Prescription drug list (formulary) — Coverage criteria
Summarizes commonly prescribed drugs covered by SelectHealth plans, including tiers, coverage rules (prior authorization, step therapy, quantity and age limits), and example drug categories and specific drugs; intended for members, providers, and pharmacies.
Policy Summary
PayerSelectHealth
PolicyPrescription drug list (formulary) — Coverage criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization or submit required documentation for drugs flagged with PA, ST, QL, SUM7, or AGE to ensure coverage.
No material clinical or coverage changes in this revision.
monthlyformulary review frequency
800-538-5038Pharmacy Services
PA, ST, QL, AGEcommon coverage controls
multipleitems with PA
specialtyspecialty lock (SUM7)
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~200+
drug entries (approx)
Formulary Coverage & Controls
General formulary coverage
Covered subject to plan rules and controls.
General coverage conditions: Drug must be on the formulary or approved via a Drug Coverage Exception for medical necessity.
Member cost-sharing varies by drug tier; see Member Payment Summary or online tool. Formulary is reviewed monthly by clinical team.
Utilization requirements may include: Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), or Age restrictions (AGE) as indicated in the formulary entry.
Lack of required PA or failure to meet ST/QL/AGE requirements may result in denial or member liability for full retail cost.
Exception process: For drugs not on the formulary, submit a Drug Coverage Exception Form with clinical rationale to request coverage based on medical necessity.
Exceptions are reviewed case-by-case.
Specialty drug coverage
Specialty and biologic agents.
Specialty drug controls: Certain specialty and biologic products require prior authorization and may also have quantity limits and specialty pharmacy/site-of-care dispensing (SUM7).
Examples include AMJEVITA, HADLIMA, RINVOQ, OTREXUP listed with PA, QL, SUM7 or ST.
Specialty dispensing requirement: When SUM7 (Specialty Pharmacy Lock) is indicated, the product must be dispensed through the plan-designated specialty pharmacy or site-of-care.
Failure to use required specialty channel may risk denial or noncoverage.
Documentation expectations: Prescribers must provide clinical documentation to support PA, QL, SUM7 or ST requests for specialty drugs.
See prior authorization process; absence of required documentation may delay or deny coverage.
Formulary utilization management
Coverage and utilization management for listed drugs.
Requirement mapping: Drugs listed with 'PA' in the Requirements/Limits field require prior authorization; those with 'QL' have quantity limits; 'SUM7' indicates a specialty pharmacy lock; coverage is contingent on meeting the listed requirements.
Many antineoplastics and specialty agents are annotated PA, QL, SUM7.
Possible utilization controls: Formulary entries may include one or more of: PA, QL, ST, SUM7, AGE.
See specific formulary row for the exact combination for each product.
Formulary coverage with utilization controls
Coverage is tier-based; some items are subject to utilization controls.
Tier assignment: Each drug is assigned a Drug Tier (commonly tiers 1–6) which influences member cost-sharing and coverage terms.
Tier information is shown on each formulary row and in member materials.
Utilization control annotations: Items may have one or more of: QL (quantity limits), ST (step therapy), PA (prior authorization), AGE (age limits), SUM7 (specialty pharmacy lock).
Specific AND/OR logic for multiple flags is defined per product in the full formulary; this extract shows examples across device and drug categories.
Device-specific controls: Medical devices and supplies (e.g., lancets, CGM sensors/receivers) have tier assignments and may carry ST, QL, and AGE requirements as listed.
Examples: Dexcom G6/G7 entries list ST, QL, AGE.
Drugs that are not on the formulary are not covered unless a coverage exception is granted. To request coverage for a non‑formulary medication, the member, prescriber, or pharmacy must submit a Drug Coverage Exception Form with clinical rationale demonstrating medical necessity; requests are reviewed and decided on a case‑by‑case basis.
No explicit exclusion list is provided in the cited formulary extracts. The formulary instead annotates drugs with requirements and limits (for example PA, QL, SUM7) that govern coverage; absence of a named exclusion in these chunks does not imply there are no exclusions elsewhere in the full policy.
