CurrentSelectHealthPolicy N/A

SelectHealth Prescription Drug List (Formulary) — summary of commonly prescribed drugs

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.

Policy Summary

PayerSelectHealth

PolicySelectHealth Prescription Drug List (Formulary) — summary of commonly prescribed drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain required prior authorization, document step therapy trials, and provide clinical rationale when requesting exceptions or approvals to ensure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug classes and individual drugs listed

tiers 1-5formulary tiers used in document

PA, ST, QL, AGE, Mcommon coverage controls present

~300line items listed in this part (approximate)

several

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specialty/high-tier (tier 5) agents listed

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.

Coverage thresholds and limits

Quantity limitsPlan-specific limits apply; preauthorization required if medication exceeds plan limits.

Maintenance supply90-day supply possible for drugs designated (M).

Preauthorization when exceeding limitsIf prescribed quantity exceeds QL, preauthorization is required and providers should include rationale and clinical necessity in the request.

Formulary Tiers and Requirement Codes

Coverage control abbreviations used in formularymixed

PA	Preauthorization required
ST	Step Therapy required
QL	Quantity Limits
AGE	Age limit applies
M	Maintenance drug (may allow 90-day supply)

Formulary tiers referencedmixed

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)

Requirement code legend appearing in itemsinternal

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)

Formulary tiers used in this excerptinternal

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

Formulary drug entries and requirement flagsmixed

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

Example drug entries (excerpted from this part)NDC-like/drug-name

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)

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Required Actions & Documentation for Providers

Prior Authorization

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.

Step Therapy

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.

Documentation Required

Submit Drug Coverage Exception requests for non-covered drugs

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

Definitions

Formulary/Drug ListA summary of commonly prescribed medications the plan covers; not exhaustive.

Preauthorization (PA)Plan approval required before coverage is provided for certain medications. Coverage of drugs is based on medical necessity; for certain drugs you will need preauthorization or you will be responsible for full retail price.

Step Therapy (ST)A requirement to try specified alternatives before the requested drug is covered. Drugs that require step therapy are covered only after an alternative therapy has been tried and failed.

Quantity Limit (QL)A plan-imposed limit on the amount of medication covered in a time period. Quantity limitations apply to certain drugs; preauthorization is required if the medication exceeds the plan limits.

Age limit (AGE)Minimum or maximum age condition for coverage of the drug; a specified age requirement must be met for coverage.

Maintenance (M)

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.

Policy Summary

PayerSelectHealth

PolicySelectHealth Prescription Drug List (Formulary) — summary of commonly prescribed drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain required prior authorization, document step therapy trials, and provide clinical rationale when requesting exceptions or approvals to ensure coverage.

SourceLink

On This Page

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.

Prior Authorization

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

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.

Documentation Required

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

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.

Documentation Required

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

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)

Documentation Required

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

Prior Authorization

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

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

Prior Authorization

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

Designation that may permit a 90-day supply for chronic medications; maintenance drugs may allow a 90-day supply.

Tier 1-5Formulary tiers indicating relative preferred status and member cost-sharing; lower tiers generally cost less and higher tiers (Tier 5) are specialty/high-cost with additional management.

SelectHealth Prescription Drug List (Formulary) — summary of commonly prescribed drugs

Formulary Coverage Controls & Exceptions

Formulary Tiers and Requirement Codes

Required Actions & Documentation for Providers

Clinical & Administrative Overview

Key Terms & Flags

Policy Dates & Changes

Other Policies to Review