Sharp-Health-Plan outpatient drug coverage & PA

Formulary management (referenced)

Formulary coverage and utilization management sections are present in the document and reference the tools used to manage outpatient drug coverage.

Formulary management sections: Sections for Prior Authorization, Quantity Limit, Step Therapy, Formulary Exceptions, Therapeutic Interchange, Generic Substitution, and Appeals are present in the formulary document.

See the Step Therapy, PRIOR AUTHORIZATION, QUANTITY LIMIT, and FORMULARY EXCEPTION sections for operational criteria.

General Coverage

Covered when ALL of the following are met:

Formulary coverage basic conditions: Drug is FDA‑approved and listed on the Formulary for the outpatient pharmacy benefit OR coverage is authorized via a Formulary Exception or Prior Authorization when Medically Necessary.

Medical Benefit (physician‑administered or designated self‑injectable) items are covered under the Medical Benefit and not the outpatient pharmacy benefit.

Formulary Exception

Formulary Exception requests are processed under the Prior Authorization process; decisions are time‑bound.

Formulary Exception Approval: A Formulary Exception request for a Nonformulary Drug will be approved or denied based on medical necessity within 72 hours for non‑urgent requests or within 24 hours for urgent/Exigent Circumstances.72 hours (non‑urgent); 24 hours (urgent)

If approved, coverage is provided for the duration of the prescription including refills; exigent approvals cover the duration of the exigency.

Generic Substitution and Biologic Interchange

Generic and biologic substitution rules that affect coverage and dispensing:

Generic substitution policy: When a generic equivalent is available, the pharmacy is required to dispense the generic unless Sharp Health Plan has authorized the brand‑name drug due to medical necessity via Prior Authorization.

If a brand is authorized for medical necessity, member cost share corresponds to the brand tier. When an interchangeable biologic is available, the pharmacy may be required to dispense the interchangeable product unless Prior Authorization for the reference biologic is obtained.

Exclusions to outpatient prescription drug benefit

Not covered under the outpatient prescription drug benefit unless an exception or law requires coverage:

Exclusion list: Prescriptions are excluded when for: (1) cosmetic services; (2) solely for hair loss, sexual dysfunction, athletic performance, cosmetic purposes, anti‑aging for cosmetic purposes, or mental performance (except when Medically Necessary for diagnosed mental illness or memory conditions); (3) solely for weight loss except when Medically Necessary for Class III obesity (program enrollment may be required); (4) solely to shorten the duration of the common cold; (5) drugs available over‑the‑counter or with an OTC equivalent (exceptions: insulin; OTC drugs covered as preventive services such as OTC contraceptives; OTC opioid overdose reversal; or an entire class when an agent becomes OTC); (6) replacement of lost or stolen drugs; (7) drugs prescribed by non‑contracting providers for non‑covered procedures not authorized by the plan.

Exceptions or legal requirements may override these exclusions.

Opioid Step Therapy — OPIOID ER 2219-M

Coverage for OPIOID ER 2219-M is provided only when ALL of the following step conditions are met:

OPIOID ER 2219-M - Step therapy criteria: Coverage is allowed when the member has met at least one of the prior opioid exposure conditions: 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.>= 7‑day IR within 90 days OR >= 30‑day ER within 90 days

Applies to listed ER opioid group (examples: fentanyl patches, hydrocodone ER, morphine ER); high‑strength formulations often additionally require PA.

Opioid Step Therapy — OPIOID IR COMBO PRODUCTS 1358-E

OPIOID IR combo product coverage is restricted as follows:

OPIOID IR COMBO PRODUCTS 1358-E: Coverage provided for up to a 7‑day supply of immediate‑release opioid combination products if the member does NOT have at least a cumulative 7‑day supply of an opioid agent (immediate‑ or extended‑release) within the past 90 days.<= 7‑day supply when no prior 7‑day opioid fill in past 90 days

This group limits initial IR combo opioid fills to a 7‑day supply absent recent opioid exposure.

Amphetamines — PA and Quantity Limits

Amphetamine‑class products require prior authorization and are subject to quantity limits. Apply ALL of the following:

Amphetamines general: Prior authorization (PA) is required for many amphetamine and related stimulant products for members aged >= 19. Quantity limits (QL) apply by product and strength (examples include 360 tabs/caps every 75 days; 270; 180; 90; or formulation‑specific mL caps for solutions).QL values vary by product (examples: 360 tabs/75 days; 540 tabs/75 days for some methylphenidate forms)

See product‑level entries for the exact QL for each strength and formulation; MO flags indicate managed coverage.

General PA and age-based PA requirement

Prior authorization applies as indicated and is age‑based for many stimulant and related agents:

PA requirement: Prior authorization is required for many stimulant, ADHD, and anti‑obesity agents listed (entries marked PA). For many products (e.g., methylphenidate, lisdexamfetamine, atomoxetine, AZSTARYS), PA is specifically required for members aged >= 19.Age >= 19 when specified

Supporting documentation must be provided with PA or Step Therapy Exception requests.

Quantity limits

Quantity limits shown on the formulary control allowed dispense quantities:

Quantity limits: Products with QL specify maximum quantities over specified time windows (examples in this formulary: 90 caps every 75 days; 540 tabs every 75 days; 5400 mL every 75 days; 55 tabs every 28 days for select agents).Varies by product as listed

Requests exceeding QL require Prior Authorization and medical necessity documentation and may be denied.

Apremilast (Otezla) — covered with restrictions

Apremilast (Otezla) coverage conditions — ALL must apply:

Apremilast coverage: Apremilast formulations are designated Specialty (SP), require Prior Authorization (PA), and are quantity‑limited — example QL: 55 tablets every 28 days for some formulations.55 tabs/28 days (example)

Some apremilast entries note 'Preferred for Psoriasis, Psoriatic Arthritis' but PA/QL/SP apply as listed.

Opioid analgesics — covered with criteria

Opioid analgesics are covered when ALL of the following apply:

Opioid coverage: Opioid products listed on the formulary are covered subject to the stated Quantity Limits (QL) and to Prior Authorization (PA) or Step Therapy (ST) where indicated. High‑strength formulations require PA. Many opioid formulations are additionally subject to an initial supply restriction (see Initial Opioid Supply Restrictions).QL and PA/ST as listed per product; high‑strength = PA

Providers must document prior opioid exposure to satisfy step therapy where required and supply limits apply at initial fill (7‑day adult; 3‑day if age <=19).

