Currentsierra health and lifePolicy N/A

Advantage 4-Tier Prescription Drug List (PDL) - Coverage Criteria

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A formulary (PDL) describing covered prescription medications, tiering, and coverage controls for Sierra Health and Life medical plan members whose pharmacy benefit uses the Advantage 4-Tier PDL.

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Currentsierra health and lifePolicy N/A

Advantage 4-Tier Prescription Drug List (PDL) - Coverage Criteria

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A formulary (PDL) describing covered prescription medications, tiering, and coverage controls for Sierra Health and Life medical plan members whose pharmacy benefit uses the Advantage 4-Tier PDL.

Policy Summary

Payersierra health and life

PolicyAdvantage 4-Tier Prescription Drug List (PDL) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line-item lists 'PA' in Requirements & Limits before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4tiers described

May 1, 2026PDL accuracy date

PA, QL, STrequirement flags

call/websitemember resources

Coverage Criteria Overview

Medications may be excluded from coverage when there are covered, lower-cost alternatives or over-the-counter options that provide the same therapeutic effect. The plan evaluates treatments for clinical effectiveness, safety and cost; if an equivalent lower-cost covered product exists (including an OTC alternative) the higher-cost product may be excluded or subject to prior authorization. Members and providers should consult benefit documents or the member website for details on exclusions and covered alternatives.

Coverage for termination of pregnancy medications is determined under the member's medical benefit plan rather than the pharmacy prescription drug benefit. Providers and members should review the medical plan documents or call the number on the member ID card to confirm applicable coverage, exclusions, and cost sharing.

These index pages list drug names and page references only and do not contain drug-specific coverage criteria or utilization rules. For coverage determinations, prior authorization requirements, step edits, quantity limits, or specialty routing, refer to the individual drug policy pages referenced by the index entries.

No explicit coverage exclusions are presented within this index segment. The index functions solely as a navigational list of medications; any exclusions or coverage rules applicable to a product will be found on the detailed policy page for that drug.

No not-medically-necessary determinations are stated in this index section. Clinical coverage decisions, including any NMN determinations, are documented on the substantive drug pages rather than in the index.

Utilization Flags and Codes

Utilization management flags from listingmixed

PA	Prior Authorization (flag seen in Requirements & Limits)
QL	Quantity Limit (flag seen in Requirements & Limits)
SP	Specialty (flag seen in Requirements & Limits)
ST	Step Therapy (flag seen in Requirements & Limits)
H	H flag appears in Requirements & Limits (meaning not defined in excerpt)

inv-07: Not applicable — placeholder key/value

Not applicableNot applicable

Provider Responsibilities and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many medications listed in the drug list. When a drug is flagged with PA in the Requirements & Limits column, the prescriber must obtain prior authorization (precertification) before the plan can approve coverage. Failure to obtain required PA may result in claim denial or delay.

Drugs flagged with PA require prescriber submission of clinical information supporting medical necessity.
Some specialty and infertility therapies (e.g., selected specialty injectables, gonadotropins) commonly require PA.
Analgesics and certain high-cost or high-risk agents in the pain drug class are frequently subject to PA and/or quantity limits.

Documentation Required

Documentation and How to Verify Coverage

Where prior authorization or other requirements apply, prescribers should follow the payer's authorization process and provide documentation as requested. Documentation should include diagnosis, prior therapies tried (when step therapy or ST is indicated), rationale for the requested agent, dose, and treatment duration. Specialty products may require specialty pharmacy routing and additional documentation.

Key Terms and Abbreviations

inv-63: PDL / Formulary definition — PDL: list of commonly prescribed meds, tiered

PDL (Prescription Drug List)A list of the most commonly prescribed FDA‑approved brand and generic prescription medications, organized by category and placed into tiers to indicate member cost-share and coverage preference.

ContentIncludes brand‑name (UPPERCASE) and generic (lowercase) entries, listed alphabetically within classes.

