SelectHealth Formulary Coverage & Prior Auth

General coverage logic

Coverage is determined by formulary status plus utilization management; drugs may be covered when plan criteria are met.

Formulary inclusion: Drug is included in the SelectHealth formulary or permitted by plan rules

Inclusion on the formulary does not guarantee a particular prescriber will choose the drug

Utilization management controls apply

Prior authorization (PA): Prior authorization is required when the formulary entry is annotated 'PA'
Coverage requires submission and approval of PA; absence of approval may result in denial and member payment responsibility
Step therapy (ST): Step therapy is required when the formulary entry is annotated 'ST'
Drug is covered only after documented trial and failure (or contraindication) of specified alternatives
Quantity and fill limits (QL / MFL / MDS1): Quantity, maximum fills per fill period, or days‑supply limits apply when entries show QL, MFL, or MDS1
Requests exceeding limits require prior authorization or will be denied
Specialty pharmacy / site‑of‑care lock (SUM7): Specialty products annotated 'SUM7' must be dispensed through designated specialty channels or site of care
Requests not routed through specialty pharmacy/site‑of‑care may be denied
Age restrictions (AGE): Age‑based restrictions apply when an entry is annotated with AGE
Coverage limited to indicated age groups as shown in formulary entries

Member cost and tiering: Drug tier determines member cost‑sharing; lower tiers generally have lower out‑of‑pocket cost

See Member Payment Summary or the online drug search tool for plan‑specific cost details

Drug coverage exceptions

Exceptions

Non‑covered drug exception: Member, prescriber, or pharmacy may request coverage for a non‑covered drug by submitting a Drug Coverage Exception Form to SelectHealth

Requests are reviewed on a case‑by‑case basis and granted only when medical necessity is demonstrated

The formulary notes that if a drug is not covered, the member, prescribing physician, or pharmacy may request coverage based on medical necessity. Such requests are evaluated on a case‑by‑case basis and must be submitted using the Drug Coverage Exception Form available on the SelectHealth website.

Within the RxCore Idaho extract there are no blanket or explicit exclusions described. Drug entries are listed with tiers and, where applicable, Requirements / Limits flags (for example QL or MFL) rather than language stating categorical exclusions.

The document does not present clinical exclusion statements in these sections. Instead, products (including diagnostic glucose test strips and other supplies) are annotated with utilization management flags such as PA (prior authorization), QL (quantity limit), and MFL (maximum fills), indicating controls applied to coverage rather than explicit clinical exclusions.

Formulary Entries & Requirement Codes

Formulary drug entries (selected examples)mixed

AMJEVITA	Amjevita (adalimumab biosimilar) — entries list PA, MFL, MDS1, SUM7
HADLIMA	Hadlima (adalimumab biosimilar) — entries list PA, MFL, MDS1, SUM7
RINVOQ	Rinvoq (upadacitinib) — entries list PA, QL, MDS1, SUM7 and lifetime MFL for 45 mg strength
TOBRAMYCIN 300 MG/5ML NEBU SOLN	Tobramycin nebulized solution — Tier 5, QL, MDS1
OTREXUP	Otrexup (methotrexate auto-injector) — PA, MFL, MDS1
RASUVO	Rasuvo (methotrexate injection) — ST and MFL entries across strengths
TYENNE	Tyenne — PA, MFL, MDS1, SUM7

Formulary requirement codes and limit markersmixed

MFL	Maximum fill limit (per Fill) as shown (e.g., MFL (1.2 / Fill))
MDS1	Metric shown as MDS1 (days supply / Fill) (e.g., MDS1 (31 / Fill))
SUM7	Specialty Pharmacy Lock indicator (SUM7)
PA	Prior Authorization required
ST	Step Therapy required
QL	Quantity Limit
AGE	Age-based restriction

Specialty injectable/LAI antipsychoticsmixedCovered

ABILIFY ASIMTUFII 720 MG/2.4ML PRSYR	Drug Tier 5; Requirements: QL (2.4 per 42 days), MDS1 (56 / Fill), SUM7 (Specialty Pharmacy Lock)
ABILIFY ASIMTUFII 960 MG/3.2ML PRSYR	Drug Tier 5; Requirements: QL (3.2 per 42 days), MDS1 (56 / Fill), SUM7 (Specialty Pharmacy Lock)
ABILIFY MAINTENA	Drug Tier 5; Requirements: MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock)
ZYPREXA RELPREVV	Drug Tier 5; Requirements: MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock)

