List of Covered Prescription Drugs (4-Tier Large Group HMO/POS)
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This document is the Sharp Health Plan prescription drug list (formulary) for employer-sponsored Large Group HMO and POS products that use a 4-tier formulary. It governs covered outpatient prescription drugs, plan-specific cost-sharing information, and formulary management for affected commercial employer groups.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Governance
Formulary scope and governance
Coverage is organized by therapeutic class and includes governance on definitions, formulary changes, prior authorization, quantity limits, step therapy, specialty drugs, and appeals.
Formulary maintained and updated periodically; see Definitions and Table of Contents for scope.
General formulary coverage rules
Covered when ALL of the following are met
Presence on the Formulary does not guarantee appropriate prescribing for a specific patient.
Refer to Member Handbook for Medical Benefit cost‑sharing and coverage details.
Authorization requirements
Prior Authorization and Step Therapy conditions
Providers submit PA by phone, fax, or electronic form; if Plan fails to respond within the timeframe a completed request is deemed granted.
Providers may request PA to bypass Step Therapy when medically necessary and must submit supporting clinical documentation.
Utilization Management Criteria
Coverage decisions and exceptions for outpatient prescription drugs are governed as follows:
If incomplete, the plan will notify the provider what additional information is needed within the same timeframes.
QLs are imposed for safety, overdose/abuse risk, or to reflect usual dosing; requests exceeding QL require justification.
Members transitioning from another plan who are already taking the medication are generally exempt to preserve continuity of care.
If approved, coverage (including refills) is provided for the duration indicated; nonformulary brand on approval is Tier 3, nonformulary generic is Tier 1.
Formulary Exception Criteria
Nonformulary drugs and formulary exceptions are handled as follows:
If approved, coverage (and refills) will be provided for the duration of the prescription; cost share will be applied per tier rules.
Opioid ER step therapy (Group 2219-M)
Covered when ONE of the following is met:
Satisfies step therapy for Step Therapy Group OPIOID ER 2219‑M.
Satisfies step therapy for Step Therapy Group OPIOID ER 2219‑M.
Opioid IR combo short-course coverage
Special allowance for short-course IR opioids:
Applies to OPIOID IR COMBO PRODUCTS (Group 1358‑E).
Coverage criteria (step therapy and PA/QL)
Coverage conditions and limits for step therapy and stimulant/weight‑management agents
From Step Therapy Group OPIOID ER 2219‑M.
From Step Therapy Group OPIOID IR COMBO PRODUCTS 1358‑E.
Includes WEGOVY and other anti‑obesity agents where PA is indicated.
Covered with conditions
Coverage requirements and limits vary by product; many are covered with conditions
Providers must follow the Formulary entry controls for each drug.
Stimulant product coverage
Methylphenidate products
Quantity limits typically apply (e.g., 90 or 180 units per 75 days depending on product/strength).
Antirheumatic coverage
JAK inhibitors and related antirheumatic agents
Examples: RINVOQ formulations listed with SP, PA, QL per indication.
Apremilast (Otezla) coverage
PDE4 inhibitors (apremilast)
Preferred for Psoriasis and Psoriatic Arthritis per formulary notes.
Low-dose aspirin coverage
Aspirin 81 mg
Otherwise aspirin 81 mg is not covered under the outpatient formulary.
Opioid product controls
Opioid analgesics
High‑strength fentanyl patches and certain ER products require PA or PA** and may be subject to ST.
Covered with Criteria
Coverage is product-specific with tiering and utilization controls. Generally covered when formulary rules (PA/QL/ST) and age limits are met.
Applies broadly across opioid and combination analgesic entries.
Age-Based Exclusions / Limits
Products not available for certain pediatric ages.
Examples include selected tramadol ER and some combination products.
Formulary coverage with utilization management
Coverage is provided according to drug tier but subject to the following utilization management controls where specified.
Providers should consult the Formulary entry for exact controls per product and strength.
Buprenorphine/Buprenorphine-naloxone products
Coverage varies by formulation and strength with explicit PA/QL rules.
High strengths (e.g., 600 mcg and above) require PA.
Some patches are also subject to ST.
Opioid combination analgesics
Immediate coverage subject to limits and age‑based initial fill rules.
Examples: TREZIX and other combination caps with QL (300 caps/25 days) or 48 caps/25 days for certain butalbital combos.
Formulary coverage with quantity limits
Coverage and limits are presented per drug and formulation with drug tier and quantity limit rules:
Examples include QL (3 inhalers every 75 days), QL (720 mL every 75 days), QL (9 inhalers every 75 days).
General coverage determination
Coverage is determined per product with assigned drug tier and coverage requirement flags; drugs are covered subject to those flags and quantity limits where specified.
Some entries marked MO indicate managed/maintenance handling; PA flags require pre‑approval.
Product-level coverage flags
Coverage and utilization management flags applied at product level
Examples: RELGAABI listed with PA and MO; ZURZUVAE listed SP, PA, QL.
Formulary listing with managed coverage
Coverage stance is presented per drug entry with tier and 'COVERAGE REQUIREMENTS AND LIMITS' shorthand.
Providers should include drug name, strength, quantity, and indication on PA requests as listed in the Formulary.
Formulary coverage entries
Coverage and utilization flags for listed drugs — considered covered subject to indicated PA, MO, and QL requirements
Refer to each product entry for exact PA/MO designation and QL where present.
See Formulary lines for RELION not covered statements and product‑level MO flags.
This Formulary is the Sharp Health Plan electronic Prescription Drug List and is subject to change; all prior versions are no longer in effect. Providers and pharmacies must use the online formulary for current coverage and member cost-sharing information. Exclusions and limitations to the outpatient prescription drug benefit are listed in the Formulary and Member Handbook and apply as described; failure to adhere to current formulary requirements may result in noncoverage or different cost sharing.
Drugs and supplies that fall within exclusions for the outpatient prescription drug benefit as described in the Member Handbook are not eligible under the pharmacy benefit. Examples include physician‑administered or self‑injectable drugs that are covered under the Medical Benefit, and items excluded by the plan such as certain medical devices or office‑administered products; refer to the Member Handbook for full details on benefit carve‑outs and coverage responsibility.
