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 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.

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 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).

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 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 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.

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.

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.