There is no standalone list labeled “Not Medically Necessary” in the provided segments. Noncovered medications may still be considered for coverage when a Drug Coverage Exception is submitted and approved based on documented medical necessity; each request is reviewed individually.
The provided excerpts do not contain explicit statements that particular drugs are universally not medically necessary. Instead, coverage decisions are expressed through formulary annotations (for example, drugs with PA, QL, SUM7) and medical necessity exception processes described elsewhere in the formulary.
strengths listed for an unspecified drug in this extract
Covered devices listedHCPCSCovered
DEXCOM G6 RECEIVER
Device entry
DEXCOM G6 SENSOR
Device entry
DEXCOM G6 TRANSMITTER
Device entry
DEXCOM G7 15 DAY SENSOR
Device entry
DEXCOM G7 RECEIVER
Device entry
DEXCOM G7 SENSOR
Device entry
inv-15: Quantity Limits
ScopeQuantity limits (QL) are applied at the drug or class level; exceeding plan QL may require prior authorization or be denied.
Applies toCertain high-risk and commonly used drugs (examples in this extract: opioids generally; fondaparinux sodium; many insulin products including HUMULIN R U-500).
Consequence of exceedancePreauthorization is required if the medication exceeds the plan limits; lack of authorization may result in noncoverage or member responsibility for full retail cost.
Examples from formularyfondaparinux sodium (Requirements / Limits = PA, QL, SUM7); HUMULIN R U-500 (Requirements / Limits = PA, QL); many insulin products (Requirements / Limits = QL).
Implementation noteSpecific numeric limits per product are listed in the formulary entries (see product rows); where QL appears with SUM7 or PA, specialty distribution and prior authorization processes also apply.
Authorization, Documentation & Denial Risk
Prior Authorization
Authorization, Documentation & Denial Risk
Coverage of drugs is based on medical necessity. For certain drugs, prior authorization (PA) or preauthorization is required before the plan will cover the medication; without prior authorization the member may be responsible for the drug's full retail price. Many specialty, biologic, antineoplastic, concentrated insulin, and high-cost agents require PA and may also be limited by quantity limits (QL), step therapy (ST), age limits (AGE), or specialty pharmacy/site-of-care locks (SUM7). Step therapy requires trying and failing an alternative therapy before the requested agent will be covered. Quantity limits apply to specified products and preauthorization is required if the requested quantity exceeds plan limits.
Prior authorization (PA) is required for many specialty and biologic drugs (examples in formulary: AMJEVITA, HADLIMA, RINVOQ, RINVOQ LQ, TYENNE, and many interleukin/JAK/antirheumatic agents). (See formulary entries annotated PA, QL, SUM7.)
Certain non-oncology agents also require PA and/or QL (examples: pyrimethamine; select topical/systemic products; multiple blood glucose test strips and CGM components list PA/QL).
Numerous antineoplastics and adjunctive cancer therapies require PA and are subject to QL and SUM7 (examples: IBRANCE, TRUQAP, ALECENSA, XALKORI, VENCLEXTA, many TKIs and kinase inhibitors).
Select specialty agents carry PA plus a specialty pharmacy/site-of-care lock (SUM7) — these must be dispensed through the plan's designated specialty channel (examples: GENOTROPIN, TYVASO, PREVYMIS, many biologic pens and injectables).
Policy Background & Scope
The formulary lists covered medications by therapeutic class and specific products and is used to communicate tiered coverage and any utilization controls. A multidisciplinary clinical review team of physicians and pharmacists reviews the formulary content regularly (monthly) to evaluate efficacy, safety, and cost‑effectiveness, and to add or remove products as appropriate. Coverage for a listed drug depends on meeting any annotated requirements such as Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or specialty dispensing locks (SUM7), and member cost‑sharing varies by drug tier.
Utilization Codes & Terms
inv-79: PA / ST / QL / AGE (definitions for common flags)
PA (Prior Authorization)Coverage requires approval from the plan before dispensing; lack of preauthorization for certain drugs may make the member responsible for full retail price.