The Plan does not cover drugs prescribed solely for cosmetic purposes, hair loss, sexual dysfunction, athletic performance, or anti‑aging for cosmetic reasons. Drugs prescribed only to shorten the duration of the common cold, prescription replacements for lost or stolen drugs, and certain products for non‑covered procedures by non‑contracting providers are also excluded. Several combination analgesic products and butalbital combinations are explicitly noted as not available under age 12 in the formulary entries where indicated.
When a generic equivalent exists, Sharp Health Plan will require dispensing of the generic and does not cover the brand‑name equivalent unless a prior authorization documents medical necessity. Interchangeable biologic substitution may also be required unless prior authorization for the reference product demonstrates medical necessity.
Certain generic amphetamine products and many stimulant agents carry utilization controls that include prior authorization and quantity limits; in particular, many listed amphetamine generics require PA for members age ≥ 19 (age‑based PA) as noted on the formulary.
Low‑dose aspirin (81 mg chewable or delayed‑release) is generally not covered except for members who are capable of pregnancy aged 12–59 years at risk for preeclampsia, for whom the formulary provides a $0 copay benefit for aspirin 81 mg.
Selected tramadol extended‑release formulations and some opioid combination products are explicitly listed as Not available under age 12. Age‑based initial supply limits also apply for many controlled combination analgesics (standard initial 7‑day supply for adults; initial 3‑day supply for members age 19 or younger) as shown in the formulary entries.
Formulary Listings and Code Tables
| No codes listed |
| No codes listed |
| 2219-M | OPIOID ER Step Therapy Group identifier |
| 1358-E | OPIOID IR COMBO PRODUCTS Step Therapy Group identifier |
| AMPHETAMINE sulfate tab 5 mg | generic amphetamine sulfate tab 5 mg (PA, QL (360 tabs every 75 days); PA required for age >=19) |
| AMPHETAMINE sulfate tab 10 mg | generic amphetamine sulfate tab 10 mg (PA, QL (360 tabs every 75 days); PA required for age >=19) |
| AMPHETAMINE ER disintegrating tab 3.1 mg | generic amphetamine extended release disintegrating 3.1 mg (PA, QL (180 tabs every 75 days); PA required for age >=19) |
| AMPHETAMINE ER disintegrating tab 6.3 mg | generic amphetamine extended release disintegrating 6.3 mg (PA, QL (180 tabs every 75 days); PA required for age >=19) |
| AMPHETAMINE ER disintegrating tab 9.4 mg | generic amphetamine extended release disintegrating 9.4 mg (PA, QL (180 tabs every 75 days); PA required for age >=19) |
| AMPHETAMINE ER disintegrating tab 12.5 mg | generic amphetamine extended release disintegrating 12.5 mg (PA, QL (90 tabs every 75 days); PA required for age >=19) |
| AMPHETAMINE ER disintegrating tab 15.7 mg | generic amphetamine extended release disintegrating 15.7 mg (PA, QL; PA required for age >=19) |
| WEGOVY TAB 1.5MG | semaglutide (weight management) — COVERAGE REQUIREMENTS = PA |
| WEGOVY TAB 4MG | semaglutide (weight management) — COVERAGE REQUIREMENTS = PA |
| WEGOVY TAB 9MG | semaglutide (weight management) — COVERAGE REQUIREMENTS = PA |
| WEGOVY TAB 25MG | semaglutide (weight management) — COVERAGE REQUIREMENTS = PA, MO |
| atomoxetine hcl cap (various strengths) | atomoxetine HCl — COVERAGE REQUIREMENTS = PA, QL (360 caps every 75 days); PA required for age >=19 |
| AZSTARYS CAP (various strengths) | serdexmethylphenidate chloride-dexmethylphenidate HCl — COVERAGE REQUIREMENTS = PA, QL (90 caps every 75 days) |
| SUNOSI TAB 75MG | solriamfetol HCl |
| SUNOSI TAB 150MG | solriamfetol HCl |
| WAKIX TAB 4.45MG | pitolisant HCl |
| WAKIX TAB 17.8MG | pitolisant HCl — COVERAGE REQUIREMENTS = SP, PA, QL (2 tabs every 1 day) |
| methylphenidate hcl tab er diffusion 27 mg | methylphenidate ER diffusion 27 mg — COVERAGE REQUIREMENTS = PA, QL (180 tabs every 75 days); PA required for age >=19 |
| methylphenidate hcl tab er diffusion 36 mg | methylphenidate ER diffusion 36 mg — COVERAGE REQUIREMENTS = PA, QL (180 tabs every 75 days); PA required for age >=19 |
| methylphenidate hcl tab er diffusion 54 mg | methylphenidate ER diffusion 54 mg — COVERAGE REQUIREMENTS = PA, QL (90 tabs every 75 days); PA required for age >=19 |
| methylphenidate hcl tab er osmotic release (osm) 18 mg | methylphenidate OROS 18 mg — COVERAGE REQUIREMENTS = PA, QL (180 tabs every 75 days); PA required for age >=19 |
| methylphenidate hcl tab er osmotic release (osm) 27 mg | methylphenidate OROS 27 mg — COVERAGE REQUIREMENTS = PA, QL (180 tabs every 75 days); PA required for age >=19 |
| methylphenidate hcl tab er osmotic release (osm) 36 mg | methylphenidate OROS 36 mg — COVERAGE REQUIREMENTS = PA, QL (180 tabs every 75 days); PA required for age >=19 |