Aspirin 81 mg — preventive coverage exception

Aspirin 81 mg preventive coverage exception — apply ALL of the following:

Aspirin 81 mg preventive exception: Aspirin chewable or delayed‑release 81 mg is listed as Preventive (PV) with a quantity limit of 100 tablets every 30 days. A $0 copay applies only for members capable of pregnancy aged 12–59 who are at risk for preeclampsia; otherwise the special $0 copay does not apply.100 tabs/30 days

Coverage cost‑share exception is age and risk dependent as specified.

Formulary coverage lines (excerpt)

Formulary listing lines include tier and optional coverage flags; examples below illustrate how entries are represented:

Example - Buprenorphine/Naloxone (ZUBSOLV): Buprenorphine‑naloxone (ZUBSOLV) is shown on the formulary with a drug tier assignment and may have the coverage requirements field blank in the excerpt; coverage follows the tier and any listed requirements.

See product line entries for specific coverage flags and QL values.

Example - Methyltestosterone/Testosterone products: Certain androgen/testosterone products are listed with 'PA, MO' indicating prior authorization and managed‑only handling may be required.

Follow PA/MO instructions when submitting authorization requests.

Example - Alprazolam QL: Alprazolam and other benzodiazepine entries include explicit quantity limits (e.g., 150 tabs every 25 days; 90 tabs every 25 days; 360 caps every 25 days) which govern covered quantities.QL values as listed

Formulary coverage with quantity limits

Formulary coverage with quantity limits — coverage conditions:

Formulary with QL: Drug is on the formulary listing AND the dispensed quantity does not exceed the listed Quantity Limit (QL) for the specified time window.Per‑product QL as listed (examples: 150 tabs/25 days; 9 inhalers/75 days)

Many entries include 'MO' which may indicate additional managed coverage or prior authorization is needed when QL or MO conditions are exceeded or invoked.

Quantity-limited coverage

Quantity‑limited coverage is allowed when the dispense does not exceed the listed limit:

Quantity‑limited drugs: Drugs that show a QL entry are covered up to that specified limit (examples: 9 inhalers every 75 days; 180 inhalations every 75 days; specified mL limits for nebulized solutions).As listed per product

Dispenses exceeding QL require Prior Authorization and medical necessity documentation and may be denied.

MO-designated coverage

Items marked 'MO' indicate managed coverage and may require additional plan processes:

MO-designated drugs: Many drugs on the formulary include 'MO' in the coverage requirements/limits field indicating managed coverage; providers should follow plan procedures for any required medical override or prior authorization associated with MO entries.MO per product as listed

MO frequently appears with PA and/or QL flags; absence of required documentation may trigger denial.

This Formulary document lists covered outpatient prescription drugs and summarizes utilization management controls that affect coverage. Refer to the Formulary sections titled "ARE THERE ANY COVERAGE REQUIREMENTS OR LIMITS?", "WHAT IS PRIOR AUTHORIZATION?", "WHAT IS QUANTITY LIMIT?" and "WHAT IS STEP THERAPY?" for the plan's procedural rules. The electronic Formulary and specific member cost sharing details are available on the Sharp Health Plan website; the document is subject to change and the version shown is current as of 03/01/2026.

Drugs covered under the outpatient pharmacy benefit are generally oral or topical products dispensed via network retail, specialty, or mail-order pharmacies. Medical Benefit drugs are physician-administered or designated self-injectable products and are covered under the Medical Benefit (see Member Handbook for cost‑share and coverage specifics).

The Formulary specifies exclusions to the outpatient prescription drug benefit. Excluded uses include drugs prescribed solely for cosmetic services, hair loss, sexual dysfunction, athletic performance, cosmetic anti-aging, or to shorten the common cold; over‑the‑counter equivalents (with stated exceptions); replacement of lost or stolen drugs; and drugs prescribed by non‑contracting providers for non‑covered procedures, unless coverage is required by law or an exception is granted.

Seven explicit outpatient prescription drug exclusions are listed: (1) cosmetic services; (2) drugs solely for hair loss, sexual dysfunction, athletic performance, cosmetic purposes, or anti‑aging for cosmetic purposes (with limited exceptions); (3) drugs solely for weight loss except when medically necessary for Class III obesity; (4) drugs solely to shorten duration of the common cold; (5) drugs available OTC or with an OTC equivalent (exceptions noted, e.g., insulin, certain preventive OTC contraceptives, opioid overdose reversal); (6) replacement of lost or stolen drugs; and (7) drugs prescribed by non‑contracting providers for non‑covered procedures not authorized by the plan.

Note: ancillary procedural details and plan‑specific exceptions referenced elsewhere in the document (e.g., appeals, formulary exceptions, and how to request Prior Authorization) should be consulted when a use may fall outside standard coverage patterns.

A specific cost‑sharing exception applies to aspirin 81 mg: the chewable or delayed‑release 81 mg product is listed as Tier = PV with a QL (100 tabs every 30 days) and carries a $0 copay only for members capable of pregnancy aged 12–59 who are at risk for preeclampsia; otherwise the special $0 copay does not apply.

Several opioid and opioid combination products include pediatric availability limits. For example, certain tramadol formulations and acetaminophen/codeine products are marked Not available under age 12. Other opioid entries indicate initial supply restrictions and age‑based limits that further constrain use in younger patients.

Entries labeled MO in the COVERAGE REQUIREMENTS AND LIMITS column represent a managed coverage flag (commonly interpreted as a medical‑only or management indicator). Where MO appears, providers should follow the plan's medical override/prior authorization processes as described in the Formulary and Member Handbook.

No explicit additional exclusions are present in the cited formulary segments beyond the seven listed exclusion categories; individual drug lines may show coverage fields that are blank in this extract but do not by themselves constitute an exclusion.

Some formulary lines in this extract display a blank COVERAGE REQUIREMENTS AND LIMITS field (for example, certain XARELTO entries and multiple lamotrigine starter/titration kits). Blank entries in this partial extract may reflect omitted detail in this segment rather than unconditional coverage; consult the complete Formulary or prior authorization resources for any required documentation.

Several starter or titration kits (e.g., lamotrigine starter kits and branded starter kits) are listed with the COVERAGE REQUIREMENTS AND LIMITS field blank in this excerpt. When coverage requirements are not specified in the line, providers should verify applicable PA/ST/QL rules in the full Formulary or prior authorization criteria before dispensing.

Certain insulin product lines (e.g., NOVOLIN, NOVOLOG) include the statement 'RELION not covered' indicating that RELION‑branded versions of these insulins are excluded from coverage under the outpatient prescription benefit.

The Formulary includes headings and sections describing appeals, formulary exceptions, and the process for requesting coverage of non‑formulary drugs (e.g., 'APPEALS DUE TO DENIAL OF COVERAGE FOR A NONFORMULARY DRUG' and Formulary Exception procedures). Providers and members should follow those processes when a prior authorization or formulary exception is denied.

