Essential 4-Tier Prescription Drug List (PDL) — Pharmacy Coverage Criteria
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PDL governing pharmacy benefit coverage tiers, prior authorization, and coverage notes for Sierra Health and Life medical plan members enrolled in the Essential 4-Tier PDL; applies to medications and informs members and providers about formulary status and coverage requirements.
No material clinical or coverage changes in this revision.
Formulary Coverage & Tiering
Tier-based coverage
Coverage and tiering decisions
Where differences exist, the benefit plan documents control coverage; use plan documents to determine member cost-share and coverage applicability.
Formulary entries with administrative controls
Coverage and administrative controls are expressed per-line as Tier and Requirements & Limits
When a line lists PA, QL, SP, or ST, providers must follow the plan's administrative processes (e.g., submit prior authorization documentation or adhere to quantity limits).
Some medications may be excluded from coverage or designated non-formulary when a lower-cost covered option or an over-the-counter alternative is available. Coverage decisions reflect an assessment of total value, including clinical effectiveness, safety, and cost; when therapeutically equivalent but less costly options exist, only the lower-cost product may be covered. Members and providers should consult the member benefit plan documents and the plan member website to confirm whether a specific medication is excluded or requires an alternative product.
Medications used for termination of pregnancy are governed by the member's medical benefit plan rather than the standard prescription drug benefit. Providers and members should review the applicable medical plan documents or call the number on the member ID card to determine coverage, exclusions, and cost-sharing for these products.
Within the provided formulary excerpt there are no explicit exclusion statements or determinations that any listed product is "not medically necessary." The lines shown assign Drug Tier levels and annotate Requirements & Limits (for example, PA, QL, SP, NF), but do not include standalone medical necessity denials in these chunks.
The excerpt does not contain clinical coverage criteria or medical necessity rules; it lists therapeutic headings, tier assignments, and administrative requirement flags (e.g., PA, QL, SP) for individual formulary lines. For clinical justification or detailed medical necessity criteria, providers must refer to the specific drug policy sections or the payer's benefit plan documents.
No entries in the provided excerpt assert 'not medically necessary' findings; the content is limited to drug listings with tier and requirements annotations rather than explicit coverage denials or clinical-necessity language.
Procedure & Billing Codes
Provider Requirements, Prior Authorization & Documentation
Prior authorization may be required
Prior authorization (PA) may be required for some medications and in situations where state mandates apply (for example, infertility coverage). Providers must submit PA requests when the formulary designates PA to access covered benefits for the member.
PA required for selected formulary drugs
Numerous formulary products are marked with 'PA' in the Requirements & Limits field; providers must obtain prior authorization for these listed drugs before dispensing to ensure coverage.
PA required for specified entries
Many individual formulary entries include 'Requirements & Limits' that list 'PA' — prior authorization is required for those specific products as shown on the drug list.
PA required for select antiviral/hepatitis agents
Several antiviral/hepatitis agents (examples: HARVONI, LEDIPASVIR‑SOFOSBUVIR, SOFOSBUVIR‑VELPATASVIR, MAVYRET, VOSEVI) are shown with 'PA' (and often QL/SP/ST) in Requirements & Limits; prior authorization must be obtained before dispensing.
Prior authorization indicated on flagged entries
Formulary flags show that several drugs require prior authorization (PA); providers must submit PA where entries are flagged to determine coverage.
PA required for select anticoagulant/biologic agents
Multiple anticoagulant and related biologic products are labeled with 'PA' in their Requirements & Limits; providers must obtain prior authorization for these specified agents prior to dispensing.
PA required for PA‑designated drugs
Numerous listed drugs show 'PA' in Requirements & Limits; providers must submit prior authorization requests per the payer process for any product so designated.
PA required for selected specialty/biologic agents
Many specialty and biologic agents (examples: NGENLA, NORDITROPIN FLEXPRO, OMNITROPE, ORENCIA products, RINVOQ, OLUMIANT, SKYRIZI, TREMFYA) are marked with 'PA' (often along with QL, ST, or SP); prior authorization is required before coverage is approved.
PA required for high‑tier/specialty drugs
Prior authorization is required for numerous high‑tier and specialty medications shown in the listing; obtain PA for products annotated with 'PA' to secure coverage.
PA required for specific agents
Specific agents in the respiratory and other categories (examples include NUCALA, ADEMPAS, OPSUMIT, TYVASO, SODIUM OXYBATE, WAKIX, XYWAV) are listed with 'PA' — providers must obtain prior authorization for these products.
No PA information in this fragment
This fragment contains no prior authorization statements; refer to the specific drug listings or the member’s benefit documents for PA requirements.
Index — no PA details
This excerpt is an index only and does not include prior authorization details or affected codes; consult the referenced drug pages for PA requirements.
Index has no PA rules
The index section does not provide prior authorization rules; providers must consult the specific formulary or drug policy sections for PA requirements.
Step therapy enforced via PA; document prior trials
Step therapy (ST) requires trying one or more other medications before the requested medication may be covered and is enforced via prior authorization; providers must document trials of required agents when ST is indicated.