| methylphenidate hcl tab er osmotic release (osm) 54 mg | methylphenidate OROS 54 mg — COVERAGE REQUIREMENTS = PA, QL (90 tabs every 75 days); PA required for age >=19 |
| methylphenidate hcl tab er osmotic release (osm) 72 mg | methylphenidate OROS 72 mg — COVERAGE REQUIREMENTS = PA, QL (90 tabs every 75 days); PA required for age >=19 |
| methylphenidate td patch 10 mg/9hr | methylphenidate transdermal patch 10 mg/9hr — COVERAGE REQUIREMENTS = PA, QL (90 patches every 75 days); PA required for age >=19 |
| methylphenidate td patch 15 mg/9hr | methylphenidate transdermal patch 15 mg/9hr — COVERAGE REQUIREMENTS = PA, QL (90 patches every 75 days); PA required for age >=19 |
| modafinil tab 100 mg | modafinil 100 mg tablet — COVERAGE REQUIREMENTS = PA, MO |
| modafinil tab 200 mg | modafinil 200 mg tablet — COVERAGE REQUIREMENTS = PA, MO |
| GRASTEK SUB 2800BAU | timothy grass pollen allergen extract (Grastek) — COVERAGE REQUIREMENTS = PA, MO |
| ODACTRA SUB | dust mite mixed allergen extract (Odactra) — COVERAGE REQUIREMENTS = PA, MO |
| ORALAIR SUB 300 IR | grass mixed pollens allergen extract (Oralair) — COVERAGE REQUIREMENTS = PA, MO |
| RAGWITEK SUB | short ragweed pollen allergen extract (Ragwitek) — COVERAGE REQUIREMENTS = PA, MO |
| RINVOQ LQ SOL 1MG/ML | upadacitinib solution 1 mg/mL — COVERAGE REQUIREMENTS = SP, PA, QL (12 mL every 1 day) |
| RINVOQ TAB 15MG ER | upadacitinib 15 mg ER tablet — COVERAGE REQUIREMENTS = SP, PA, QL (1 tab every 1 day) |
| RINVOQ TAB 30MG ER | upadacitinib 30 mg ER tablet — COVERAGE REQUIREMENTS = SP, PA, QL (1 tab every 1 day) |
| RINVOQ TAB 45MG ER | upadacitinib 45 mg ER tablet — COVERAGE REQUIREMENTS = SP, PA, QL (84 tabs every 84 days) |
| XELJANZ SOL 1MG/ML | tofacitinib solution 1 mg/mL — COVERAGE REQUIREMENTS = SP, PA, QL (10 mL every 1 day) |
| XELJANZ TAB 5MG | tofacitinib 5 mg tablet — COVERAGE REQUIREMENTS = SP, PA, QL (2 tabs every 1 day) |
| XELJANZ TAB 10MG | tofacitinib 10 mg tablet — COVERAGE REQUIREMENTS = SP, PA, QL (2 tabs every 1 day) |
| XELJANZ XR TAB 11MG | tofacitinib XR 11 mg tablet — COVERAGE REQUIREMENTS = SP, PA, QL (1 tab every 1 day) |
| OTEZLA TAB 20MG | apremilast 20 mg tablet — COVERAGE REQUIREMENTS = SP, PA, QL (55 tabs every 28 days) |
| OTEZLA TAB 30MG | apremilast 30 mg tablet — COVERAGE REQUIREMENTS = SP, PA, QL (2 tabs every 1 day) |
| OTEZLA XR TAB 75MG | apremilast XR 75 mg tablet — COVERAGE REQUIREMENTS = SP, PA, QL (1 tab every 1 day) |
| Aspirin Chew Tab 81 mg | aspirin chewable 81 mg — COVERAGE REQUIREMENTS = MO, QL (100 tabs every 30 days); $0 copay for members capable of pregnancy age 12-59 at risk for preeclampsia |
| aspirin tab delayed release 81 mg | aspirin delayed-release 81 mg — COVERAGE REQUIREMENTS = MO, QL (100 tabs every 30 days); $0 copay for members capable of pregnancy age 12-59 at risk for preeclampsia |
| fentanyl td patch 72hr 12 mcg/hr | fentanyl transdermal patch 12 mcg/hr — COVERAGE REQUIREMENTS = ST, QL (10 patches every 25 days); PA** |
| fentanyl td patch 72hr 25 mcg/hr | fentanyl transdermal patch 25 mcg/hr — COVERAGE REQUIREMENTS = ST, QL (10 patches every 25 days); PA** |
| fentanyl td patch 72hr 37.5 mcg/hr | fentanyl transdermal patch 37.5 mcg/hr — COVERAGE REQUIREMENTS = ST, QL (10 patches every 25 days); PA** |
| fentanyl td patch 72hr 50 mcg/hr | fentanyl transdermal patch 50 mcg/hr — COVERAGE REQUIREMENTS = PA; High Strength Requires PA |
| hydrocodone bitartrate cap er 12hr 10 mg | hydrocodone ER 10 mg cap (12 hr) — COVERAGE REQUIREMENTS = ST, QL (60 caps every 25 days); PA** |
| codeine sulfate tab 30 mg | generic codeine sulfate 30 mg tablet — COVERAGE REQUIREMENTS = PA, QL (42 tabs every 25 days); initial 7-day limit; if age <=19 initial 3-day limit |
| hydrocodone-acetaminophen soln 7.5-325 mg/15ml | hydrocodone-acetaminophen solution — COVERAGE REQUIREMENTS = PA, QL (2700 mL every 25 days); subject to initial limits |
| acetaminophen w/ codeine soln 120-12 mg/5ml | acetaminophen with codeine solution — COVERAGE REQUIREMENTS = ST, QL (2700 mL every 25 days); PA**; subject to initial limits |
| acetaminophen w/ codeine tab 300-15 mg | acetaminophen with codeine tab 300-15 mg — COVERAGE REQUIREMENTS = ST, QL (400 tabs every 25 days); PA**; subject to initial limits |
| acetaminophen w/ codeine tab 300-30 mg | acetaminophen with codeine tab 300-30 mg — COVERAGE REQUIREMENTS = ST, QL (360 tabs every 25 days); PA**; subject to initial limits |
| acetaminophen w/ codeine tab 300-60 mg | acetaminophen with codeine tab 300-60 mg — COVERAGE REQUIREMENTS = ST, QL (180 tabs every 25 days); PA**; subject to initial limits |
| acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg | acetaminophen-caffeine-dihydrocodeine cap — COVERAGE REQUIREMENTS = ST, QL (300 caps every 25 days); PA**; subject to initial limits |