A cosmetic‑use denial rationale is embedded in the exclusions: drugs prescribed solely to alter appearance rather than function are excluded. The plan defines cosmetic as drugs intended to improve appearance rather than physiologic function and may deny coverage for such purposes.

Drugs prescribed solely for cosmetic indications are not considered medically necessary for the outpatient prescription drug benefit, except where medical necessity is established (for example, treatments for diagnosed mental illness or conditions affecting memory are excepted).

This extract does not contain standalone, explicit definitional statements titled 'Not Medically Necessary.' However, the exclusion language and Formulary Exception/appeals sections together govern determinations of medical necessity for coverage decisions.

Within the provided extract there are no separate, explicit policy paragraphs labeled 'Not Medically Necessary' that expand on the exclusions; absence of those statements here does not preclude their presence elsewhere in the full policy document.

No explicit standalone 'Not Medically Necessary' declarations appear in this extract. Coverage determinations rely on the exclusion list, Formulary Exception rules, and Prior Authorization criteria as applicable.

Drug Codes, Tier Symbols, and Quantity Rules

Phosphodiesterase 4 (PDE4) InhibitorsmixedCovered

OTEZLA TAB 10/20	Brand: OTEZLA TAB 10/20 (apremilast) - DRUG TIER = 4; COVERAGE REQUIREMENTS AND LIMITS = SP, PA, QL (55 tabs every 28 days); Preferred for Psoriasis, Psoriatic Arthritis.
OTEZLA TAB 10/20/30	Brand: OTEZLA TAB 10/20/30 (apremilast) - DRUG TIER = 4; COVERAGE REQUIREMENTS AND LIMITS = SP, PA, QL (55 tabs every 28 days); Preferred for Psoriasis, Psoriatic Arthritis.
OTEZLA TAB 20MG/30MG/XR75MG	Forms include OTEZLA TAB 20MG, OTEZLA TAB 30MG, and OTEZLA XR TAB 75MG (apremilast) - DRUG TIER = 4; COVERAGE REQUIREMENTS AND LIMITS = SP, PA, QL (2 tabs every 1 day for 20/30 mg; 1 tab every 1 day for XR 75 mg).

Opioid Analgesics (including methadone)mixedCovered

methadone formulations	Includes methadone oral formulations - listed with applicable DRUG TIER and COVERAGE REQUIREMENTS consistent with opioid analgesic class (subject to PA/QL/ST where specified in opioid section).
Fentanyl patches and other opioids	Examples listed elsewhere: fentanyl td patch strengths 12-100 mcg/hr with ST/QL and PA requirements for high strengths.

Steroid InhalantsmixedCovered

ASMANEX HFA (mometasone furoate)	ASMANEX HFA AER 50MCG / 100MCG / 200MCG (mometasone furoate inhalation) - DRUG TIER = 2; COVERAGE REQUIREMENTS AND LIMITS = QL (3 inhalers every 75 days), MO.
BREO ELLIPTA INH 50-25MCG	BREO ELLIPTA INH 50-25MCG (fluticasone furoate - vilanterol) - DRUG TIER = 2; COVERAGE REQUIREMENTS AND LIMITS = QL (9 inhalers every 75 days) displayed as QL (3 inhalers every 75 days), MO for this formulation.

Anti-Obesity / GLP-1 / Incretin AgentsmixedCovered

MOUNJARO INJ 2.5/0.5 - 15MG/0.5	MOUNJARO INJ available in multiple strengths including 2.5/0.5 up through 15MG/0.5 (tirzepatide) - DRUG TIER = 2; COVERAGE REQUIREMENTS AND LIMITS = PA, MO as listed by strength.
OZEMPIC INJ 2MG/3ML - 8MG/3ML	OZEMPIC INJ strengths include 2MG/3ML, 4MG/3ML, and 8MG/3ML (semaglutide) - DRUG TIER = 2; COVERAGE REQUIREMENTS AND LIMITS = PA, MO.
RYBELSUS TAB 3MG/7MG/14MG	RYBELSUS oral semaglutide tablets 3MG, 7MG, 14MG - DRUG TIER = 2; COVERAGE REQUIREMENTS AND LIMITS = PA (3mg listed; 7mg and 14mg PA, MO).
TRULICITY INJ 0.75 - 4.5	TRULICITY INJ dulaglutide available as 0.75, 1.5, 3.0, and 4.5 mg formulations - DRUG TIER = 2; COVERAGE REQUIREMENTS AND LIMITS = PA, MO.

Insulins and Related ProductsmixedCovered

NOVOLIN / NOVOLOG / TOUJEO / TRESIBA

Includes NOVOLIN (70/30, N, R), NOVOLOG (insulin aspart pens, vials, mixes), TOUJEO (insulin glargine 300 U/mL), and TRESIBA (insulin degludec) - DRUG TIER = 2 for many brand presentations; COVERAGE REQUIREMENTS AND LIMITS = MO as noted; RELION brand noted as not covered in some NOVOLIN entries.

Formulary Listing Examplesmixed

Formulary listing guidance

Brand-name listed for reference; generic substitution required by contracted pharmacies unless PA for brand is obtained.

Stimulant Products (examples)mixedCovered

ADHD stimulant classes

Extensive methylphenidate and amphetamine product listings with PA and QL restrictions (e.g., methylphenidate XR/LA/CD caps and tabs with QL 90-540 per 75 days as specified).

Quantity Limit Statements (examples)mixed

Example QLs

Quantity limits explained: QL symbol on formulary indicates limits based on safety/abuse/prescribing norms; PA can be requested for excess quantities with medical necessity.

Other Notable Drug Entriesmixed

Wegovy / Ozempic / Mounjaro class notes

Anti-obesity and incretin class entries include Wegovy (semaglutide for weight management), Ozempic, Rybelsus, Mounjaro, and coverage specifics (PA, MO, QL) per strength/formulation.

Benzodiazepines and Psychotropics QL examplesmixedCovered

Clonazepam / Alprazolam / Diazepam

Multiple benzodiazepine formulations listed with QL (e.g., clonazepam OD tabs QL limits, alprazolam QL 150 tabs per 25 days, diazepam soln/tablet QLs).

Formulary Listing Examples (sample codes)mixed

FIBRICOR TAB 35MG	Brand-Name and Generic-Name listing example: FIBRICOR TAB 35MG (fenofibric acid) with generic equivalence noted.
AMIODARONE (PACERONE)	Generic marketed with brand-name example: (Amiodarone Hcl Tab 100 mg) PACERONE - generic required unless PA for brand.

