CurrentSelectHealthPolicy N/A

Prescription drug formulary — utilization management and coverage flags

This document summarizes the insurer's prescription drug formulary, including tiering, coverage rules (preauthorization, step therapy, quantity limits, age limits), and examples of drug classes and specific drugs with requirements; it affects SelectHealth members, providers, and pharmacies.

Policy Summary

PayerSelectHealth

PolicyPrescription drug formulary — utilization management and coverage flags

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line is marked PA and ensure specialty pharmacy enrollment for SUM7-designated products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyformulary review frequency

PA, ST, QL, AGEcoverage controls described

SUM7specialty pharmacy lock referenced

COstate-specific formulary referenced

800-538-5038Pharmacy Services contact

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Formulary Coverage & Utilization Management

Formulary coverage with utilization management

Drugs in this formulary extract are covered subject to listed utilization management flags when present.

Formulary coverage rules: Coverage depends on drug tier with additional requirements when Requirements / Limits lists PA, QL, or SUM7

Specific clinical criteria for prior authorization, step therapy, quantity limits, or specialty pharmacy lock are not provided in this extract; refer to individual drug line for exact requirements and documentation needs.

Drugs that are listed as not covered may still be considered for payment if the member, the prescribing physician, or the dispensing pharmacy submits a Drug Coverage Exception Form requesting coverage based on medical necessity. Requests are reviewed and decided on a case‑by‑case basis; the exception process is the route for coverage of non‑covered products when medical necessity is documented.

The formulary lines in this extract do not include explicit medical‑necessity or exclusion criteria tied to individual products. Instead, each entry is presented with a Drug Tier and any associated Requirements / Limits flags (for example PA, QL, ST, SUM7). Specific clinical criteria that would define approval under a prior authorization or exclusion are not provided in these sections.

Many formulary lines — including topical dermatologic agents shown here — are listed only with a tier assignment and any flags for utilization management (e.g., QL, ST). There are no standalone clinical exclusion statements in these listings; clinical applicability and any detailed exclusion logic would be determined through the plan’s authorization process where applicable.

Formulary Product & Code Listings

Formulary drug entries (no billing codes present)mixed

No codes listed

Formulary product descriptorsmixed

valsartan (40 mg tab, 80 mg tab, 160 mg tab, 320 mg tab)

valsartan formulations listed with tiers and requirements

Antineoplastics - mTOR kinase inhibitorsmixed

everolimus (2 mg tab sol, 3 mg tab sol, 5 mg tab sol)	everolimus (2 mg/3 mg/5 mg tab sol) listed with PA, QL, SUM7
everolimus (2.5 mg tab, 7.5 mg tab, 10 mg tab)	everolimus (2.5 mg/7.5 mg/10 mg tab) listed with PA, QL, SUM7

Antiretrovirals - examplesmixed

SUNLENCA (4 X 300 MG TAB THPK, 5 X 300 MG TAB THPK)	Drug Tier = 5; Requirements / Limits = QL
SUNLENCA 463.5 MG/1.5ML SOLUTION	Drug Tier = 5; Requirements / Limits = QL
maraviroc	Drug Tier = 3; Requirements / Limits = QL
RUKOBIA	Drug Tier = 6; Requirements / Limits = PA, QL

Antiretrovirals - integrase/protease examplesmixed

ISENTRESS (25 MG CHEW TAB, 100 MG CHEW TAB, 100 MG PACKET)	Drug Tier = 5; Requirements / Limits = QL
ISENTRESS 400 MG TAB	Drug Tier = 6; Requirements / Limits = QL
TIVICAY 50 MG TAB	Drug Tier = 6; Requirements / Limits = QL
darunavir	Drug Tier = 3; Requirements / Limits = QL

Hepatitis & CMV agentsmixed

PREVYMIS (240 MG TAB, 480 MG TAB)	Drug Tier = 6; Requirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Lock)
valganciclovir hcl 450 mg tab	Drug Tier = 6; Requirements / Limits = QL
HARVONI 33.75-150 MG PACKET	Drug Tier = 5; Requirements / Limits = ST, QL, SUM7 (Specialty Pharmacy Site of Care Lock)
MAVYRET 100-40 MG TAB	Drug Tier = 4; Requirements / Limits = QL, SUM7 (Specialty Pharmacy Site of Care Lock)