| Butalbital-Acetaminophen-Caffeine cap | butalbital combinations — COVERAGE REQUIREMENTS = QL (48 caps every 25 days); Not available under age 12 |
| TREZIX (acetaminophen-caffeine-dihydrocodeine) | TREZIX cap 320.5-30-16 mg — COVERAGE REQUIREMENTS = ST, QL (300 caps every 25 days); PA**; subject to initial limits |
| QL (150 tabs every 25 days) | Quantity limit for alprazolam formulations as listed |
| QL (90 tabs every 25 days) | Quantity limit for alprazolam ER 3 mg |
| QL (360 caps every 25 days) | Quantity limit for chlordiazepoxide caps |
| QL (240 mL every 25 days) | Quantity limit for diazepam concentrate |
| QL (1200 mL every 25 days) | Quantity limit for diazepam oral solution |
| QL (150 mL every 25 days) | Quantity limit for lorazepam concentrate/tabs (example) |
| QL (720 mL every 75 days) | Quantity limit for cromolyn sodium nebule |
| QL (6 inhalers every 75 days) | Quantity limit for ipratropium HFA inhaler |
| QL (938 mL every 75 days) | Quantity limit for ipratropium inhalation solution |
| QL (90 caps every 75 days) | Quantity limit for Spiriva HandiHaler caps |
| QL (3 inhalers every 75 days) | Quantity limit for Spiriva Respimat inhalers |
| QL (270 mL every 75 days) | Quantity limit for revefenacin (YUPELRI) nebule |
| rivaroxaban tab 2.5 mg | generic rivaroxaban — COVERAGE REQUIREMENTS = MO |
| XARELTO TAB 10MG | rivaroxaban — COVERAGE REQUIREMENTS = MO |
| XARELTO TAB 15MG | rivaroxaban — COVERAGE REQUIREMENTS = MO |
| XARELTO TAB 20MG | rivaroxaban — COVERAGE REQUIREMENTS = MO |
| XARELTO SUS 1MG/ML | rivaroxaban suspension — COVERAGE REQUIREMENTS = MO |
| dabigatran etexilate mesylate cap 75 mg | dabigatran — COVERAGE REQUIREMENTS = MO |
| dabigatran etexilate mesylate cap 110 mg | dabigatran — COVERAGE REQUIREMENTS = MO |
| dabigatran etexilate mesylate cap 150 mg | dabigatran — COVERAGE REQUIREMENTS = MO |
| clobazam suspension 2.5 mg/ml | clobazam suspension — COVERAGE REQUIREMENTS = MO |
| clobazam tab 10 mg | clobazam 10 mg tablet — COVERAGE REQUIREMENTS = MO |
| clobazam tab 20 mg | clobazam 20 mg tablet — COVERAGE REQUIREMENTS = MO |
| clonazepam orally disintegrating tab 0.125 mg | generic clonazepam ODT 0.125 mg — COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| clonazepam orally disintegrating tab 0.25 mg | COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| clonazepam orally disintegrating tab 0.5 mg | COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| clonazepam orally disintegrating tab 1 mg | COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| clonazepam orally disintegrating tab 2 mg | COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| clonazepam tab 0.5 mg | COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| clonazepam tab 1 mg | COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| clonazepam tab 2 mg | COVERAGE REQUIREMENTS = QL (300 tabs every 25 days) |
| diazepam rectal gel delivery system 2.5 mg | diazepam rectal gel — DRUG TIER = 1 |
| diazepam rectal gel delivery system 10 mg | diazepam rectal gel — DRUG TIER = 1 |
| diazepam rectal gel delivery system 20 mg | diazepam rectal gel — DRUG TIER = 1 |
| NAYZILAM SPR 5MG | midazolam spray — DRUG TIER = 2 |
| VALTOCO SPR 5MG | diazepam nasal spray — DRUG TIER = 2 |
| VALTOCO SPR 15MG | diazepam nasal spray — DRUG TIER = 2 |
| brivaracetam oral soln 10 mg/ml | brivaracetam oral solution — AND LIMITS = MO (table shows numeric limits) |
| BRIVIACT SOL 10MG/ML | brand brivaracetam solution — AND LIMITS = 2, MO |
| BRIVIACT TAB 10MG | brivaracetam tablet — AND LIMITS = 2, MO |
| carbamazepine cap er 12hr 100 mg | carbamazepine — AND LIMITS = MO |
| CARBATROL CAP 100MG | brand carbamazepine — AND LIMITS = 2, MO |
| eslicarbazepine acetate tab 200 mg | eslicarbazepine acetate — AND LIMITS = MO |
| gabapentin cap 100 mg | gabapentin — AND LIMITS = MO |
| lacosamide oral solution 10 mg/ml | lacosamide solution — AND LIMITS = MO |
| lacosamide tab 50 mg | lacosamide tablet — AND LIMITS = MO |
| lamotrigine various tabs and starter kits | multiple lamotrigine formulations — COVERAGE REQUIREMENTS = MO |
| levetiracetam oral soln 100 mg/ml and tabs | levetiracetam formulations — COVERAGE REQUIREMENTS = MO |
| oxcarbazepine susp 300 mg/5ml and tabs | oxcarbazepine — COVERAGE REQUIREMENTS = MO |
| pregabalin cap 25–300 mg and soln | pregabalin formulations — COVERAGE REQUIREMENTS = MO |
| RELGAABI CAP 200MG | brand gabapentin 200 mg — COVERAGE REQUIREMENTS = PA, MO |
| rufinamide susp 40 mg/ml and tabs 200/400 mg | rufinamide — COVERAGE REQUIREMENTS = MO |
| topiramate ER caps and oral soln | topiramate formulations — COVERAGE REQUIREMENTS = MO |
| RELGAABI CAP 200MG | (brand gabapentin) — COVERAGE REQUIREMENTS = PA, MO |
| pregabalin cap 75 mg | pregabalin capsule — COVERAGE REQUIREMENTS = MO |