AntiretroviralsmixedCovered

BIKTARVY	Drug Tier 5; Requirements: QL, MDS1 (90 / Fill)
GENVOYA	Drug Tier 5; Requirements: QL, MDS1 (90 / Fill)
TRIUMEQ	Drug Tier 5; Requirements: QL, MDS1 (90 / Fill)
darunavir	Drug Tier 2; Requirements: QL, MDS1 (90 / Fill)

Hepatitis C agentsmixedCovered

HARVONI 33.75-150 MG PACKET	Drug Tier 4; Requirements: ST, QL, MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Site of Care Lock)
MAVYRET 100-40 MG TAB	Drug Tier 3; Requirements: QL, MDS1 (28 / Fill), SUM7 (Specialty Pharmacy Site of Care Lock)
SOFOSBUVIR-VELPATASVIR	Drug Tier 3; Requirements: QL, MFL (28 / Fill), MDS1 (28 / Fill), SUM7 (Specialty Pharmacy Site of Care Lock)
VOSEVI	Drug Tier 4; Requirements: QL, MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Site of Care Lock)

CMV agentsmixedCovered

PREVYMIS (240 MG TAB, 480 MG TAB)

Drug Tier 5; Requirements: PA, QL (100 per 365 days), MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock)

Nucleotide RTI agentsmixedCovered

VIREAD (150 MG TAB, 200 MG TAB, 250 MG TAB)	Drug Tier 5; Requirements: QL, MDS1 (90 / Fill)
tenofovir disoproxil fumarate	Drug Tier 2; Requirements: QL

COVID antiviral PAXLOVID formulationsmixedCovered

PAXLOVID (150/100)	Drug Tier 5; Requirements: QL, MFL (20 / Fill), MDS1 (5 / Fill)
PAXLOVID (300/100 & 150/100)	Drug Tier 5; Requirements: MFL (11 / Fill), MDS1 (5 / Fill)
PAXLOVID (300/100)	Drug Tier 5; Requirements: QL, MFL (30 / Fill), MDS1 (5 / Fill)

Utilization management codes presentmixed

MDS1	Days supply / limit code shown next to many products
MFL	Maximum fill limit code shown for some products
SUM7	Specialty pharmacy lock

Authorization codesmixed

PA	Prior authorization required (example: EOHILIA)
ST	Step therapy required (examples: clindamycin topical entries)

No procedure or billing codes in these chunksmixed

No codes listed

Diuretics and potassium-sparing diureticsmixed

bumetanide	listed with tablet strengths (0.5 mg, 1 mg, 2 mg) and tier information
furosemide	listed with multiple formulations (10 mg/ml solution, 20 mg tab, 40 mg tab, 80 mg tab)
ethacrynic acid	listed (Requirement: PA, QL)

Bisphosphonates and calcimimeticsmixed

alendronate sodium	listed strengths 35 mg, 70 mg; Requirements: MFL (4 / Fill) for some formulations
risedronate sodium	multiple strengths with ST, QL, or MFL as noted
cinacalcet hcl	listed with QL requirement

Selected specialty/specialty-located agentsmixedCovered

XPHOZAH	CKD agent - NHE3 inhibitor; Tier 5; Requirements: PA, QL, MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock)
GENOTROPIN 12 MG CARTRIDGE	Tier 5; Requirements: PA, MFL (8 / Fill), MDS1 (38 / Fill), SUM7 (Specialty Pharmacy Site of Care Lock)
STRENSIQ 18 MG/0.45ML SOLUTION	Tier 5; Requirements: PA, MFL (10.8 / Fill), MDS1 (31 / Fill)
ENTYVIO PEN	Integrin receptor antagonist; Tier 5; Requirements: PA, QL, MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock)
SKYRIZI 180 MG/1.2ML SOLN CART	Interleukin antagonist; Tier 5; Requirements: PA, MFL (1.2 / Fill), MDS1 (56 / Fill), SUM7 (Specialty Pharmacy Lock)

Antibiotics and gastrointestinal agentsmixed

levofloxacin	listed formulations (25 mg/ml solution, 250 mg, 500 mg, 750 mg)
moxifloxacin hcl 400 mg tab	listed
mesalamine	multiple formulations with QL for several

