CurrentSelectHealthPolicy N/A
Prescription drug list (formulary) - Coverage Criteria
Customize your policy alerts
Sign up for all SelectHealth policy alerts
Know when SelectHealth releases new policies or updates existing guidance.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
Summarizes commonly prescribed drugs covered by SelectHealth plans, explains tiers, cost-sharing, and administrative controls (e.g., prior authorization, step therapy, quantity limits) for members and providers.
Policy Summary
PayerSelectHealth
PolicyPrescription drug list (formulary) - Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionObtain prior authorization from SelectHealth before coverage for drugs flagged with (PA).
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
monthlyformulary review frequency
90-daymaintenance drug supply option referenced
PA, QL, M, ST, AGEauthorization flags observed
1/1/2026document effective date
Coverage rules and general formulary guidance
General coverage rule per listed requirement flags
Covered when ALL of the following are met:
Standard formulary coverage conditions: Item is covered at the assigned tier when all listed administrative requirements are satisfied
Administrative requirement flags include: (PA) prior authorization, (QL) quantity limits, (ST) step therapy, (M) maintenance/medical-necessity review, (AGE) age limits. See item-level Requirements & Limits for flags applicable to the specific product.
Some drugs in the formulary are designated as noncovered. For those items, members, their prescribing physician, or the dispensing pharmacy may request coverage by submitting a Drug Coverage Exception Form and providing documentation of medical necessity. Requests for noncovered drug coverage are considered on a case‑by‑case basis.
Within the provided extract there are no explicit exclusion lists shown that categorically remove specific drug classes or products from coverage; formulary entries instead show tier assignments and utilization flags (e.g., PA, QL, M, ST, AGE) that govern coverage conditions.
The source segments reviewed do not include any statements explicitly labeling products as not medically necessary. Coverage determinations in this extract are driven by tier assignments and administrative requirement flags rather than explicit 'not medically necessary' language.
Formulary entries, tiers, and flags (coding view)
Formulary entries (no billing codes provided in this section)mixed
| No codes listed |
Formulary tier and requirement flagsmixed
| Tier 2 | Drug Tier = 2 (assigned to multiple entries such as Glipizide, Fluorouracil Cream in one line, etc.) |
| PA | Prior Authorization requirement flag |
| QL | Quantity Limit requirement flag |
| M | Requirement flag (document-specific) |
Utilization management flagsmixed
| ST | Step Therapy requirement flag |
| AGE | Age limit flag |
inv-08: Age limit (AGE)
AGE marker presentDocument flags an AGE requirement for some products, but specific minimum/maximum ages are not listed in the extracted chunks
ImplicationWhen (AGE) appears in Requirements & Limits, member age verification will be required to determine coverage
Examples referencedMultiple device and vaccine entries show (AGE) (e.g., Free Libre2 Kit, Dexcom G7, Gardasil 9) but exact age thresholds are not included here
What providers must do (authorizations, documentation, step therapy)
Prior Authorization
Prior authorization required
Coverage of certain drugs requires prior authorization (PA) before the plan will pay. If a drug is marked with (PA) in the formulary, obtain PA prior to dispensing — otherwise the member may be held responsible for the drug's full retail cost and the claim may be denied.
- Examples: Repatha, Mounjaro, Trulicity, Soliqua and other products shown with (PA) in the formulary.
- Claims submitted without required PA are subject to denial or member liability.
Note
Authorization-related flags (PA, ST, QL, M, AGE)
Entries flagged with administrative indicators — (PA), (ST), (QL), (M), (AGE) — indicate program controls that affect coverage. Review the formulary flags carefully and meet the associated requirements when prescribing or dispensing.
- (PA) = Prior authorization required.
- (ST) = Step therapy required (trial/failure of specified alternatives).
- (QL) = Quantity limits apply; requests above limits may need PA.
- (M) = Medical necessity criteria apply.
- (AGE) = Age limits — member age must meet criteria.
Step Therapy
Step therapy requirement (ST)
When (ST) appears next to a drug, the product requires step therapy. Coverage is provided only after documented trial and inadequate response or intolerance to required first-line alternatives. Include prior-treatment documentation when requesting PA for step-therapy drugs.
- Examples of drugs with (ST): some statins, levothyroxine entries, and other branded products shown with (ST).
- Provide dates, drugs tried, reason for failure or intolerance, and any relevant lab results when supporting a step-therapy exception request.