Pulmonary hypertension agentsmixed

ORENITRAM (multiple strengths and monthly kits)	Drug Tier = 6; Requirements / Limits = PA, QL
TYVASO (kits, maintenance, titration, refill, starter)	Drug Tier = 6; Requirements / Limits = PA, QL
ADEMPAS	Drug Tier = 6; Requirements / Limits = PA, QL
bosentan (62.5 mg tab, 125 mg tab)	Drug Tier = 6; Requirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Lock)

Selective PDE5 inhibitors, sinus node inhibitor, cephalosporinsmixed

tadalafil (2.5 mg tab, 10 mg tab, 20 mg tab)	Drug Tier = 4; Requirements / Limits = PA, QL
tadalafil 5 mg tab	Drug Tier = 4; Requirements / Limits = ST, QL
ivabradine hcl	Drug Tier = 4; Requirements / Limits = ST, QL
cephalexin (multiple oral formulations)	Drug Tier = 2; Requirements / Limits = none listed

Product list (no billing codes provided)mixed

No codes listed

Authorization, Documentation & Dispensing Requirements

Prior Authorization

Preauthorization Required

Prior authorization (PA) is required for many drugs listed on the formulary. Without an approved PA the claim may be denied and the member may be responsible for full cost. Providers should submit a Drug Coverage Exception Form for noncovered drugs when appealing based on medical necessity.

PA applies to many specialty, oncology, biologic, antiviral, and high-tier agents (examples below).
Noncovered drug exception requests: Drug Coverage Exception Form available on SelectHealth website.

Prior Authorization

PA Required for OTEZLA Products

Select specialty oral agents OTEZLA and OTEZLA XR require prior authorization and are specialty-pharmacy locked (SUM7). Quantity limits also apply; provide clinical documentation supporting medical necessity and prior treatment history.

OTEZLA (20 mg, 30 mg) and OTEZLA XR = PA, QL, SUM7 (Specialty Pharmacy Lock).
Include prior therapy trials and clinical rationale when requesting PA.

Key Flags & Acronyms

Authorization flags — key mapping

PAPrior Authorization — approval required before the payer will cover the medication; lack of PA may result in denial and member responsibility for full retail price.

STStep Therapy — coverage requires trial and failure (or intolerance) of specified alternative therapy before the listed agent is covered.

QLQuantity Limits — plan-imposed maximum quantity or frequency for a product; exceeding limits typically requires preauthorization.

SUM7 (Specialty Pharmacy Lock) definition and implications

SUM7 (Specialty Pharmacy Lock)A formulary designation indicating the product must be dispensed via the payer's designated specialty pharmacy program (specialty-site or site-of-care lock); many specialty biologics and oncology agents are marked SUM7.

Implication — Dispensing

Step Therapy Requirements

Requirement	Description
Step therapy (ST)
Drugs marked 'ST' are covered only after trial and failure (or intolerance) of specified alternative therapy as defined by the formulary; step therapy most often applies to brand‑name drugs.

Product / class	Formulary flags / note
Extended‑release and high‑strength opioid formulations (examples in opioid listings)
Some ER opioid products and select opioid formulations are annotated 'ST' (step therapy) and may require prior steps before coverage; certain high‑concentration oxycodone formulation lists PA as well.

Product	Formulary flags / note
Budesonide (2 mg foam, 2 mg/act foam)
Requirements / Limits = ST, QL, SUM7 (Specialty Pharmacy Lock) — budesonide foam is specifically listed with ST in the formulary.

Class / example	Formulary management
Cyclin‑dependent kinase (CDK) inhibitors (e.g., IBRANCE, KISQALI, VERZENIO)
These agents are managed with utilization controls including PA, QL, and SUM7 (Specialty Pharmacy Lock); specific step therapy details are not provided in the extract.

Policy	Enforcement
Step therapy requirement
Step therapy must be met per the formulary — drugs marked 'ST' will require trial and failure of specified alternatives before coverage is approved.

Product / class	Formulary flags / note
Hepatitis C combination agents (e.g., HARVONI packets)
HARVONI packets are listed with ST, QL, and SUM7 (specialty/site‑of‑care lock); some hepatitis agents carry ST requirements. Tadalafil 5 mg and ivabradine are cardiovascular examples flagged ST.

