Prescription drug list (formulary) — Coverage criteria
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Summary of commonly prescribed drugs covered by SelectHealth plans, tiering, coverage limits, and requirements (e.g., preauthorization, step therapy, quantity limits) for members and providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Drugs that are not covered may still be considered for coverage on a case-by-case basis. To request an exception you, the prescribing physician, or the dispensing pharmacy must submit a Drug Coverage Exception Form and demonstrate that coverage is medically necessary. Requests are reviewed individually and approved only when the documented medical necessity supports coverage.
This segment does not list any explicit exclusion conditions beyond the standard formulary flags. Individual line items include requirement flags (e.g., (PA), (QL), (M), (ST), (AGE)) but no separate, named exclusions are specified in the excerpt.
Within this excerpt there are no statements declaring specific drugs or uses as not medically necessary. Coverage determinations reference requirement flags (such as (M) for medical necessity) that trigger review, but no standalone 'not medically necessary' declarations appear in the provided text.
Coding and Requirement Flags
| (PA) | Prior Authorization |
| (QL) | Quantity Limit |
| (M) | Medical Benefit / Medical necessity indicator |
| (ST) | Step Therapy |
| (AGE) | Age limit applies |
| PA | Prior authorization required (indicator shown next to some drugs) |
| QL | Quantity limits (indicator shown next to many drugs) |
| M | Medical necessity review indicator |
| AGE | Age limit indicator |
| ST | Step therapy indicator |
Provider Actions, Authorization & Documentation
Preauthorization required
Coverage of certain drugs requires preauthorization — items marked (PA) must have prior authorization before the plan will cover them. If preauthorization is not obtained, the member may be responsible for the full retail cost.
- Examples: Repatha Injectable, Repatha Sure Injectable, Trikafta, many specialty injectables and test supplies are flagged (PA).
- Preauthorization is commonly required for high-cost specialty agents and certain injectables; see the formulary entries for (PA) flags.
Prior authorization and requirement indicators
Prior authorization and other requirement flags (PA, QL, ST, M, AGE) appear next to drug entries and determine coverage conditions. Providers must review these flags on the formulary and submit the appropriate documentation when requesting coverage.
- (PA) = Prior authorization required; (QL) = quantity limits; (ST) = step therapy; (M) = medical necessity documentation; (AGE) = age-based limits.
- Examples: Trikafta = (PA)(QL)(AGE)(M); many diabetes supplies and injectables show (PA)(QL)(M).
Age-based coverage limits
Some formulary entries include explicit age limits (AGE). Claims for members outside the indicated age ranges may be denied if age-based criteria are not met.
- Examples: Vaccines (Gardasil 9, Ipol) and certain pediatric or geriatric therapies include (AGE) flags.
- When (AGE) is present, include the patient’s date of birth and supporting clinical rationale if requesting an exception.
Denial triggers for unmet requirements
Claims or pharmacy requests may be denied if preauthorization, step therapy, quantity limits, age restrictions, or required documentation are not met. Absence of PA for (PA)-flagged drugs is a common denial trigger.
- Denial triggers include: no prior authorization for (PA) drugs; exceeding (QL) without approval; failure to document required step-therapy trials (ST); missing medical necessity (M) documentation; or age outside (AGE) limits.
- If a claim is denied, providers and members may follow the coverage exception process (Drug Coverage Exception Form).
Prior authorization indicated
Prior authorization flags (PA) throughout the formulary indicate the plan requires approval before filling. Providers should initiate PA requests promptly to avoid claim denials and member financial responsibility.
- Commonly PA-required items: specialty injectables, oncology agents, certain diagnostic test supplies and select topical agents.
- PA requirements apply to both pharmacy-dispensed drugs and some medical benefit products (injectables, devices).
Coverage exception process
To request coverage for a noncovered drug or to appeal a denied claim, members, physicians, or pharmacies must submit a Drug Coverage Exception Form with supporting documentation showing medical necessity.