Documentation Required
Documentation required for age limits (AGE)
Age limits (AGE) shown in the formulary must be documented in any prior authorization or exception submission. If a product is flagged (AGE) you must confirm the member meets the age-based criteria to receive coverage.
- Examples: vaccines and selected chronic therapies in the formulary list include (AGE) indicators.
- Include member date of birth and relevant clinical rationale when submitting PA or exception requests.
Formulary structure and scope
The formulary groups medications by clinical category and assigns each item a drug tier that determines cost sharing. A clinical/pharmacy review team evaluates efficacy, safety, and cost‑effectiveness on a recurring schedule to maintain the list. Administrative controls — including prior authorization (PA), quantity limits (QL), step therapy (ST), maintenance (M), and age limits (AGE) — are applied at the item level and must be satisfied for coverage at the assigned tier.
Key flags and terms
inv-32: Preauthorization (PA) definition
DefinitionPreauthorization (PA) = Authorization required from the payer before coverage is approved for certain drugs
Effect of not obtaining PAIf preauthorization is not obtained where required, the member may be responsible for the drug's full retail price
Where shownItems flagged (PA) in the Requirements & Limits column require prior authorization prior to coverage
inv-33: Maintenance drug (M) — 90-day supply reference
DefinitionMaintenance drug (M) = Drugs designated for maintenance therapy that may be available in a 90-day supply
PurposeDesigned for ongoing therapy convenience (90-day supply option)
Flag usageThe (M) flag appears in Requirements & Limits to denote maintenance status for selected products
inv-34: Step Therapy (ST) definition
DefinitionStep Therapy (ST) = Coverage condition requiring trial and failure of a specified alternative therapy before the requested drug is covered
Typical applicationMost often applies to brand‑name drugs; prior steps must be documented
ConsequenceDrugs with (ST) require evidence of prior therapy failure or adverse reaction to preferred agents
inv-35: Quantity Limits (QL) definition
DefinitionQuantity Limits (QL) = Plan-imposed limits on drug quantities; exceeding the limit may require prior authorization
ScopeApplied to selected drugs (e.g., opioids, injectables, vaccines) to limit amount dispensed in a time period
Operational noteClaims exceeding QL may be subject to denial or require PA per formulary rules
inv-36: Age limit (AGE) definition
DefinitionAge limit (AGE) = A minimum or maximum age requirement must be met for coverage of certain drugs
DocumentationWhen (AGE) appears, supporting age documentation will be required to determine coverage eligibility
Appearance in tableAGE appears in Requirements & Limits for vaccines, devices, and medications in the formulary extract
inv-37: PA (short)
PA (short)Prior authorization required before coverage
When usedShown as (PA) in Requirements & Limits for affected drugs
ConsequenceNo PA may result in member financial responsibility
inv-38: QL (short)
QL (short)Quantity limit applies; may restrict amount dispensed per time period
When usedShown as (QL) for selected products (e.g., Auvi-Q, vaccines, injectables)
ConsequenceExceeding QL may require prior authorization or be denied
inv-39: M (short)
M (short)Maintenance drug — may be dispensed as a 90-day supply
When usedFlagged as (M) in Requirements & Limits to denote maintenance status
PurposeIndicates chronic or ongoing therapy where extended supply is appropriate
inv-40: ST (short)
ST (short)Step therapy required — trial and failure of preferred agent(s) first
When usedFlagged as (ST) in Requirements & Limits for affected drugs
DocumentationPrior steps and rationale for failure or intolerance must be documented
inv-41: AGE (short)
AGE (short)Age-based coverage limitation — minimum or maximum age applies
When usedDisplayed as (AGE) in the Requirements & Limits column for certain products
Provider actionVerify and document member age to support coverage determinations
inv-42: Prior Authorization required (alternate)
Prior Authorization required (alternate)PA indicates payer approval must be obtained before coverage; absence may result in member paying full retail price
Usage noteApplied to specific drugs as shown in the Requirements & Limits column
Example actionSubmit PA request to SelectHealth prior to dispensing when (PA) is shown
inv-43: Quantity Limit (alternate)
Quantity Limit (alternate)QL denotes plan-imposed dispensing limits; vaccines and many injectables list (QL) in Requirements & Limits
Operational impactClaims over QL may be denied or require PA per formulary rules
ExamplesFluzone and many influenza vaccines show (QL) in the extract
