SelectHealth Prescription Drug List (Formulary) — summary of commonly prescribed drugs
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This document is a summary 'drug list' (formulary) describing commonly prescribed medications, their formulary tier, and plan-level controls (preauthorization, step therapy, quantity limits, age limits, maintenance/90-day). It is intended for SelectHealth members, providers, pharmacies, and internal billing/clinical operations.
No material clinical or coverage changes in this revision.
Formulary Coverage Controls & Exceptions
Coverage controls and exception process
Coverage for drugs is determined by medical necessity and plan rules; some drugs require preauthorization, step therapy, quantity limits, or have age limits. Exceptions may be requested.
ALL of the following
- A drug is covered according to its formulary tier and any plan-specific controls (PA, ST, QL, AGE, M).
If drug has special controls
- Preauthorization (PA) required for certain drugs
- Step therapy (ST) required for specified drugs (often brand-name drugs)
- Quantity limits (QL) apply to certain drugs; PA required if exceed plan limits
- Age limits (AGE) — minimum or maximum age may be required
- Maintenance (M) — eligible drugs may allow 90-day supply
- For drugs not covered on the formulary, a Drug Coverage Exception Form can be submitted by member, physician, or pharmacy and will be evaluated case-by-case for medical necessity.
Formulary Tiers and Requirement Codes
| PA | Preauthorization required |
| ST | Step Therapy required |
| QL | Quantity Limits |
| AGE | Age limit applies |
| M | Maintenance drug (may allow 90-day supply) |
| Tier 1 | Lowest cost sharing tier (generics/ preferred) |
| Tier 2 | Preferred brand / mid-tier |
| Tier 3 | Non-preferred brand / higher cost |
| Tier 4 | Specialty/brand - higher cost |
| Tier 5 | Highest tier (specialty/high-cost) |
| PA | Prior Authorization required |
| QL | Quantity Limit applies |
| M | Medical necessity or member-specific medical requirement |
| ST | Step therapy required |
| AGE | Age limit applies (age-specific criteria) |
| 1 | Tier 1 (preferred generic/low cost) |
| 2 | Tier 2 |
| 3 | Tier 3 |
| 4 | Tier 4 (non-preferred/brand) |
| 5 | Tier 5 (specialty/high cost) |
| DIABETES - TESTING AND SUPPLIES | Category/tier label used for diabetes supplies |
| PA | Prior Authorization required |
| QL | Quantity Limit applies |
| ST | Step Therapy applies |
| M | Medical necessity criteria applies / medical management |
| AGE | Age limit applies |
| Tier 1 | Preferred/low-cost tier |
| Tier 2 | Standard tier |
| Tier 3 | Non-preferred/higher tier |
| Tier 4 | Specialty/high cost tier |
| Tier 5 | Highest specialty tier / restricted |
| Quetiapine ER | Drug Tier = 1; Requirements & Limits = (M) |
| Risperidone | Drug Tier = 1; Requirements & Limits = (QL)(M) |
| Suprep Bowel Solution (Rivastigmine listed under same) | Drug Tier = 3; Requirements & Limits = . |
| Savella Tablet | LAXATIVES category; Drug Tier = 3; Requirements & Limits = (ST)(QL)(M) |
| Tranylcyprom Tablet | LOCAL ANESTHETICS - TOPICAL; Requirements & Limits = (M) |
| Lidocaine | Requirements & Limits = (QL)(M) |
| Abilify Asim Injectable | Drug Tier = 5; Requirements & Limits = (QL)(M) |
| Asenapine Sub | Drug Tier = 3; Requirements & Limits = (ST)(QL)(M) |
| Asenapine Sub (Javygtor) | Drug Tier = 5; Requirements & Limits = (PA)(QL)(M) |
| Bupropion Tablet | Drug Tier = 1; Requirements & Limits = (M) |
Required Actions & Documentation for Providers
Obtain preauthorization when required
Providers must request preauthorization for drugs marked (PA) before dispensing or administration to ensure coverage. Failure to obtain required preauthorization may result in the member being responsible for the drug's full retail cost.