RINVOQ 45 mg lifetime max — MFL

LimitMFL (84 / lifetime)

Applies toRINVOQ 45 MG TAB ER 24H

Requirement tagsPA, QL, MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock)

MDS1 (days per fill)

Standard days-supply codeMDS1 (31 / Fill)

Examples of products using MDS1RINVOQ (various strengths), many specialty agents

ContextMDS1 indicates maximum days supply per fill as shown in formulary entries

Example MFL/MDS1 limits

Example MFLMFL (1.2 / Fill)

Example MDS1MDS1 (31 / Fill)

Larger MFL exampleMFL (66.8 / Fill)

ABILIFY ASIMTUFII 720 MG per 42 days

Limit (per 42 days)2.4 per 42 days

ProductABILIFY ASIMTUFII 720 MG/2.4ML PRSYR

Other requirement tagsMDS1 (56 / Fill), SUM7 (Specialty Pharmacy Lock)

ABILIFY ASIMTUFII 960 MG per 42 days

Limit (per 42 days)3.2 per 42 days

ProductABILIFY ASIMTUFII 960 MG/3.2ML PRSYR

Other requirement tagsMDS1 (56 / Fill), SUM7 (Specialty Pharmacy Lock)

SUNLENCA — QL (5 per 135 days)

Quantity limitQL (5 per 135 days)

Product presentation examplesSUNLENCA (4 x 300 mg, 5 x 300 mg) — QL 5 per 135 days

Related tagsMDS1 (31 / Fill) or MFL as specified for other presentations

SUNLENCA (4 x 300 mg / 5 x 300 mg) — Example QL

Pack-size QL5 (for 4x300 mg or 5x300 mg packs)

ProductSUNLENCA (4 x 300 mg / 5 x 300 mg)

Per periodper 135 days as QL example

MDS1 / MFL limits

MDS1 exampleMDS1 (31 / Fill)

MFL exampleMFL (8 / Fill)

Higher MDS1 exampleMDS1 (56 / Fill)

Authorization, Documentation & Denial Risk

Prior Authorization

Prior Authorization Required for Listed Specialty/Brand Drugs

Prior authorization (PA) is required for many specialty, high‑tier, and selected branded drugs listed in the formulary. Claims submitted without required PA may be denied and the member may be responsible for full retail cost.

Affected products include many biologics, specialty injectables, oncology agents, antiretrovirals, and high‑cost brand drugs (examples in formulary: AMJEVITA, HADLIMA, RINVOQ, TYENNE, ENBREL, RUKOBIA, PREVYMIS).
Specialty pharmacy lock (SUM7), maximum fills per fill (MFL), quantity limits (QL), and medical dispense size (MDS1) often accompany PA; review Requirements / Limits entries on the formulary for specifics.

Prior Authorization

Prior Authorization Required for Selected High‑Tier/Specialty Agents

Certain specialty and high‑tier agents are specifically marked PA (prior authorization) and often also carry QL, MFL, MDS1, or SUM7 flags. Providers must request authorization before dispensing.

Examples: OTEZLA, ENBREL formulations, RINVOQ, CRESEMBA, many antineoplastics (e.g., LORBRENA, XALKORI) and MTOR/CDK/targeted agents.
PA requests should reference the formulary Requirements / Limits codes shown with each product.

Prior Authorization

Prior Authorization Required for Listed Products

Some listed products carry PA alongside explicit quantity/fill limits or specialty dispensing requirements; prescribers must submit supporting clinical documentation to satisfy authorization criteria.

Examples: fondaparinux sodium (PA, MDS1), HUMULIN R U‑500 (PA, QL, MDS1), FARYDAK (PA, MFL), ELIGARD / LUPRON DEPOT (MFL, SUM7) and many growth‑hormone/cancer therapies.
If PA is granted, it may include numeric limits (e.g., MDS1 90 / Fill) or site‑of‑care specialty locks (SUM7) that must be honored at dispensing.

Prior Authorization

Prior Authorization Requirement and Triggers for Additional Authorization

When a formulary entry lists PA, ST, QL, MFL, MDS1 or SUM7 for a drug or device, that entry is a trigger for additional authorization steps. Failure to meet the listed requirements can result in denial of coverage.