inv-44: Step Therapy (alternate)
Step Therapy (alternate)ST requires trial of preferred therapy first; often applies to brand-name agents
Documentation requirementEvidence of prior therapy failure or intolerance must be provided to satisfy ST
Result if unmetCoverage may be denied until step requirements are met
inv-45: M flag — may indicate medical management or miscellaneous requirement
M flag meaningMay indicate medical management or miscellaneous requirement — used to denote drugs/devices needing additional review
Context(M) appears alongside PA/QL/ST flags for items requiring extra documentation or ongoing management
Provider actionBe prepared to supply clinical rationale or documentation when (M) is present
inv-46: AGE — age limit applies
AGE appliesAGE flag indicates an age limit applies to coverage for the listed drug or product
Where seenAGE is used across the formulary including dermatologics and vaccines in the extracted chunks
RequirementSupporting age documentation is expected when AGE is flagged
inv-47: PA (definition instance)
PA (definition instance)PA = Preauthorization required from SelectHealth prior to coverage approval
ConsequenceWithout required PA the claim may be denied or member may pay full retail price
ApplicationApplied to specific injectable and specialty products as shown in Requirements & Limits
inv-48: QL (definition instance)
QL (definition instance)QL = Quantity Limit applied to a drug, limiting amount dispensed in a given time period
Interaction with PAPreauthorization is required if dispensing exceeds the plan limit
Applied toExamples include injectables, vaccines, and certain chronic medications
inv-49: M (definition instance)
M (definition instance)M = Maintenance drug designation; may allow dispensing up to a 90-day supply
Intended useFor chronic therapy where longer supply is clinically appropriate
Flag presence(M) appears in Requirements & Limits to identify maintenance products
inv-50: ST (definition instance)
ST (definition instance)ST = Step Therapy requiring trial and failure of a preferred alternative before coverage
Typical scenarioOften used for higher-cost brand agents to encourage use of preferred therapies first
DocumentationProvider must document prior trials and outcomes to meet ST requirements
inv-51: AGE (definition instance)
AGE (definition instance)AGE = Minimum or maximum age requirement must be met for coverage of certain drugs or products
EvidenceAge verification/documentation will be requested when AGE is shown
Commonly appliedUsed for vaccines, pediatric formulations, and some devices in the formulary extract
inv-52: PA (definition instance)
PA (definition instance)Prior authorization indicates payer approval required before coverage — listed as (PA) in Requirements & Limits
ExamplesRepatha Injectable and other biologics are listed with (PA) in the extract
Provider implicationObtain PA from SelectHealth before dispensing PA‑flagged agents
inv-53: QL (definition instance)
QL (definition instance)QL = Plan quantity restriction; vaccines and many injectables show (QL) in Requirements & Limits
EffectLimits define allowed dispensing frequencies/amounts and may trigger denials if exceeded
ExamplesFluzone and other influenza vaccines are shown with (QL) in the extract
inv-54: AGE (definition instance)
AGE (definition instance)AGE = Age-based coverage limitation; the formulary requires age criteria for some items
Where appliedAppears across therapeutic categories including dermatologics and cardiovascular agents in the extracted chunks
DocumentationProviders should verify age and include supporting documentation when required
inv-55: M (definition instance)
M (definition instance)M = Maintenance; indicates drugs appropriate for ongoing therapy and potential 90-day dispensing
ExamplesAppears for many chronic therapy products and diabetes supplies in the extract
Operational note(M) may trigger different dispensing options and documentation expectations
inv-56: ST (definition instance)
ST (definition instance)ST = Step Therapy; trial of preferred agent(s) required first and documentation of failure/intolerance needed
ExamplesDiltiazem and other agents show (ST) with additional flags (QL)(M) in the extract
ConsequenceCoverage may be denied until step criteria are satisfied
Drugs subject to step therapy requirements
| Requirement | Description / Policy |
|---|---|
| Step therapy (ST) | |
| Drugs marked with (ST) require trial and failure of an alternative (preferred) therapy before the requested drug is covered; step therapy most often applies to brand‑name drugs. |
| Agent(s) | Requirements noted |
|---|---|
| Diltiazem (e.g., Dilt‑XR, Diltiazem Er) | |