Follow step therapy requirements
For drugs marked (ST), coverage is allowed only after trial and failure or intolerance of specified alternative therapies; document prior therapies and clinical outcomes when requesting coverage.
Submit Drug Coverage Exception requests for non-covered drugs
If a drug is not on the formulary, the member, physician, or pharmacy may submit the Drug Coverage Exception Form; requests are evaluated case-by-case based on medical necessity.
Quantity limit exceedance
If the prescribed quantity exceeds the formulary's QL, submit a preauthorization request that includes the clinical rationale and documentation of medical necessity to support coverage.
Prior Authorization required for many items
Items marked with (PA) require prior authorization before coverage; providers must submit PA requests following SelectHealth procedures to obtain approval prior to dispensing or administration.
Quantity limits and medical necessity
For items flagged (QL) and (M), provide supporting clinical documentation demonstrating medical necessity and the dosing/quantity requested when submitting coverage requests or appeals.
Step therapy required for some products
Items marked (ST) require step therapy; document prior trials of preferred agents and the patient's intolerance or failure of those therapies when requesting coverage for the non-preferred product.
Age limits
Items with (AGE) have age-based coverage restrictions; confirm the patient's age meets the policy criteria before prescribing and include age information when requesting coverage.
Prior authorization required for specific high-tier or specialty drugs
Providers must obtain prior authorization when the drug entry includes (PA); this commonly applies to many Tier 5 specialty, oncology, rare-disease, or high-cost injectable agents listed in the formulary.
- Example PA-marked drugs: Ibrance, Lynparza, Venclexta, Tymlos, Asenapine Sub (Javygtor)
Document medical necessity when (M) flag present
When a drug entry includes (M), prescribers should include supporting clinical documentation consistent with medical necessity to support coverage decisions.
- Example M-marked drugs: Quetiapine ER, Lidocaine, Bimatoprost, Prednisone
Quantity limits
Entries flagged (QL) are subject to quantity limits; ensure dosing and days' supply match the formulary QL prior to claim submission to avoid claim denials.
- Example QL-marked drugs: Risperidone, Citalopram, Hydroxyurea, Naloxone HCl
Step therapy required for certain agents
Drugs marked (ST) require failure or intolerance to preferred agents before coverage for the non-preferred agent; document prior therapies, trial durations, and outcomes when requesting coverage.
- Example ST-marked drugs: Savella Tablet, Clobazam (where marked ST), Donepezil
Age limits enforcement
Entries with (AGE) require age-based eligibility; include the patient's date of birth or age on the prior authorization request or prescription to verify coverage.
- Example AGE-marked items: Chantix, Gardasil 9, Pneumovax 23
Clinical & Administrative Overview
This document is a high-level summary of the SelectHealth prescription drug list (formulary) and covers commonly prescribed medications, their formulary tier, and plan-level coverage controls. It is not an exhaustive listing of every covered product; the full, searchable formulary with complete drug listings and member-specific cost-sharing is available through a member's online account (drug search tool) or by contacting Pharmacy Services for pricing and coverage details. Providers and members may also request coverage information or assistance from Pharmacy Services by phone.
SelectHealth maintains an active clinical review process: the formulary contents are reviewed each month by a team of doctors and pharmacists who evaluate clinical efficacy, safety, and cost effectiveness and may add or remove drugs from the list. For drugs not listed on the formulary, members, prescribers, or pharmacies may submit a Drug Coverage Exception Form for case‑by‑case medical necessity review.
Key Terms & Flags
Policy Dates & Changes
Document effective date: 2026-01-01. This version does not list entries for last review or next review dates.
There are no recorded changes noted for this excerpt (changes list is empty). For updates or historical changes, see the header changes list component in the document or the formulary change log accessible via the member portal or Pharmacy Services.
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