| XCOPRI TAB 25MG | cenobamate — COVERAGE REQUIREMENTS = MO |
| ZURZUVAE CAP 20MG | zuranolone — COVERAGE REQUIREMENTS = SP, PA, QL (2 caps every 1 day) |
| TRINTELLIX TAB 5MG | vortioxetine hbr — COVERAGE REQUIREMENTS = MO |
| TRINTELLIX TAB 10MG | vortioxetine hbr — COVERAGE REQUIREMENTS = MO |
| TRINTELLIX TAB 20MG | vortioxetine hbr — COVERAGE REQUIREMENTS = MO |
| vilazodone hcl tab 10 mg | vilazodone — COVERAGE REQUIREMENTS = MO |
| vilazodone hcl tab 20 mg | vilazodone — COVERAGE REQUIREMENTS = MO |
| vilazodone hcl tab 40 mg | vilazodone — COVERAGE REQUIREMENTS = MO |
| desvenlafaxine succinate tab er 24hr 25 mg | desvenlafaxine — COVERAGE REQUIREMENTS = MO |
| desvenlafaxine succinate tab er 24hr 50 mg | desvenlafaxine — COVERAGE REQUIREMENTS = MO |
| desvenlafaxine succinate tab er 24hr 100 mg | desvenlafaxine — COVERAGE REQUIREMENTS = MO |
| duloxetine hcl enteric coated pellets cap 20 mg | duloxetine — COVERAGE REQUIREMENTS = MO |
| duloxetine hcl ... 60 mg | duloxetine — COVERAGE REQUIREMENTS = MO |
| venlafaxine hcl cap er 24hr 37.5 mg | venlafaxine — COVERAGE REQUIREMENTS = MO |
| venlafaxine hcl cap er 24hr 75 mg | venlafaxine — COVERAGE REQUIREMENTS = MO |
| venlafaxine hcl cap er 24hr 150 mg | venlafaxine — COVERAGE REQUIREMENTS = MO |
| amitriptyline hcl tab 10 mg | amitriptyline — COVERAGE REQUIREMENTS = MO |
| amitriptyline hcl tab 25 mg | amitriptyline — COVERAGE REQUIREMENTS = MO |
| amitriptyline hcl tab 50 mg | amitriptyline — COVERAGE REQUIREMENTS = MO |
| acarbose tab 25 mg | acarbose — COVERAGE REQUIREMENTS = MO |
| acarbose tab 50 mg | acarbose — COVERAGE REQUIREMENTS = MO |
| acarbose tab 100 mg | acarbose — COVERAGE REQUIREMENTS = MO |
| miglitol tab 25 mg | miglitol — COVERAGE REQUIREMENTS = MO |
| miglitol tab 50 mg | miglitol — COVERAGE REQUIREMENTS = MO |
| miglitol tab 100 mg | miglitol — COVERAGE REQUIREMENTS = MO |
| GLYXAMBI TAB 10-5 MG | empagliflozin-linagliptin (brand) — COVERAGE REQUIREMENTS = MO |
| GLYXAMBI TAB 25-5 MG | empagliflozin-linagliptin (brand) — COVERAGE REQUIREMENTS = MO |
| SOLIQUA INJ 100/33 | insulin glargine-lixisenatide — COVERAGE REQUIREMENTS = MO |
| SYNJARDY TAB (various strengths) | empagliflozin-metformin — COVERAGE REQUIREMENTS = MO |
| TRIJARDY XR TAB | empagliflozin-linagliptin-metformin — COVERAGE REQUIREMENTS = MO |
| metformin hcl oral soln 500 mg/5ml | metformin solution — COVERAGE REQUIREMENTS = MO |
| metformin hcl tab 500 mg | metformin — COVERAGE REQUIREMENTS = MO |
| metformin hcl tab 850 mg | metformin — COVERAGE REQUIREMENTS = MO |
| BAQSIMI ONE POW 3MG/DOSE | BAQSIMI glucagon — COVERAGE REQUIREMENTS = (listed) |
| GVOKE HYPO 1 INJ 0.5/.1ML | GVOKE glucagon injection — COVERAGE REQUIREMENTS = (listed) |
| QL (12 tabs every 21 days) | Granisetron tab quantity limit as listed |
| QL (200 mL every 21 days) | Ondansetron oral solution quantity limit |
| QL (18 tabs every 21 days) | Ondansetron tablet/disintegrating tablet quantity limit |
| QL (2 patches every 21 days) | Sancuso patch quantity limit |
| QL (3 caps every 180 days) | Aprepitant capsule 40 mg limit |
| QL (4 caps every 21 days) | Aprepitant capsule 80 mg limit |
| QL (2 caps every 21 days) | Aprepitant capsule 125 mg limit |
| QL (6 caps every 21 days) | Aprepitant therapy pack limit |
| QL (20 packets every 5 days) | Vistogard pak limit |
| QL (4 sprays every 25 days) | Naloxone nasal spray limit |
Provider Steps, Prior Authorization and Documentation
Follow formulary PA/coverage requirement process
The formulary includes sections describing Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), Medication Override (MO), Specialty (SP), and other coverage requirement flags; providers must follow the specified process in the formulary to obtain coverage.
- PA, PA** require prior authorization based on clinical criteria; PA** applies when step therapy is not met
- QL limits coverage to a specified quantity per prescription/time period; PA required for other quantities
- ST requires trial of specified agents before coverage; exceptions can be requested
- MO indicates maintenance/mail-order eligibility; SP indicates specialty pharmacy handling
Obtain prior authorization for PA / PA** drugs
Drugs flagged 'PA' or 'PA**' require the Prescribing Provider to submit a Prior Authorization request; PA** means PA is required if Step Therapy criteria have not been met.
- PA decisions: 72 hours for non‑urgent requests; 24 hours for urgent/exigent requests
- PA** applies when Step Therapy is unmet; provider may request PA to bypass steps with medical justification
Submit PA via phone, fax, or electronic form with supporting information
Prescribing providers must request Prior Authorization by phone, fax, or electronic Prior Authorization form and submit all required supporting clinical information for review.
