CurrentSelectHealthPolicy N/A

Prescription drug list (formulary) — coverage criteria

This document summarizes commonly prescribed drugs that SelectHealth covers, explains tiers, cost-sharing, and special requirements (preauthorization, step therapy, quantity limits, age limits) and directs members to the full online formulary and pharmacy services for details.

Policy Summary

PayerSelectHealth

PolicyPrescription drug list (formulary) — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain required prior authorization, step-therapy documentation, or quantity/age justification where the formulary lists PA, ST, QL or AGE to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyformulary review frequency

tiers 1-6drug tiers referenced

PApreauthorization required

STstep therapy required

QLquantity limits

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Formulary Coverage Criteria

Formulary drug entries

Coverage entries show drug tier and any requirement flags (PA, ST, QL, AGE, M).

drug_entry_example: Multiple formulary entries list the drug name, assigned drug tier, and one or more Requirements & Limits tokens (examples in this excerpt: Linezolid Tablet — Tier 3 — (QL); Auvi-Q Injectable — Tier 4 — (QL); Epinephrine Injectable — (QL); Juluca Tablet — Tier 2 — (QL)(M); Mounjaro Injectable — Tier 4 — (PAJQL)(M)).

Full per‑drug clinical coverage criteria are not present in this excerpt.

Formulary coverage contingent on listed requirement flags

Coverage is determined by drug-specific tier plus fulfillment of listed requirement flags (e.g., PAJ, QL, M, AGE).

General formulary coverage requirement: Drug coverage requires that the member meet any requirement flags shown adjacent to the drug entry. Examples of requirements: obtain prior authorization when PAJ/PAJQL/PA are indicated; comply with quantity limits when (QL) is listed; meet medical necessity documentation when (M) is present; meet any age restriction when (AGE) applies.

Specific clinical criteria for prior authorization or medical necessity are not included in this excerpt; refer to the full policy for detailed PA/M criteria.

Formulary coverage tokens

Coverage and management indicated by tier and requirement tokens

Formulary coverage logic: Drugs are assigned to tiers and may carry one or more management tokens that control coverage: PA / PAJ / PAJQL (prior authorization variants), QL (quantity limits), ST / STH / STJ (step therapy variants), M (maintenance / medical necessity marker), AGE (age‑based restriction).

This listing shows tokenized requirement annotations per drug entry; numeric QL values and the detailed PA/M criteria are not present in these chunks.

Drugs that are not on the formulary are not covered unless a Drug Coverage Exception is granted. A request for exception must be submitted using the Drug Coverage Exception Form and include medical necessity justification; requests are decided on a case‑by‑case basis.

Within the excerpt provided there are no explicit exclusion conditions listed. The listing shows formulary entries with tier assignments and administrative requirement codes but does not state specific exclusion criteria in these chunks.

No explicit clinical exclusions are stated in this excerpt. Entries in the listing primarily convey drug tiers and Requirements & Limits tokens (for example, PAJQL, QL, M, ST) adjacent to drug or device names rather than detailed clinical exclusion rules.

The document segments provided do not contain explicit exclusion statements. Instead, they show multiple drug and device entries with tier designations and management tokens (e.g., (PAJQL), (QL), (M), (ST)). Any exclusionary determinations are not present in these chunks.

There are no explicit 'not medically necessary' statements in the excerpted content. Some entries are annotated with (M) indicating medical necessity may be required for coverage, but the source does not include blanket 'not medically necessary' determinations in these chunks.

Within the provided chunks there are no explicit 'not medically necessary' determinations. The listing uses markers such as (M) to indicate that medical necessity documentation may be required for specific products, but no product is identified here as categorically not medically necessary.

Requirement Codes and Tokens

Formulary requirement codesmixed

PAJ	Prior authorization (document shorthand)
QL	Quantity limit
M	Medical necessity
AGE	Age limit
STHQL	Step therapy / prior step edit with QL (document shorthand)
STJQL	Step therapy indicator with QL (document shorthand)

Administrative requirement codes found in listmixed

PAJQL	Requirements & Limits code appearing on multiple items
QL	Quantity limit annotation
M	Medical necessity annotation
ST	Step therapy annotation
AGE	Age limit annotation header repeated in excerpt
PAJ(QL)(M)	Variant combination of annotations
STJ(QL)(M)	Variant combination of annotations

Formulary requirement tokensmixed

PA	Prior Authorization
PAJQL	Compound prior auth/quantity limit/j code/M indicator (document uses combined token)
QL	Quantity Limit
M	May indicate medical management or specialty handling (document token 'M')
ST	Step Therapy
STH	Step Therapy H variant
STJ	Step Therapy J variant

Quantity Limits and Requirement Flags — QL, PAJQL, PAJ, M, AGE

Observed requirement tokensEntries in the formulary list include administrative tokens such as QL, PAJQL, PAJ, M, and AGE indicating applicable utilization controls; numeric QL values are not provided in this excerpt.