Stimulant Products (sample)mixedCovered

methylphenidate class	Multiple methylphenidate ER/LA/XR and chew/tab/soln presentations listed with PA and QL (examples: chew tabs 2.5-10 mg QL up to 540 tabs per 75 days; cap ER/XR QLs 90-180 per 75 days).
lisdexamfetamine	Lisdexamfetamine chew tabs 40/50/60 mg - DRUG TIER = 1; COVERAGE REQUIREMENTS AND LIMITS = PA, QL (90 tabs every 75 days) and age-based PA requirements.

Anti-Obesity AgentsmixedCovered

phentermine/topiramate (Qsymia)	Multiple ER strengths listed with DRUG TIER = 1 for generics and DRUG TIER = 2 for brand Qsymia; COVERAGE REQUIREMENTS = PA.
WEGOVY / semaglutide (weight management)	WEGOVY tablets 1.5/4/9/25 mg listed as ND/Brand with DRUG TIER = 2 and COVERAGE REQUIREMENTS = PA, MO.

ADHD-related and Wakefulness AgentsmixedCovered

atomoxetine / guanfacine / clonidine	Non-stimulant ADHD agents with QL and PA entries (example atomoxetine caps with QL 360 caps every 75 days and PA for age >=19).
pitolisant (Wakix)	WAKIX TAB 4.45MG and 17.8MG listed with SP, PA, QL (2 tabs every day).

Methylphenidate Class and Misc StimulantsmixedCovered

dexmethylphenidate / methylphenidate ER	Extensive strengths with DRUG TIER = 1 and QL/PA per strength (caps and tabs; many entries with 90-360 per 75 days limits).
AZSTARYS	AZSTARYS caps with DRUG TIER = 2; COVERAGE REQUIREMENTS = PA, QL (90 caps every 75 days); age-based PA for >=19.

Apremilast (Otezla) EntriesmixedCovered

OTEZLA TAB 10/20	Listed as Brand OTEZLA TAB 10/20 (apremilast) - DRUG TIER = 4; COVERAGE REQUIREMENTS = SP, PA, QL (55 tabs every 28 days); Preferred indications noted.
OTEZLA TAB 10/20/30 and XR 75MG	Includes OTEZLA TAB 10/20/30 and OTEZLA XR TAB 75MG with DRUG TIER = 4; COVERAGE REQUIREMENTS = SP, PA, QL (per strength/day as specified).

Opioid AnalgesicsmixedCovered

fentanyl patches	Fentanyl td patch 72hr strengths 12-100 mcg/hr listed with ST, QL (10 patches every 25 days) and PA requirements; higher strengths require PA.
hydrocodone / morphine / oxycodone	Multiple ER and immediate-release forms with QL and PA (subject to initial 7-day limit; pediatric age-specific initial limits).

Aspirin / Preventive RecommendedmixedCovered

Aspirin 81 mg

Aspirin chew/delayed release 81 mg entries with PV tier and QL (100 tabs every 30 days) for members capable of pregnancy at risk for preeclampsia; otherwise coverage notes apply.

Urinary Anti-Infectives (selected)mixedCovered

nitrofurantoin / fosfomycin / methenamine

Selected urinary anti-infective agents listed with coverage tiers and specifics (e.g., fosfomycin 3 gm pack).

Benzodiazepines and Anxiolytics (selected)mixedCovered

alprazolam / clonazepam / diazepam / lorazepam

Multiple formulations listed with QL restrictions (alprazolam ODT and ER QLs, clonazepam OD QLs, diazepam soln/tablet QLs, lorazepam QLs).

Sample Generic Psychotropic Agents with QLmixedCovered

clonazepam OD tablets	Clonazepam orally disintegrating tablets QL (300 tabs every 25 days) example.
zuranolone (Zurzuvae)	ZURZUVAE / zuranolone entries with SP, PA, QL (2 caps every day) noted elsewhere in the document.

Respiratory Agents and LimitsmixedCovered

ipratropium / spiriva / revefenacin	Bronchodilators and anticholinergics with QLs (e.g., ipratropium inhalation solution QL 720 mL every 75 days; SPIRIVA entries).
BREO ELLIPTA and BREZTRI	BREO ELLIPTA INH strengths 50-25, 100-25, 200-25 listed with QL (9 inhalers every 75 days) and per-formulation inhaler QLs (3 inhalers every 75 days for certain entries).

AntiarrhythmicsmixedCovered

amiodarone / dronedarone / flecainide / propafenone

Antiarrhythmic agents with tiering and MO flags (amiodarone examples include branded PACERONE references).

Inhaled Combination Products (listed)mixedCovered

budesonide-formoterol / fluticasone-salmeterol

Multiple inhaled combinations with QLs (examples: budesonide-formoterol aerosol entries; fluticasone-salmeterol WIXELA INHUB entries).

Inhaled and Nebulized Respiratory ProductsmixedCovered

albuterol inhalers/solutions

Albuterol inhaler and nebulizer solutions with QL examples (e.g., albuterol inhaler QL 9 inhalers every 75 days listed equivalently to QL 6 inhalers in places; nebulizer solution volumes listed).

AnticoagulantsmixedCovered

warfarin / apixaban / rivaroxaban

Warfarin tablets and DOAC branded entries (Eliquis) with MO coverage notes and tiering; rivaroxaban suspension and tablets noted.

Anticonvulsants - Benzodiazepines and RescuemixedCovered

clobazam / diazepam rectal gel / Nayzilam

Rescue and benzodiazepine anticonvulsant options listed with MO and QL where applicable.

Quantity Limit Statementsmixed

General QL rationale

Quantity limits are applied based on safety, overdose/abuse potential, and usual monthly dosing approximations not exceeding FDA max; PA process described for overrides.

Antidepressants (examples)mixedCovered

tricyclics / SNRIs / SSRIs

Examples provided with MO tiering and coverage requirements; imipramine and nortriptyline entries included.

Antidiabetic Combination AgentsmixedCovered

Glyxambi / Synjardy / Xigduo etc.

Multiple combination oral agents listed with DRUG TIER = 2 for branded combos and MO coverage requirements.

GLP-1/GIP Agonists and InsulinsmixedCovered

MOUNJARO / OZEMPIC / RYBELSUS / TRULICITY	MOUNJARO INJ (2.5/0.5 up to 15MG/0.5) - DRUG TIER = 2 with PA; OZEMPIC INJ (2mg/3ml, 4mg/3ml, 8mg/3ml) - DRUG TIER = 2 with PA; RYBELSUS TAB 3/7/14 mg - DRUG TIER = 2 with PA; TRULICITY INJ 0.75 - 4.5 mg listed with PA, MO.
Insulin products (Novolin, Novolog, Toujeo, Tresiba)	NOVOLIN (70/30, N, R), NOVOLOG (aspart vials/pens/mixes), TOUJEO (glargine 300 U/mL), TRESIBA (degludec) - DRUG TIER = 2 for many branded insulin products; COVERAGE REQUIREMENTS = MO with RELION brand notes for noncoverage in some NOVOLIN lines.

