CurrentSelectHealthPolicy N/A

Prescription Drug Formulary Coverage Criteria (summary)

This document summarizes commonly prescribed drugs covered by SelectHealth plans, explains tiering, cost-sharing, and utilization management (e.g., prior authorization, step therapy, quantity limits), and provides example drug-category entries. It applies to SelectHealth members and providers seeking coverage and cost information.

Policy Summary

PayerSelectHealth

PolicyPrescription Drug Formulary Coverage Criteria (summary)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain required prior authorization and document applicable quantity limits or step therapy trials before submitting a coverage request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyformulary review frequency

PAutilization management types listed

QLlimits apply to certain drugs

90-daymaintenance supply option

partialdocument completeness

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Coverage rules and scope

Coverage contingent on requirement flags

Covered when the formulary line's administrative requirements are met.

Formulary line coverage: Drug or supply is covered if the conditions implied by attached requirement flags (e.g., PA, QL, STH, M, AGE) are satisfied and any required prior authorization is approved.

Follow payer processes for prior authorization, quantity limits, step therapy, age restrictions, and maintenance supply rules as indicated by flags on each formulary line.

For drugs that are not listed as covered on the formulary, a coverage request may be submitted using the Drug Coverage Exception Form. The form may be submitted by the member, their physician, or the dispensing pharmacy and requests are evaluated on a case‑by‑case basis based on medical necessity.

This excerpt does not contain explicit blanket exclusion statements. However, coverage is tied to the presence of requirement flags on each formulary line; failure to satisfy or document those flags (for example, prior authorization, quantity limits, step therapy, age limits, or maintenance supply modifiers) may effectively result in denial or noncoverage for that item.

The document excerpt does not define specific "not medically necessary" (NMN) conditions. Lines in this extract that are shown only with tiering and without additional requirement flags such as (PA) or (M) do not include explicit NMN language within this portion of the formulary.

Formulary groups and therapeutic headers

Formulary groups and supply items shownmixed

INSULIN*	Listed as a formulary group/line for insulins
3MI Luer Loc Mis	Supply item listed with tier and requirement flags
SMI Syringe Mis	Insulin syringes supply line

Formulary supply items (details)mixed

140MI Syring Mis	Ins Prot Injectable Asp, drug name listed as 140MI Syring Mis
1MI Allr Syr Mis	Insulin Aspa Injectable, drug name listed as 1MI Allr Syr Mis
1MI Slip Tip Mis	Lantus Injectable, drug name listed as 1MI Slip Tip Mis
30MI Syringe Mis	Novolog Mix Injectable, drug name listed as 30MI Syringe Mis
Guardian Rt Mis	3MI Luer Loc Mis, drug name listed as Guardian Rt Mis
Hypo Needle Mis	3MI Syringe Mis, drug name listed as Hypo Needle Mis

Therapeutic class headersmixed

GALLSTONE SOLUBILIZING AGENTS	Therapeutic class header
GASTROINTESTINAL (DIGESTIVE) MISC	Therapeutic class header
GNRH/LHRH ANTAGONISTS	Therapeutic class header

Authorization, step therapy, and documentation requirements

Prior Authorization

Preauthorization requirement

Coverage of certain drugs is subject to utilization management. Preauthorization (PA) is required for specific drugs and may be required when medications exceed plan quantity limits; without required PA the member may be responsible for full retail cost.

Preauthorization (PA) required when plan quantity limits (QL) are exceeded
Drugs flagged with PA, PAJQL, PAJQLM, PAJ(QL)(M) etc. require prior authorization and may also have quantity, age, or medical-justification requirements
Failure to obtain required PA may result in claim denial or member financial liability

Prior Authorization

Prior authorization required for listed specialty drugs

Several specialty and high-cost injectable drugs on the formulary require prior authorization and additional controls. Examples include Trikafta, Repatha (injectable), Fasenra Pen, Epidiolex, and multiple other specialty injectables listed with PAJQL or similar flags.

Examples of specialty drugs with PA/controls: Trikafta (PAJQLJAGE), Repatha Sure Injectable (PAJQL)(M), Fasenra Pen Injectable (PAJQL)(M), Epidiolex Solution (PAJQL)(MJ(AGE)

Formulary governance and maintenance

The formulary content is maintained and reviewed on a regular cadence by clinical staff. As noted in the full policy, the formulary is reviewed monthly by a team of doctors and pharmacists who assess clinical efficacy, safety, and cost‑effectiveness; inclusion on the formulary and any associated requirements (e.g., PA, QL, ST) are determined through that review process.

