Formulary includes PA, QL, ST and related controls

The formulary includes coverage controls (PA, PA**, QL, ST, SP, MO). Refer to the Step Therapy and Prior Authorization sections of the Formulary for specific requirements for each drug.

• Symbols: PA = Prior Authorization; PA** = PA if Step Therapy not met; QL = Quantity Limit; ST = Step Therapy; SP = Specialty Pharmacy; MO = Mail Order (90-day)

Obtain Prior Authorization for PA‑designated drugs

Drugs marked 'PA' in the Coverage Requirements and Limits column require a prior authorization submitted by the Prescribing Provider; approvals are based on Sharp Health Plan clinical criteria and follow PA timelines (72 hours non‑urgent; 24 hours urgent/exigent).

• Submit PA by phone, fax, or electronic Prior Authorization form.
• If denied, member/provider may file an appeal as described in the Formulary.

PA and PA** require PA submission (PA** when ST unmet)

Drugs listed with 'PA' or 'PA**' require prior authorization; PA** indicates PA is required when Step Therapy has not been met and may be requested to bypass ST when medically necessary.

• PA** is Prior Authorization if Step Therapy not met; submit clinical justification to request bypass.

Meet step therapy tied to opioid Step Therapy Group IDs

Opioid products in Step Therapy Group OPIOID ER (2219‑M) and OPIOID IR COMBO (1358‑E) are subject to step therapy; coverage requires meeting the group criteria tied to those Step Therapy Group IDs.

• Check Step Therapy Group identifiers: OPIOID ER = 2219‑M; OPIOID IR COMBO = 1358‑E.

Opioid ER: document cumulative IR/ER prior exposure

For Opioid ER group (OPIOID ER 2219‑M) prior authorization/coverage requires prior opioid exposure: a cumulative ≥7‑day supply of an immediate‑release opioid in the past 90 days OR cumulative ≥30 days of an extended‑release opioid in the past 90 days.

• Document prior fills to show either: cumulative ≥7 days IR in 90 days, or cumulative ≥30 days ER in 90 days.

Opioid IR combo: allow up to 7‑day IR supply when no recent exposure

Opioid IR combo group (OPIOID IR COMBO PRODUCTS 1358‑E) allows coverage of up to a 7‑day supply of immediate‑release opioids if the member does not have at least a cumulative 7‑day opioid supply (IR or ER) within the past 90 days.

• Coverage limited to ≤7 days when no prior cumulative ≥7‑day opioid supply in prior 90 days.

Obtain PA and adhere to QLs for amphetamine‑class products

Many amphetamine‑class stimulants and related anorexiant/anti‑obesity agents require prior authorization and have quantity limits; providers must request PA and follow QL limits noted for each product.

• QL examples: 360 tabs/75 days, 180 tabs/75 days, 90 tabs/75 days, or mL limits for oral solutions.
• PA is required for patients age ≥19 for many listed products.

Obtain PA where formulary shows 'PA' for ADHD/related agents

Multiple ADHD/amphetamine‑class products show 'Coverage Requirements and Limits = PA'; providers must obtain prior authorization where PA is indicated before coverage is granted.

• Confirm product‑specific QL and age‑based PA (PA required for age ≥19) when submitting PA.

PA required for methylphenidate ER/patch in adults (age ≥19)

Methylphenidate extended‑release products and transdermal patch formulations require prior authorization and have specified quantity limits; PA is specifically required for members age ≥19 for listed methylphenidate ER/OSM/patch entries.

• QL examples for methylphenidate ER: 270, 180, or 90 tabs per 75 days depending on strength.
• Include age verification when requesting PA for age ≥19.

Route selected specialty immunomodulators via Specialty Pharmacy with PA and QL

Select specialty immunomodulators (e.g., upadacitinib, tofacitinib, apremilast) require prior authorization and must be routed via the specialty pharmacy; quantity limits apply per product.

• These agents are flagged SP and PA; QLs shown (e.g., upadacitinib QL 12 mL every 1 day; Otezla QL 55 or 41 tabs per interval).