Glucagon Rescue ProductsmixedCovered

GVOKE / GVOKE HYPO / GVOKE KIT

Glucagon rescue products (GVOKE HYPO and related) listed with DRUG TIER = 2 and coverage notes.

Required Provider Actions, PA, Step Therapy, and Denial Risks

Prior Authorization

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.

Step Therapy

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

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.

Prior Authorization

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

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.

Documentation Required

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.

Prior Authorization

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

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.

Documentation Required

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.

Prior Authorization

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

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.

Billing Rule

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.

Prior Authorization

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.

Prior Authorization

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 Required

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 Risk

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.

Denial Risk

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.

Note

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.

Quantity Limits by Product/Class

Unspecified (applies to drugs marked QL)

Applies to QL‑marked drugsWhen a drug is marked QL in the coverage table the formulary specifies a maximum quantity for a prescription/time period; requests above the QL require prior authorization with medical necessity documentation.

Decision timeframePrior authorization requests for quantities exceeding QL are adjudicated within 72 hours for non‑urgent requests or within 24 hours for urgent/Exigent Circumstances.

PurposeQLs are intended to align dispensing with usual dosing, reduce overdose/abuse risk, and keep doses within FDA‑approved maximums.

amphetamine sulfate tab (various strengths) — QL 360 tabs

Product groupAmphetamine sulfate tablets (various strengths) are listed with Prior Authorization and Quantity Limit designations.

Common QLMany strengths show QL 360 tablets every 75 days (example for several strengths).

Age-based PAPA is required for members age greater than or equal to 19 for these amphetamine products.

dextroamphetamine sulfate oral solution 5 mg/5ml — QL 3600 mL

ProductDextroamphetamine sulfate oral solution 5 mg/5 mL (generic and PROCENTRA) listed with QL.

Quantity LimitQL 3600 mL every 75 days for dextroamphetamine sulfate oral solution 5 mg/5 mL.

PA requirementPA required for members age greater than or equal to 19 for this formulation.

amphetamine-dextroamphetamine ER/IR (various strengths) — ranges include 90–360 units

Product classAmphetamine‑dextroamphetamine ER/IR formulations across multiple strengths are listed with PA and QL varying by strength.

Range of QLsQL ranges shown include 90, 180, 270, and 360 units every 75 days depending on strength/formulation.

PA age rulePA is required for members age greater than or equal to 19 for these products.

lisdexamfetamine chew tabs — QL 90 tabs

ProductLisdexamfetamine dimesylate chewable tabs (various strengths) are listed with PA and QL.

Quantity LimitQL 90 tabs every 75 days for chewable lisdexamfetamine formulations.

PA requirementPA required for members age greater than or equal to 19.

methamphetamine hcl tab 5 mg — QL 450 tabs

ProductMethamphetamine HCl tablet 5 mg is listed with PA and a quantity limit.

Quantity LimitQL 450 tablets every 75 days for methamphetamine HCl 5 mg.

PA requirementPA required for members age greater than or equal to 19.

QELBREE caps (viloxazine ER) — QL 270 caps

ProductQELBREE (viloxazine ER) capsules are listed with QL and MO.

Quantity LimitQL 270 capsules every 75 days for QELBREE ER formulations.

TierListed drug tier = 2 for QELBREE in examples.

methylphenidate chew tabs — QL 540 tabs

Product categoryMethylphenidate chewable tablets and other methylphenidate formulations are listed with PA, MO, and QL varying by formulation.

Common QLMethylphenidate chew tabs: QL 540 tabs every 75 days; methylphenidate soln 5 mg/5 mL: QL 5400 mL every 75 days.

Age-based PAPA required for members age greater than or equal to 19 for many methylphenidate products.

methylphenidate solution 5 mg/5ml — QL 5400 mL

FormulationMethylphenidate oral solution 5 mg/5 mL is listed with PA and QL.

Quantity LimitQL 5400 mL every 75 days for methylphenidate 5 mg/5 mL solution.

Age-based PAPA required for members age greater than or equal to 19.

methylphenidate formulations — assorted QLs by formulation

SummaryMethylphenidate formulations display assorted QLs by formulation and strength (examples include 90 caps, 270 tabs, 540 tabs, 5400 mL depending on product).

PA and MOMany methylphenidate products require PA and are marked MO for mail order eligibility where applicable.

Age rulePA commonly required for members age >=19 across these formulations.

methylphenidate soln 5 mg/5ml — 5400 mL every 75 days

FormulationMethylphenidate solution 5 mg/5 mL — dosing window stated as a 75‑day QL period.

Quantity Limit per 75 days5400 mL every 75 days for methylphenidate soln 5 mg/5 mL.

PAPA required for members age >=19.

methylphenidate soln 10 mg/5ml — 2700 mL every 75 days

FormulationMethylphenidate solution 10 mg/5 mL — dosing window stated as a 75‑day QL period.

Quantity Limit per 75 days2700 mL every 75 days for methylphenidate soln 10 mg/5 mL.

PAPA required for members age >=19.

RINVOQ, XELJANZ, OTEZLA — assorted QLs (examples)

ExamplesRINVOQ, XELJANZ, and OTEZLA entries show assorted QLs by product and formulation (e.g., RINVOQ SOL 12 mL every 1 day; RINVOQ TAB 84 tabs every 84 days; OTEZLA QL 55 tabs every 28 days).

DesignationThese specialty immunomodulators are frequently designated SP and require PA in addition to QL limits.

Provider actionPA and medical necessity documentation required to exceed QL or for SP drugs.

apremilast (Otezla) — QL 55

ProductApremilast (OTEZLA) tablets across strengths/formulations listed with SP, PA, and QL designations.

Standard QLOTEZLA TAB (10/20/30 mg): QL 55 tablets every 28 days (listed as QL in multiple entries).

Alternate QLsOther OTEZLA entries show per‑day QLs for certain strengths (e.g., 2 tabs every 1 day for some formulations).

fentanyl transdermal patch — QL 10

ProductFentanyl transdermal patches (multiple strengths) listed with ST/PA and QL.

Common QLLower‑strength fentanyl patches: QL 10 patches every 25 days; higher strengths require PA.

Step/PA notesSome fentanyl patch entries are marked ST with PA** indicating PA contingent on step therapy criteria for certain groups.

hydrocodone ER — QL 60 (example)

Example QLHydrocodone ER examples shown with QL 60 caps every 25 days (example in opioid listings).

