CurrentSelectHealthPolicy N/A

Prescription drug list (formulary) — utilization management and coverage criteria

Summary of commonly prescribed drugs covered by SelectHealth plans, including tiering, restrictions (preauthorization, step therapy, quantity and age limits), and guidance for members and providers on coverage and costs.

Policy Summary

PayerSelectHealth

PolicyPrescription drug list (formulary) — utilization management and coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required documentation for drugs listed with 'PA' to ensure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RxSelect T4 2026formulary edition/reference

PA, ST, QL, AGEcommon restriction types

monthlyreview frequency

NCapplicable state

partialdocument part

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General coverage and restrictions

Covered when ALL of the following are met:

Formulary coverage overview: Drugs listed on the formulary are covered according to their assigned drug tier, but coverage may be subject to additional requirements such as prior authorization (PA), step therapy (ST), quantity limits (QL), or age limits (AGE).

Member cost-sharing varies by tier and plan; use the member drug search tool or Member Payment Summary for plan-specific cost information.

Coverage with utilization management

Coverage with utilization management — apply when the drug listing includes specific flags:

PA_and_QL_required: When a drug's Requirements / Limits field lists 'PA, QL', prior authorization is required and quantity limits apply as indicated for that product.PA and QL present

Examples in this section include antineoplastic and specialty agents (e.g., VENCLEXTA, TRUQAP, ALECENSA) which are listed with PA, QL.

Drugs that are not on the formulary are not covered except when a medical-necessity exception is approved. To request coverage for a non‑covered medication, the member, prescribing clinician, or pharmacy must submit a Drug Coverage Exception Form available on the plan website; requests are evaluated and granted on a case‑by‑case basis.

Formulary entries include per‑product Requirements / Limits flags (for example, entries such as "PA, QL" appear next to specialty agents). These flags indicate that coverage for the listed strength or presentation may require prior authorization and be subject to quantity limits as noted on the formulary line item.

The formulary lists drug tier assignments and utilization management designations at the drug‑form level (examples in this section include agents with "PA, QL" requirements and drugs assigned to higher tiers when specialty handling applies). Providers should consult each line item for specific tier and restriction details when determining coverage steps.

Prior Authorization, Step Therapy, Quantity Limits — Provider Responsibilities

Prior Authorization

Preauthorization Required

Coverage of certain drugs requires preauthorization. If preauthorization (PA) is listed for a product, providers must obtain approval from SelectHealth before the drug will be covered. Failure to obtain required preauthorization may result in the member being responsible for the full retail cost and claims being denied.

Preauthorization (PA) required for many listed drugs — specialty, oncology, pulmonary hypertension, biologics and others are commonly flagged with PA.
If a drug is marked PA, the prescriber must submit the appropriate prior authorization form and supporting medical documentation (see items below).

Prior Authorization

Prior Authorization for Select Drugs

Select high‑tier and specialty products explicitly require prior authorization. Examples include (but are not limited to) PALFORZIA formulations, ORALAIR, AMJEVITA, OTEZLA, ORENCIA, ENBREL, DIACOMIT, EPIDIOLEX, many antineoplastics (e.g., VENCLEXTA, TRUQAP, ALECENSA, LORBRENA), and numerous biologics and injectables.

Prior authorization applies across categories: allergenic extracts/biologicals, antineoplastics, pulmonary hypertension agents, specialty injectables, and others.
Products listed with PA typically also have quantity limits (QL) and/or age (AGE) restrictions noted in the formulary lines.

Prior Authorization

Prior Authorization for Specialty and Oncology Agents

Many specialty agents and oncology drugs require both prior authorization and adherence to quantity limits. Examples from the formulary include ORENITRAM, TYVASO, CAMZYOS, VOXZOGO, various kinase inhibitors, PARP inhibitors, and assay/test supplies (e.g., select glucose test strips).

Specialty drug PAs often require submission of clinical rationale, prior treatment history, staging/diagnosis, or genetic test results where applicable.
High‑cost specialty agents listed with PA without an approved authorization are subject to denial.

Step Therapy

Step Therapy Enforcement

Step therapy (ST) is enforced for numerous products. Drugs with an ST designation require that specified alternative therapies be tried and documented as ineffective or not tolerated before the requested agent will be approved.

Common categories with ST include certain ADHD agents, some antiseizure agents (e.g., APTIOM, CARBATROL, TEGRETOL, TOPAMAX), topical agents, and select cardiovascular agents (e.g., tadalafil 5 mg tab, ivabradine).
Coverage may be denied until the member has tried and failed the required step(s). Documentation of trials and reasons for failure (efficacy or adverse events) must be provided.