PurposeTiering signals relative out‑of‑pocket cost and preferred options to guide prescriber/member choices.

inv-64: Tier — explanation of tiers (Tier 1 lower-cost to Tier 4 higher-cost)

Tier structureTier 1 = lower‑cost (mostly generics); Tiers 2–3 = mid‑range cost (mix of brand and generic); Tier 4 = highest‑cost (mostly brand); using lower tiers may lower out‑of‑pocket costs.

Application

Step Therapy Rules and Affected Products

Policy note	Coverage flag
Some medications are noted with 'ST' indicating step therapy is required — the member may need to try other medications and obtain prior authorization before the requested medication is covered.
ST = Step therapy (requires prior authorization and may require trials of other medications before coverage).

Formulary indicator	Interpretation
Tier and 'H' markers appear on drug entries to indicate formulary hierarchy and special handling (e.g., preventive benefit or restricted status).
H (Health Care Reform Preventive) and tier assignments imply formulary preference and may interact with step/hierarchy requirements for certain classes such as nicotine replacement and anti-addiction agents.

Drug	Requirement
AUVELITY
Listed with Requirements & Limits = ST, QL indicating step therapy applies

Drug examples	Requirements & Limits
Multiple branded specialty and oncology agents (examples include IBRANCE, EXKIVITY, GAVRETO)
Entries show 'ST' among Requirements & Limits for several specialty/oncology drugs indicating step therapy applies prior to coverage

Example products	ST present
B JORNAY PM (line-item)
Requirements & Limits include ST, QL — ST flag present for this product

Product / class	Requirements & Limits
Dermatologic topical agents (examples: B EFUDEX external cream, B ENSTILAR, B EUCRISA)
Some dermatology entries list ST in Requirements & Limits (ST appears with QL on selected products)

Product	ST indicated
B VOQUEZNA DUAL PAK / TRIPLE PAK
Requirements & Limits = ST, QL for Dual/Triple Pak — ST applies

Product	Requirements & Limits
lansoprazole oral tablet delayed release dispersible
Requirements & Limits = PA, ST, QL — step therapy required as noted

Drug	ST flag
Norethindrone-ethinyl estradiol products (example: B SLYND listing)
Requirements & Limits include PA, ST for some contraceptive entries — ST required prior to coverage where indicated

Drug examples	ST implication
OLUMIANT, ORENCIA (various presentations), GONAL-F referenced in listing
Entries show ST among Requirements & Limits (e.g., OLUMIANT: PA, ST, QL, SP; ORENCIA: PA, ST, QL, SP) — step therapy required before coverage unless exceptions met

Quantity Limits and Affected Products

inv-81: Multiple analgesic entries — QL applied as noted next to specific products

Analgesics QLMultiple analgesic entries are annotated with QL on the line‑item (e.g., BELBUCA listed with PA, QL; various opioid combinations show QL).

ExamplesFentanyl transdermal patches and several butalbital/acetaminophen combinations show QL entries in the PDL excerpts.

ImplicationQuantity limits may trigger claim edits or denials if dispensing exceeds the listed QL without authorization.

inv-82: fidaxomicin — QL noted

FidaxomicinListed with Requirements & Limits = QL on the PDL (fidaxomicin oral tablet).

TieringFidaxomicin appears with a tier assignment in the listing (tier shown in the PDL excerpt).

Background and Context

Specialty medications are high-cost therapies used to treat rare or complex conditions and often require special handling, storage, or administration. These agents are commonly managed through specialty pharmacy channels and subject to additional utilization controls such as prior authorization, quantity limits, step therapy, and specialty routing. The PDL groups medications by class and assigns tier levels to indicate relative member cost-share and formulary preference.

Policy Summary

Payersierra health and life

PolicyAdvantage 4-Tier Prescription Drug List (PDL) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line-item lists 'PA' in Requirements & Limits before dispensing.