Other opioid QLsOxycodone/oxymorphone/morphine IR forms show assorted QLs (e.g., 180 tabs, 900 mL, 90 mL depending on strength/formulation).

Initial supplyMany opioid entries note subject to an initial 7‑day limit (3‑day if age ≤19).

oxycodone/oxymorphone/morphine IR forms — assorted QLs

Concentrated solutionOxycodone HCl concentrate 100 mg/5 mL (20 mg/mL): QL 90 mL every 25 days.

Oral solutionOxycodone HCl solution 5 mg/5 mL: QL 900 mL every 25 days.

Tablets by strengthOxycodone tablets QLs vary by strength (example: 5 mg = 180 tabs every 25 days; 30 mg = 60 tabs every 25 days).

oxycodone conc 100 mg/5ml — QL 90 mL every 25 days

ProductOxycodone HCl concentrate 100 mg/5 mL (20 mg/mL) is listed with PA and QL.

Quantity LimitQL 90 mL every 25 days for oxycodone concentrate 100 mg/5 mL.

Initial supplySubject to initial 7‑day limit; if age 19 or younger subject to initial 3‑day limit.

oxycodone soln 5 mg/5ml — QL 900 mL every 25 days

ProductOxycodone HCl solution 5 mg/5 mL listed with PA and QL.

Quantity LimitQL 900 mL every 25 days for oxycodone solution 5 mg/5 mL.

Initial supplySubject to initial 7‑day limit (3‑day for age ≤19).

oxycodone tablets (5–30 mg) — assorted QLs by strength

Range by strengthOxycodone tablets (5–30 mg) have strength‑specific QLs (examples: 5 mg = 180 tabs/25 days; 30 mg = 60 tabs/25 days).

PA and initial limitsThese tablet QLs are accompanied by PA and are subject to initial 7‑day supply limits (3‑day for age ≤19).

Coverage typeEntries are typically DRUG TIER = 1 with coverage requirements noted in the formulary lines.

tramadol solution 5 mg/ml — QL 1800 mL every 25 days

ProductTramadol oral solution 5 mg/mL is listed with PA and QL.

Quantity LimitQL 1800 mL every 25 days for tramadol solution 5 mg/mL.

Age/availabilitySubject to initial 7‑day limit; subject to initial 3‑day limit under age 19; not available under age 12 for some formulations.

acetaminophen w/ codeine solutions/tabs — assorted QLs

ExamplesAcetaminophen with codeine solutions/tabs are listed with QLs (examples: 2700 mL every 25 days for soln; 400 tabs every 25 days for tabs).

Opioid documentationEntries note initial supply limits and PA/PA** where applicable.

Age restrictionsSome opioid combination products are not available under age 12 and have age‑based initial supply rules.

BELBUCA films — QL 60 films every 25 days

ProductBELBUCA buprenorphine films are listed with Step Therapy and QL.

Quantity LimitQL 60 films every 25 days for BELBUCA formulations.

Coverage noteMany are marked ST and PA**, requiring step or prior auth per plan rules.

buprenorphine TD patch weekly — QL 4 patches per month

ProductBuprenorphine transdermal patches (weekly) are included with coverage limits.

Quantity LimitQL 4 patches per month for lower strengths (example shown in listing).

Step/PASome patch strengths are ST or require PA for higher strengths.

alprazolam (multiple formulations) — assorted QLs

Alprazolam examplesAlprazolam multiple formulations are assigned assorted QLs (e.g., 150 tabs every 25 days for many strengths; ER 3 mg = 90 tabs every 25 days).

ER specificsAlprazolam ER formulations commonly use a 150‑tab (25‑day) window; some ER strengths have lower QLs (90 tabs/25 days).

Related benzodiazepinesChlordiazepoxide: QL 360 caps every 25 days; diazepam solutions and tabs have mL/tab QLs as listed.

alprazolam ER formulations QL specifics

Alprazolam ER detailsAlprazolam ER formulations: QL typically 150 tablets every 25 days; some strengths 90 tablets every 25 days.

ChlordiazepoxideChlordiazepoxide caps (5/10/25 mg): QL 360 caps every 25 days.

Diazepam solutionDiazepam oral solution: QL 1200 mL every 25 days (example listed).

chlordiazepoxide caps — QL 360 caps

ProductChlordiazepoxide capsule formulations (5/10/25 mg) appear with QL in formulary entries.

Quantity LimitQL 360 capsules every 25 days for chlordiazepoxide caps.

TierListed as Drug Tier = 1 in the formulary extract.

diazepam oral solution — QL 1200 mL every 25 days

ProductDiazepam oral solution is listed with a specific volume limit.

Quantity LimitQL 1200 mL every 25 days for diazepam oral solution 1 mg/mL.

Associated formsOther diazepam forms (tabs, concentrated solutions) have separate QLs as listed.

inhaled steroid/bronchodilator product QLs (examples)

Class examplesInhaled steroid/bronchodilator products show QLs such as 3 inhalers every 75 days or 720 mL every 75 days depending on product.

TRELEGY/STIOLTO examplesTRELEGY and STIOLTO entries show QL 3 inhalers every 75 days (example for combination inhalers).

Nebulized volumesIpratropium and formoterol nebule solutions show mL‑based QLs (e.g., 720 mL, 360 mL every 75 days).

budesonide-formoterol aerosol — QL 9 inhalers

ProductBudesonide‑formoterol fumarate dihydrate aerosol 160/4.5 mcg/act is listed with a QL for inhalers.

Quantity LimitQL 9 inhalers every 75 days for budesonide‑formoterol aerosol 160/4.5 mcg/act.

Equivalent inhalationsThis appears alongside other inhaler QLs that convert inhalers to inhalation counts where relevant.

fluticasone-salmeterol aer powder — QL 9 inhalers = 180 inhalations

ProductFluticasone‑salmeterol aerosol powder (100/50 and 250/50 mcg/act) listed with inhaler and inhalation QLs.

Quantity LimitQL 9 inhalers every 75 days which equals QL 180 inhalations every 75 days.

MO flagEntries include MO indicating mail‑order/maintenance eligibility where applicable.

formoterol solution nebule — QL 360 mL

ProductFormoterol fumarate solution nebule 20 mcg/2 mL is included among nebulized products with volume limits.

Quantity LimitQL 360 mL every 75 days for formoterol nebule solution.

Coverage flagMO appears alongside QL in these nebulized product entries.

levalbuterol solution nebu — QL 900 mL

ProductLevalbuterol HCl solution for nebulization (various strengths) listed with QLs.

