Prior authorization may be required

Some drugs listed on the Formulary require Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), Mail Order (MO), Specialty (SP), or other coverage controls. Providers must obtain any required PA or Step Therapy exception from Sharp Health Plan before the plan will cover the drug. Check member-specific plan documents for exact cost sharing and coverage details; this Formulary is subject to change and prior versions are not in effect.

• Check member-specific cost sharing via member portal: sharphealthplan.com/login.
• Document last updated 03/01/2026; check for later revisions before submitting requests.

Prior Authorization and Step Therapy (overview)

Step Therapy is referenced throughout the Formulary. When a drug is marked ST or PA**, coverage may depend on prior use of an alternate therapy. Providers may request a Step Therapy Exception by submitting clinical justification and supporting documentation; Sharp Health Plan will respond within 72 hours for non-urgent requests or 24 hours for exigent circumstances.

• If a completed Step Therapy Exception or PA request is not answered within the required timeframe it is deemed granted.
• Continuity of therapy is allowed when members move from another insurer; document prior coverage.
• If requests are incomplete, plan will notify provider within the same response timeframes what additional information is needed.

Prior Authorization required for PA drugs

Drugs coded PA or PA** require Prior Authorization. Providers must submit a completed PA request by phone, fax, or electronic prior authorization form and include all supporting clinical documentation. Turnaround is 72 hours for non-urgent and 24 hours for urgent/Exigent Circumstances; if the plan fails to respond in time, the request is deemed granted.

• Acceptable submission methods: Customer Service phone, fax, or electronic PA form.
• Include prescription details (drug name, strength, quantity, duration), diagnosis, prior therapies tried, and relevant clinical notes or test results.
• PA** indicates PA is required only if Step Therapy has not been met.
• Deemed grant applies to both PA and Step Therapy Exception requests when timelines are missed.

PA** (Prior Authorization contingent on Step Therapy)

PA** indicates the drug requires Prior Authorization only if Step Therapy has not been met; providers may document medical necessity to request a PA when Step Therapy is clinically inappropriate. Follow standard PA submission and include Step Therapy rationale.

• When requesting PA for a PA** drug, state why Step Therapy is not appropriate and include supporting clinical records.
• If deemed urgent or exigent, indicate this on submission for expedited review.

Prior authorization for brand or reference biologic

When a brand biologic is dispensed but an interchangeable biosimilar is available, contracted pharmacies are generally required to dispense the interchangeable product unless a PA for the reference product is obtained and the reference product is determined medically necessary.

• Pharmacy-level substitution rules may apply; if requesting the reference biologic, submit documentation supporting medical necessity for the reference product versus the interchangeable biologic.
• Brand-name listing in the Formulary is for reference only unless the Plan has authorized the brand.

Amphetamine prior authorization and quantity limits (provider action)

Certain amphetamine and stimulant products require Prior Authorization and are subject to quantity limits and Mail Order (MO) provisions. For age-restricted PAs (e.g., PA required for age ≥ 19), include patient age, prior treatment history, and justification for use. Quantity limits (examples: 90 or 360 tabs every 75 days) must be observed; submit PA for any quantity over the limit.

• Document age-based PA requirements (PA required for age ≥ 19 for many stimulant strengths).
• Include prior medication trials and rationale for higher quantities when requesting override.
• MO (mail order) options may apply for maintenance supplies.

Opioid step therapy prior authorization

Opioid Step Therapy and high-strength opioid products frequently carry ST, PA**, PA, and explicit high-strength PA requirements. Before prescribing ER/High-Strength opioids, confirm the member meets Step Therapy criteria (for example cumulative immediate-release exposure) or submit PA with documentation of prior opioid exposure and clinical necessity. Initial fill limits (e.g., 3- or 7-day limits) apply to many opioid agents.

• ST groups define required prior exposure (e.g., cumulative 7 days of IR opioid within 90 days or 30 days of ER in past 90 days).
• High-strength strengths (listed in the Formulary) require PA even if the lower strengths do not.
• Document prior fills and clinical justification when requesting PA for high-strength opioids.

Prior authorization flags for select injectables (GLP-1/GIP and insulins)

Stimulant, ADHD, and certain anti-obesity injectables and GLP-1/GIP agents carry PA and MO flags; many of these agents are also specialty (SP) and require specialty pharmacy dispensing. For injectables (e.g., tirzepatide, semaglutide, liraglutide), submit PA and include dosing, indication, prior therapy, and member weight/BMI or diabetes control metrics as applicable.

• Examples: MOUNJARO, OZEMPIC, RYBELSUS list PA and MO; MOUNJARO and OZEMPIC entries note PA and mail order.
• Some GLP-1/GIP products may have formulary tier impacts; check the drug entry for tier/step implications.
• SP designation requires specialty pharmacy; include documentation to support SP dispensing if requested.

Methylphenidate PA requirement (age-based)

Methylphenidate and many formulations of stimulants have age-based PA requirements and quantity limits. When requesting PA for these agents, include the recipient's age, diagnostic information, previous medication trials, and the requested quantity/days' supply.

• Examples: multiple methylphenidate strengths and formulations indicate PA required for age ≥ 19.
• Quantity limits are frequently expressed as 'X tabs every 75 days' — document rationale for quantities exceeding those limits.
• Mail Order (MO) options apply for many maintenance formulations.

Specialty immunomodulators PA noted (SP designation)

Specialty immunomodulators and other SP-designated drugs require Prior Authorization and are limited to specialty pharmacy dispensing (SP). Providers must include diagnosis, prior therapies, and relevant laboratory or imaging results to support medical necessity. Quantity limits and refill-supply restrictions (e.g., 30-day supply per fill) often apply.