ST (Step Therapy)Requires trying and failing preferred alternative therapies before the requested drug will be covered (commonly used for brand-name drugs).
QL (Quantity Limit)Restrictions on the quantity of medication covered in a specified period; exceeding QL may require prior authorization.
SUM7 (Specialty Pharmacy Lock)Designation requiring dispensing through the plan's designated specialty pharmacy or site-of-care; often appears with PA and QL for specialty agents.
AGE (Age limit)An age-based coverage restriction; member age must meet the product-specific criterion for coverage to be approved.
Tiering & Initiation Requirements
Tier & utilization management at initiation
Formulary-tier and requirement assignments relevant at therapy initiation.
Tier and requirement assignment at initiation: At therapy initiation, each product's Drug Tier and Requirements/Limits (PA, QL, ST, SUM7, AGE) apply to coverage and prior authorization determinations.
Examples: oncology and specialty agents (e.g., sorafenib, LONSURF, KISQALI) list Tier plus PA/QL/SUM7 designations.
Prior authorization trigger at initiation: When 'PA' is shown for a product, prescribers must obtain prior authorization before the plan will cover initial dispensing.
Failure to obtain required PA may result in member financial responsibility for the drug.
Other initiation controls: Some products require completion of step therapy (ST) or are subject to quantity limits (QL) at initiation; specialty products may require specialty pharmacy routing (SUM7).
Step Therapy Requirements & Examples
Requirement
Policy summary / examples
Step therapy (ST)
Step therapy must be completed before coverage of the requested drug; members must try and fail specified alternative therapy (or have documented intolerance) prior to coverage. (Definition and general rule: 'Drugs that require step therapy are covered only after you have tried an alternative therapy and it didn’t work' and 'Step therapy must be completed before coverage of the requested drug').
Requirements / Limits = ST, QL (SOLIQUA listed with ST)
Scope
Policy implication / example
Antineoplastics and many specialty agents
PA required before coverage for numerous antineoplastic and specialty agents; examples include LORBRENA, XALKORI, VENCLEXTA and other oncology agents listed with Requirements / Limits = PA, QL, SUM7; many agents require PA as indicated in the formulary entries.
Observation
Detail
No explicit step-therapy sequences provided
The formulary extract annotates products with utilization controls (PA, QL, SUM7, ST) but does not provide step-by-step therapeutic sequences or specified prior-step agents in this excerpt; ST flags indicate a step requirement but specific preceding agents/steps are not shown here.
Formulary entries show multiple products annotated with ST indicating step therapy is required prior to coverage (example: budesonide er; certain systemic antipsoriatic biologics such as BIMZELX, COSENTYX are shown with ST in Requirements / Limits).
Agent / class
Formulary flag(s) / Notes
COSENTYX (systemic antipsoriatic biologic)
Requirements / Limits = ST indicated; many antipsoriatic biologics list PA, QL, SUM7 and ST where shown (COSENTYX entries show ST in the antipsoriatic systemic section).
SKYRIZI
Requirements / Limits = PA, QL, SUM7; ST noted for some antipsoriatic biologic listings (formulary indicates ST applies in systemic antipsoriatic section)
Requirements / Limits = ST (ketoconazole 2% foam marked ST)
calcipotriene-betamethasone (combination topical)
Requirements / Limits = ST indicated for some topical combination products as shown in list (ST noted in Requirements / Limits where present)
Product
Formulary flag(s) / Notes
risedronate sodium
Requirements / Limits = ST, QL for some risedronate entries (risedronate sodium flagged with ST where present)
Summary
Policy note / limitation
Some agents flagged ST in formulary
The formulary marks various agents with ST indicating step therapy applies; however, specific step sequences (which therapy must be tried first) are not detailed in this excerpt. Entries show ST flags across hypnotics, antipsychotics, and device entries but without step sequencing instructions here.
Product / device
Formulary flag(s) / Notes
Selected hypnotics (e.g., FLURAZEPAM)
Requirements / Limits = ST, QL noted for some hypnotics (formulary shows ST for select hypnotic entries) — specific step details not provided.