Implication for coverageCoverage of a listed drug is contingent on meeting any adjacent requirement flags (e.g., obtain prior authorization if PAJ/PAJQL shown; comply with quantity limits if QL shown).

Scope of flagsTokens appear across drug classes including specialty agents, injectables, and testing supplies; they mark prior auth, quantity limits, medical-necessity checks, and age restrictions.

Age limit

AGE token meaning(AGE) indicates a minimum or maximum age requirement must be met for coverage of the drug or product.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization required

Certain specialty or high‑tier drugs require prior authorization (PA) before they will be covered. Drugs annotated with PA, PAJQL, PAJ, or similar codes in the formulary indicate PA is required — failure to obtain PA may result in claim denial or the member being responsible for full retail cost.

Examples: oncology, specialty injectables, and select high‑tier branded products noted with (PA) or (PAJQL).
Mounjaro Injectable specifically listed with (PAJQL)(M) — PA plus medical necessity documentation required at initiation.

Prior Authorization

Prior authorization required for many test supplies

Many test supplies and devices (blood glucose meters, test strips, syringes, etc.) carry PA or PAJQL flags. Prior authorization and documentation of medical necessity, quantity limits, and age may be required for coverage of these supplies.

Examples: multiple glucose test kits and syringe items listed with (PAJQL)(M) or (PAJQL).
60mL, 140mL syringes and many meter/test kit SKUs appear with PA/PAJQL annotations.

Legend and Definitions

The formulary groups medications by therapeutic categories and into drug tiers to guide coverage and member cost‑sharing. A clinical review team of physicians and pharmacists evaluates drugs regularly (monthly) for efficacy, safety, and cost‑effectiveness, which can result in additions or removals from the formulary. The excerpted listing shows each drug or device with its drug tier and any adjacent Requirements & Limits tokens (examples: (PAJQL), (QL), (M), (ST)) that determine whether additional actions—such as prior authorization, adherence to quantity limits, step therapy, or age documentation—are required for coverage.

LEGEND terms

PAPreauthorization — coverage of drugs is based on medical necessity; certain drugs require preauthorization or the member may be responsible for the full retail price.

MMaintenance drug — marker indicating eligibility for a 90-day supply for convenience.

STStep Therapy — requires trial and failure of an alternative therapy before coverage of the listed drug.

QLQuantity Limits — indicates a plan-imposed maximum quantity; exceeding QL may require prior authorization or be denied.

Step Therapy Requirements

Drug / Item	Requirement token	Notes
{"text":"Adapalene Gel","status":""},{"text":"ST","status":""},{"text":"Listed with (ST) indicating step therapy is required before coverage","status":""}
{"text":"Clindamy/Ben Gel","status":""},{"text":"ST","status":""},{"text":"Marked (ST) in Requirements & Limits","status":""}
{"text":"Dapsone","status":""},{"text":"ST","status":""},{"text":"Entry shows (ST) indicating step therapy requirement","status":""}
{"text":"Auvi-Q Injectable","status":""},{"text":"QL","status":""},{"text":"Although shown with (QL), nearby legend and entries indicate ST applies to some anaphylaxis agents; include for context","status":""}

Drug / Item	Indicator token	Interpretation
{"text":"Dofetilide Capsule","status":""},{"text":"STHQL","status":""},{"text":"Listed with (STHQL) indicating a step therapy edit combined with QL in Requirements & Limits","status":""}
{"text":"Icosapent Capsule","status":""},{"text":"STJQL","status":""},{"text":"Marked (STJQL) showing a step therapy indicator variant combined with quantity limit","status":""}
{"text":"Nicotine (Ra Nicotine variant)","status":""},{"text":"STHQL","status":""},{"text":"Nicotine products include (STHQL) on some SKUs indicating hierarchical step/QL constraints","status":""}

Device / Supply	Step token present	Coverage implication
{"text":"Assure 3 Tes","status":""},{"text":"STJ","status":""},{"text":"Requirements & Limits include STJ (and QL/AGE/M variants) indicating step controls before coverage","status":""}
{"text":"Easy Trak Tes / Easy Trak Ii Tes","status":""},{"text":"STJ","status":""},{"text":"Entries show STJ(QL)(AGE)(M) variants — step therapy controls apply to these test supplies","status":""}
{"text":"Easy Talk Tes","status":""},{"text":"ST","status":""},{"text":"One listing shows (ST)QL)(M) marking step therapy plus quantity/medical limits","status":""}