Legend: abbreviations and requirement flags

Formulary legends and utilization management terms

PA (Preauthorization)Coverage for certain drugs requires prior authorization from the plan; without it the member may be responsible for full retail cost.

M (Maintenance drug)Drugs designated M may allow a 90-day supply for convenience.

ST (Step Therapy)Drugs marked ST require trial and failure of an alternative therapy before the listed drug is covered.

QL (Quantity Limits)Quantity limitations apply to certain drugs; preauthorization is required if the medication exceeds plan limits.

AGE (Age limit)AGE indicates age-related restrictions or limits applied to the drug or supply line.

PA, QL, ST, AGE, M, J — shorthand

Step therapy entries and examples

Drug / Class	Step therapy requirement
Drugs designated with (ST)
Step therapy required: member must try and have an inadequate response or adverse reaction to an alternative therapy before the listed drug is covered (per (ST) definition).

Example agent / entry	Step therapy flag and implication
Acetazolamid and similar dermatologic/respiratory entries (examples shown in document excerpt)
Marked (ST) or (STHQL) — indicates step therapy required prior to coverage of the listed agent (document shows multiple entries with (ST) or (STHQL)).

Product / Supply example	STH / STHQL implication
Device and supply entries (e.g., Dexcom 67 Mis, Deflux Needle Mis, Enlite Gluco Mis)
Flagged with STH or STHQL in the list — step therapy applies to those specific products or device kits (document shows STH(QL) or STHQL on supply/device lines).

Antiepileptic agent / entry	Step therapy marker
Aptiom Tablet, Keppra Xr Tablet, Fycompa, Eslicarbazep, Lamictal and other agents listed under SEIZURE DISORDER / Antiepileptics
Annotated with (ST), (STJ), (STH) or combinations (e.g., (STHQL), (STJQL)) — indicates step therapy is required prior to coverage or for specified formulations/age groups per the formulary lines shown.

Drugs and supplies subject to quantity limits

Auvi-Q and related anaphylaxis agents (quantity limits)

Auvi-Q (epinephrine auto-injector)Listed with (QL) — subject to quantity limits per the formulary line.

Epinephrine generics / epinephrineEpinephrine entries also show (QL), indicating quantity limits apply.

Anaphylaxis therapy agents groupAuvi-Q appears under ANAPHYLAXIS THERAPY AGENTS with QL indicated for injectables.

Repatha Push / Sure / Sure Injectable (requirements)

Repatha Sure / Push / Injectable variantsRepatha injectable lines are annotated (PAJQL)(M) or (PAJQL)M indicating prior authorization and quantity limits apply (with maintenance modifier).

Specialty injectable documentationThe PAJQL(M) modifiers on Repatha imply documentation and quantity justification may be required for injectable administration forms.

Policy Summary

PayerSelectHealth

PolicyPrescription Drug Formulary Coverage Criteria (summary)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain required prior authorization and document applicable quantity limits or step therapy trials before submitting a coverage request.

SourceLink

On This Page

Documentation Required

Prior authorization indicated by requirement flags

Formulary requirement flags indicate the specific utilization controls that apply. Common flags include: (PA) prior authorization, (QL) quantity limits, (ST) step therapy, (AGE) age limits, (M/J) medical justification, and combined flags (e.g., PAJQL, PAJQLM, STHQL).

Read combined flags literally: e.g., (PAJQL)(M) = PA + injectable quantity limits + medical justification
Supplies and injectables often show (PAJQL) variants indicating PA plus quantity limits for injectable forms
Age-based restrictions appear as (AGE) or embedded in combined flags (e.g., PAJQLJAGE)

Step Therapy

Step therapy requirement

Step therapy (ST) requirements apply to selected agents and classes — coverage for the listed drug may be conditional on documented trial and failure of a specified alternative. Some entries use variants like (STH), (STJ), or (STHQL) to denote step therapy plus other controls.

(ST) denotes step therapy — must try and fail authorized alternative(s) before coverage
Variants such as (STH), (STJ), (STHQL) indicate step therapy combined with other limits (e.g., quantity limits, prior authorization)
Antiepileptic and other agents commonly show (ST) markers — verify required prior steps before prescribing

Documentation Required

Supporting documentation for supplies

Supplies and devices may require documentation, prior authorization, and age verification. Syringes, glucose monitoring devices, and certain respiratory therapy supplies frequently carry (PAJQL), (AGE), (M), or similar flags—submit supporting clinical documentation with PA requests.