Quantity LimitQL commonly 900 mL every 75 days for many strengths; concentrated forms may have QL 270 mL every 75 days.

MOMO flag present for these nebule entries indicating managed/maintenance medication rules.

clonazepam ODT QL 300 tablets

ProductClonazepam orally disintegrating tablets and standard tablets are listed with MO and QL.

Quantity LimitClonazepam ODT and tablets: QL 300 tablets every 25 days.

Coverage flagMO appears in the coverage requirements indicating managed coverage procedures apply.

TRELEGY and STIOLTO inhaler QL examples

ProductsTRELEGY AER and STIOLTO AER inhalers are listed with QLs in the formulary extract.

Quantity LimitTRELEGY and STIOLTO: QL 3 inhalers every 75 days (example for these combination inhalers).

MOMO flag accompanies these QLs indicating managed coverage rules.

ZURZUVAE cap QLs (20/25 mg = 2 caps; 30 mg = 1 cap)

ProductZURZUVAE (zuranolone) capsule entries include SP, PA, and QL in coverage requirements.

20 mg / 25 mg QLZURZUVAE CAP 20 mg and 25 mg: QL 2 caps every 1 day.

30 mg QLZURZUVAE CAP 30 mg: QL 1 cap every 1 day.

ZURZUVAE cap QL — 30 mg = 1 cap

ProductZURZUVAE CAP 30 mg has a distinct, lower QL compared with 20/25 mg strengths.

Quantity LimitQL 1 cap every 1 day for the 30 mg strength.

CoverageEntries include MO and PA indicating management and prior authorization requirements.

Definitions and Formulary Terminology

Formulary definitions (what is drug tier, PA, QL examples)

FormularyFormulary: complete list of drugs preferred for use and eligible for coverage under Sharp Health Plan's outpatient prescription drug benefit.

Prior Authorization (PA)Prior Authorization: requirement that the enrollee or prescribing provider obtain Sharp Health Plan authorization before coverage will be provided.

Quantity Limit (QL)Quantity Limit: maximum quantity allowed within the specified time period (e.g., 55 tabs every 28 days).

Formulary

FormularyThe Formulary is the complete list of drugs preferred for use and eligible for coverage under the Sharp Health Plan outpatient prescription drug benefit.

UsageFormulary entries indicate drug tier, coverage requirements (PA, QL, ST, MO, SP), and any applicable limits.

ReferenceDefined terms are capitalized and explained in the Formulary and Member Handbook Glossary.

Brand-Name Drug

DefinitionBrand-Name Drug: a drug marketed under a proprietary, trademark‑protected name; listed in all CAPITAL letters in the Formulary.

ImplicationWhen a generic equivalent exists, pharmacies must dispense the generic unless prior authorization for the brand is obtained.

Coverage noteBrand‑name coverage may require PA to justify medical necessity when generic available.

Generic Drug

DefinitionGeneric Drug: the same drug as its brand equivalent in dosage, strength, route, quality, performance, and intended use; listed in bold italicized lowercase letters when covered separately.

Pharmacy practicePharmacies are required to dispense generics when available unless PA for the brand is obtained.

Formulary displayGenerics appear with specific coverage requirements and QLs where applicable.

Prior Authorization

DefinitionPrior Authorization (PA): Sharp Health Plan's requirement that the enrollee or prescribing provider obtain plan authorization prior to coverage; PA is granted when medically necessary.

PA**PA** indicates prior authorization based on clinical criteria if Step Therapy has not been met (PA may be requested for medical necessity to bypass step therapy).

SubmissionPA requests are submitted via phone, fax, or electronic form and processed within the stated timeframes (72 hours non‑urgent, 24 hours urgent).

Drug Tier

DefinitionDrug Tier: grouping that corresponds to cost‑sharing level for prescription drugs (PV, Tiers 1–4).

Tier meaningsTier placement determines member copayment/coinsurance and may indicate specialty drugs in higher tiers (Tier 4 = Specialty).

Formulary useEntries show drug tier alongside coverage requirements and limits.

Specialty Drug (SP)

DefinitionSpecialty Drug (SP): drugs that must be filled by a Specialty Pharmacy network, require special handling, training, or clinical monitoring, and are limited to a typical 30‑day supply per fill.

DistributionSP designation implies specialty distribution (e.g., CVS Specialty) and prior authorization may be required.

Formulary displaySP appears in the coverage requirements and limits column where applicable.

Cosmetic

DefinitionCosmetic: drugs prescribed solely to alter or improve appearance rather than function; excluded from outpatient prescription drug benefit except where required by law.

Exclusion impactPrescriptions for cosmetic purposes may be denied under the drug benefit and are not eligible for Exception Requests in most cases.

ExamplesExclusion list includes hair loss, sexual dysfunction, athletic performance, anti‑aging for cosmetic purposes, and others.

Class III obesity (exception to weight-loss exclusion)

ExceptionClass III obesity is an exception to the weight‑loss drug exclusion when medically necessary; enrollment in a comprehensive weight‑loss program may be required.

DocumentationMedical necessity and program enrollment documentation may be required for coverage of weight‑loss agents for Class III obesity.

ReferenceThe exclusion list notes the exception without specifying BMI thresholds in the excerpt.

QL (Quantity Limit) definition

DefinitionQL (Quantity Limit): the maximum quantity allowed within the specified time period (e.g., 55 tabs every 28 days).

PurposeQLs are applied to manage safety, overdose/abuse risk, and align with usual dosing; exceeding QL requires PA with medical necessity justification.

Formulary displayQL appears in the 'Coverage Requirements and Limits' column for affected products.

PA / PA**

DefinitionsPA / PA**: PA indicates prior authorization required; PA** indicates PA if Step Therapy is not met (PA may be used to bypass ST when medically necessary).

UsageThese flags appear in the coverage requirements column and trigger provider action to submit authorization documentation.

TimeframesPA decisions: 72 hours non‑urgent, 24 hours urgent/exigent circumstances (deemed granted if timeframe missed).

ST (Step Therapy)

DefinitionST (Step Therapy): process requiring trial of one or more preferred drugs in sequence before coverage of a requested drug; exceptions may be requested and granted when criteria met.

Provider actionProviders may submit Step Therapy exception requests with supporting clinical documentation per plan rules.

Relationship to PAST designations may be accompanied by PA or PA** flags in the formulary.

Formulary abbreviations note

NoteFormulary abbreviations such as PA, QL, ST, MO, SP appear in the coverage requirements column to indicate utilization management controls.

MOMO indicates mail‑order/maintenance designation (90‑day supply eligible) and appears next to many entries.

ReferenceSee the Formulary definitions section for full descriptions of these abbreviations.