Dexcom devices (G6, G7) and FreeStyle Libre readers/sensors
Requirements / Limits = ST, QL, AGE for Dexcom G6/G7; FreeStyle Libre devices also show ST, QL, AGE — ST is listed but the specific step therapy requirements are not provided in this extract.
Device / family
Formulary flag(s) / Notes
Dexcom G6/G7 receivers, sensors, transmitters
Requirements / Limits = ST, QL, AGE (Dexcom G6 and G7 components listed with ST flag indicating step therapy is required prior to coverage)
Quantity Limits (QL) by Product/Class
inv-122: multiple (class-level and specific products) — Plan-specified quantity limits
Plan practicePlan-specified quantity limits (QL) are applied per drug or formulation; many products across classes carry QL flags in the formulary extract.
ExamplesExamples include anticonvulsants, insulin products, antineoplastics, contraceptives, topical agents, blood glucose test strips, lancets, and CGM sensors/transmitters.
Associated controlsQL often appears with PA, ST, and SUM7 on specialty/high-cost products; check all Requirements / Limits when preparing authorizations.
ReferenceSpecific QL entries are shown on product rows; numeric limits or period (monthly/yearly) are specified per product where applicable.
inv-123: fondaparinux sodium — QL
Product
Specialty Pharmacy & Dispensing Channels
Note
Note
Note
Note
Note
Policy Summary
PayerSelectHealth
PolicyPrescription drug list (formulary) — Coverage criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization or submit required documentation for drugs flagged with PA, ST, QL, SUM7, or AGE to ensure coverage.
DefinitionAGE indicates an age-based coverage restriction; coverage applies only when the member meets the minimum or maximum age specified for the product.
Applies toVarious therapeutic classes and devices (examples in these chunks: diagnostic products, vaccines, digestive aids, CGM devices/readers/sensors).
Evidence in formularyEntries show AGE alongside Requirements / Limits for numerous classes (see AGE index listings and device rows such as Dexcom G6/G7 and FreeStyle Libre sensors/readers).
ConsequenceItems flagged with AGE require verification of member age to be approved; lack of age criteria documentation may lead to denial.
Implementation noteExact minimum/maximum ages are specified on the formulary per product row; refer to the product entry for the precise age requirement.
inv-17: Dose-specific tiering
ExampleKISQALI dose-specific entries: 400 mg and 600 mg doses are assigned Drug Tier = 5 with Requirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Lock).
MeaningDose-specific tiering assigns different formulary tier and utilization controls based on the product dose strength.
ImplicationPrescribers and pharmacists must check the exact dose listed to determine applicable tier and whether PA/QL/SUM7 apply at that dose level.
Other oncology examplesVERZENIO and select antineoplastics also show PA, QL, SUM7 tied to specific doses or strengths in the formulary extract.
inv-18: AGE (age-based limits)
PresenceAGE flags are used for select products and devices (for example: erythromycin suspensions and multiple CGM readers/sensors list AGE in Requirements / Limits).
Device examplesDexcom G6 and G7 components and FreeStyle Libre sensors/readers include AGE alongside ST and QL in their product rows.
Formulary guidanceExact age thresholds are specified on individual product rows; consult the formulary entry for the precise age requirement when requesting coverage.
Insulin concentrated products (Humulin R U-500 and Humulin R U-500 KwikPen) require PA and are subject to QL.
Step therapy (ST) flags appear on specific products (examples: RASUVO, SOLIQUA, HARVONI, certain antipsoriatic biologics); failure to meet ST requirements may result in denial.
Devices and durable medical supplies (e.g., Dexcom G6/G7 sensors, transmitters, certain CGM devices) may require ST, QL, and AGE documentation for coverage.
Multiple glucose test strips and diagnostic test kits are listed with PA and QL — verify authorization before dispensing.
Requests for coverage of non-covered drugs may be submitted via the Drug Coverage Exception Form with supporting clinical rationale.