Topical / acne product	Formulary flags / note
Clindamycin phosphate 1% foam; dapsone 5% gel; adapalene formulations; tretinoin microsphere (acne products)
Several topical and acne therapies are identified with ST (step therapy) and in some cases AGE restrictions prior to coverage; examples include clindamycin foam and dapsone gel marked ST.

Topical product	Formulary flags / note
Fluocinonide 0.1% cream; triamcinolone acetonide aerosol; ivermectin 1% cream
These topical agents are marked 'ST' (step therapy) and also show QL in the formulary (e.g., fluocinonide 0.1% cream = ST, QL; triamcinolone aerosol = ST, QL; ivermectin 1% cream = ST, QL).

Product	Formulary flags / note
Risedronate sodium (some formulations; e.g., 5 mg tab, 30 mg tab)
Requirements / Limits include ST and QL for certain risedronate formulations — the formulary notes 'ST' for some risedronate entries.

Device / product	Formulary flags / note
Dexcom G6/G7 sensors, transmitters, receivers
Multiple Dexcom items (G6, G7 sensors/receivers/transmitters) are listed with ST, QL, and AGE flags; step therapy (ST) is required for certain Dexcom products per the formulary.

Quantity Limits & Unit Restrictions

Plan-specified quantity limits summary (opioids & specialty drugs)

Various opioids and specialty drugs — summaryThe formulary applies plan‑specified quantity limits and other flags (PA, ST, SUM7) to many opioids and specialty agents; exceeding QL or missing PA/ST may result in denial.

ExamplesHigh‑concentration opioid formulations (e.g., oxycodone 100 mg/5 ml) and extended‑release morphine products are shown with ST and/or QL in Requirements / Limits.

Provider actionConfirm QL and PA/ST requirements for opioid and specialty drug prescriptions before dispensing to avoid coverage denial.

Various aspirin products — QL entries

Aspirin products — QL entriesMultiple adult and pediatric aspirin presentations (including 81 mg chewable, EC formulations and branded generics) are listed with Quantity Limits and Age restrictions in Requirements / Limits.

Specialty Pharmacy & Infusion/Dispensing Requirements

Note

Formulary Organization & Scope

This formulary groups medications by therapeutic class and assigns a drug tier to each product. Entries may include utilization management flags — commonly PA (prior authorization), ST (step therapy), QL (quantity limits), and SUM7 (Specialty Pharmacy Lock) — that indicate additional administrative requirements before coverage. A clinical review team evaluates efficacy, safety, and cost‑effectiveness on a regular basis (monthly) and applies these flags to guide coverage and routing (including specialty pharmacy/site‑of‑care requirements) for high‑cost and specialty agents.

Policy Summary

PayerSelectHealth

PolicyPrescription drug formulary — utilization management and coverage flags

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line is marked PA and ensure specialty pharmacy enrollment for SUM7-designated products.

SourceLink

On This Page

Denial Risk

PA for Select High‑Strength Opioids

Some high-strength opioid formulations (including concentrated oxycodone 100 mg/5 mL) require prior authorization. Quantity limits and step-therapy rules may also apply to extended‑release opioid products.

Oxycodone HCl 100 mg/5 mL concentrate = PA.
ER opioids (various morphine and oxymorphone ER formulations) may be subject to ST and QL.

Prior Authorization

Prior Authorization for Listed Specialty Agents

Many specialty agents (including numerous oncology, antiviral, and biologic products) require prior authorization and may be specialty‑pharmacy routed (SUM7). Providers must route prescriptions to the designated specialty pharmacy when SUM7 is indicated.

Examples: NUBEQA, XTANDI, ICLUSIG, ROZLYTREK, LYNPARZA, IBRANCE — many require PA, QL, SUM7.
Antineoplastics and targeted therapies often have PA + QL + SUM7 requirements; include regimen and dosing details in the PA request.

Prior Authorization

PA Required for Many High‑Tier Agents

Numerous high‑tier agents across therapeutic classes require prior authorization and may have quantity limits or specialty‑pharmacy site‑of‑care locks. Requests that do not meet documented criteria may be denied.