Example product	Attached step token(s)	Meaning in list
{"text":"Lansoprazole","status":""},{"text":"STH","status":""},{"text":"Entry includes (STH(QL)(AGE)(M)) variant — shows STH step-therapy variant is applied with QL/AGE/M modifiers","status":""}
{"text":"Easy Touch / Easy Max Glc Tes","status":""},{"text":"ST / STJ","status":""},{"text":"Multiple glucose test device entries include ST or STJ tokens combined with PAJQL and M annotations","status":""}
{"text":"Topamax Spr Capsule","status":""},{"text":"ST","status":""},{"text":"Marked (ST)QL)(M) indicating step therapy requirement for this product","status":""}

Product / Group	Marking	Policy statement
{"text":"General step-therapy flag (legend)","status":""},{"text":"ST","status":""},{"text":"(ST) denotes step therapy: coverage only after trial and failure of an alternative therapy","status":""}
{"text":"Selected antiepileptic entries (e.g., Topamax Spr Capsule)","status":""},{"text":"ST","status":""},{"text":"Products labeled (ST) require completion of step therapy prior to coverage","status":""}
{"text":"Nicotine cessation SKUs","status":""},{"text":"STH","status":""},{"text":"Some nicotine products include (STH) / (STHQL) indicating hierarchical step edits possibly combined with QL/AGE modifiers","status":""}

Product / Category	Token shown	Constraint type
{"text":"Ra Nicotine (selected SKUs)","status":""},{"text":"STHQL","status":""},{"text":"Indicates hierarchical step therapy combined with quantity limit and other modifiers for nicotine/cessation products","status":""}
{"text":"Qc Nicotine Dis","status":""},{"text":"PAJQL / M","status":""},{"text":"Some nicotine products shown with (PAJQL)M or (STHQL) reflecting combined step/PA/QL/medical requirements","status":""}
{"text":"Chantix Tablet","status":""},{"text":"QLJMJAGE","status":""},{"text":"Smoking cessation product shows QL and age constraints in Requirements & Limits (QL/J/M/AGE tokens) — hierarchical controls apply","status":""}

Quantity Limits and Examples

Auvi-Q Injectable / Epinephrine Injectable examples

Auvi-Q / Epinephrine examplesAuvi-Q Injectable and Epinephrine Injectable entries include (QL) indicating quantity limits apply to these anaphylaxis therapy agents.

Practical effectQuantity limits on epinephrine injectables control dispensed supply; exceeding plan limits may require prior authorization.

Reference locationAuvi-Q and Epinephrine entries are listed in the ANAPHYLAXIS THERAPY AGENTS section showing (QL).

Various examples with QL

Examples with QL presentMultiple formulary entries show (QL) adjacent to the drug name — examples include Valacyclovir Tablet, Repatha Injectable, and Nexlizet Tablet; numeric limits are not shown here.

Compound tokens

Policy Revision History

2025-10-01policy_effective_dateLatest

Formulary effective date updated to 2025-10-01; formulary content is current as of this date.

Policy Summary

PayerSelectHealth

PolicyPrescription drug list (formulary) — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain required prior authorization, step-therapy documentation, or quantity/age justification where the formulary lists PA, ST, QL or AGE to avoid coverage denial.

SourceLink

On This Page

Location in documentAGE appears both as a section header and alongside individual drug entries in the formulary listing.

Numeric ages not suppliedThis excerpt shows the AGE token but does not provide specific numeric age thresholds for the affected products.

Prior Authorization

Prior authorization required for select injectables

Some injectable products are subject to prior authorization. Look for (PA) or compound PA codes beside injectable entries — these require PA before dispensing to avoid coverage denial.

Example: Certain injectables and specialty biologics in the formulary are annotated with (PA).

Step Therapy

Step therapy requirement

Step therapy (ST, STH, STJ, STJQL and related flags) requires that specified alternate therapy be tried and fail before the requested drug will be covered. Failure to meet step requirements may prevent coverage.

Step therapy commonly applies to brand‑name drugs and some device/supply bundles.
Entries show ST, STH, STJ, STJQL — treat these as step edits requiring prior step(s).

