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Prescription drug formulary — Coverage criteria and utilization controls

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Summary of commonly prescribed drugs covered by SelectHealth plans, describing formulary structure, cost tiers, and coverage rules that affect members, providers, and pharmacies.

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CurrentSelectHealthPolicy N/A

Prescription drug formulary — Coverage criteria and utilization controls

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Summary of commonly prescribed drugs covered by SelectHealth plans, describing formulary structure, cost tiers, and coverage rules that affect members, providers, and pharmacies.

Policy Summary

PayerSelectHealth

PolicyPrescription drug formulary — Coverage criteria and utilization controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when the PA flag appears on a drug line to ensure coverage and avoid full retail charges.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyFormulary review cadence

PAPreauthorization required

STStep therapy present

QLQuantity limits

NCApplicable state

Coverage Criteria

SelectHealth does not cover drugs that are not listed on the formulary unless coverage is granted through a formal exception. To request coverage for a non‑formulary medication, the prescriber, member, or pharmacy must submit a Drug Coverage Exception Form with documentation supporting medical necessity. Exception requests are reviewed on a case‑by‑case basis and must be approved before coverage will be provided for a non‑formulary drug.

Provider Actions & Requirements

Prior Authorization

Preauthorization required for PA-marked drugs

Obtain prior authorization for drugs marked with the PA flag before dispensing or billing; without an approved preauthorization the member may be responsible for the drug's full retail price.

Use the payer's prior authorization process before providing drugs that display (PA).
If a drug is noncovered, submit a Drug Coverage Exception Form with medical necessity justification.

Prior Authorization

Follow PA and quantity‑limit flags (PA / QL)

Submit prior authorization when the formulary line shows PA or combined PA/QL flags; where QL is present, confirm quantity requested is within plan limits or include justification for amounts above limits.

PA and QL appear together on many lines (e.g., Prevymis Tablet listed with (PAJQL)M)).
Preauthorization is required if the medication exceeds plan quantity limits.

Prior Authorization

PA required for listed specialty biologics

Obtain prior authorization for multiple specialty biologics that are listed with PAJQL or similar requirement codes before coverage will be approved.

Examples include Adbry Injectable, Amjevita Injectable, Cimzia, Cosentyx, Enbrel, Skyrizi (lines show (PAJQL)M or variants).

Prior Authorization

Treat PAJQL flag as prior authorization trigger

When a drug line includes the PAJQL (or variant) code, submit prior authorization — the presence of PAJQL indicates an authorization requirement tied to quantity controls and possible additional review.

PAJQL variants appear across multiple entries (e.g., Javygtor (PAJQL)(M), Mounjaro Injectable (PAJQL)M).

Prior Authorization

PA required for select injectables

Obtain prior authorization for injectable agents marked (PA); claims may be denied without approved authorization for these injectable products.

Examples include Chor Gonadot Injectable, Novarel Injectable, Pregnyl Injectable noted with (PA).

Prior Authorization

PA combined with quantity limits and medical review

Where lines show combined flags such as (PAJQL) or (PAJQL)(M), submit prior authorization and ensure requested quantity complies with limits; include medical documentation if (M) is present.

Combined codes (PAJQL) and (PAJQL)(M) denote both authorization and quantity limits plus possible medical necessity review (e.g., Droxidopa Capsule (PAJQL)).

Step Therapy

Step therapy — required trial of alternative therapy

Follow step therapy requirements for drugs marked with ST/STH/STJ flags; coverage is only approved after documented trial and failure of the required alternative therapy.

Step therapy typically applies to brand‑name products and must be documented (the member must have tried and failed the alternative).

Step Therapy

Follow STH / STJ step edits when present

Adhere to plan step edits when products display STH/STJ flags (or variants like STHQL/STJQL); these indicate the plan enforces a step edit before coverage.

Examples: Benzonatate noted with (PAJQL)M) and Steglatro Tablet marked (STJQL)(M) — follow the step edit process shown.

Step Therapy

Step therapy indicators (ST / STJQL / STHQL) require documentation

Items with (ST), (STJQL), (STHQL) or similar indicators require step‑therapy compliance prior to coverage; document previous trial of required alternatives to support approval.

Imvexxy Main Sup shows (ST)QL)(M) and Tyenne Injectable shows (STHQL)M) as examples of step therapy indicators.

Step Therapy

Step edits indicated — provide trial/failure evidence

Drugs listed with (ST), (STH), or other step flags are covered only after meeting the step requirement; include clinical documentation of trial and failure of the prior agent when requesting coverage.