| Listed with requirement flags including (ST)(QL)(M) or (M) depending on formulation — indicates step therapy may apply to some Diltiazem products. | |
| Icosapent / Omega‑3 Acid Capsule | |
| Example entries show Requirements & Limits = (ST) or blank depending on item; referenced as therapies with ST indicated in formulary segments. | |
| Benzonatate | |
| Included among items in formulary segments where (ST)(QL) or (ST) flags appear — denoting step therapy may apply to some formulations. |
| When (ST) is present | Policy implication |
|---|---|
| Requirements & Limits column includes (ST) | |
| Products with (ST) require documentation of prior trial and failure of preferred agent(s) before coverage is approved; prior steps must be documented per formulary rules. |
| Context | Action required |
|---|---|
| Formulary entries where (ST) indicated (e.g., diabetes testing & supplies and device kit listings; other therapeutic areas) | |
| Step therapy is required for drugs/items flagged with (ST); providers must document that required prior therapies were tried and failed (or were not tolerated) before the requested product will be covered. |
| Product | Requirement flags |
|---|---|
| Levothyroxin | |
| Requirements & Limits = (ST)(QL)(M) — indicates step therapy may be required for some Levothyroxin formulations in addition to quantity limits and medical necessity review. |
Products subject to quantity limits
inv-62: Auvi-Q Injectable / Epinephrine Injectable — QL applies (examples)
Auvi-Q / Epinephrine QL exampleAuvi-Q Injectable and Epinephrine Injectable are listed with (QL) in Requirements & Limits
ImplicationQuantity limits apply to epinephrine auto-injectors per the formulary extract
ReferenceSee formulary dermatologic/anaphylaxis entries for QL usage
inv-63: Paxlovid — QL indicated
Paxlovid QLPaxlovid is indicated with (QL) in the Requirements & Limits column
PlacementPaxlovid appears in the antiviral section with QL noted
Operational noteDispensing of Paxlovid may be subject to quantity limits per formulary rules
inv-64: Repatha Injectable — QL indicated
Repatha QLRepatha Injectable is listed with (PA)(QL)(M) indicating quantity limits apply (among other flags)
ContextRepatha appears in lipid therapy entries with PA and M flags alongside QL
Provider implicationPrior authorization and adherence to QL will be required for Repatha claims
inv-65: Mounjaro Injectable — QL indicated
Mounjaro QLMounjaro Injectable is listed with (PA)(QL)(M) indicating quantity limits apply
Additional flagsAlso requires prior authorization and is flagged as maintenance in some entries
Operational impactDispensing of Mounjaro will follow PA and QL enforcement per formulary rules
inv-66: Fluorouracil Cream — QL indicated
Fluorouracil Cream QLFluorouracil Cream is listed with (PA)(QL) indicating quantity limits apply
CategoryListed under dermatologicals with PA and QL flags
Provider notePA and QL must be considered when requesting coverage for fluorouracil cream
inv-67: Trulicity Injectable — QL indicated
Trulicity QLTrulicity Injectable appears with (PA)(QL)(M) indicating quantity limits apply
ContextListed in diabetes injectable entries with maintenance and PA flags
Provider actionPA and QL compliance required for coverage of Trulicity
inv-68: multiple entries flagged with (QL) — per formulary QL
Multiple QL entriesNumerous formulary entries are flagged with (QL) indicating per‑formulary quantity limits apply
ScopeQL appears across categories including testing supplies, injectables, and chronic meds
Operational noteClaims exceeding these limits may require PA or be denied
inv-69: Fluzone Injectable — (QL)
Fluzone QLFluzone Injectable is shown with (QL) in Requirements & Limits
CategoryAppears in vaccine listings where QL is commonly applied
Provider implicationVaccine dispensing may be limited per QL and require documentation
inv-70: Gardasil 9 Injectable — (AGE) flagged (age-specific limits)
Gardasil 9 AGE flagGardasil 9 Injectable is listed with (AGE) indicating age‑specific limits apply
ImplicationPatient age must meet the formulary age criteria for Gardasil 9 to be covered
DocumentationProviders must verify and document patient age when AGE is flagged for Gardasil 9
inv-71: Pedia Iron Dro — (QL)(AGE)
Pedia Iron Dro QL/AGEPedia Iron Dro is listed with (QL)(AGE) indicating both quantity limits and age restrictions apply
CategoryPediatric iron formulations show combined QL and AGE flags in the extract
Provider actionVerify patient age and adhere to QL when dispensing pediatric iron drops
Policy Summary
PayerSelectHealth
PolicyPrescription drug list (formulary) - Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionObtain prior authorization from SelectHealth before coverage for drugs flagged with (PA).
SourceLink
On This Page
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.