Prior authorization and plan requirement indicators

Some drugs in the formulary are annotated with plan requirement flags — (PA), (QL), (M), (AGE), and (ST). These flags indicate prior authorization, quantity limits, medication management documentation, age restrictions, and step therapy requirements respectively. Verify the flag(s) shown for a drug before prescribing or billing to determine what actions or documentation are needed.

• (PA) = Prior authorization required before coverage; without approval the member may be responsible for full retail cost.
• (QL) = Quantity limits enforced; quantities above the limit require preauthorization and may be denied.
• (M) = Medical management/documentation may be required to support medical necessity.
• (AGE) = Coverage limited by patient age; verify the member meets age criteria.
• (ST) = Step therapy required; alternative therapy trials and failure documentation may be required.

Prior authorization required for selected specialty agents

Selected specialty injectables and other high-cost agents are specifically marked with (PA) and require prior authorization before the plan will cover them. Obtain prior authorization prior to dispensing or administering these specialty agents to avoid claim denials and member liability.

• Examples in the formulary include Repatha Injectable / Repatha Sure Injectable and other specialty injectables marked (PA).
• High-cost specialty drugs across therapeutic classes may carry (PA) — check the drug entry for the flag.

Prior authorization/age restrictions for select injectables

Certain injectables and vaccines include age-based restrictions (AGE) and/or other Requirements & Limits flags. Confirm the member's age and any associated documentation before administering or billing these products.

• Vaccines such as Gardasil 9, Prevnar 23, Comirnaty and others show (AGE) where applicable.
• Many injectables list (QL) and (M) in addition to (AGE) — review all flags on the drug entry.

Quantity limits enforcement

Quantity limits (QL) are actively enforced on many agents (for example, opioids, select injectables, and certain chronic therapies). If the requested quantity exceeds the plan limit, submit a prior authorization request and supporting documentation; failure to do so may result in denial or the member being billed.

• Examples: opioids and select chronic therapies are shown with (QL).
• Repatha Injectable and Repatha Sure Injectable include (QL) alongside (PA) and (M).
• If the pharmacy exceeds the plan QL at point of sale, the claim may reject — obtain PA to override limits.

PA and QL for Mounjaro

Mounjaro Injectable is listed with (PA)(QL)(M) in the formulary. Prior authorization is required for coverage, quantity limits apply, and medical management documentation may be requested to demonstrate medical necessity.

• Before initiating Mounjaro, confirm PA approval and that requested quantity is within plan limits or supported by PA documentation.
• Include clinical rationale and prior therapy history as part of the PA submission to address the (M) documentation requirement.

Prior authorization and other requirement indicators present

The formulary uses combined flags across many drug entries — (PA),(QL),(M),(AGE),(ST) — which can affect coverage determinations and claims processing. Always review the Requirements & Limits column on the drug entry to determine applicable conditions and next steps.

• Many drugs across classes (e.g., HIV agents, inhalers, CV agents, injectables) show combinations of flags such as (PA)(QL)(M).
• Failure to satisfy the indicated requirements may result in claim denial or member financial responsibility.

Requirements & Limits may trigger denial

Drugs annotated with Requirements & Limits flags may be denied if the specified conditions are not met. Submit complete documentation and, when applicable, a prior authorization before dispensing to reduce denial risk.

• Common denial triggers: PA not obtained; requested quantity exceeds QL without PA; age restriction not met; step therapy requirements not satisfied.
• When a claim is denied for not meeting Requirements & Limits, the member may be liable for the cost.

Coverage exception process

For drugs that are not covered, or when coverage is denied, providers, members, or pharmacies may request a Drug Coverage Exception based on medical necessity. Use the plan's Drug Coverage Exception Form available on the payer website and include clinical documentation supporting the exception request.

• Submit supporting clinical records, rationale for the requested non‑formulary drug, and prior therapy history.
• The exception request is reviewed case-by-case; approval is not guaranteed and is based on medical necessity.

Documentation for QL/M/AGE

When a drug entry shows (QL), (M), or (AGE), include explicit documentation to justify the request: e.g., quantities needed and frequency (for QL), clinical rationale and prior treatment attempts (for M), and patient date of birth or age-specific indication (for AGE). Incomplete documentation increases the chance of denial.

• For QL overrides, provide exact dosing schedule and clinical justification for higher quantity.
• For (M) flags, attach relevant clinical notes, labs, prior authorization forms, and progress notes showing medical necessity.
• For (AGE) flags, include the patient’s DOB and evidence the patient meets the indicated age criteria.

Documentation expectations for QL/M entries

When (QL) or (M) appear on an entry, be prepared to supply supporting evidence as part of any prior authorization or exception request. The plan may require objective clinical data or documentation of failure/intolerance to preferred therapies.

• Typical supporting documentation: treatment history, lab results, specialist notes, and reason why preferred/step therapies were inappropriate or failed.
• Documentation should directly address the specific Requirement & Limits flags shown on the drug entry.

Check Requirements & Limits annotations

Before prescribing or submitting a claim, check the drug's Requirements & Limits annotations on the formulary entry. Confirm whether (PA),(QL),(M),(AGE),(ST) apply and follow the plan's operational steps — obtain PA, supply documentation, or confirm age/step therapy status as required.

• Verify the drug entry in the formulary or the plan's prior authorization tool for up-to-date flags.
• If multiple flags apply (e.g., (PA)(QL)(M)), address all requirements in the PA submission to avoid incomplete reviews.

Step therapy requirement

Step therapy (ST) requires that members try and fail specified alternative therapies before the requested drug is covered. Coverage will generally follow documentation that an appropriate alternative was ineffective or not tolerated. Step therapy most commonly applies to brand-name drugs.

• When a drug is marked (ST), include trial dates, duration, and reason for failure or intolerance to the step drug in the PA or exception submission.
• Examples of ST flags appear in the formulary (e.g., certain acne agents, some migraine agents, and select CNS agents).

Step therapy flags present

Numerous formulary entries display (ST) alongside other flags. Identify these step therapy flags early in treatment planning to avoid delays. If step therapy is required, document the required prior therapy and outcome in any authorization request.

• Examples in the formulary include Adapalene Gel (ST), Clindamy/Ben Gel (ST), some migraine agents (e.g., Frovatriptan noted with ST), and select CNS medications.
• For ST denials, use the Drug Coverage Exception Form to request coverage if clinical justification supports bypassing the step requirement.

Several CNS and other agents show (M) and (QL)

Some CNS and other agents frequently display (M) and (QL) flags indicating medical management and quantity limits. Anticipate requests for clinical documentation (e.g., treatment history, dosing justification) when prescribing these agents to ensure timely review and reduce denial risk.

• CNS examples include memantine products, many antidepressants/antipsychotics with (M) and/or (QL).
• Prepare to submit clinical notes, prior therapy trials, and objective measures when (M) is present.