Documentation Required

Quantity Limits and PA/QL Interaction

Quantity limits (QL) are enforced for many formulary products. Prescribers must request prior authorization if the prescribed quantity exceeds the plan limits; otherwise, claims may be denied or reduced.

QL applies broadly — examples include many inhaled agents (ANORO, TRELEGY), insulin and GLP‑1 agents (MOUNJARO, TRULICITY), opioids, and numerous specialty injectables.
When PA and QL are noted together, both the authorization and any supporting documentation must justify quantities above the limit.

Documentation Required

Required Prior Authorization Documentation

Required documentation and supporting materials must accompany PA requests. For complex and specialty therapies, SelectHealth may require medical records, prior treatment history, lab or genetic testing, dosage/titration schedules, and rationale for medical necessity.

Providers must use the SelectHealth prior authorization forms and include clinical notes demonstrating why lower‑cost or step therapies were inappropriate or ineffective.
Antineoplastic and other specialty drug requests commonly require oncology notes, staging, prior regimen details, and supportive labs or test results.

Billing Rule

Utilization Controls and Coverage Exceptions

Follow the plan processes for any entry marked PA, ST, QL, or AGE. Utilization control designations on the formulary indicate the administrative requirements that must be met for coverage.

When a formulary line includes PA/ST/QL/AGE, prescribers must submit the corresponding documentation and complete any step therapy requirements prior to dispensing.
Coverage exception requests for non‑formulary drugs or medical‑necessity exceptions must be submitted using the Drug Coverage Exception Form available on the SelectHealth website.

Note

Pharmacy Services Contact

Contact Pharmacy Services to confirm coverage, verify PA/ST/QL requirements, or get assistance with forms. SelectHealth Pharmacy Services phone: 800‑538‑5038.

Providers should call Pharmacy Services to confirm whether a PA is required, what documentation is necessary, and to verify current formulary restrictions.
Pharmacy Services can also guide on submission routes (fax, portal) and expected turnaround times.

Abbreviations and Terms

Formulary restriction abbreviations

PAPreauthorization

STStep Therapy

QLQuantity Limits

AGEAge limit

PA — definition

PAPrior Authorization — approval required before coverage; prescriber must obtain authorization prior to dispensing to avoid member financial responsibility.

QL — definition

QLQuantity Limit — maximum allowed quantity over a defined period; preauthorization required if medication exceeds plan limits.

AGE — definition

AGEAge-based restriction — age limits applied to specific products or presentations as noted in formulary entries.

PA definition (supporting)

PA (supporting)Coverage of drugs is based on medical necessity; for certain drugs you will need preauthorization or the member may be responsible for full retail price.

QL definition (supporting)

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

ST definition (supporting)

ST (supporting)Step therapy requires trial of specified alternatives before the requested drug is covered; applies to many brand-name agents.

PA definition (supporting)

PA (supporting)Prior authorization — an approval requirement that coverage be approved by the payer before dispensing for many specialty and oncology agents.

QL definition (supporting)

QL (supporting)Quantity limit — restriction on the amount of medication covered within a time period or per fill; many products list QL flags enforced by the plan.

ST definition (supporting)

ST (supporting)Step therapy — requirement to try one or more preferred products before coverage is provided for a specified product; documented trial/failure required.

ST (supporting example)

ST exampleTadalafil 5 mg tab and ivabradine hcl are listed with ST and QL, illustrating step therapy plus quantity limits can apply concurrently.

AGE (supporting example)

AGE exampleORALAIR starter packs and other products include AGE flags; select diuretics and specialty agents also show age-based restrictions.

Step Therapy Requirements (per-product)

Requirement	Policy detail
Step therapy (ST)
Trial and documented failure or intolerance of preferred or alternative therapy is required before coverage is provided for drugs labeled 'ST'.

Documentation required	Notes / examples
Evidence of prior trial and failure or intolerance of required step therapy agents
When 'ST' appears on a formulary line, providers must document prior therapy trials and reasons for failure (e.g., OTREXUP 20 mg listed as ST, QL).

Agent	Requirement
BEVESPI AEROSPHERE
Requirements / Limits = ST, QL — step therapy must be completed per plan before coverage.
INCRUSE ELLIPTA
Requirements / Limits = ST, QL — step therapy required prior to coverage.
FYCOMPA
Requirements / Limits = ST, QL — ST listed for multiple FYCOMPA presentations.
KEPPRA / CARBATROL / TEGRETOL
Selected anticonvulsants listed with ST and QL; plan requires step completion before coverage.

Statin	Requirement
Fluvastatin sodium (including ER)
Requirements / Limits = ST, QL (step therapy and quantity limits apply).
Pitavastatin calcium
Requirements / Limits = ST, QL (step therapy and quantity limits apply).