PA = prior authorization required before benefit will apply.
ST = step therapy; members must trial and fail specified alternatives prior to coverage.
QL/MFL/MDS1 = quantity and fill limits; exceeding limits usually requires PA.
SUM7 = specialty pharmacy lock; product must be dispensed by plan‑designated specialty pharmacy.

Prior Authorization

Prior Authorization for RUKOBIA

RUKOBIA specifically requires prior authorization and is subject to quantity and days‑supply limits; submit PA with clinical justification to avoid claim denial.

Formulary entry: RUKOBIA — Requirements / Limits = PA, QL, MDS1 (90 / Fill).
Ensure PA documentation demonstrates indication and appropriateness per plan criteria.

Prior Authorization

Prior Authorization for PREVYMIS

PREVYMIS requires prior authorization, is subject to quantity limits and specialty pharmacy dispensing; providers must include supporting clinical documentation with the PA request.

Formulary entry: PREVYMIS (240 mg, 480 mg) — Requirements / Limits = PA, QL (100 per 365 days), MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock).
Requests not meeting the plan’s clinical criteria or limits risk denial.

Prior Authorization

PA + Quantity Limits for Diagnostic Test Strips

Many diagnostic glucose meters, readers, sensors and test strips are designated PA and QL. Prior authorization and adherence to quantity limits are required to obtain coverage for these products.

Examples: wide range of blood glucose test strips and meters in the formulary are labeled PA, QL (e.g., ACCU‑CHEK, CONTOUR NEXT, FREESTYLE models).
Glucose test products often also carry MDS1 and MFL values — exceeding these without PA may lead to denial.

Prior Authorization

ENLITE Sensor Prior Authorization

The ENLITE GLUCOSE SENSOR is subject to prior authorization and quantity/day‑supply restrictions; obtain PA with clinical rationale before dispensing.

Formulary entry: ENLITE GLUCOSE SENSOR — Requirements / Limits = PA, QL, MDS1 (90 / Fill).
Claims for the ENLITE sensor submitted without PA may be denied.

Prior Authorization

CGM Devices Prior Authorization / Requirements

Continuous glucose monitoring (CGM) components (sensors, receivers, transmitters/readers) frequently carry step‑therapy, age criteria, quantity limits, MDS1/MFL and may require prior authorization — verify eligibility and submit required documentation.

Examples: DEXCOM G6/G7 sensors, receivers and transmitters; FREESTYLE LIBRE readers/sensors — Requirements / Limits include ST, AGE, QL, MDS1, MFL.
Step therapy (ST) flags indicate trials of preferred devices or supplies are required prior to coverage of higher‑tier CGM devices.

Step Therapy

Step Therapy Enforcement

Step therapy (ST) requirements mean a drug/device is covered only after trial and failure of specified alternatives. Providers must document prior therapy trials when requesting coverage under ST rules.

Examples: RASUVO injectables, SOLIQUA, HARVONI and some CGM devices are marked ST.
If step therapy is not met, prior authorization or a drug coverage exception with supporting medical necessity may be required to obtain coverage.

Denial Risk

Quantity Limits and Fill Restrictions

Quantity limits (QL), maximum fills per fill (MFL), and medical dispense size (MDS1) are used across the formulary to control utilization. Prescribers must request PA for quantities exceeding these limits.

Examples: many insulins and GLP‑1 agents have MDS1 (40/Fill) or QL designations; oncology and specialty meds often have MFL or MDS1 numeric limits.
PA requests should state the clinical need for quantities beyond plan limits and reference relevant clinical documentation.

Prior Authorization

Prior Authorization / Specialty Lock Required for Some Products

Specialty pharmacy locks (SUM7), site‑of‑care locks, and other utilization flags require dispensing through plan‑designated channels; authorization must reflect these requirements or the claim may be denied.

Many biologics, oncology agents, antivirals, and specialty therapies include SUM7 in their Requirements / Limits.
If a drug is SUM7‑locked, dispense only through the plan’s specialty pharmacy unless an exception is approved.

Denial Risk

Triggers for Potential Denial & Denial Risk from Unmet Requirements

Failure to submit required PA documentation, or to meet ST/QL/MFL/MDS1/SUM7 requirements, is a common trigger for claim denial. Providers should verify and supply all requested supporting records with PA submissions.