Denial Risk

Potential triggers for denial

Formulary Requirement & Limits codes such as PAJQL, PA, QL, ST, M, and AGE can trigger prior authorization requests, quantity limit denials, step edits, or age‑based coverage restrictions. When these flags appear on a product, verify PA/criteria and supporting documentation before dispensing.

PAJQL / PAJ indicate PA is required and may result in coverage denial if not obtained.
QL flags indicate quantity limits; exceeding QL typically needs PA.
AGE flags indicate age restrictions — age must be documented at adjudication.

Documentation Required

Documentation for PA / medical‑necessity requirements

When entries include (M) or compound codes like (PAJQL)(M), medical necessity documentation is expected at PA initiation and/or ongoing coverage review. Provide clinical notes, prior medication history, and rationale for therapy to support PA requests.

M = medical necessity documentation required.
Products like Mounjaro list (PAJQL)(M) — both PA and medical justification are required.

Documentation Required

Documentation expectations

Providers should be prepared to supply supporting documentation for step edits, PA criteria, quantity limits, and age restrictions. Include patient age, prior therapy trials, dosing history, clinical notes, and any relevant lab results with the PA submission to avoid processing delays or denials.

Age‑restricted items (AGE) require age verification in the documentation.
Step therapy flags (ST, STH, STJ) require documentation of prior trial(s) and reasons for failure.

Note

Noncovered drug exception process

Noncovered drugs may be considered via a Drug Coverage Exception; the Drug Coverage Exception Form on SelectHealth's website must be used to request coverage based on medical necessity. Requests are reviewed case‑by‑case.

Use the Drug Coverage Exception Form found on the SelectHealth website.
Decisions are made based on submitted medical necessity documentation.

Note

Pharmacy Services contact

Contact SelectHealth Pharmacy Services to verify coverage rules, PA requirements, and member benefits before prescribing or dispensing. SelectHealth members and providers may call Pharmacy Services at 800‑538‑5038 for assistance.

Pharmacy Services can confirm formulary status, PA needs, and member cost‑sharing.
Have NDC, strength, quantity, and clinical rationale available when calling.

QL — Quantity limit indicator

Presence(QL) appears throughout the formulary adjacent to many drug entries indicating quantity limits apply to those products.

ExamplesExamples in the listing include Linezolid Tablet (QL), Paxlovid (QL), and multiple vaccine entries showing (QL).

Effect on requestsRequests exceeding quantity limits may be denied without prior authorization; QL may be combined with other tokens (e.g., QL)(M).

PAJ / PAJQL — Prior authorization variants

DefinitionPAJ / PAJQL are compound prior-authorization tokens used in the formulary to indicate prior authorization requirements often combined with quantity limits for specialty or high-cost drugs.

ExamplesNexlizet Tablet is listed with (PAJQL)(M); many test supplies and devices (e.g., Accu-Chek, Assure Tes series) show (PAJQL) annotations.

Coverage impactDrugs with PAJ or PAJQL require prior authorization and may be denied if authorization or required documentation is not obtained.

M — Medical necessity / maintenance marker

Meaning(M) marks items that require medical-necessity review or indicates maintenance-supply handling (e.g., eligibility for 90-day supply).

OccurrencesM appears with multiple products including Metformin (M), Mounjaro Injectable (PAJQL)(M), and certain vaccines (M).

Combined tokens(M) is frequently combined with other tokens (e.g., (QL)(M), (PAJQL)(M)) indicating concurrent documentation/medical necessity requirements.

AGE — Age limit indicator

Indicator use(AGE) flags products that have minimum or maximum age requirements for coverage and appears in section headers and next to individual drug entries.

ExamplesTretinoin Cream and several vaccine entries (e.g., Abrysvo, Adacel) include AGE-related annotations in the listing.

Documentation implicationProducts flagged with (AGE) imply that age documentation may be required at dispensing or for adjudication, though exact ages are not listed here.

Requirements & Limits codes — examples

Common administrative codesExamples of Requirements & Limits tokens seen in the formulary include PAJQL, QL, M, ST (and variants such as STJ, STH, STJQL, STHQL).

RoleThese codes annotate each drug entry to indicate utilization management controls that affect coverage adjudication and provider actions.

Combination usageTokens are often combined (e.g., (STJ(QL)(M)(AGE)) to signal multiple concurrent requirements on a single product.

Quantity Limit — QL token

Definition(QL) — Quantity Limit: plan-imposed limits on the amount of drug dispensed over a time period; exceeding limits may require prior authorization or be denied.

Document referenceThe policy states quantity limitations apply to certain drugs and that preauthorization is required if medication exceeds plan limits.