High‑tier oncology and targeted agents (e.g., ROZLYTREK, BRUKINSA, everolimus formulations) = PA, QL, and frequently SUM7.
Provide diagnosis, prior therapies, and planned dosing to support PA.

Prior Authorization

PA Required for Select Products

Selective products across the formulary are flagged for prior authorization and will require supporting documentation at submission. Examples include XIFAXAN, TEZSPIRE, FASENRA and other specialty respiratory/biologic agents.

XIFAXAN = PA.
TEZSPIRE = PA, QL, SUM7 (Specialty Pharmacy Lock).

Prior Authorization

PA Required for Selected Items

Certain selected items (topical specialty products, diagnostics and glucose meters/strips) are subject to PA and quantity limits. Claims may be denied if PA/QL criteria are not satisfied.

Topical specialty items and some diagnostic tests (specific products listed in formulary) = PA and/or QL.
Blood glucose test strips and some meters require PA and adhere to plan QLs.

Prior Authorization

PA + SUM7 for Selected Specialty Drugs

Some specialty drugs require both prior authorization and dispensing through the plan's designated specialty pharmacy (SUM7). Prescribers must indicate specialty pharmacy routing on the PA and send required documentation to that vendor.

Examples: many biologics (AMJEVITA, HADLIMA), ENBREL products, and multiple JAK inhibitors = PA, QL, SUM7.
SUM7 = specialty pharmacy lock; claims routed elsewhere may be denied.

Prior Authorization

PA Required for Select CGM Devices

Continuous glucose monitoring (CGM) devices, sensors, transmitters, and receivers are often subject to prior authorization, step‑therapy, quantity limits and age restrictions. Devices lacking required authorization may be denied.

Examples: Dexcom G6/G7 components and FreeStyle Libre readers/sensors = ST, QL, AGE (and some items PA).
Guardian and Enlite sensors/transmitters = PA, QL, AGE for certain models.

Billing Rule

Quantity Limits Enforcement

Quantity limits (QL) are enforced for many drugs. If the requested quantity exceeds plan limits, prior authorization is required; otherwise the claim may be denied or paid at the member's expense.

QL commonly applies to opioids, inhalers, topical agents, and many chronic therapy drugs.
When requesting PA for quantities over limits, include rationale and dosing schedule.

Step Therapy

Step Therapy Requirements

Step therapy (ST) applies to specific drug classes and formulations; coverage is typically allowed only after documented trial and failure of preferred alternatives. This includes some ER opioid formulations, topical acne treatments, and select CGM products.

Examples: select ER opioids and morphine ER products = ST, QL.
Topical acne agents (clindamycin, dapsone, tretinoin microsphere) = ST.
CGM devices/readers (Dexcom, FreeStyle Libre) may have ST requirements.

Documentation Required

Supporting Documentation for PA

When PA is required, providers must submit supporting clinical documentation (diagnosis, prior therapies, lab results, treatment history) to demonstrate medical necessity. Insufficient documentation may delay or result in denial.

Include prior treatment trials, contraindications/intolerances, and relevant labs or imaging when applicable.
For oncology/antiviral/biologic agents, provide regimen details, dose, and duration.

Documentation Required

Specialty Pharmacy Documentation & SUM7

Specialty pharmacy‑routed drugs (SUM7) require prescriptions to be dispensed by the designated specialty vendor and may need additional site‑of‑care documentation. Ensure specialty pharmacy routing is noted on the PA and prescription.

SUM7 indicates dispensing via designated specialty pharmacy or site‑of‑care lock; failure to route appropriately can cause denial.
Provide documentation for infusion/site‑of‑care where required (e.g., some hepatitis C agents with SUM7).

Denial Risk

Documentation & Denial Risk for PA/QL/SUM7 Items

Drugs flagged with PA and/or QL carry a higher denial risk if criteria are not met. For biologics and systemic specialty agents, prior authorization plus specialty‑pharmacy handling and quantity limits are common — include all requested documentation to avoid denial.

Biologics for psoriasis and other systemic conditions (e.g., BIMZELX, COSENTYX, SKYRIZI) = PA, QL, SUM7 and often ST.
Failure to obtain PA or to route through SUM7 may lead to claim denial.

Documentation Required

Specialty / Site‑of‑Care Documentation Indications

Specialty/site‑of‑care documentation may be required for agents with SUM7 or site locks (for example, certain hepatitis C regimens, oncology infusions, growth hormones). Include facility/provider details when requesting PA for site‑of‑care locked products.