- Submit complete supporting documentation to avoid delays (plan will notify within 72 hours (24 hours exigent) if additional info is needed)
- Decisions rendered within 72 hours non‑urgent or 24 hours urgent/exigent
Obtain PA and observe QLs for amphetamine products (age ≥19)
Many generic amphetamine products require prior authorization for members age ≥19 and are subject to quantity limits; providers must obtain PA and document age and justification when prescribing for adults.
- Examples of QL include 360 tabs every 75 days, 180 tabs every 75 days, 90 tabs every 75 days (product dependent)
- PA is required for age greater than or equal to 19 for multiple amphetamine entries
Follow opioid ER step‑therapy exposure requirements
Step Therapy applies to certain extended‑release opioid products (OPIOID ER Group 2219‑M); coverage requires documented prior opioid exposure per the formulary step criteria.
- Coverage for OPIOID ER 2219‑M is allowed if member has cumulative ≥7 days IR opioid in past 90 days OR cumulative ≥30 days ER opioid in past 90 days
- If prior exposure not met, limited 7‑day IR supply may be provided per OPIOID IR COMBO PRODUCTS 1358‑E
Obtain PA for listed stimulants and selected agents
Many stimulant and related agents listed (amphetamines, methylphenidate, atomoxetine, select anti‑obesity agents) require prior authorization; obtain PA before prescribing when the formulary flags PA.
- Examples include WEGOVY and orlistat (PA for anti‑obesity agents) and numerous stimulant formulations flagged PA
- Some entries also include MO or QL in addition to PA
Document prior opioid exposure to meet ER opioid PA/ST
Coverage for specified ER opioid products requires prior opioid exposure as defined in the opioid step therapy rules; providers must document pharmacy fill history demonstrating required exposure.
- Required prior exposure: cumulative ≥7 days IR within past 90 days or cumulative ≥30 days ER within past 90 days
- If no prior opioid supply, coverage may be limited to a 7‑day IR supply (OPIOID IR COMBO PRODUCTS 1358‑E)
Obtain PA for listed stimulant/related products (WEGOVY, atomoxetine, methylphenidate)
Numerous stimulant and related agents (including semaglutide/WEGOVY, atomoxetine, methylphenidate/dexmethylphenidate, AZSTARYS, QELBREE) list PA and often QL or MO; obtain PA and document clinical rationale.
- Atomoxetine example QL: 360 caps every 75 days
- Methylphenidate/dexmethylphenidate entries specify PA and QL and PA required for age ≥19
PA and QL required for methylphenidate ER/patch products (age ≥19)
Many methylphenidate ER/OROS formulations and transdermal patches require prior authorization for members age ≥19 and are subject to quantity limits (e.g., 90 or 180 units per 75 days); include age and quantity on PA requests.
- Examples: methylphenidate OSM/ER entries show PA, QL (90–180 units every 75 days)
- PA required for age greater than or equal to 19
Submit PA for select JAK inhibitors (SP, PA, QL)
Select JAK inhibitor products (RINVOQ, XELJANZ) are specialty (SP) designated and require prior authorization and quantity limits; submit specialty PA documentation when requesting these agents.
- RINVOQ and XELJANZ entries: SP, PA, QL (e.g., RINVOQ QL and preferred strengths noted)
- Provide indication and product‑specific information with PA for specialty agents
Obtain PA for opioid products and high‑strength formulations
Many opioid products—especially high‑strength formulations—require prior authorization or are subject to step therapy; verify PA/ST flags and obtain authorization when required before dispensing.
- High‑strength fentanyl patches and some hydrocodone ER products are marked ST and/or require PA** or PA
- Initial supply limits (7‑day adult; 3‑day if age ≤19) apply to many opioid entries
Verify PA for specified high‑risk products (opioid combos, buprenorphine)
Numerous listed products require prior authorization including certain opioid combinations, high‑strength buprenorphine films/patches, and other controlled products; confirm PA flags before prescribing.
- BELBUCA high strengths require PA; buprenorphine TD patches >15 mcg/hr require PA
- Opioid combinations often show ST, QL, and PA**
Follow MO/MANAGED coverage guidance and PA when indicated
Products marked with 'MO' or other coverage requirement flags may indicate managed coverage and prior authorization or medical necessity review; providers should follow product‑level guidance and include required documentation on PA requests.
- Many entries show COVERAGE REQUIREMENTS AND LIMITS = MO indicating managed coverage controls
- Requests that do not meet MO requirements may be limited or denied
Request PA when qty exceeds QL or for higher‑tier brands
Branded products with QL or tiering may trigger PA when requests exceed QL or are for nonpreferred tiers; obtain PA for quantities above listed limits and include justification.
- PA may be required for requests exceeding QL or for nonpreferred brand tiers
- Document clinical necessity when requesting quantities above QL
Obtain PA for products explicitly flagged PA (examples: RELGAABI)
Medications flagged 'PA' (e.g., RELGAABI cap 200 mg) require prior authorization before coverage; providers must obtain PA to avoid coverage denials.
- RELGAABI entry explicitly lists PA and MO in coverage flags
- Obtain PA prior to dispensing to prevent denial
Confirm and obtain PA for specified brand entries
Certain brand entries list PA in their coverage flags (example: RELGAABI cap 200 mg); verify product‑level flags and submit PA for brand‑specific entries as required.
- Check formulary line for brand entries indicating PA
- Submit PA with required documentation for brand‑specific coverage
Submit SP/PA with indication and QL justification for zuranolone
ZURZUVAE (zuranolone) entries are marked SP, PA, and have QL (e.g., 2 caps every 1 day or 1 cap for 30 mg); prior authorization must document the indication and justify the requested quantity.