Denial triggers include lack of PA, exceeded quantity limits, absence of documented step therapy failures, or dispensing outside specialty‑pharmacy requirements.
Use the formulary Requirements / Limits codes as a checklist when preparing PA requests (PA, ST, QL, MFL, MDS1, SUM7, AGE).

Documentation Required

Exception Requests and Medical Necessity Documentation

Providers may request coverage exceptions for non‑covered drugs or to override formulary requirements based on medical necessity. Use the plan’s Drug Coverage Exception Form and include supporting clinical documentation.

Exceptions are considered case‑by‑case; attach relevant medical records, prior therapy history, and rationale when submitting.
If an exception is approved, retain approval documentation and comply with any specified limits.

Documentation Required

Documentation for Specialty Biologics and Plan Requirements

When PA is required, prescribers must submit clinical documentation supporting the request. For specialty biologics and oncology agents this often includes diagnosis, prior treatments, weight/dosing calculations, and therapy goals.

Documentation expectations: current diagnosis, prior medication trials and outcomes, relevant labs/imaging, and rationale for the requested agent/dose.
For agents with MDS1/MFL limits, include intended dosing schedule and anticipated days‑supply to justify quantities.

Documentation Required

Documentation of Plan Requirements and Requirement Tags

Formulary requirement tags (PA, ST, QL, MFL, MDS1, SUM7, AGE) indicate the specific utilization controls that must be met and documented. Review these tags for each product prior to prescribing or dispensing.

Use the requirement tags as operational triggers: e.g., PA = submit prior authorization; ST = document step failures; SUM7 = specialty pharmacy dispensing.
Queries to the plan should reference the exact codes from the formulary entry to ensure correct processing.

Step Therapy

Step Therapy / Site‑of‑Care Restrictions for Select Hepatitis C Agents

Some agents carry site‑of‑care or specialty‑site locks (e.g., hepatitis C agents like HARVONI) in addition to step‑therapy and quantity limits. These restrictions must be observed and justified in PA requests.

Examples: HARVONI and LEDIPASVIR‑SOFOSBUVIR show ST and SUM7 (Specialty Pharmacy Site of Care Lock).
If treatment requires a specific site of care or specialty dispensing, include that information in the PA submission.

Documentation Required

Documentation of Fill Limits, MFL and MDS1

For products with numeric fill limits (MFL) or medical dispense size (MDS1) restrictions, clearly document dosing schedule and intended fills in the PA; the plan will compare requested quantity against these limits when adjudicating.

Examples of MFL/MDS1 usage: ELIGARD kits, ABILIFY ASIMTUFII, tadalafil MFL (30 / Fill), many specialty injectables.
Requests that exceed MFL/MDS1 values require prior authorization and clinical justification.

Documentation Required

Authorization Risk and Documentation for CGM Components and Readers

CGM devices and components often combine step therapy, age restrictions, quantity limits, and MDS1/MFL values; confirm member eligibility and prior device trials, and submit all device‑specific clinical information with the PA to minimize denial risk.

Examples: DEXCOM G6/G7 and FREESTYLE LIBRE readers/sensors — Requirements include ST, AGE, QL, MDS1, MFL.
Document prior home‑glucose monitoring use, frequency of testing, and rationale for CGM to support the PA.

Step Therapy Instances & Affected Products

Product	Listing / Strengths	Requirement
RASUVO
RASUVO 7.5 mg – 30 mg injectable presentations (7.5 mg/0.15 mL through 30 mg/0.6 mL)
ST (step therapy) indicated for listed RASUVO injectable presentations; specific entries show ST and MFL per strength (e.g., ST; MFL 0.6–2.4 / Fill).

RASUVO Strength	Requirement / Limit
RASUVO 7.5 mg / 0.15 mL
ST; MFL (0.6 / Fill)
RASUVO 10 mg / 0.2 mL
ST; MFL (0.8 / Fill)
RASUVO 12.5 mg / 0.25 mL
ST; MFL (1 / Fill)
RASUVO 15 mg / 0.3 mL
ST; MFL (1.2 / Fill)
RASUVO 17.5 mg / 0.35 mL
ST; MFL (1.4 / Fill)
RASUVO 20 mg / 0.4 mL
ST; MFL (1.6 / Fill)
RASUVO 22.5 mg / 0.45 mL
ST; MFL (1.8 / Fill)
RASUVO 25 mg / 0.5 mL
ST; MFL (2 / Fill)
RASUVO 30 mg / 0.6 mL
ST; MFL (2.4 / Fill)

Branded Formulation	Example Requirement
TEGRETOL-XR (carbamazepine extended-release)
Requirements / Limits = ST (step therapy) indicated in formulary entries (example listed among anticonvulsant entries).
TOPAMAX SPRINKLE (topiramate sprinkle formulation)
Requirements / Limits = ST (step therapy) noted for select formulations).
SOLIQUA (insulin–GLP-1 fixed-dose combination)
Requirements / Limits = ST; MFL (30 / Fill); MDS1 (50 / Fill).