Practical effectAppears next to many formulary entries to control utilization (e.g., Gabapentin (QL)(M)).

Prior Authorization — PA token

Definition(PA) — Preauthorization: coverage of certain drugs requires prior authorization based on medical necessity; without it the member may be responsible for full retail price.

Operational notePA appears as a standalone token and as part of compound tokens (e.g., PAJQL) in the formulary listing.

Coverage implicationDrugs annotated with PA may be denied at point of service if prior authorization is not obtained.

Step Therapy — ST token

Definition(ST) — Step Therapy: coverage requires trial and failure of an alternative therapy before the listed drug is covered.

VariantsThe formulary uses step-therapy variants such as STH, STJ and combined tokens (e.g., STJQL) to express specific step-edit structures.

Coverage riskFailure to complete required step therapy may prevent coverage of the requested drug.

Age-based restriction — AGE token

Meaning(AGE) — Age-based restriction: denotes that minimum or maximum age requirements apply to coverage of the product.

Where shownAGE is shown as a section header and as an inline Requirements & Limits token adjacent to drugs and vaccines in the formulary.

DocumentationAGE flags imply age verification may be required during dispensing or prior authorization; numeric age thresholds are not provided in the excerpt.

Initial therapy authorization examples

Initial authorization markersSome agents are flagged with prior authorization and medical-necessity tokens at initiation (e.g., Mounjaro Injectable shown as (PAJQL)(M)).

ImplicationInitial therapy for these agents typically requires approval and supporting documentation to establish medical necessity before coverage.

Example classesInitial-authorization flags appear for specialty injectables and high-tier oral agents in the listing.

Some of these entries combine QL with other tokens (e.g., Nexlizet (PAJQL)(M); Repatha noted in prior-auth contexts), reflecting layered controls.

Action for providersProviders should check the full formulary or prior-authorization guidance for numeric quantity limits and documentation requirements before prescribing.

140MI Syring Mis

140MI Syring Mis annotation140MI Syring Mis is listed with (PAJQL)M) indicating it is subject to prior authorization combined with quantity limits and medical-necessity review.

CategoryThis syringe SKU is shown in the DIABETES TESTING AND SUPPLIES section where PAJQL and M annotations are common.

Coverage implicationPrior authorization and documentation of medical necessity may be required for coverage of these supplies.

Assure 3 Tes

Assure 3 Tes annotationsAssure 3 Tes is listed with tier 4 and the compound annotations STJ(QLJ(MJ(AGE) — indicating step therapy, quantity limits, medical-necessity, and age constraints are applied.

Device classAssure 3 Tes is part of diabetes test supplies (Dexcom and related devices) where layered controls are frequent.

Provider implicationCoverage likely requires meeting step criteria, quantity/medical justification, and age eligibility; consult complete policy for specifics.

Multiple (tokenized list)

Tokenized occurrencesThe formulary contains many entries presented as tokenized requirement lists; where QL is present it denotes a quantity limit on that product.

BreadthThese token patterns recur across drug classes including testing supplies, GI agents, vaccines, and oncology agents.

No numeric QL in excerptWhile QL is frequently shown, this excerpt does not provide the numeric quantity thresholds associated with each QL token.

Gabapentin

Gabapentin entryGabapentin appears with (QL)(M) in the listing and also elsewhere with (PA), indicating both quantity limits and prior-authorization annotations are used for this agent across entries.

Coverage effectRequests may be subject to quantity limits or require prior authorization depending on the specific SKU/entry.

Action for providersConfirm specific QL and PA requirements for the gabapentin formulation being prescribed to ensure coverage and avoid denials.

Chantix Tablet

Chantix annotationsChantix Tablet is listed with compound tokens (QLJMJAGE) indicating quantity limits, maintenance handling (90-day?), and age restriction markers are applied.

Smoking-cessation classChantix appears in the SMOKING CESSATION section where similar tokens apply to nicotine products and cessation aids.

Provider actionConfirm age eligibility and quantity/maintenance rules when prescribing Chantix; numeric age/quantity details are not in this excerpt.

Fluzone HD Injectable

Fluzone HD markerFluzone HD Injectable is shown with an (M) marker in the vaccines listing indicating maintenance/medical-necessity handling (e.g., administration seasonally or documentation required).

Vaccine contextMultiple vaccine entries include (M), (QL), and (AGE) tokens highlighting age and utilization controls in the immunization section.

Documentation implicationProviders should verify medical-necessity and any age/quantity rules for vaccines flagged with (M) when submitting claims or administering doses.