- ZURZUVAE CAP 20/25 mg: QL 2 caps every 1 day and SP, PA flags
- ZURZUVAE CAP 30 mg: QL 1 cap every 1 day and SP, PA flags
Provide diagnosis and PA documentation for MO‑designated drugs
Products labeled 'COVERAGE REQUIREMENTS AND LIMITS = MO' indicate medications subject to managed coverage or authorization review; providers should include diagnosis and required prior authorization forms when requesting coverage.
- MO flag appears across multiple branded and generic products
- Documentation expectations include indicated diagnosis and PA forms for MO‑designated items
Obtain PA (and respect MO) for GLP‑1/incretin agents
Many GLP‑1 receptor agonists and oral semaglutide (MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) require prior authorization and may also be limited by MO flags; obtain PA and follow MO limits as applicable.
- Examples: MOUNJARO, RYBELSUS, TRULICITY entries show PA and/or MO
- Include clinical justification and prior therapy history with PA requests for incretin agents
Follow Step Therapy processes and request exceptions when medically necessary
The formulary contains a Step Therapy Criteria section; Sharp Health Plan may require Step Therapy where coverage depends on prior use of alternative drugs, and providers can request Step Therapy exceptions.
- If Step Therapy exemption is requested, submit clinical justification and supporting documentation with the Step Therapy Exception request
- If plan fails to respond within the required timeframe, the exception is deemed granted
Document clinical rationale for Step Therapy exceptions
If a Step Therapy Exception is requested, providers must document why the required step is inconsistent with good professional practice and submit supporting clinical documentation; incomplete requests will be followed up within 72 hours (24 hours exigent).
- Provide clinical rationale and relevant records to support exception requests
- Plan will notify provider within 72 hours (24 hours exigent) if additional information is needed
Document prior opioid fills to satisfy opioid step therapy
To meet opioid step therapy requirements, documentation must show pharmacy fill history demonstrating either a cumulative ≥7‑day supply of an immediate‑release opioid within the past 90 days or a cumulative ≥30‑day supply of an extended‑release opioid within the past 90 days.
- Include dates, days supplied, and drug names for prior opioid fills on PA/step therapy requests
- If prior exposure not shown, coverage may be limited to a 7‑day IR supply
Apply 7‑day short‑course allowance for opioid IR combos when no prior exposure
For OPIOID IR COMBO PRODUCTS (1358‑E), coverage is allowed for up to a 7‑day supply if the member does not have at least a cumulative 7‑day supply of any opioid in the past 90 days — document this on the PA/claim.
- Short‑course allowance is limited to up to 7 days when no prior opioid supply exists in prior 90 days
- Include pharmacy history to demonstrate absence of recent opioid exposure
Risk of PA denial — ensure complete clinical support
Prior Authorization requests may be denied if supporting clinical information does not meet Sharp Health Plan clinical policies; denied requests mean coverage will not be provided unless an Appeal/Grievance is filed.
- If PA is denied, the Member, Authorized Representative, or Prescribing Provider may file an Appeal or Grievance per formulary procedures
- Ensure PA submissions include the clinical evidence required by plan policies to reduce denial risk
Opioid step therapy — denial risk if prior exposure not documented
Coverage may be denied if the member has not met opioid step therapy requirements (no record of cumulative ≥7 days IR opioid within past 90 days or cumulative ≥30 days ER opioid in past 90 days); verify and document prior fills.
- Lack of documented prior opioid exposure will trigger denial under opioid step therapy rules
- Provide pharmacy fill history to support prior exposure
Amphetamine PA/QL — denial risk for age ≥19 without PA or QL exceedance
Requests for amphetamine‑class products for members aged 19+ without required PA or exceeding quantity limits risk denial; include age and justification on PA requests.
- Multiple amphetamine entries explicitly state PA required for age ≥19
- Exceeding listed QL (e.g., 360 tabs/75 days) without PA may result in denial
Adult stimulant fills — denial risk without PA
Failure to obtain PA for many methylphenidate/amphetamine products for members aged ≥19 may result in coverage denial; verify PA requirements before dispensing adult stimulant fills.
- Methylphenidate ER/OROS and patches list PA and QL and require PA for age ≥19
- Providers should confirm PA prior to prescribing to adult members
PA required for specialty antirheumatics — denial risk if missing
Specialty (SP) antirheumatic agents and select agents (e.g., RINVOQ, XELJANZ, apremilast) require prior authorization and are subject to quantity limits; lack of PA may lead to noncoverage.
- RINVOQ and XELJANZ entries show SP, PA, and QL; apremilast entries show SP, PA, QL (e.g., 55 tabs every 28 days)
- Submit specialty PA documentation including diagnosis and prior therapy history
Denial risk for QL or high‑strength requests without PA
Requests exceeding listed quantity limits (QL) or for high‑strength products without prior authorization are subject to denial or require PA; confirm QL and PA flags before authorizing larger quantities or high strengths.
- High‑strength formulations (e.g., BELBUCA ≥600 mcg; buprenorphine TD >15 mcg/hr) require PA
- Requests exceeding QL (measurement periods commonly every 75 days) may be denied
High‑strength formulations require PA
High‑strength formulations (e.g., higher‑strength BELBUCA films and buprenorphine patches >15 mcg/hr) explicitly require prior authorization; obtain PA before prescribing these strengths.
- BELBUCA 600 mcg+ flagged 'PA; High Strength Requires PA'
- Buprenorphine transdermal patches 15–20 mcg/hr flagged PA for higher strengths
Document age and quantity for opioid initial limits and QLs
Controlled combination analgesics and many opioid products are subject to quantity limits and initial short‑duration limits (initial 7‑day for adults; initial 3‑day for members ≤19); document patient age and quantity on PA/claim.
- Examples: codeine QL 42 tabs every 25 days with initial 7‑day limit (3‑day if age ≤19)
- Opioid combination products often list ST, QL, and initial supply limits
Coverage flags (MO/PA/QL) can trigger denial if unmet
Entries with coverage flags such as MO (managed coverage), PA, and QL can trigger coverage denials if their requirements are not met; check product‑level flags and comply before prescribing or dispensing.