Product / Class	Requirement
SOLIQUA (insulin–incretin combination)
ST; MFL (30 / Fill); MDS1 (50 / Fill).
Select statins and fenofibrate entries (examples)
Some entries list ST in Requirements / Limits (e.g., fluvastatin, pitavastatin show ST).

Agent / Class	Utilization Controls
High‑tier antineoplastics (examples: VENCLEXTA, XALKORI, LORBRENA)
Typically require PA and may have QL, MDS1, MFL and specialty site-of-care locks (SUM7); specific step therapy sequences are not detailed in excerpt.
Bicalutamide
Example quantity control: MFL (90 / Fill) as shown for some antiandrogens; PA/QL/MDS1/SUM7 applied to various oncology agents.

Product	Requirement
HARVONI (ledipasvir‑sofosbuvir) 33.75–150 mg packet and 45–200 mg packet
ST; QL; MDS1 (31 / Fill); SUM7 (Specialty Pharmacy Site of Care Lock).
LEDIPASVIR‑SOFOSBUVIR (generic)
ST; QL; MDS1 (31 / Fill); SUM7 (Specialty Pharmacy Site of Care Lock).

Product	Requirement
tadalafil 5 mg tablet
ST; MFL (30 / Fill).
ivabradine (ivabradine HCl)
ST; QL as listed in formulary entries.

Topical Acne Agent	Requirement
clindamycin phosphate 1% foam / gel / combination products
Requirements / Limits include ST for several clindamycin topical formulations.
dapsone 5% gel
Requirements / Limits = ST.
adapalene 0.1% cream
Requirements / Limits = ST.

Dermatologic Product / Class	Requirement
tazarotene (0.05% gel, 0.1% cream/gel)
ST; AGE noted where applicable.
pimecrolimus
Listed with ST in Requirements / Limits.
ketoconazole 2% foam
Requirements / Limits = ST for foam formulation.

Product	Requirement
risedronate sodium (various strengths)
Some formulations list ST and/or QL/MFL per formulary entries (example: risedronate sodium entries show ST, QL).
VOWST (live fecal microbiota)
Requirements / Limits = ST; MFL (12 / Fill); MDS1 (31 / Fill).

CGM Device / Reader	Requirement
DEXCOM G6 receiver / sensor / transmitter
Requirements / Limits = ST; QL (1 per 292 days for receivers); AGE; MFL (1 / fill); MDS1 (365 / fill) for receivers; sensors/transmitters list ST, AGE, QL, MDS1 (90 / Fill).
DEXCOM G7 receiver / sensor
Requirements / Limits = ST; QL (1 per 292 days for receivers where listed); AGE; MFL (1 / fill); MDS1 (90 / Fill for sensors).
FREESTYLE LIBRE readers / sensors (14‑day, 2, 3 series)
Requirements / Limits = ST; QL (1 per 292 days for readers); AGE; MFL (1 / fill); MDS1 (365 / fill for readers; 90 / Fill for sensors).

Quantity, Days Supply & Fill Limits

AMJEVITA — MFL range

AMJEVITA MFL rangeMFL (0.8 - 1.6 / Fill depending on presentation)

Associated tagsPA, MDS1 (31 / Fill), SUM7 (Specialty Pharmacy Lock)

Product typeAdalimumab biosimilar presentations

RINVOQ 45 MG TAB ER 24H — MFL

LimitMFL (84 / lifetime)

ProductRINVOQ 45 MG TAB ER 24H

Other requirement tagsPA, QL, MDS1 (31 / Fill), SUM7

Stimulants and methylphenidate products — QL

Requirement typeQL (quantity limits) applied across many strengths and formulations

Product examplesstimulants and methylphenidate products (multiple strengths)