Multiple entries include ST/ STH markers (e.g., Lamotrig Odt (STHQL)(M), Topamax Spr (STHQL)(M)).

Note

Documentation Required

Request drug coverage exception for noncovered drugs

If a drug is not on the formulary, submit a Drug Coverage Exception Form with medical necessity justification to request coverage; requests are decided case‑by‑case.

The Drug Coverage Exception Form is available on the plan website and must include medical necessity supporting documentation.

Documentation Required

Interpret requirement code shorthand on formulary lines

Recognize and act on inline requirement code shorthand (PAJQL, QL, M, AGE, ST, STHQL, etc.) — these codes indicate the specific utilization controls that must be met for coverage.

When codes include (M), include supporting medical documentation; (AGE) indicates age‑based limits; (QL) indicates quantity limits.

Billing Rule

Confirm quantity limits and provide medical review documentation when required

When entries include (QL) or (QL)(M), ensure the quantity requested is within the specified limits or provide medical documentation to justify quantities exceeding the limit.

Several anticonvulsants and NSAIDs show (QL)(M) or (QL) — preauthorization is required if medication exceeds plan limits.

Denial Risk

Denial risk if formulary controls not met

Claims may be denied if drug‑specific requirements (PA, PAJ, QL, ST, M, HQL) shown on the formulary line are not met; verify flags before dispensing or billing to reduce denial risk.

Noncompliance with PA/QL/ST requirements can result in claim denial or member financial responsibility.

Documentation Required

Handle (PAJQL)(M) and similar combined flags as multiple requirements

Entries with combined flags such as (PAJQL)(M) indicate multiple controls (prior authorization, quantity limits, and possible medical necessity review); submit complete PA requests including quantity and clinical justification.

Examples include Tb Syrng 1MI Mis and several injectables showing (PAJQL)(M) or similar variants.

Note

Formulary Requirement Codes & Flags

Formulary requirement codes and flagsmixed

PAJQL	prior authorization + other requirement flags as listed
PAJ(QL)(M	documented variation of prior authorization/QL/M
QL	quantity limits
M	medical necessity
AGE	age-related limit
ST	step therapy flag
STHQL	step therapy + high-level QL flag (document shows this form)
STJQL	variant of step therapy/QL coding as presented
MJ	documented code fragment appearing in requirements strings
PAJ(QL)(M).	another textual variant present in the file

Formulary requirement codes and flags (documented PA variants)mixed

PAJ(QL)(M	documented variation of prior authorization/QL/M (appears in multiple lines)
PAJ(QL)(M).	textual variant present in chunks showing combined flags
PAJ(QL)J(MJ(AGE)	longer combined variant fragments appearing in syringe/supply lines

Age limit

AGE flagAGE flag is present on formulary line items; specific age thresholds are not shown in this excerpt

Examples showing AGETretinoin Cream and Auvi-Q injectables include (AGE) or QL annotations in the source listings

Scope of AGE usageAGE appears combined with other flags (e.g., (PAJQL)(MJ(AGE) on syringe/supply lines), indicating age-based restrictions may apply alongside other requirements

Definitions & Legend

Formulary legend terms

PAPreauthorization — coverage of certain drugs requires preauthorization from the payer; without it the member may be responsible for the drug's full retail price

MMaintenance drug — may allow a 90-day supply for convenience

STStep Therapy — drug covered only after trial and failure of an alternative therapy

QLQuantity Limits — plan-specific quantity limits apply; preauthorization required if the medication exceeds plan limits

PA — Prior authorization

PA (Prior authorization)Flag appears inline next to drug entries (e.g., Prevymis Tablet shows (PAJQL)M and Repatha Injectable shows (PAJQL)M) — providers must submit prior authorization when PA is present

Step Therapy Requirements

Rule	Explanation
Must try required alternative therapy before coverage of step therapy drugs	Drugs that require step therapy are covered only after you have tried an alternative therapy and it didn’t work (i.e., the drug didn’t alleviate your symptoms or caused adverse reactions). Step therapy most often applies to brand-name drugs.

Products with flags	Flag shown / Meaning
Benzonatate	Example entries in the formulary show STH or STH(QL) flags indicating step edits apply to the product.
Steglatro Tablet	Listed with (STJQL)(M) indicating a step-therapy edit (STJ) combined with quantity limits (QL) and maintenance marker (M).

Flag type	Where it appears / implication
ST	Appears on items such as Imvexxy Main Sup (Requirements = (ST)QL)(M)), indicating step therapy edits apply prior to coverage.
STHQL / STJQL	Shown on multiple products (e.g., Tyenne Injectable shows (STHQL)M, Steglatro Tablet shows (STJQL)(M)) implying step therapy plus quantity-limit modifiers on those lines.