Obtain PA for opioid products (high‑strength require PA)

Many opioid formulations are designated PA or PA**; high‑strength formulations explicitly require prior authorization—obtain PA before dispensing to avoid denial.

• High‑strength patches/tables (e.g., fentanyl ≥50 mcg/hr, hydrocodone ER high mg) require PA.
• PA** may apply for ER/ER products when ST not met.

Follow PA/ST and initial‑fill rules for opioid and buprenorphine products

Numerous opioid and buprenorphine products require prior authorization or step therapy; providers must follow PA/ST flags and initial‑fill limits where specified.

• Many products are ST or PA**; initial 7‑day limit applies (3‑day if age ≤19) for many liquids/tablets.
• Buprenorphine buccal films may be ST with QL (e.g., BELBUCA 60 films/25 days) and PA**.

Obtain PA (and satisfy MO) for selected topical/hormonal products

Several topical and hormonal androgen/testosterone products are listed with 'PA, MO' coverage requirements; providers must obtain prior authorization and follow any MO processes required by the plan.

• Examples: METHITEST, NATESTO gel and testosterone topical gels list PA and MO.

Follow MO and QL codes; do not exceed listed quantity limits

Products marked with MO or QL carry managed coverage or quantity limits; prescribers should follow the MO process if applicable and ensure prescriptions do not exceed listed QLs.

• MO entries may require medical/other authorization per plan practice.
• Claims may be denied if QLs (e.g., inhaler or mL limits) are exceeded.

Comply with MO/QL coverage codes when present

Coverage requirement codes (MO, QL) indicate that prescribers must meet the plan's managed‑coverage or quantity‑limit processes; prior authorization may be required where MO is indicated.

• MO often denotes coverage requirements or medical override pathways; follow instructions in Formulary.
• Submit PA with supporting documentation if MO/PA noted.

Oxtellar XR entries may require PA/MO prior to coverage

Some branded extended‑release oxcarbazepine (Oxtellar XR) entries are shown with DRUG TIER = 2 and coverage requirement 'MO', implying prior authorization/management oversight may be required for coverage.

• Confirm MO/PA requirements for Oxtellar XR strengths (150/300/600 mg) when submitting authorization.

PA and Specialty Pharmacy routing required for ZURZUVAE (zuranolone)

Certain products (e.g., ZURZUVAE/zuranolone) require prior authorization and must be routed through specialty pharmacy; PA and QL enforcement apply for listed strengths.

• ZURZUVAE is flagged SP, PA, QL — QL: 2 caps/day for 20/25 mg; 1 cap/day for 30 mg.
• Submit PA and route via Sharp Health Plan specialty network (CVS Specialty) per site‑of‑care rules.

Obtain PA for selected incretin‑mimetic agents

Several incretin‑mimetic agents (Mounjaro, Ozempic, Rybelsus, Trulicity) are designated 'PA' (some also 'MO'); prescribers must obtain prior authorization for these agents before coverage.

• Mounjaro, Ozempic, Rybelsus and Trulicity list PA; some strengths also show MO.
• Include required clinical documentation with PA submission.

Step Therapy section applies to multiple classes

The Formulary includes a Step Therapy Criteria section; drugs marked 'ST' require step adherence and providers should consult the Step Therapy Criteria for class‑specific step rules.

• Step Therapy exceptions may be requested via the Prior Authorization process with clinical justification.

Require and document trials for Step Therapy; submit exceptions via PA

Sharp Health Plan may require trials of specified drugs (Step Therapy) before covering higher‑step agents; providers may submit Step Therapy Exception requests with clinical justification via the PA process.

• If ST exception is requested, decision timelines follow PA timelines (72 hours non‑urgent; 24 hours urgent/exigent).

Submit Step Therapy Exceptions via Prior Authorization with clinical justification

Providers may submit a Step Therapy Exception with clinical justification through the Prior Authorization process; Step Therapy Exception requests follow PA decision timelines (72 hours non‑urgent; 24 hours urgent/exigent).