SourceLink

On This Page

Verify member coverage and PA requirements by calling the toll-free number on the member ID card or by visiting the member website listed on the ID card.
When ST is indicated, document prior trial(s) and reason for failure or contraindication to step agents.
Specialty (SP) products often must be obtained through a designated specialty pharmacy and may have separate submission requirements.

Denial Risk

Authorization and Denial Triggers

Requirement flags in the drug list (PA, ST, QL, SP, H, H-PA) can trigger coverage limits or denials if conditions are not met. Claims exceeding quantity limits (QL), drugs requiring step therapy (ST), or those requiring PA or specialty routing (SP) may be rejected until supporting documentation or approval is received.

PA — prior authorization required before coverage determination; may be listed alone or combined with other flags (e.g., PA, PA, QL, PA, ST).
ST — step therapy requires documented failure, intolerance, or contraindication to preferred agents before coverage of the requested drug.
QL — quantity limits restrict the amount covered per time period; requests above QL may require prior authorization.
SP — specialty routing indicates the medication may need to be dispensed through a specialty pharmacy.
H / H-PA — health care reform preventive flags indicate coverage and may require PA for no-cost preventive benefit.

Note

Index: no authorization details

Index pages in this document list drug names and page references only and do not show PA or other requirement details. To determine whether a specific drug requires prior authorization, refer to the detailed drug listing pages where the Requirements & Limits field is displayed.

The Index contains only entries and page references; it does not contain PA rules or documentation requirements.
Always use the detailed section for the drug to confirm PA, ST, QL, or SP flags and any associated criteria.

Step Therapy

Step Therapy Requirements

Step therapy (ST) and formulary hierarchy may apply to select drug classes. Drugs marked ST require that specified alternative medication(s) be tried first, with documentation of treatment failure, intolerance, or contraindication to the preferred agents before the requested drug will be authorized.

Step therapy requirements are shown next to drug entries as ST and may be combined with PA and/or QL.
Prescribers must document prior agent(s) tried, duration, and reason for discontinuation to satisfy ST criteria.

Tier cost levels may vary by plan; high deductible plans may apply tier costs after deductible is met.

Member guidancePatients and prescribers are advised to consider lower‑tier alternatives to reduce costs.

inv-65: Requirements & Limits — field indicating utilization management flags such as H, QL, PA, SP, ST

Field purpose'Requirements & Limits' indicates utilization management flags applied to a formulary line (examples: H, QL, PA, SP, ST).

Common flagsFlags denote specific controls such as prior authorization, quantity limits, specialty routing, or step edits on a per‑product basis.

Where shownDisplayed next to drug line items in the PDL to indicate coverage controls that must be met for claims processing.

inv-66: Requirement/Limit flags mapping — PA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy; SP = Specialty

PAPrior Authorization

QLQuantity Limits

STStep Therapy

SPSpecialty

inv-67: PA — Prior Authorization (listed in Requirements & Limits)

DefinitionPA = Prior authorization — requires the prescriber to provide information about why the medication is being used before the plan decides coverage.

DisplayShown in the 'Requirements & Limits' field next to line‑item drugs where prior approval is required.

ImplicationClaims for PA‑flagged drugs may be denied if authorization criteria are not met.

inv-68: QL — Quantity Limit (listed in Requirements & Limits)

DefinitionQL = Quantity limits — the maximum quantity of a medication covered per copayment or within a defined time period.

DisplayShown in 'Requirements & Limits' next to specific formulations or products (e.g., fidaxomicin, many insulin presentations).

ImplicationClaims exceeding the QL may be denied or require additional authorization/documentation.

inv-69: ST — Step Therapy (listed in Requirements & Limits)

DefinitionST = Step Therapy — requires trials of one or more other medications (step edits) before the requested medication may be covered.

DisplayAppears in 'Requirements & Limits' for products subject to step edits (examples include AUVELITY, TRINTELLIX, and select specialty agents).

Provider actionPrescribers must document trial/failure or contraindication to preferred therapy per plan rules to satisfy ST requirements.

inv-70: Formulary index — index definition / presence

DefinitionFormulary index — alphabetical listing of drug names with page references; index pages do not typically include coverage rules.