- MO‑flagged products commonly require additional documentation or PA
- Coverage flags are attached at the product line and must be satisfied to obtain coverage
PA and MO limits for GLP‑1 agents — follow product guidance
For GLP‑1/incretin agents and other MO‑flagged products, providers must follow PA and MO guidance; failure to meet PA or MO limits may result in denial.
- MOUNJARO, RYBELSUS, TRULICITY entries show PA and/or MO
- Include prior therapy and relevant clinical data on PA requests for incretin agents
Verify MO limits for insulin products
Many insulin products are marked MO; prescriptions not meeting MO (member/managed) limits may be limited or denied — verify plan‑specific insulin MO rules before dispensing.
- RELION‑branded insulin products noted as not covered in some entries
- Check MO flags and plan coverage details for insulin products
Initial Therapy and Age-Based Limits
Opioid initial therapy
Opioid step therapy initial exposure requirements
If criteria not met, up to a 7‑day IR supply may be covered per IR combo rules.
Age-specific prior authorization
Documentation should include member age on PA requests.
Initial Therapy Limits
Initial therapy rules for many opioids include limited initial supplies and age‑based shorter limits.
Applies to many opioid liquids, tablets, and combination products; providers must document age to apply the shorter limit.
Initial therapy limits
Initial fill limits and age‑based restrictions
Examples: many opioid combinations and certain tramadol ER products.
Document age/quantity when requesting opioid supply beyond initial limits
Initial opioid prescribing is limited (initial 7‑day supply for adults; initial 3‑day supply for members age 19 or younger); providers must document patient age and quantity when requesting coverage beyond these limits.
- Many opioid and combination products are subject to initial supply limits at point of dispensing.
- If requesting quantities beyond the initial limits, include justification and prior fill history with the PA.
Step Therapy Criteria and Program Rules
| Step Therapy Section | Summary |
|---|---|
| Formulary Step Therapy Criteria section | |
| The formulary contains a dedicated Step Therapy Criteria section and therapeutic-class pages where step therapy may apply; providers should refer to those sections for product-specific step requirements. |
| Step Therapy Requirement | Implication |
|---|---|
| Members may be required to trial specified alternate drug(s) prior to coverage of a requested drug (ST) | |
| Drugs flagged PA** require prior authorization if Step Therapy criteria have not been met (i.e., PA applies when steps aren't satisfied) |
| Provider Documentation Requirement | Action |
|---|---|
| When a required Step Therapy drug is inconsistent with good professional practice, the prescribing provider must submit a Step Therapy Exception request | |
| Provider must include justification and supporting clinical documentation with the Step Therapy Exception request; if complete the plan will decide within required timeframes or the request is deemed granted if the plan does not respond timely |
| Opioid Step Therapy Exposure Requirement | Coverage Condition |
|---|---|
| Cumulative >= 7 days' supply of immediate‑release (IR) opioid within past 90 days | |
| OR cumulative >= 30 days' supply of extended‑release (ER) opioid within past 90 days |
| Opioid IR Short‑Course Allowance | Limit |
|---|---|
| Applies to OPIOID IR COMBO PRODUCTS (Group 1358‑E) | |
| Coverage allowed for up to a 7‑day supply if the member does not have at least a cumulative 7‑day supply of any opioid (IR or ER) in the past 90 days |
| Opioid ER Coverage Requirement | Required Prior Exposure |
|---|---|
| OPIOID ER group (Group 2219‑M) | |
| Member must have either a cumulative >=7‑day IR opioid fill in the past 90 days OR a cumulative >=30‑day ER opioid supply in the past 90 days to obtain ER opioid coverage |
| High‑Risk Opioid Products | Formulary Controls |
|---|---|
| Certain fentanyl transdermal patches (multiple strengths) | |
| These patches are subject to Step Therapy (ST), quantity limits (QL), and many higher strengths require prior authorization (PA) or are flagged 'High Strength Requires PA' |
| ER Opioid Entries Requiring ST/PA** | Notes |
|---|---|
| Selected extended‑release opioid products (e.g., hydromorphone ER, morphine ER, hydrocodone ER) | |
| Many ER products are marked ST and may also require PA**; coverage contingent on meeting step‑therapy opioid exposure or obtaining PA when steps unmet |
| Products Subject to Step Therapy | Formulary Indication |
|---|---|
| Selected opioid combination analgesics, buprenorphine films/patches, and select hydrocodone/oxycodone combinations | |
| Step Therapy (ST) is indicated alongside entries; specific step sequences are provided in the therapeutic‑class sections of the formulary rather than in the summary |
| ZURZUVAE (zuranolone) SP Flag | Implication |
|---|---|
| ZURZUVAE entries are labeled SP (special program) and show PA and QL | |
| SP flag may indicate management via a specialty program or additional step/program requirements; explicit step sequence is not provided in this excerpt |
Quantity Limits and Measurement Periods
Dispensing Channels and Supply Options
Specialty drugs dispensed via CVS Specialty
Specialty drugs are dispensed through CVS Specialty Pharmacy and mailed; specialty prescriptions presented at CVS retail will be forwarded to CVS Specialty for fulfillment.
- Providers should direct specialty drug prescriptions to CVS Specialty® Pharmacy enrollment at CVSspecialty.com.
- Alternatively, prescriptions brought to CVS retail will be sent to CVS Specialty for processing.
MO drugs eligible for 90‑day retail or mail‑order fills
Maintenance drugs (MO) can be filled for a 90‑day supply at retail or via mail order through CVS Caremark; providers should advise members about mail order enrollment options.
- MO designation permits up to a 90‑day supply through retail or CVS Caremark mail order.
- Enroll at info.caremark.com/mailservice for mail order fulfillment.
Background and Definitions
The formulary organizes covered outpatient prescription drugs by therapeutic class and includes definitions and program guidance for Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), Specialty (SP) designations, and other managed‑coverage flags (e.g., MO). It functions as the master drug list for employer‑sponsored Large Group HMO and POS plans using a 4‑tier formulary and provides instructions on coverage requirements, utilization management, and where to find plan‑specific cost‑sharing information.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.