Denial risks: coverage may be denied or limited if PA, QL, ST, AGE, or SUM7 requirements are not met; requests that exceed quantity limits or lack required documentation are subject to denial.
inv-80: SUM7 — Specialty Pharmacy Lock
DefinitionSUM7 indicates Specialty Pharmacy Lock — the product must be dispensed through the payer's designated specialty pharmacy or specialty distribution channel.
ContextSUM7 typically appears for high-cost specialty biologics and antineoplastics and often accompanies PA and QL in product rows (e.g., AMJEVITA, CRESEMBA, KISQALI, GENOTROPIN).
ImplicationRequests for SUM7-designated products may be routed to the plan's specialty pharmacy; failure to use the required channel can result in denial or noncoverage.
inv-81: ST — Step Therapy definition
DefinitionST (Step Therapy): the member must try and have an inadequate response or intolerance to specified alternative therapies before the requested drug is covered.
Common useApplied to selected agents and devices in the formulary (examples: TEGRETOL-XR, TOPAMAX SPRINKLE, budesonide er, certain CGM readers/sensors).
Effect on authorizationDocumentation of prior trials of alternatives may be required when ST is indicated; failure to meet ST criteria can lead to denial.
inv-82: QL — Quantity Limit definition
DefinitionQL (Quantity Limit): a restriction on the amount of medication or number of units the plan will cover in a defined time period.
ScopeApplied across many drug classes and products in the formulary (examples in this extract include anticonvulsants, insulin products, test strips/lancets, topical agents).
When PA is requiredIf a requested quantity exceeds the plan's QL, prior authorization is required for coverage; exceeding limits without PA may result in noncoverage.
inv-83: Drug Tier — definition
DefinitionDrug Tier: a formulary classification that determines member cost-sharing (tiers range in this extract from 1 through 6).
Dose/delivery impactTier assignment may vary by strength or formulation (e.g., oncology doses assigned to higher tiers; KISQALI doses = Tier 5).
Relation to utilization controlsHigher-tier specialty drugs often carry additional controls such as PA, QL, and SUM7; check Requirements / Limits with the tier listing.
DefinitionSUM7 (Specialty Pharmacy Lock): a designation requiring that the medication be dispensed through the plan's designated specialty pharmacy or specialty distribution channel.
Typical productsApplied to specialty biologics, growth hormones, antineoplastics, and certain high-cost injectables (examples: AMJEVITA, CRESEMBA, GENOTROPIN, BIMZELX).
Coverage consequenceIf SUM7 requirements are not met (e.g., dispensing through incorrect channel), coverage may be denied or noncovered.
DefinitionSUM7 indicates the product must be dispensed via the payer's designated specialty pharmacy or site-of-care lock; often appears with PA and QL.
ExamplesCRESEMBA, KISQALI, RINVOQ, and many biologics in this extract are annotated SUM7 in their Requirements / Limits fields.
Provider actionPrescribers should route prescriptions to the plan's specialty pharmacy and include required PA documentation when SUM7 is present.
inv-86: PA — Prior Authorization definition
DefinitionPA (Prior Authorization): coverage requires approval from the payer prior to dispensing; without authorization the member may be liable for full cost.
Common pairingsPA is frequently listed with QL and SUM7 for specialty and high-cost agents (examples: sorafenib tosylate, CRESEMBA, octreotide acetate).
Required documentationPrescribers must submit clinical rationale and supporting documentation per the plan's prior authorization process when PA is indicated.
DefinitionQL (Quantity Limit): plan-specified limits on the number or amount of a product covered in a given period; noted in the product's Requirements / Limits field.
Widespread useQL appears across many classes including anticonvulsants, topical dermatologics, insulin products, diagnostic strips, and device supplies.
Authorization linkageWhere QL is exceeded, prior authorization may be required and claims may be denied without it.
Specialty dispensing requirementSUM7 requires specialty pharmacy/site-of-care dispensing for designated products; appears alongside PA and QL on many specialty agents.