• Examples: upadacitinib (RINVOQ) and tofacitinib (XELJANZ) entries show SP, PA, QL.
• For SP drugs, identify preferred indications when present (e.g., psoriasis, RA, Crohn's).
• Specialty drugs may have additional prior authorization criteria; include previous treatment failures when applicable.

Prior authorization/managed-only for rifaximin (Xifaxan)

Rifaximin (Xifaxan) and certain other products are managed-only (MO) or require PA/MO for coverage and may only be available through designated fill channels. When prescribing rifaximin, follow the Plan's PA/MO process and include indication and prior therapy information.

• Rifaximin entries may be coded MO; confirm whether PA is additionally required for the specific indication.
• If the drug is MO, write prescriptions and claims to conform to mail order limits and days' supply rules.

MO entries may require medical override/prior authorization

Some drugs listed as MO (mail order) or MO-coded in the Formulary may still require a medical override or Prior Authorization for a non-mail-order dispense or for quantities outside the MO parameters. When prescribing, conform to MO/QL rules or submit PA/medical override requests with clinical justification.

• If requesting non-mail-order pickup or different quantity, include rationale and clinical necessity for override.
• MO-designated maintenance drugs are eligible for up to a 90-day supply through mail order; prescribe accordingly and document if request differs.

Brand-name prior authorization

Brand-name drugs usually require prior authorization when a generic or interchangeable product exists. Pharmacies are required to dispense the generic or interchangeable biologic unless a PA for the brand/reference product is approved. Providers requesting brand coverage must submit documentation demonstrating medical necessity for the brand over the generic/biosimilar.

• Include prior trial of the generic unless contraindicated and clinical rationale for brand necessity.
• When interchangeable biologics exist, identify the reference product and provide documentation supporting the need for the reference product.

Modafinil PA

For modafinil and armodafinil entries (including generic and brand strengths), Prior Authorization and Mail Order (MO) flags are present. Providers should submit PA requests with the indication (narcolepsy, shift work sleep disorder, obstructive sleep apnea-related excessive sleepiness), prior therapies tried, and any supporting sleep study or specialist documentation.

• Armodafinil and modafinil list PA and MO in coverage columns—include prior therapy documentation where applicable.
• If continuity from prior coverage is claimed, include evidence of previous insurer coverage to avoid unnecessary Step Therapy.

Documentation for PA/MO items

Documentation is required for all PA and MO requests. Include the prescription (drug name, strength, quantity, directions), diagnosis, relevant clinical notes, prior medication trials and dates, laboratory or imaging data when relevant, patient age, and any prior insurance coverage history to support continuity or exceptions.

• Required formulary identifiers: drug name, strength, NDC when available, and quantity/days' supply.
• For PA/Step Therapy exceptions, include clinical justification explaining why required prior therapy is inappropriate.
• Provide supporting documentation for PA and MO items (labs, imaging, specialist notes).

Denial triggers and risks

Denial risks: PA, Step Therapy, Quantity Limits, MO and SP flags can trigger denials if requirements are not met. Additional denial triggers include prescriptions from non‑contracting providers for non-covered procedures, replacement of lost/stolen drugs, or prescribing excluded indications (cosmetic, weight loss not meeting criteria, etc.).

• Prescriptions from non-contracting providers for non-covered procedures may be denied—confirm provider network status.
• Replacement of lost or stolen drugs is excluded.
• If quantity limits or PA requirements are not met, the claim may be denied; submit PA or appeal as needed.

Quantity and PA non-compliance

Quantity limits and PA non-compliance commonly cause coverage denials. When prescribing, adhere to documented QL values (for example '90 tabs every 75 days' or '540 tabs every 75 days') and submit PA for any requested quantity that exceeds the listed limits with supporting medical necessity.

• Document the exact quantity limit shown on the Formulary per drug and timeframe.
• When requesting overrides, provide clear clinical rationale and previous treatment records.
• Failure to follow QL and PA rules may result in denial and the need for an appeal.

Formulary tier/step implications and documentation

Formulary tier and step mapping affect member cost sharing and coverage sequencing. Providers should check the drug's formulary tier and any step/coverage mapping in the drug entry to understand preferred products, required steps, and potential cost-sharing implications for the member.

• Formulary tier (e.g., Tier 1–4) and SP/MO flags may change member copay/coinsurance—confirm in member plan documents.
• The Formulary may list preferred indications or preferred products within a class; use that information when selecting therapy.
• When step sequences are not explicitly listed, contact the Plan for the preferred first-line agent or submit a PA/Step Therapy Exception with rationale.

Covered dispensing sites (retail, specialty, mail order, office)

Network retail, specialty, mail order, and office sites are covered dispensing locations for outpatient prescription drugs; specialty drugs must be filled by the plan's specialty pharmacy network and are mailed.

• Specialty drugs: CVS Specialty® Pharmacy; mail order: CVS Caremark®.

Specialty pharmacy and mail order distribution notes

Specialty drugs must be filled by the Sharp Health Plan specialty pharmacy network (CVS Specialty) and are mailed to the member; mail order maintenance drugs are available through CVS Caremark.

Specialty pharmacy designation for SP agents

Agents designated SP (specialty) must be distributed through the specialty pharmacy network and are limited to a 30‑day supply per fill; obtain prior authorization as required for SP products.

Interchangeable biologic substitution — pharmacy may be required to substitute

When an interchangeable biologic product is available, the pharmacy may be required to fill with the interchangeable product unless prior authorization for the reference biologic is obtained stating medical necessity.

Reference biologic prior authorization requirement

If the prescriber requests dispensing of the reference biologic instead of an interchangeable product, prior authorization must be obtained and documentation of medical necessity provided to the plan.