ContextFormulary entries denote QL for these CNS stimulant agents

RASUVO (various strengths) — MFL range

MFL range by strengthMFL (0.6 - 2.4 / Fill depending on strength)

ProductRASUVO (various strengths)

Requirement tagsST and MFL as listed per strength

TYENNE (162 mg/0.9 ml) — Limits

MFLMFL (3.6 / Fill)

MDS1MDS1 (31 / Fill)

ProductTYENNE (162 mg/0.9 ml)

ENBREL formulations — MFL / MDS1

MFL rangeMFL (4-8 / Fill depending on presentation)

MDS1MDS1 (31 / Fill)

Product familyENBREL formulations

FIASP — MDS1 (40 / Fill)

MDS1MDS1 (40 / Fill)

Product examplesFIASP and related insulin presentations

ContextMDS1 denotes days-supply per fill for insulin products

SOLIQUA — MFL / MDS1

MFLMFL (30 / Fill)

MDS1MDS1 (50 / Fill)

ProductSOLIQUA

XCOPRI — MFL by pack size

MFL pack examplesMFL (28 or 56 / Fill depending on pack)

ProductXCOPRI (certain pack sizes)

ContextPack-dependent MFL for seizure medication

NOVOLOG FLEXPEN and certain insulin products — MDS1

MDS1MDS1 (40 / Fill)

ProductsNOVOLOG FLEXPEN and certain insulin products

ContextIndicates days-supply per fill for insulin pens/cartridges

CRESEMBA — MDS1 (31 / Fill)

MDS1MDS1 (31 / Fill)

ProductCRESEMBA (isavuconazonium caps)

Requirement tagsPA, QL, SUM7 also apply

dronabinol — MFL (60 / Fill)

MFLMFL (60 / Fill)

Productdronabinol

Requirement tagsPA also noted in formulary entries

REPATHA — MFL variations

MFLMFL (2 / Fill)

Alternate pushtronexMFL (3.5 / Fill) for Pushtronex system

ProductREPATHA (evolocumab)

abiraterone acetate 250 mg tab — MDS1

MDS1MDS1 (90 / Fill)

Productabiraterone acetate 250 mg tab

Other tagsQL and SUM7 may also apply

VENCLEXTA STARTING PACK — QL

Quantity limitQL (42 per 274 days)

ProductVENCLEXTA STARTING PACK

Other tagsPA, MDS1 (31 / Fill), SUM7 noted

FARYDAK — MFL (6 / Fill)

MFLMFL (6 / Fill)

ProductFARYDAK

Other tagsPA may apply

TEPMETKO — MDS1 (31 / Fill)

MDS1MDS1 (31 / Fill)

ProductTEPMETKO

Other tagsPA, QL, SUM7 may apply

ELIGARD 22.5 MG KIT — MFL / MDS1

MFLMFL (1 / Fill)

MDS1MDS1 (90 / Fill)

ProductELIGARD 22.5 MG KIT

INVEGA HAFYERA — QL / MDS1

QLQL (3.5 per 135 days)

MDS1MDS1 (180 / Fill)

ProductINVEGA HAFYERA 1092 MG/3.5ML

asenapine maleate — Limit

Limit value60

Productasenapine maleate

ContextListed as limit in formulary (MFL 60 / Fill for some entries)

ABILIFY ASIMTUFII 720 MG/2.4ML PRSYR — 2.4

Numeric MFL value2.4

ProductABILIFY ASIMTUFII 720 MG/2.4ML PRSYR

Unit/contextmg per 42 days as listed

ENTRESTO, ORENITRAM, TYVASO, select contraceptives — Examples

Varies by productExamples: MFL 112/Fill, MFL 336/Fill, MFL 30/Fill; MDS1 31/Fill, MDS1 90/Fill, MDS1 180/day(s)

Product groupsENTRESTO, ORENITRAM, TYVASO, select contraceptives

ContextFormulary entries list variable MFL/MDS1 values per presentation

Transdermal contraceptives — MFL / MDS1 examples

MFL examplesMFL (32/Fill or 16/Fill)

MDS1 examplesMDS1 (90-180/Fill depending on product)

Productsnorelgestromin-eth estradiol (TWIRLA, xulane, zafemy)

Extended-cycle oral contraceptives — Limits

Extended-cycle limitsMFL (91 / Fill) and MDS1 (91 / Fill) — or MFL (182 / Fill) for 91/182-day formulations