ExamplesGENOTROPIN, CRESEMBA, KISQALI, BIMZELX and multiple antineoplastics show SUM7 in this extract.
inv-89: PA / QL — definitions (alternate)
PAPrior authorization: payer approval required before coverage is granted; documented in Requirements / Limits on product rows.
QLQuantity limits: plan-specific maximums on units or frequency; exceeding QL may require PA.
Operational notePA and QL commonly co-occur on specialty and oncology products; verify both when submitting an authorization request.
DefinitionSUM7 (Specialty Pharmacy Lock): product must be dispensed through designated specialty channels; used for many biologics and specialty injectables.
ImpactSUM7 frequently appears with PA and QL; prescribers should coordinate specialty pharmacy routing as part of the authorization process.
inv-91: QL — Quantity limit definition
DefinitionQL (Quantity Limit): the plan's limit on quantity dispensed in a time period; noted in Requirements / Limits and applied per product row.
Clinical implicationFor patients needing quantities above the QL, submit PA with clinical justification to request an exception.
inv-92: PA — Prior Authorization definition (alternate)
DefinitionPA (Prior Authorization): prior approval required from the plan before the drug will be covered; absence of PA can result in member liability.
DocumentationPA requests must include indication, prior therapies, and dosing information as applicable to the product's requirements.
DefinitionQL (Quantity Limit): a specified limit on the amount of product covered per time period; often listed per month or per device/year for sensors.
ExamplesLancets and test strips carry monthly QL; CGM sensors/transmitters are subject to QL and sometimes annual device limits.
inv-94: ST — Step Therapy definition (alternate)
DefinitionST (Step Therapy): member must try specified preferred alternatives and demonstrate inadequate response or intolerance before coverage of the requested agent.
ExamplesST is noted for select anticonvulsants, budesonide er, and certain CGM readers/sensors (FreeStyle Libre entries).
Provider actionSubmit documentation of prior trials when requesting coverage for ST-flagged products; failure to meet ST can result in denial.
inv-95: PA — Prior Authorization definition (alternate)
DefinitionPA (Prior Authorization): an approval process requiring submission to and acceptance by the payer before coverage is provided for the drug.
RiskWithout PA where indicated, the member may be responsible for the full retail price or coverage may be denied.
Common pairingPA often appears with QL and SUM7 on specialty, oncology, and high-cost agents in the formulary listed entries.
DefinitionQL (Quantity Limit): plan-enforced restriction on the amount of drug or device covered in a defined period; exceeding requires PA or exception.
Device exampleCGM sensors/transmitters and lancets are subject to QL (sensors often limited per year; lancets per month).
DefinitionSUM7: Specialty Pharmacy Lock / Site-of-Care restriction — requires dispensing via designated specialty pharmacy or site-of-care.
Use caseUsed for specialty biologics, growth hormones, antineoplastics, and certain high-cost agents listed with SUM7 in Requirements / Limits.
Operational impactAuthorization and dispensing workflows must follow SUM7 routing to avoid denial; documentation should note intended specialty pharmacy when submitted.
inv-98: ST — Step Therapy definition (alternate)
DefinitionST (Step Therapy): requirement to try specified alternatives first; listed as 'ST' in the Requirements / Limits field for certain products.
ExamplesTEGRETOL-XR, TOPAMAX SPRINKLE, budesonide er, and some CGM readers/sensors are flagged ST in the formulary extract.
inv-99: SUM7 (Specialty Pharmacy Lock) — plan designation
Plan designationSUM7 (Specialty Pharmacy Lock): a plan designation indicating specialty pharmacy/site-of-care dispensing is required for the product.
Common associationsFrequently listed with PA and QL for specialty and high-cost agents (e.g., CIMZIA, CRESEMBA, GENOTROPIN).
inv-100: PA — Prior authorization definition (alternate)
DefinitionPA (Prior Authorization): payer approval required before the plan will cover the medication; absence can lead to member responsibility or denial.
ExamplesPA is indicated for many antineoplastics, specialty injectables, and selected devices in the formulary extract.