Statement	Detail
Some drugs are tiered without ST
Certain formulary entries list only tier or QL without 'ST' — no step therapy requirement is indicated for those products in this excerpt.

Examples	Requirement
RYTARY
Requirements / Limits = ST, QL — step therapy required before coverage.
NEUPRO
Requirements / Limits = ST, QL — step therapy required before coverage.
pramipexole ER
Requirements / Limits = ST, QL — step therapy required before coverage.
ONGENTYS
Requirements / Limits = ST, QL — step therapy required before coverage.

Product	Requirement
Tadalafil 5 mg tablet
Requirements / Limits = ST, QL — step therapy and quantity limits apply.
Ivabradine HCl
Requirements / Limits = ST, QL — step therapy and quantity limits apply.

Topical agent	Requirement
Fluocinonide 0.1% cream
Requirements / Limits = ST, QL — step therapy required before coverage.
Pimecrolimus
Requirements / Limits = ST — step therapy indicated for certain topical immunomodulators.
Ivermectin 1% cream
Requirements / Limits = ST, QL — step therapy and quantity limits apply.
Triamcinolone aerosol (0.147 mg/g)
Requirements / Limits = ST — step therapy indicated for some triamcinolone aerosol presentations.

Risedronate formulation	Requirement
Risedronate sodium (5 mg, 30 mg; other strengths)
Some risedronate formulations flagged with ST, QL — step therapy must be met before coverage for those presentations.

Agent	Requirement
TRULANCE
Requirements / Limits = PA, QL (listing indicates utilization controls; other entries note ST where applicable).
Alosetron HCl
Requirements / Limits = ST, QL — step therapy and quantity limits indicated for alosetron.

Quantity Limits (per-product)

Quantity limits — general note

Formulary-wide noteMultiple products across the formulary have QL flags; see individual drug lines for specific quantity limits.

Multiple products — QL applies where indicated

Per-drug QL indicatorsQuantity limits (QL) apply where indicated next to each product entry in the formulary listing.

Various listed products — QL applied

Various products with QLSeveral drugs across therapeutic classes are annotated with QL in their Requirements / Limits fields; refer to drug_name entries for details.

MOUNJARO — utilization flags

MOUNJARORequirements / Limits = PA, QL

EXJADE — utilization flags

EXJADERequirements / Limits = PA, QL

posaconazole 40 mg/ml suspension — flags

posaconazole 40 mg/ml suspensionRequirements / Limits = PA, QL

VENCLEXTA STARTING PACK — QL

VENCLEXTA STARTING PACKRequirements / Limits = PA, QL (starting pack specifically noted as subject to QL)

abiraterone acetate 250 mg tab — QL

abiraterone acetate 250 mg tabRequirements / Limits = QL

leucovorin calcium — QL

leucovorin calciumRequirements / Limits = QL

risperidone — QL

risperidone (multiple formulations)Requirements / Limits = QL

ENTRESTO — QL

ENTRESTO (sacubitril-valsartan)Requirements / Limits = QL

ORENITRAM / TYVASO / VENTAVIS — PA, QL

ORENITRAM and TYVASO/VENTAVISRequirements / Limits = PA, QL

Multiple listed products — 'Requirements / Limits = QL' flags

Multiple entries with QL flagNumerous topical, test-strip and other product lines show 'Requirements / Limits = QL' — see each listing for specifics.

Glucose test strips — per-formulary QL

Glucose test stripsMultiple glucose test strip products (FORA, FORACARE, ACCU-CHEK, etc.) are listed with PA and/or QL; subject to formulary QL.

CREON — QL

CREONRequirements / Limits = QL

GENOTROPIN and growth hormones — PA, QL

GENOTROPIN and other growth hormonesRequirements / Limits = PA, QL

Multiple listed lines — QL

Multiple listed specialty linesSeveral specialty drug lines throughout the formulary carry QL flags; review each drug-form entry for the exact limit.

40 mg	valsartan (40 mg tab) — listed strengths
80 mg	valsartan (80 mg tab) — listed strengths
160 mg	valsartan (160 mg tab) — listed strengths
320 mg	valsartan (320 mg tab) — listed strengths

OpenPayer

Prescription drug list (formulary) — utilization management and coverage criteria

Formulary Coverage and Restrictions

Coding, NDCs and Strengths

Prior Authorization, Step Therapy, Quantity Limits — Provider Responsibilities

Formulary Structure and Purpose

Abbreviations and Terms

Initial Therapy and Step Rules

Step Therapy Requirements (per-product)

Quantity Limits (per-product)

Policy Revision History