• If Plan fails to respond within timelines, a completed request is deemed granted.
• Include clinical rationale and supporting documentation with the exception request.

Ensure member meets supply‑history thresholds under Step Therapy

Members must meet the Step Therapy supply‑history thresholds for coverage; prescribers should document prior fills and supply to demonstrate step fulfillment as defined in the Step Therapy Criteria.

• Opioid thresholds: cumulative ≥7 days IR in past 90 days or cumulative ≥30 days ER in past 90 days.
• For IR combo, document absence of prior cumulative ≥7‑day opioid supply to support a ≤7‑day allowance.

Document prior opioid exposure per opioid step therapy rules

Coverage for many opioid ER/IR agents is contingent on prior short‑term IR opioid exposure or prior ER opioid use as specified by the opioid step therapy group rules; document prior opioid use accordingly.

• Document dates, agent names, and days' supply of prior opioid fills to show step criteria fulfillment.

When Step Therapy not specified, follow PA/MO/QL flags

Some sections do not specify explicit Step Therapy rules in this extract; when ST is not shown, follow PA/MO/QL flags indicated for the product.

• If ST is not listed, check Coverage Requirements column for PA, QL, MO and follow those processes.

Submit PA with required clinical information; timelines apply

PA requests must be submitted by the Prescribing Provider (phone/fax/electronic) with supporting clinical information; determinations are made within 72 hours for non‑urgent requests and within 24 hours for urgent/exigent requests.

• Incomplete requests will trigger notification of needed information within 72 hours (24 hours if exigent).
• If Sharp Health Plan fails to respond within timelines to a completed PA request, the request is deemed granted.

Provide complete supporting documentation with PA to avoid delays

Providers must supply all required supporting clinical information when submitting a PA; incomplete or missing information will prompt a request for additional information and can delay determinations.

• Notification of missing info: within 72 hours (24 hours exigent).
• Decisions issued within 72 hours (non‑urgent) or 24 hours (urgent/exigent) after receipt of all required info.

Document cumulative opioid supply thresholds (7‑day IR or 30‑day ER within 90 days)

For opioid step therapy, documentation must show cumulative supply thresholds: at least a cumulative 7‑day supply of IR opioid within the past 90 days or at least a cumulative 30‑day supply of ER opioid within the past 90 days.

• Include prior fill dates, agent names, and days' supply to demonstrate the cumulative thresholds.

Include prior opioid fill details when requesting opioid PA

When requesting PA for opioids under step therapy, include prior opioid fill records (dates, agent, and days' supply) to demonstrate fulfillment of step criteria.

• Records should cover the prior 90‑day period and show cumulative days' supply.

Provide age and justification for amphetamine/anorexiant PA requests (age ≥19)

When requesting PA for amphetamine/anorexiant products for patients age ≥19, prescribers must provide the member's age and clinical justification supporting medical necessity.

• Age verification is required for PA (many entries state 'PA Required for age ≥19').
• If requesting quantities above QL, supply medical necessity rationale.

Supply medical necessity documentation for methylphenidate ER/patch PA

Prescribers should include clinical documentation supporting medical necessity when requesting prior authorization for methylphenidate ER/OSM/patch formulations and related PA‑designated stimulant entries.

• Include indication, prior therapies tried (if applicable), and age when member is ≥19.

Adhere to initial‑fill limits (7‑day standard; 3‑day if age ≤19)

Initial‑fill limits apply to many opioid products: a standard initial 7‑day limit for adults and an initial 3‑day limit for patients age 19 or younger; documentation may be required for overrides.

• Apply initial 7‑day limit for adult initial fills; if member is ≤19, initial 3‑day limit applies.
• Document clinical rationale if requesting override of initial‑fill limits.

Provide PA/ST documentation per product designations

Prior authorization documentation is required for PA‑designated products and for PA** or high‑strength designations; Step Therapy (ST) may require additional documentation for exception requests.