Hepatitis C agents (HARVONI, MAVYRET) often require ST, QL, and SUM7 (site‑of‑care lock).
Growth hormones and certain genetic therapies require PA and specialty pharmacy/site‑of‑care documentation.

Denial Risk

Prior Authorization Triggers and Denial Risk

Denial triggers: drugs marked PA, ST, QL, SUM7, or AGE in the formulary will be subject to the associated requirements. Claims submitted without meeting these requirements risk denial or administrative delay.

Review formulary flags (PA/ST/QL/SUM7/AGE) prior to prescribing and dispensing.
If PA is required, obtain approval before dispensing to avoid member balance billing.

Drugs marked SUM7 must be filled through the designated specialty pharmacy channel; dispensing outside that channel may be restricted or denied.

Implication — DocumentationSpecialty pharmacy enrollment and associated prior authorization documentation are expected for SUM7‑flagged products.

QL — Quantity Limits

DefinitionQuantity Limits (QL) — payer-defined maximum allowable quantity or frequency for a medication or supply within a specified time period.

EnforcementClaims exceeding QL require prior authorization; without approval the claim may be denied.

ExamplesCommon QL applications include opioids, inhaled corticosteroids, topical high-potency corticosteroids, diagnostic test strips, lancets, and CGM components.

PA — Prior Authorization

DefinitionPrior Authorization (PA) — payer approval required before the medication will be covered; lack of an approved PA may result in denial and member responsibility for full cost.

Expected documentationWhen PA is required, clinical rationale and documentation of medical necessity and member eligibility should be submitted with the request.

Common targetsMany specialty, oncology, antiviral, and high‑cost agents (e.g., OTEZLA, PREVYMIS, select antineoplastics) are listed with PA requirements.

ST — Step Therapy

DefinitionStep Therapy (ST) — a coverage requirement that a patient must try and fail specified alternative therapy(ies) before the requested agent is covered.

Typical applicationMost often applied to brand‑name drugs and select classes (examples include some NSAIDs, ER opioids, systemic biologics and certain topical/acne agents).

OutcomeCoverage is contingent on evidence of trial/failure or intolerance of prior therapy per the formulary's step criteria.

SUM7 (Specialty Pharmacy Lock) — alternate reference

SUM7 (Specialty Pharmacy Lock) — alternate referenceSUM7 indicates specialty pharmacy/site‑of‑care lock for certain agents; examples in this formulary include oncology and specialty biologics that require specialty-channel dispensing.

Related requirementSUM7 is frequently paired with PA and QL for specialty products, signaling both distribution and authorization controls.

Examples in listEntries such as NUBEQA, XTANDI, LYNPARZA and selected antineoplastics show SUM7 in Requirements / Limits.

PA — cross-reference definition

PA — cross-reference definitionPrior Authorization requires payer approval before coverage; drugs flagged 'PA' (e.g., many antineoplastics, PREVYMIS, XPHOZAH) may be denied without an approved PA.

Denial riskRequests without required PA are at risk of denial and member financial responsibility per the formulary language.

Documentation notePrescribers must submit supporting clinical documentation when seeking PA for specialty or high‑cost drugs.

QL — cross-reference definition

QL — cross-reference definitionQuantity Limit indicates a payer limit on amount or frequency covered; many device supplies and medications (e.g., glucose test strips, lancets, inhaled products) carry QL flags.

Authorization tie‑inExceeding QL commonly triggers a requirement for PA; claims over QL may be denied if not authorized.

Examples in formularyLancets, many blood glucose test strips/meters, inhaled corticosteroid inhalers and topical high‑potency corticosteroids are shown with QL entries.

SUM7 — definition repeated

SUM7 — repeated definition for section coverageSUM7 marks products that must be dispensed via the designated specialty pharmacy program; specialty products shown with SUM7 require enrollment and routing through that channel.

Associated flagsSUM7 often appears with PA and QL on specialty biologics and specialty therapies in the formulary.

Operational effectPharmacies must use the specialty pharmacy channel specified by the payer for SUM7 items to avoid claim rejection.