UseIndex directs users to detailed PDL pages where tier and 'Requirements & Limits' are specified.

NoteRefer to detailed drug policy sections referenced by the index for authorization or documentation requirements.

ImplicationClaims for fidaxomicin are subject to plan quantity limits as noted in the formulary entry.

inv-83: LAMICTAL products — PA (some XR/ODT formulations) noted (related to limits/auth)

LAMICTAL productsCertain LAMICTAL branded and formulation lines are noted as requiring PA; some XR and ODT formulations are specifically listed with PA.

ExamplesB LAMICTAL and LAMICTAL ODT and LAMICTAL XR entries in the PDL show Requirements & Limits = PA for some presentations.

ImplicationProviders must obtain prior authorization for the PA‑flagged lamotrigine formulations to secure coverage.

inv-84: Generic entries with 'QL' — see formulary flags

Generics with QLMultiple generic line items in the formulary excerpts are annotated with QL indicating quantity limits apply (see line items in antifungal and dermatologic sections).

SectionsExamples include griseofulvin, nystatin formulations, and various topical generics showing QL in Requirements & Limits.

ImplicationQuantity limits on generics may require overrides or result in claim edits when exceeded.

inv-85: Multiple flags present — QL for listed drugs

Multiple QL flagsMany listed products across therapeutic areas include QL as a Requirements & Limits flag indicating quantity limits are applied on those line items.

ExamplesEntries in the cardiovascular, CNS and gastrointestinal sections show QL among other flags (e.g., PA, ST, SP) where applicable.

ImplicationClaims for these drugs may be limited to plan‑specified quantities unless additional authorization is obtained.

inv-86: Topical and systemic dermatologic agents — QL noted

Dermatologic agentsMultiple topical and systemic dermatologic agents are listed with QL in the Requirements & Limits field (e.g., adapalene‑benzoyl peroxide gel, clobetasol products).

ExamplesAKLIEF, pimecrolimus, clobetasol formulations and others are shown with PA and/or QL in the dermatology listings.

ImplicationPrescriptions for dermatologic agents may be subject to quantity limits and prior authorization per line‑item flags.

inv-87: Multiple listed products — QL where noted

Multiple products with QLSeveral listed products (including many insulin presentations and specialty biologics) show QL in their Requirements & Limits entries.

ExamplesINSULIN LISPRO KWIKPEN, LANTUS SOLOSTAR, B LYUMJEV, and selected biologics are annotated with QL in the PDL excerpts.

ImplicationQuantity limits apply across product types and may require specialty pharmacy processing or authorization when exceeded.

inv-88: Multiple entries — QL when specified on line-item

Line‑item QLMany individual entries in the GI and bowel prep sections explicitly list QL when that limit applies (e.g., B PYLERA, B CLENPIQ, PLENVU show QL where indicated).

Associated flagsSome of these line items combine QL with other flags such as PA, ST, or SP depending on the product.

ImplicationQuantity limits on these products may restrict dispense amounts and trigger prior authorization workflows.

inv-89: zovia 1/35 (28) — QL

Zovia 1/35 (28)Listed in the PDL with Requirements & Limits = QL.

ContextZovia appears among contraceptive products in the listing and is subject to quantity limits per the formulary entry.

ImplicationDispensing beyond the QL may require authorization or result in claim edits.

inv-90: FOLLISTIM AQ, TERIPARATIDE, others flagged QL — see listing

FOLLISTIM AQ and TERIPARATIDEThese products are flagged with QL (and TERIPARATIDE also shows PA, SP in the listing), indicating quantity limits and specialty/authorization controls.

ExamplesTERIPARATIDE SOLUTION PEN‑INJECTOR is listed with Requirements & Limits = PA, SP; INSULIN LISPRO presentations list QL.

ImplicationThese specialty and high‑cost agents require adherence to QL and may require prior authorization and specialty pharmacy routing.