Coverage condition	Policy effect
ST or STH flag present on formulary line	Step therapy must be met before the listed product is covered; claims may be denied if step requirements are not satisfied.
Products showing (STJQL) or (STHQL)	These indicators denote the requirement to complete the prior step (failure or intolerance to alternative therapy) before coverage and may be combined with QL or M modifiers.

Agent / example	Step-therapy flag shown
Tyenne Injectable	Requirements & Limits = (STHQL)M) shown on the formulary line, indicating step-therapy flag (STHQL) applies prior to coverage.
Vtama Cream	Listed with (STJQL) indicating a step-therapy edit (STJ) with a QL modifier.
Metaxalone Tablet	Requirements & Limits = (ST) listed, indicating step therapy applies to this product.

Quantity Limits

Quantity limits overview

OverviewSubject to plan-specific quantity limits (QL); preauthorization is required if a requested quantity exceeds the plan limit

Documented examplesPrevymis Tablet, Repatha Injectable, and Repatha Sure Injectable are shown with QL-related flags; Steglatro Tablet is shown with (STJQL)(M)

Provider actionIf prescribing beyond QL, submit prior authorization and supporting medical documentation to request approval

Prevymis / Repatha quantity-limit entries

Prevymis TabletRequirements & Limits = (PAJQL)M) — QL present alongside PA and M modifiers

Repatha InjectableRequirements & Limits = (PAJQL)M) — prior authorization plus quantity limits and maintenance modifier shown

Background

The formulary identifies commonly prescribed medications and the payer’s coverage expectations, and it is the primary tool providers and pharmacies should consult when prescribing or dispensing. Where a drug is not covered, or where utilization controls apply, the formulary directs users to follow the documented exception and authorization processes — including submission of the Drug Coverage Exception Form with supporting clinical information to request coverage based on medical necessity.

Policy Summary

PayerSelectHealth

PolicyPrescription drug formulary — Coverage criteria and utilization controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when the PA flag appears on a drug line to ensure coverage and avoid full retail charges.

SourceLink

On This Page

PA on injectablesSeveral injectable agents display (PA) or PA variants (examples in the document include Chor Gonadot Injectable, Novarel Injectable, Pregnyl Injectable)

PA combined with other codesPA commonly appears in compound flags such as (PAJQL) or (PAJQL)(M) indicating PA plus quantity limits or medical review

QL — Quantity limit

QL (Quantity Limit)Flag appears inline next to drug entries (e.g., Prevymis Tablet (QL)(M), Repatha Injectable (PAJQL)M, Xigduo Xr Tablet (QL)M) — specified quantities are limited by plan rules

QL and preauthorizationPreauthorization is required when requested quantity exceeds the plan limit

QL combined with modifiersQL may appear with modifiers such as (M) or as part of compound flags (e.g., (STJQL), (PAJQL))

STH / STJ — Step therapy edit indicators

STH / STJ (Step therapy indicators)Step-edit indicators like STH and STJ appear in formulary flags (examples: Benzonatate marked with (STH(QL)), Steglatro Tablet marked (STJQL)(M)) — these indicate step therapy edits apply

ST variantsFlags appear as STHQL, STJQL and ST, showing multiple abbreviated step-therapy forms used in the list

Action when presentWhen STH/STJ/ST appears, the plan's step therapy requirements must be met before coverage of the listed product

M / AGE — Additional requirement/limit annotations

M (Maintenance)Indicates maintenance drugs that may allow a 90-day supply (documented as (M) on many entries)

AGE modifierAGE used to denote age-related limits on certain line items (document shows AGE appended or combined with other flags)

Combined modifiersM and AGE often combine with other requirement flags (e.g., (QL)(M), (PAJQL)(M)) to indicate maintenance status or age limits plus other controls

Requirement codes — shorthand flags

Common requirement codesShorthand flags used throughout the formulary include (PAJQL), (QL), (M), (AGE), (ST), (STHQL), (STJQL)

PurposeThese codes denote utilization management controls such as prior authorization, quantity limits, step therapy, maintenance/medical review, or age limits

Textual variantsThe source includes textual variants and fragments (e.g., PAJ(QL)(M, PAJ(QL)(M), PAJQL)M) reflecting how codes appear in the file

Requirement codes — post-tier shorthand

PAJ, QL, ST, M, HQLShort codes appearing after drug tier include PAJ, QL, ST, M, HQL which denote payer-specific controls (e.g., Hadlima Push Injectable (PAJQL)(M), Javygtor (PAJQL)(M))