PA — definition repeated

PA — repeated definition for section coveragePrior Authorization indicates coverage requires approval before dispensing; drugs listed with 'PA' require an authorization to avoid denial.

Clinical supportAuthorization requests should include medical necessity documentation as indicated by the formulary entries.

Common classesPA is commonly applied to specialty, oncology, antiviral, and select high‑cost medications in this formulary extract.

QL — definition repeated

QL — repeated definition for section coverageQuantity Limit indicates the maximum quantity or frequency the plan will cover for an item; QL is enforced across drugs and supplies including test strips, lancets, inhalers, and topical products.

Effect on claimsClaims exceeding QL require PA and may be denied if not authorized.

ExamplesMany blood glucose test strips/meters and lancet products in the formulary show Requirements / Limits = PA, QL or QL.

SUM7 — additional reference

SUM7 — additional referenceSUM7 is used throughout specialty and oncology sections to indicate specialty pharmacy/site‑of‑care lock; products like GENOTROPIN, LONSURF and multiple antineoplastics include SUM7.

Implication for site of careSUM7 may indicate site‑of‑care dispensing rules (infusion centers or specialty pharmacy) depending on the product.

Pairing with PA/QLSUM7 frequently appears alongside PA and QL, denoting both distribution and utilization controls.

ST — step therapy indicator reference

ST — step therapy indicator referenceST marks products that require trial and failure of specified alternatives before coverage (examples: some NSAIDs, ER opioids, topical acne and certain biologics).

Practical effectPrescribers must document prior trials or rationale for bypassing steps when requesting coverage for ST‑flagged agents.

Device applicationSome CGM devices and sensors are also flagged ST, indicating step requirements for devices in addition to drugs.

PA — prior authorization indicator reference

PA — prior authorization indicator referencePA indicates payer authorization is required prior to coverage; many specialty, oncology and device items in this formulary carry the PA indicator.

Provider actionSubmit PA requests with supporting clinical documentation per the formulary's expectations to avoid denial.

ExamplesListed PA items include oncology agents, biologics (e.g., COSENTYX), PREVYMIS, XPHOZAH, and multiple CGM sensors.

QL — quantity limit indicator reference

QL — quantity limit indicator referenceQL flags indicate the plan applies quantity limits to the product; many medications and supply items display QL in Requirements / Limits.

Operational impactPharmacies and prescribers should verify QL values and seek PA when required for quantities beyond the limit.

Common itemsHigh‑use products with QL include topical high‑potency steroids, budesonide formulations, lancets, and blood glucose test strips.

PA — topical/device region reference

PA — definition reference in topical/device regionPrior Authorization requires payer approval before coverage; topical agents and devices noted with PA (e.g., select topical specialty items, CGM sensors) must have authorization to be covered.

DocumentationWhen PA is present for topical or device items, submit condition‑specific supporting documentation per the formulary rules.

Denial riskClaims for topical/device items lacking required PA may be denied.

QL — topical/device region reference

QL — definition reference in topical/device regionQuantity Limits restrict amounts of topical medications and device supplies (e.g., clobetasol 0.05% liquid, budesonide ER, blood glucose test strips); exceeding QL requires PA.

ExamplesClobetasol 0.05% liquid and budesonide ER entries show QL in Requirements / Limits; many device test strips list PA, QL.

Provider implicationPrescribers should check QL for topical/device prescriptions and request PA if prescribed quantities exceed formulary limits.

ST — topical/device region reference

ST — step therapy reference in topical/device regionStep Therapy (ST) applies to some topical products and devices in the formulary (examples include certain acne topicals and CGM devices like Dexcom and FreeStyle Libre sensors).

Device examplesDexcom G6/G7 sensors and receivers are listed with ST, QL, AGE — indicating step and age requirements for device coverage.

Prescriber actionDocument prior trials of required alternatives (or medical reason to bypass) when requesting coverage for ST‑flagged topical/device items.

Adult low‑dose aspirin, aspirin 81 mg, aspirin EC and various branded aspirin regimens all show Requirements / Limits = QL, AGE.

ImplicationAge limits apply to aspirin products in addition to quantity limits; verify age and QL prior to coverage decisions.

OTEZLA products — PA, QL, SUM7

OTEZLA products — flagsOTEZLA (apremilast) and OTEZLA XR are listed with Requirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Lock).