Product examplesamethia, ashlyna, camrese and other extended-cycle oral contraceptives

ContextFormulary indicates 91- and 182-day fill patterns for extended-cycle products

budesonide er — ST, MFL, MDS1, SUM7

Requirement flagsST, MFL (30 / Fill), MDS1 (31 / Fill), SUM7

Productbudesonide er

ContextSpecialty lock and step therapy noted where applicable

clobetasol propionate 0.05% liquid — MFL

MFLMFL (125 / Fill)

Productclobetasol propionate 0.05% liquid

ContextTopical corticosteroid fill limit as listed

triamcinolone acetonide 0.147 mg/gm aerosol solution — MFL

MFLMFL (63 / Fill)

Producttriamcinolone acetonide 0.147 mg/gm aerosol solution

Related examplesOther topical/systemic MFL entries exist for corticosteroids

Selected biologics — MFL / MDS1 examples

Typical MFL/MDS1MFL (2 / Fill) or MDS1 (56/84 / Fill) as specified per product

Product groupSelected biologics (e.g., COSENTYX, SKYRIZI, PYZCHIVA)

Specialty tagsPA and SUM7 often accompany biologic limits

Diagnostic test strips — QL examples

QL designationQL (quantity limits) as indicated per product

Product categoryDiagnostic test strips (many entries)

Associated tagsMany entries also include PA and QL together

FREESTYLE series — MDS1 (90 / Fill)

MDS1MDS1 (90 / Fill)

Product examplesFREESTYLE INSULINX TEST, FREESTYLE LITE, FREESTYLE PRECISION NEO, FREESTYLE TEST

ContextDays-supply limits for test supplies are commonly set at 90 per fill

PRECISION XTRA BLOOD GLUCOSE — QL / MDS1

QL and MDS1QL, MDS1 (90 / Fill)

ProductPRECISION XTRA BLOOD GLUCOSE

ContextFormulary lists both QL and a 90-day MDS1 for this product

GENOTROPIN 12 MG CARTRIDGE — MFL

MFLMFL (8 / Fill)

ProductGENOTROPIN 12 MG CARTRIDGE

Other tagsPA, MDS1 (38 / Fill), SUM7 may apply

STRENSIQ 18 MG/0.45ML SOLUTION — MFL

MFLMFL (10.8 / Fill)

ProductSTRENSIQ 18 MG/0.45ML SOLUTION

Associated tagsPA and MDS1 (31 / Fill) often listed

ENTYVIO PEN — MDS1

MDS1MDS1 (31 / Fill)

ProductENTYVIO PEN

Other tagsPA, QL, SUM7 may apply

SKYRIZI 180 MG/1.2ML SOLN CART — MDS1 / MFL

MDS1MDS1 (56 / Fill)

MFLMFL (1.2 / Fill)

ProductSKYRIZI 180 MG/1.2ML SOLN CART

Condom products — MFL

MFLMFL (12 / Fill)

Product categoryCondom products (many brands)

ContextStandard maximum fills per fill for condom listings

Lancets — MDS1

MDS1MDS1 (90 / Fill)

Product categoryLancets (many brands)

Context90-day days-supply commonly applied to lancet listings

CGM receivers/readers — Device limits

Device limitsQL (1 per 292 day(s)); MFL (1 / fill); MDS1 (365 / fill)

ProductsCGM receivers/readers (Dexcom, Freestyle Libre examples)

ContextSite-of-care and step therapy flags may also apply

PRECISION XTRA-GLUCOSE/KETONE — Limits

MFLMFL (1 / Fill)

MDS1MDS1 (365 / Fill)

ProductPRECISION XTRA-GLUCOSE/KETONE

DEXCOM G6 SENSOR — MDS1 (90 / Fill)

MDS1MDS1 (90 / Fill)

ProductDEXCOM G6 SENSOR

ContextSensor days-supply limit per fill as listed

OpenPayer

Prescription Drug Formulary / Coverage Criteria

Coverage Determination & Exceptions

Formulary Entries & Requirement Codes

Authorization, Documentation & Denial Risk

Utilization Management Codes & Meanings

Step Therapy Instances & Affected Products

Quantity, Days Supply & Fill Limits

Specialty Pharmacy & Site-of-Care Locks

Policy Background & Scope

Biosimilar & Reference Biologic Notes