Management/coverage requirement indicator examples (MO)

ExamplesMO appears alongside QL and PA for many antiepileptic and CNS drugs; ZURZUVAE shows MO = SP, PA, QL as an example of combined flags.

MeaningMO functions as a coverage/management indicator adjacent to product entries and implies additional plan procedures may apply.

Provider implicationWhen MO appears providers should follow payer processes for medical override or prior authorization as applicable.

Specialty drug designation (SP) example

DesignationSP (Specialty) indicates a drug requiring specialty pharmacy distribution and is typically limited to a 30‑day supply per fill.

ExamplesApremilast (OTEZLA), RINVOQ, XELJANZ and some GLP‑1/GIP agents are designated SP where noted.

Provider actionSP designation often accompanies PA and QL requirements; specialty pharmacy processes will apply.

Prior Authorization (PA) shorthand

ShorthandPA shorthand denotes prior authorization is required before coverage; providers must submit supporting clinical documentation.

ProcessingPA requests processed via phone, fax, or electronic forms with stated timeframes (72/24 hours).

Relation to QL/STPA may be required to exceed QL or to bypass Step Therapy (PA**).

Quantity Limit (QL) shorthand

QL shorthandQL denotes a Quantity Limit appearing in the coverage requirements column indicating the maximum supply allowed per time period.

EffectRequests above QL require PA and medical necessity documentation; decision timeframes apply.

ExampleOTEZLA QL 55 tabs every 28 days is a representative QL entry in the formulary.

MO (coverage requirement/managed coverage indicator)

MO meaningMO appears as a coverage requirement/limit code beside many products and is interpreted in the document as a managed coverage flag (may indicate mail‑order or medical override/management).

ImplicationItems marked MO often require additional coverage steps or documentation; providers should follow payer instructions when MO appears.

ExamplesSeveral GLP‑1/GIP agents and antiepileptics include MO flags in their entries.

PA flags for select injectables

PA flag examplesPA flags appear for multiple injectables and select high‑cost agents (e.g., liraglutide, tirzepatide, semaglutide, dulaglutide, MOUNJARO), indicating prior authorization is required.

MO coexistenceSome injectable agents show both MO and PA indicating managed coverage with PA processes.

Provider actionProviders should submit PA and required documentation for these injectables per formulary guidance.

Step Therapy Criteria and Mapping

Aspect	Summary
Presence of Step Therapy (ST)
Formulary includes a dedicated 'STEP THERAPY CRITERIA' section and ST is referenced in the Table of Contents; multiple therapeutic classes may be subject to step therapy.

Aspect	Summary
Requirement
Sharp Health Plan may require trial of one or more drugs in a specified sequence before covering a requested drug; providers may request Step Therapy exceptions and the plan will grant exceptions when criteria are met.

Aspect	Operational detail
Coverage dependency
Drugs labeled with ST are covered only after prior use of specified alternatives; exceptions are processed via the Step Therapy Exception/Prior Authorization process and deemed granted if not decided within stated timeframes.

Policy	Implication
Dispense generic when available
Pharmacy is required to dispense a generic when available unless prior authorization for the brand is obtained; same approach applies to interchangeable biologics vs reference biologic with prior authorization for the reference product required to override substitution.

Step Therapy Group	Criteria (cumulative exposure thresholds)
OPIOID ER 2219-M
Coverage provided if member has filled a cumulative ≥7-day supply of an immediate‑release opioid within the past 90 days OR has been receiving an extended‑release opioid for a cumulative ≥30 days within the past 90 days. (See Step Therapy Group OPIOID ER 2219‑M)

Product class	PA requirement (age threshold)
Amphetamine-class products
Many amphetamine products are designated PA with an age-based requirement: prior authorization is required for members age greater than or equal to 19. Quantity limits also apply per product/strength.

Labeling/flags	Presence of SP / PA / QL and step therapy detail
Preferred-for labels & SP/PA/QL flags
Several agents are labeled 'Preferred for' specific indications and show SP, PA and QL flags (e.g., RINVOQ, XELJANZ, OTEZLA); these entries include PA/MO flags but explicit step therapy sequences are not specified in these chunks.

Formulation type	ST applicability
ER opioid formulations
Multiple extended‑release opioid formulations (e.g., fentanyl patches, hydrocodone ER, tramadol ER, BELBUCA films) are designated ST or ST/PA in the formulary and therefore are subject to step therapy requirements before coverage.

Examples	Designation
Tramadol ER; BELBUCA films; hydrocodone ER; fentanyl patches
These products are shown with ST and QL (and often PA or PA**) in the formulary lines; they illustrate items explicitly designated as step therapy examples in the excerpt.

Observation	Gap in excerpt
Explicit step sequences absent
The excerpt includes ST references and group rules but does not list comprehensive per‑drug ordered step sequences (no multi‑step fail‑first sequences are specified in these chunks).

Notation observed	Meaning (undefined in excerpt)
Numeric mappings (e.g., '1 = 1', '1 = 2')
Some therapeutic class entries show numeric mappings such as '1 = 1' and '1 = 2' but the document segment does not define these mappings or their relation to step order in the provided excerpt.

Finding	Supporting detail
Absence of explicit ST requirements in many lines
Many formulary product lines show tiers and coverage flags (MO, PA, QL) but do not include explicit step therapy (fail‑first) requirement text in this excerpt; PA is often the controlling utilization management mechanism in those lines.

Tier assignment	Implication for preferred‑first
Non‑preferred tier examples
Several brand agents (e.g., AUVELITY, some GLP‑1/GIP agents) are assigned to higher/non‑preferred tiers (tier 2) with MO/PA flags, implying that preferred agents may be expected to be tried first though explicit ST steps are not listed in the excerpt.

Class / products	Tier and flags (step/PA implication)
GLP‑1/GIP injectables and tirzepatide (e.g., MOUNJARO, OZEMPIC, TRULICITY)
These agents are frequently placed at tier = 2 and carry MO and/or PA flags in the formulary lines, implying prior authorization or managed coverage and suggesting preferred‑first placement though explicit step therapy sequences are not present in the provided chunks.

OpenPayer

List of covered prescription drugs (4 Tier Commercial Large Group HMO and POS)

Coverage Criteria and Formulary Rules

Drug Codes, Tier Symbols, and Quantity Rules

Required Provider Actions, PA, Step Therapy, and Denial Risks

Quantity Limits by Product/Class

Where Drugs Are Dispensed and Specialty Pharmacy Rules

Biosimilar and Interchangeable Biological Product Rules

Definitions and Formulary Terminology

Initial Therapy and Opioid Supply Restrictions

Step Therapy Criteria and Mapping

Document Purpose and Scope