ImplicationThese post-tier codes imply combinations of prior authorization, quantity limits, step edits, or medical review as part of claim adjudication

Multiple appearancesCodes repeat across many line items and supply entries, indicating consistent application of these shorthand requirement codes

Quantity Limit

QL definitionQuantity Limit — QL indicates plan-specific quantity limitations apply to the drug or supply line

ExamplesExamples in the source include Auvi-Q Injectable (QL), Apap/Codeine Tablet (QL), and many anticonvulsant entries with (QL)(M)

Effect on coverageExceeding the QL typically requires prior authorization and may result in claim denial without approval

Prior Authorization

PA definitionPrior Authorization — PA indicates the payer requires authorization before the drug is covered; failure to obtain PA may leave the member responsible for full retail cost

PA examplesDocumented examples include Repatha Injectable and Repatha Sure Injectable showing (PAJQL)M and multiple biologics listed with PA-related flags

PA combined flagsPA often appears within compound codes (e.g., (PAJQL), (PAJQL)(M)) indicating PA plus other requirements like quantity limits or medical review

Step therapy / step requirement

STH / STHQL (Step requirement)Abbreviated step-therapy flags such as STH, STHQL, STJQL appear on formulary lines (e.g., Lamotrig Odt (STHQL)(M), Topamax Spr (STHQL)(M)) indicating step edits apply

Action requiredWhen these step flags are present, the plan requires documented trial and failure of specified alternatives before coverage

Variants across classesStep indicators appear across therapeutic classes including anticonvulsants and other agent groups in the source

Additional modifiers

M, AGE, JQL modifiersModifiers such as M (medical/maintenance review), AGE (age limit), and JQL (combined quantity-limit variant) appear appended to requirement flags (e.g., (PAJQL)(M), (QL)(MJ(AGE))

MeaningThese modifiers indicate additional review requirements (M), age-based restrictions (AGE), or compound limit codes (JQL) when present

Combined usageModifiers commonly combine with PA or QL in the source to form compound requirement strings used for adjudication

Repatha Sure InjectableRequirements & Limits = (PAJQL)M_ — compound PA/QL/M flag appears on the Repatha Sure entry

Steglatro Tablet

Steglatro TabletRequirements & Limits = (STJQL)(M) — indicates step therapy plus quantity limit and maintenance modifier

ContextSteglatro appears in diabetes class entries and is shown with combined ST/QL/M flags in the source

ImplicationProviders should follow step edits and QL rules; prior authorization may be required if limits are exceeded

Xigduo Xr Tablet

Xigduo Xr TabletRequirements & Limits = (QL)M — quantity limit with maintenance modifier

ContextListed in diabetes section alongside supplies (e.g., Dexcom) and other antidiabetic agents

Provider noteQL with (M) may indicate limits plus maintenance-supply allowance; prior authorization required if exceeding QL

Tb Syrng 1MI Mis (Genotropin reference)

Tb Syrng 1MI Mis (Genotropin ref)Requirements & Limits = (PAJQL)(M) — compound flag indicating prior authorization, quantity limits, and maintenance/medical review

Supply contextThis syringe/supply line is associated with Genotropin and other injectable supply items that carry compound requirement codes

ActionPrior authorization and adherence to QL/M documentation required for coverage when this code appears

Multiple listed drugs — QL present

Multiple listed drugs — QL presentNumerous drug and supply line items include (QL) or variations (e.g., (QL)(M), (PAJQL)) indicating quantity limits apply where indicated

Examples across sectionsAnticonvulsants, pain medications, diabetes agents, and supplies frequently show QL flags in the source extract

Effect on claimsClaims exceeding these QLs may require prior authorization or be denied without authorization

Multiple entries — (QL) flag

QL flag on multiple entriesSeveral distinct entries explicitly show (QL) as the indicator for quantity limits (e.g., Celecoxib (QL)(M), Divalproex ER (QL)(M), Apap/Codeine Tablet (QL))

Per-period specificationSome QL entries are noted with monthly or unspecified-period limits in the source; the document indicates QL per month for some groups

Provider actionWhen QL is present, follow formulary limits or submit PA for quantities beyond the listed QL

Droxidopa Capsule

Droxidopa CapsuleRequirements & Limits = (PAJQL) — document shows PAJQL on Droxidopa Capsule indicating prior authorization plus quantity limits

ContextListed under vaccine/injectable and uncategorized sections alongside other PAJQL entries

ImplicationCoverage requires authorization consistent with PAJQL rules; claims without required authorization may be denied