Examples: Insulin syringes and lancets with (PAJ(QL)(MJAGE) or similar flags
Continuous glucose monitor components (Enlite, Dexcom items) showing (PAJQL) or (STH(QLJ(MJ(AGE)) flags
Respiratory therapy supplies listed with (PAJQL)M indicating PA plus quantity/medical justification

Note

Exception requests

For drugs that are not covered or when an exception to formulary rules is needed, the member, prescribing physician, or pharmacy may submit a Drug Coverage Exception Form to request coverage based on medical necessity. Exception requests are evaluated case-by-case.

Use the Drug Coverage Exception Form available on the payer website
Provide clinical rationale and supporting documentation to demonstrate medical necessity
Exceptions may be granted when standard criteria (PA, ST, QL, AGE) are not met but medical necessity is established

PAIndicates prior authorization is required for the formulary line.

QLIndicates a quantity limit applies to the drug or supply.

STIndicates step therapy (trial of alternative therapy required) applies.

AGEIndicates age-based coverage restrictions or requirements.

M / JM and J are modifiers used on lines to denote maintenance (M) and other plan-specific modifiers (J) applied to requirements.

Formulary requirement flags

Requirement flags — examplesFlags appearing after drug lines (e.g., PAJQL, STH, QL, M, AGE) denote administrative controls that must be met for coverage.

PAJQLCombined flags such as PAJQL indicate prior authorization plus quantity limits (and additional modifiers) apply to the formulary line.

STH / STHQLSTH or STHQL indicate step-therapy requirements specific to certain products or device kits.

QL onlyA standalone QL flag indicates the product is subject to plan quantity limits even if no PA or M flag is present.

Requirement codes (document excerpt)

PA = Prior authorizationParenthetical PA denotes that prior authorization is required by the plan for coverage of the drug.

QL = Quantity limitQL indicates the drug is subject to quantity limits imposed by the plan.

ST = Step therapyST denotes step therapy is required (trial and failure of alternatives) before coverage of the listed agent.

AGE = Age limitAGE marks products with age-based coverage restrictions or documentation requirements.

M / J / H modifiersAdditional single-letter modifiers (e.g., M, J, H) denote maintenance status or other plan-specific modifiers attached to requirement flags.

TieringRepatha Sure Injectable is listed at Drug Tier = 2 alongside the requirement flags.

Antivirals (Valacyclovir, Valtrex, others)

Antivirals generalMultiple antiviral entries (e.g., Acyclovir, Valtrex/Valacyclovir) are marked with (QL) or (PAJQL) indicating quantity limits and sometimes prior authorization apply.

Biktarvy, Descovy, DovatoThese antiviral agents are shown with (QL)(M) or (QL)M indicating quantity limits and maintenance modifiers on some formulations.

Valtrex specificValtrex Tablet is listed with (PAJQL)M in at least one extract, indicating PA plus QL for that entry.

Enlite Gluco Mis (diabetes supplies requirements)

Enlite Gluco MIS (sensor/supplies)Annotated (PAJQL)(M) — indicates prior authorization, quantity limits, and maintenance designation apply to this diabetes supply line.

Dexcom entriesDexcom 67 and other Dexcom supplies show STH(QL)(MJ(AGE) flags on some lines, indicating complex limits and step-therapy/age modifiers (supporting that Enlite also carries PAJQL-type flags).

Supply kit associationsEnlite Gluco Mis is associated with syringe/needle supply lines (Toomey Syrin Mis) and carries the PAJQL(M) requirement set.

Aerosol Spacer (quantity limit)

Aerosol SpacerListed under RESPIRATORY THERAPY SUPPLIES with Requirements & Limits = (QL), indicating a quantity limit applies to the device.

Respiratory supplies groupAerosol Spacer appears in the RESPIRATORY THERAPY SUPPLIES section which includes other items marked with PAJQL or QL modifiers.

Monthly/per-device implicationThe document lists Aerosol Spacer QL (per month / device) as a quantity-limited respiratory supply.

Ferrous Sul Solution (QL, AGE)

Ferrous Sul SolutionFerrous Sul Solution is listed with Requirements & Limits = (QLJAGE), indicating quantity limits and age-related restrictions apply.

Iron product familyOther iron formulations (Iron Drops, Iron Inf/Tod, Pediatric Iron Drops) similarly show (QL(AGE) flags in the extract.

TieringFerrous Sul Solution is shown at Drug Tier = 1 alongside the QL/AGE requirement flags.