ImplicationCoverage for OTEZLA formulations requires prior authorization and specialty pharmacy dispensing; quantity limits also apply.

Provider actionSubmit PA with supporting clinical documentation and route dispensing through the designated specialty pharmacy for SUM7 items.

ENBREL products — PA, QL, SUM7

ENBREL products — flagsENBREL and ENBREL variants (ENBREL MINI, ENBREL SURECLICK) are listed with Requirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Lock).

ImplicationENBREL products require prior authorization and must be dispensed via the specialty pharmacy program; quantity limits apply.

Provider actionEnsure PA is obtained and the specialty pharmacy channel is used for ENBREL dispensing to avoid denial.

Vancomycin HCl — QL flagged

Vancomycin HCl (caps & recon) — QL flaggedVancomycin HCl oral capsule strengths and reconstitution solutions are listed with Requirements / Limits = QL.

ExamplesEntries include 125 mg and 250 mg capsules and 25/50/250 mg/5 mL reconstitution solutions with QL specified.

ImplicationQuantity limits apply to oral and reconstituted vancomycin products; verify QL before approving coverage beyond standard amounts.

Abiraterone acetate 250 mg tab — QL

Abiraterone acetate 250 mg tab — QL flaggedAbiraterone acetate entries show Requirements / Limits = QL (and SUM7 noted elsewhere for some antiandrogen/oncology agents).

ImplicationQuantity limits apply to this antineoplastic/antiandrogen presentation; check QL values when submitting claims.

Related controlsMany oncology and antiandrogen agents in the same section also carry PA and SUM7 flags in addition to QL.

Leuprolide acetate — QL

Leuprolide acetate — QL flaggedLeuprolide acetate (3‑month and other depot presentations) are listed with Requirements / Limits = QL; several depot products also show SUM7.

ExamplesLUPRON DEPOT (3‑month/4‑month/6‑month) entries show QL and in many cases SUM7 (Specialty Pharmacy Lock).

Provider actionVerify QL and specialty dispensing requirements for depot leuprolide presentations when requesting coverage.

PIQRAY dosing strengths — QL

PIQRAY dosing strengths — QL flaggedPIQRAY (200 mg, 250 mg, 300 mg daily doses) entries are listed with Requirements / Limits = QL.

ImplicationQuantity limits apply to each dosing strength of PIQRAY; prior authorization or specialty routing may be required for exceptions.

ContextPIQRAY appears in the PI3K inhibitor group alongside other agents that may carry PA/QL/SUM7 controls.

SUNLENCA (all forms) — QL

SUNLENCA (all forms) — QL flaggedSUNLENCA tablet packs and liquid formulation entries are listed with Requirements / Limits = QL.

ExamplesSUNLENCA 4x300 mg and 5x300 mg tablet packs and 463.5 mg/1.5 mL solution are shown with QL.

ImplicationQuantity limits apply to SUNLENCA presentations; confirm QL prior to coverage decisions.

PREVYMIS dosing entries — QL

PREVYMIS dosing entries — QL flaggedPREVYMIS (240 mg and 480 mg tablet presentations) are listed with Requirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Lock).

ImplicationPREVYMIS requires prior authorization, quantity limits and specialty pharmacy routing per SUM7 for coverage.

Provider actionSubmit PA and ensure specialty pharmacy handling for PREVYMIS to meet formulary requirements.

ORENITRAM — QL flagged

ORENITRAM (various strengths/kits) — QL flaggedMultiple ORENITRAM strengths and monthly kits are listed with Requirements / Limits = PA, QL.

ExamplesORENITRAM 0.125, 0.25, 1 mg, 2.5 mg and monthly kits (Month 1–3) are shown with PA and QL.

ImplicationCoverage requires attention to both prior authorization and quantity limits for ORENITRAM formulations.

TYVASO — QL flagged

TYVASO (kits/refill/starter) — QL flaggedTYVASO kits (maintenance, titration), refills and starter kits are listed with Requirements / Limits = PA, QL.

ExamplesTYVASO DPI maintenance kit, titration kit, refill and starter entries explicitly show PA and QL in Requirements / Limits.

ImplicationTYVASO coverage requires prior authorization and adherence to quantity limits per the formulary listing.

