprazole)

Quantity limit1 (per day)

NotesQL and PA apply as listed

VRAYLAR (cariprazine) — 1

ProductVRAYLAR (cariprazine)

Quantity limit1 (per day)

NotesQL and PA noted where applicable

asenapine (sublingual) — 2

Productasenapine (sublingual)

Quantity limit2 (per day)

NotesFormulary lists PA; QL (2 EA per 1 day)

AJOVY — 1.5

ProductAJOVY (225 mg/1.5 mL)

Quantity limit1.5 ML per 28 days

NotesPA; QL (1.5 ML per 28 days)

EMGALITY — 1

ProductEMGALITY (pen/syringe) 120 mg/mL

Quantity limit1 ML per 28 days (per some entries) or 3 ML per 28 days in grouped examples)

NotesFormulary lists PA; QL (1 ML per 28 days) for many EMGALITY presentations

AIMOVIG — 1

ProductAIMOVIG autoinjector 140 mg/mL

Quantity limit1 ML per 28 days

NotesPA; QL (1 ML per 28 days)

NURTEC — 16

ProductNURTEC ODT 75 mg

Quantity limit16 EA per 30 days

NotesListed with PA; QL (16 EA per 30 days)

REYVOW — 8

ProductREYVOW oral tablet 100 mg

Quantity limit8 EA per 30 days

NotesPA; QL (8 EA per 30 days)

NAYZILAM — 10 mg

ProductNAYZILAM nasal spray 5 mg/spray

Quantity limit10 mg per 30 days (total mg limit noted)

NotesFormulary lists QL (10 MG per 30 days)

VALTOCO — 10

ProductVALTOCO nasal spray 10 mg/spray

Quantity limit10 EA per 30 days

NotesFormulary lists QL (10 EA per 30 days)

sumatriptan succinate subcutaneous pen injector/solution — 4 ML per 30 days

Productsumatriptan succinate subcutaneous pen injector/solution

Quantity limit4 ML per 30 days

NotesFormulary notes specify QL (4 ML per 30 days)

zolmitriptan nasal spray 2.5 mg — 12 EA per 30 days

Productzolmitriptan nasal spray 2.5 mg

Quantity limit12 EA per 30 days

NotesFormulary lists QL (12 EA per 30 days)

REYVOW ORAL TABLET 100 mg — 8 EA per 30 days

ProductREYVOW oral tablet 100 mg

Quantity limit8 EA per 30 days

NotesPA; QL (8 EA per 30 days)

sodium oxybate oral solution / XYWAV — 540 ML per 30 days

Productsodium oxybate oral solution / XYWAV

Quantity limit540 ML per 30 days

NotesListed with PA; QL (540 ML per 30 days); LA; S

rivastigmine oral capsule — 2 EA per 1 day

Productrivastigmine oral capsule

Quantity limit2 EA per 1 day

NotesFormulary lists QL (2 EA per 1 day)

ANNOVERA vaginal ring — 1 per 365 days

ProductANNOVERA vaginal ring

Quantity limit1 EA per 365 days

NotesFormulary lists QL (1 EA per 365 days)

SELARSDI; STEQEYMA; YESINTEK and similar biologics — 0.5 mL per 84 days or 1 mL per 84 days

ProductsSELARSDI; STEQEYMA; YESINTEK and similar biologics

Quantity limit0.5 mL per 84 days or 1 mL per 84 days depending on presentation

NotesEntries list PA; QL (per 84 days); S

BIMZELX — 1 mL per 28 days (or 2 mL per 56 days)

ProductBIMZELX autoinjector (160 mg/mL; 320 mg/2 mL)

Quantity limit1 mL per 28 days (or 2 mL per 56 days for larger presentations)

NotesListed with PA; QL; S

EUCRISA; ZORYVE; SANTYL topical products — EUCRISA/ZORYVE QL (60 GM per 30 days); SANTYL QL (30 GM per 30 days)

ProductsEUCRISA; ZORYVE; SANTYL topical products

Quantity limitsEUCRISA/ZORYVE: QL (60 GM per 30 days); SANTYL: QL (30 GM per 30 days)

NotesTopical QL stated in grams per 30 days in formulary entries

OpenPayer

Prescription Drug 6-Tier Formulary — Coverage Criteria

Coverage Criteria and Formulary Rules

Coding, Identifiers, and Quantity Rules

Actions Required by Prescribers and Providers

Specialty Pharmacy and Site Restrictions

Quantity Limits and Examples

Biosimilars and Related Notes

Definitions and Notation