- The Drug Coverage Exception Form is available on the payer website.
- Include clinical notes, previous treatment history, and any test results that support the exception request.
Documentation for flagged drugs
Providers must supply supporting documentation when requesting PA, QL overrides, or exceptions. Documentation should demonstrate medical necessity, prior trials (for ST), dosing and quantity rationale, and patient age when (AGE) applies.
- Documentation examples: prior therapy trial records (for ST), treatment failure/intolerance notes, labs or diagnostic reports, and prescriptions or dispensing history.
- Quantity limit (QL) exceedance requests should include justification for higher dosing or duration; medical necessity (M) items require clinical notes.
Step therapy requirement
Step therapy (ST) requires documented trial and failure or intolerance of specified alternative therapies before the requested drug will be covered. Items marked (ST) will be denied if required prior steps are not shown.
- Examples of ST: Pitavastatin and other agents noted with (ST); some inhaled and topical products also require step therapy.
- When submitting PA for an ST item, include dates and outcomes of prior medication trials and reasons for switching.
Background
The formulary is maintained and reviewed by a clinical pharmacy team together with physician reviewers who evaluate each product for efficacy, safety, and cost‑effectiveness. Inclusion on the formulary reflects that review, but coverage for a given prescription still depends on any plan-specific requirements (for example, prior authorization, step therapy, quantity limits, medical necessity, or age limits).
Definitions and Flag Key
Step Therapy Details
| Formulary flag | Meaning / requirement |
|---|---|
| (ST) | |
| Step therapy — drug requires trial and failure or intolerance of specified alternative therapy before coverage is approved; documentation must be provided. |
| Example drug | Requirements & Limits |
|---|---|
| Midodrine | |
| Shown with (ST) indicating step therapy is required prior to coverage. | |
| Pitavastatin | |
| Shown with (ST)(QL)(M) on formulary lines — step therapy required before coverage. | |
| Dilt-Xr | |
| Listed among agents with (ST) — step therapy requirement applies. |
| Device / product | Formulary flags |
|---|---|
| Soliqua Injectable | |
| Requirements & Limits = (ST)(QL)(M) — step therapy must be met prior to coverage. | |
| Assure 3 / Assure 4 test supplies | |
| Assure 3 Tes and Assure 4 Tes shown with 3 (ST)(QL)(M)(AGE) indicating step therapy applies to these entries. | |
| Free Libre2 / Free Libre3 / Freestyle entries | |
| Freestyle/ Freesty Libr and Free Libre kits listed with (ST)(QL)(M)(AGE) flags — step therapy requirement present. |
| Formulary entry | Notes on (ST) |
|---|---|
| Estradiol (select formulations) | |
| Some estradiol entries show (ST) among other flags — step therapy must be satisfied prior to coverage. | |
| Laxatives category | |
| LAXATIVES entries include (ST)(QL)(M) for some products, indicating step therapy requirement for coverage. |
| Category / drug | ST indication |
|---|---|
| Metaxalone Tablet | |
| Requirements & Limits = (ST) — step therapy applies. | |
| Xhance (nasal) / Brimonidine | |
| Xhance Mis shows (ST)(QL)(M) on formulary lines — step therapy required where indicated. | |
| Topiramate and related seizure agents | |
| Some seizure/neurology entries list (ST)(QL)(M) indicating step therapy is required prior to coverage. |
| Listed product | Step therapy (ST) status |
|---|---|
| Nicotine / smoking cessation products | |
| Multiple nicotine products and quit aids display (ST)(QL)(M)(AGE) on formulary lines — step therapy indicated where shown. | |
| Levothyroxin / thyroid products | |
| Levothyroxin listed with (ST)(QL)(M) — step therapy required before coverage for entries that include (ST). | |
| General policy statement | |
| As defined in the formulary, (ST) flags indicate the member must try and fail specified alternatives; coverage is contingent on satisfying step therapy requirements. |
Quantity Limits
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