Budesonide ER — QL flagged

Budesonide ER — QL flaggedBudesonide ER entry is listed with Requirements / Limits = ST, QL, SUM7 (Specialty Pharmacy Lock).

ImplicationBudesonide ER requires step therapy, quantity limits and specialty pharmacy routing where SUM7 applies.

Provider actionConfirm ST and QL criteria and route via specialty pharmacy for budesonide ER if SUM7 applies.

COSENTYX / SKYRIZI / BIMZELX — QL examples

COSENTYX / SKYRIZI / BIMZELX — QL flagged examplesSystemic antipsoriatic biologics COSENTYX, SKYRIZI and BIMZELX are listed with Requirements / Limits = ST, PA, QL, SUM7 in many presentations.

ImplicationThese biologics require step therapy and prior authorization in many cases, are subject to quantity limits, and must be dispensed via specialty pharmacy (SUM7).

Provider actionProvide required documentation for PA/ST and ensure specialty pharmacy handling for these systemic biologics.

Clobetasol propionate 0.05% & other high‑potency topicals — QL

Clobetasol propionate 0.05% liquid & high‑potency topicals — QL flaggedClobetasol propionate 0.05% liquid and other high‑potency topical corticosteroid presentations are listed with Quantity Limits in Requirements / Limits.

ExamplesClobetasol propionate 0.05% liquid specifically shows Requirements / Limits = QL; related high‑potency topicals include QL flags across entries.

ImplicationQuantity limits apply to high‑potency topical corticosteroids; confirm QL before approving large supplies.

Blood glucose test strips/meters — PA and QL

Blood glucose test strips/meters — PA and QL notedMany blood glucose test strips and meters are listed with Requirements / Limits = PA, QL (some entries show PA, QL explicitly).

ExamplesMultiple branded strips (e.g., ACCUTREND GLUCOSE, ADVANCE series, ASSURE, FREESTYLE variants) display PA and QL in the formulary.

ImplicationCoverage of test strips/meters may require prior authorization and adherence to quantity limits; verify device‑specific rules before dispensing.

Many listed blood glucose test strips — QL

Many listed blood glucose test strips — QL flaggedA broad set of blood glucose test strips across brands are assigned Quantity Limits in the formulary; several also require PA.

ExamplesEntries across FORA, FREESTYLE, ASSURE and other brands show Requirements / Limits = PA, QL or QL depending on the product.

Provider actionCheck the specific strip model's requirements for PA and QL when prescribing or dispensing to ensure coverage.

GENOTROPIN presentations — QL

GENOTROPIN presentations — QL flaggedGENOTROPIN growth hormone presentations are listed with Requirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Site of Care Lock).

ImplicationGENOTROPIN requires prior authorization, quantity limits and specialty‑site handling under SUM7 for coverage.

Provider actionSubmit PA with documentation and use specialty pharmacy site‑of‑care routing for GENOTROPIN per formulary requirements.

STRENSIQ — QL flagged

STRENSIQ strengths — QL flaggedSTRENSIQ presentations (multiple strengths) are listed with Requirements / Limits = PA, QL.

ImplicationCoverage for STRENSIQ requires prior authorization and is subject to quantity limits per the formulary.

Provider actionProvide required documentation for PA and verify QL when requesting coverage for STRENSIQ.

Lancets — QL applied

Lancets (multiple brands) — QL appliedExtensive lancet product listings (CVS, Diathrive, E‑Z Ject, Drug Mart, etc.) are assigned Quantity Limits (Requirements / Limits = QL).

ExamplesMany lancet SKUs are shown with QL across the formulary's device/supply section.

ImplicationLancet dispensing is subject to monthly quantity limits; check QL before authorizing larger supplies.

CGM sensors/transmitters/receivers — QL and other flags

CGM sensors/transmitters/receivers — QL applied (some with PA/ST/AGE)Continuous glucose monitoring components (Dexcom G6/G7, Guardian sensors, transmitters, receivers, FreeStyle Libre) are listed with Quantity Limits and many also include PA, ST and age restrictions.

ExamplesDexcom G6/G7 sensors/receivers/transmitters and Guardian sensors/transmitters are shown with ST, QL, AGE; ENLITE sensor lists PA, QL.

Provider actionConfirm device‑specific PA, ST and AGE criteria and QL before requesting coverage to avoid denial.