• Include clinical justification, prior treatment history, and any requested quantity rationale for PA/ST decisions.

Formulary is subject to change — verify current version

This Formulary document is subject to change and prior versions are not in effect; providers should verify current Formulary status as coverage may change with updates.

• Check the online electronic drug list for the most current Formulary updates (last updated 04/01/2026).

Risk of PA denial — appeals available

Prior Authorization requests may be denied if supporting information does not meet Sharp Health Plan clinical policies; denied requests may be appealed by the member, authorized representative, or prescribing provider.

• If PA is denied, follow the Formulary 'You Have the Right to Appeal' instructions and timelines.

Nonformulary coverage requires a Formulary Exception (appealable)

Nonformulary drugs are not covered unless a Formulary Exception is approved via the Prior Authorization/Formulary Exception process; denials of exceptions can be appealed.

• If a nonformulary drug is approved, Tier 3 cost share applies for brand‑name; Tier 1 applies for generic nonformulary approvals.

Step Therapy non‑fulfillment may cause coverage denial

Coverage may be denied if the member does not meet Step Therapy supply thresholds (e.g., no cumulative 7‑day IR opioid supply in past 90 days and not receiving cumulative 30‑day ER opioid use in past 90 days).

• Verify prior opioid supply before submitting PA for opioid ER group; absence of required prior use may trigger denial.

Opioid Step Therapy denial trigger if criteria unmet

Requests may be denied for opioid Step Therapy groups if step criteria are not met (no recent IR opioid fill ≥7 days in past 90 days or no cumulative ER opioid use ≥30 days in past 90 days).

• Ensure opioid step thresholds are documented in the PA to avoid denial.

AMPHETAMINES: PA/QL denials possible if age or QL requirements not met

Prior authorization denials for amphetamine products can occur if age requirements (PA required for age ≥19) or quantity limits are not met or supported by documentation.

• Include age and medical justification when PA required for patients age ≥19.
• Provide rationale when requesting quantities exceeding listed QLs.

Claims may be denied if PA is not obtained for PA‑flagged drugs

Coverage for products marked 'PA' may be denied if prior authorization is not obtained before dispensing; obtain PA to prevent claim denial.

• Verify PA requirement on the Formulary entry before prescribing/dispensing.

Methylphenidate ER/patch: PA required — risk of denial if not obtained

Prior authorization is a trigger for methylphenidate ER/OSM/patch products; PA is required for many strengths and for members age ≥19 — failure to obtain PA risks denial.

• Confirm PA requirement and include age/clinical justification in the PA submission.

PA required for modafinil, allergenics and certain specialty agents

PA is required for modafinil and listed allergenic biologics, and for select specialty agents (e.g., upadacitinib, tofacitinib, apremilast); lack of PA can lead to denial.

• Modafinil entries show PA and MO; specialty immunomodulators show SP and PA.

Obtain PA for select incretin agents to avoid denial

Prescriptions for select incretin mimetic agents (Mounjaro, Ozempic, Rybelsus, Trulicity) list 'PA' (and sometimes 'MO'); prescribers must obtain prior authorization before coverage is approved.

• Include required clinical information when submitting PA for incretin agents.

Use network retail, specialty, or mail order pharmacy for coverage

Outpatient prescription drugs are covered only when dispensed through network retail, specialty, or mail‑order pharmacies; specialty drugs must be filled by the Sharp Health Plan specialty network pharmacy (CVS Specialty) and are limited to 30‑day supply per fill.

• Specialty fills: route via CVS Specialty; mail order for maintenance drugs via CVS Caremark (90‑day eligible).

Specialty Pharmacy requirement and 30‑day supply limit

Specialty drugs must be dispensed through the Sharp Health Plan specialty network pharmacy (CVS Specialty) and are limited to a 30‑day supply per fill; ensure specialty routing for SP‑flagged products.

• Enroll at CVSspecialty.com for specialty drug fulfillment; SP entries also often require PA and QL.