DefinitionQL (Quantity Limit): a limit on quantity dispensed within a time period; noted in Requirements / Limits on product rows and enforced by the plan.
ExamplesAnticonvulsants, topical agents, test strips, lancets, insulin, and CGM sensors are shown with QL flags across the formulary extract.
inv-102: ST — Step therapy definition (alternate)
DefinitionST (Step Therapy): requirement to trial preferred therapy alternatives before the requested product is covered; documented as 'ST' in product rows.
Provider requirementWhen ST is present, prior therapy history should be included in authorization requests to demonstrate steps tried and failure/intolerance.
inv-103: QL — Quantity limits (CGM-related)
CGM-related QLCGM sensors/transmitters and some readers are subject to quantity limits; sensors often listed with annual or per-sensor limits (e.g., sensors flagged QL and ST).
Device examplesENLITE, Dexcom G6/G7 components, FreeStyle Libre sensors/readers show QL (and often ST/AGE) in their product rows.
ImplicationAuthorization requests for CGM devices should address QL, ST, and AGE criteria; where QL is exceeded, PA may be required.
inv-104: PA — Prior authorization (CGM chunk)
PA for CGMCertain CGM sensors and transmitters are designated PA and QL (examples: ENLITE GLUCOSE SENSOR; Guardian sensors/transmitters; MiniLink/MiniMed devices).
DocumentationAuthorization must document medical necessity and compliance with step therapy/age criteria where applicable for CGM coverage.
inv-105: ST — Step therapy (CGM chunk)
ST for CGMSome CGM readers and sensors are flagged ST (step therapy) requiring completion of specified step therapy before coverage (e.g., FreeStyle Libre entries).
Practical noteConfirm completion of required steps and include that information in the PA submission for ST-flagged CGM devices.
inv-106: AGE — Age-based coverage restriction (CGM chunk)
AGE for devicesAge-based coverage restrictions appear for select devices and formulations (e.g., erythromycin suspensions and many CGM sensors/readers list AGE alongside ST/QL).
ActionVerify member age against product-specific age criteria on the formulary row when submitting authorization for devices or age-limited medications.
See product row for the combination of controls that apply at initiation.
Aromatase inhibitors & relatedAnastrozole, exemestane, letrozole, leucovorin calcium and many others are listed with QL applied per product in the formulary.
ImplicationQL applies across many endocrine/oncology supportive agents; review each product row for specific limit details.
inv-135: contraceptives and others — QL indicated
ContraceptivesMany contraceptive brands and formulations are assigned QL in the formulary (examples: azurette, tri-estarylla, numerous combination oral products).
Practical noteQuantity limits for contraceptives may affect dispensing (e.g., pack size or refill frequency); check the product row for the QL specification.
inv-136..inv-141: select biologics and specialty agents — PA/QL/SUM7
EOHILIARequirements / Limits = PA, QL, SUM7 (Specialty Pharmacy Lock) as listed in the formulary.
BIMZELX and COSENTYXBoth listed with PA, QL, SUM7 indicating specialty controls and prior authorization for biologic antipsoriatics.
inv-142..inv-144: topical agents and diagnostic strips — QL/PA indicated
Topical agents & stripsTriamcinolone acetonide aerosol solution and multiple topical agents are indicated with QL; numerous blood glucose test strips/meters are listed with PA and QL.
Provider actionFor test strips and topical agents with QL/PA, include clinical justification when requesting quantities beyond limits.
inv-144..inv-148: test strips, lancets, CGM sensors/transmitters — QL/PA indicated
Range and scopeMany blood glucose test strips, meters, lancets, and CGM sensors/transmitters are subject to PA and/or QL in the formulary extract.
Precision XtraPrecision Xtra Ketone and Precision Xtra blood glucose products are listed with QL (Precision Xtra also shows ketone entry with QL).
Lancets and CGM sensorsLancets are subject to monthly QL; CGM sensors/transmitters are subject to QL and may have annual/device limits — examples include ENLITE, Dexcom G6/G7, FreeStyle Libre.