Follow step‑number sequencing where shown
Some formulary entries include explicit step numbers (e.g., nicotine 'step 1/2/3') indicating progression through step therapy; follow the plan‑specific step sequence where listed.
Document prior therapy for ST‑flagged drugs
Entries flagged 'ST' on the formulary indicate step therapy applies to those drugs; prescribers must document failure, contraindication, or intolerance to required prior agents when requesting coverage.
ST present for select agents (document trials)
When 'ST' appears in Requirements & Limits for listed products (examples include HARVONI and LEDIPASVIR‑SOFOSBUVIR), prior trials of preferred agents must be documented on PA submissions.
ST may require trial of preferred agents
Some formulary entries include ST flags meaning a lower‑tier or preferred agent trial is required before the requested drug will be approved; providers should include evidence of prior therapy in the PA documentation.
ST flags noted for some GI agents
Certain gastrointestinal and other agents (for example, esomeprazole oral packet, pantoprazole tablet) include 'ST' flags; step therapy protocols apply to these products.
ST requires documented failure/intolerance
Step therapy applies to drugs listed with 'ST' in Requirements & Limits; providers must document failure or intolerance to required prior agents when ST is enforced.
Biologics/specialty agents may have ST
Multiple biologic and specialty agents list 'ST' indicating they are subject to step therapy prior to approval; include trial history in PA requests for those agents.
ST flagged for select ophthalmic agents
Step therapy flags appear for select agents (example: tafluprost (pf) annotated with ST and QL); follow the formulary’s ST requirements when requesting coverage.
Index — no step therapy details
This index fragment does not list step therapy rules; review the specific drug policy pages for ST requirements where applicable.
Provide clinical documentation when PA/QL/ST/SP flags present
Medication entries marked with letters such as PA, QL, SP, or ST indicate coverage requirements; providers must supply the clinical information requested by the payer when submitting prior authorization requests.
Verify coverage and PA/QL/ST requirements
Providers and members should verify current coverage, PA requirements, and quantity limits by calling the toll‑free number on the member ID card or by visiting the plan member website before prescribing or dispensing.
Follow formulary Requirements & Limits annotations
Requirements & Limits annotations (PA, ST, QL, SP, H‑PA) on formulary lines imply documentation and administrative steps must be provided per the formulary when those designations are present.
Documentation expectations for PA/QL/ST/SP
When products are marked PA, QL, ST, or SP, documentation supporting medical necessity, prior therapy, or specialty handling is required as part of the authorization process.
Examples where PA, QL, SP documentation required
Some agents (example: DUPIXENT) are annotated with multiple flags such as 'PA, QL, SP', indicating that prior authorization, quantity‑limit compliance, and specialty program documentation must be provided.
Submit PA and specialty/QL documentation where flagged
Entries listing 'Requirements & Limits = PA, QL, SP' indicate prior authorization, quantity limits, and specialty pharmacy requirements apply; providers must submit PA and supporting documentation where indicated.
Document generic substitution/product equivalence
Some products are noted as generic equivalents and have QL requirements; documentation should indicate appropriate substitution or justification when applicable.
Include QL and specialty distribution details in PA
Drugs flagged with combinations like 'PA, QL, SP' require prior authorization and may have quantity limits and specialty distribution requirements; include all relevant clinical information when requesting approval.
Provide diagnosis and prior therapy evidence for PA
Prescribers must supply diagnosis, prior therapies attempted, and other clinical information to support PA, quantity limit, and specialty pharmacy requirements when those flags appear on a formulary entry.
Ensure PA submission meets documentation and QL limits
Providers must provide the information necessary to meet prior authorization requirements where PA is listed, and ensure dispensed quantity complies with any QL annotations.
Denial risk when lower‑cost alternatives exist
Medications may be excluded or denied when lower‑cost covered options exist or formulary choices favor lower‑cost alternatives; providers should review benefit plan documents and discuss lower‑cost options with patients.
PA/QL may trigger denial if not obtained
Prior authorization (PA) or quantity limits (QL) are specified for many listed drugs; failing to obtain PA or to comply with QL as required may result in coverage denial.
Failure to meet Requirements & Limits may cause denial
Drugs with Requirements & Limits that include PA, ST, QL, or SP may be denied if those conditions are not met; providers must follow the listed program requirements to avoid claim denial.
PA and QL noncompliance can trigger denial
Requests for products listed with 'PA' or 'H‑PA' may be subject to denial unless the PA conditions are met; exceeding quantity limits may result in partial fills or denial.
PA/QL/ST/SP flags indicate potential denial triggers
Drugs marked with PA, QL, ST, or SP may be denied if utilization management requirements are not satisfied; these flags indicate potential denial triggers during claims adjudication.
Requirement flags may lead to denial or additional review
Claims for drugs flagged with PA, QL, SP, ST, or NF may be denied or require additional review if the applicable program requirements are not met; verify flags before prescribing.
Noncompliance with listed requirement types may cause denial
Requests for drugs requiring PA, ST, QL, or SP may be denied when those program requirements are unmet; providers should confirm requirements and submit complete documentation to mitigate denial risk.
Authorization flags can trigger administrative enforcement
Entries marked with PA, ST, QL, SP, or NF indicate utilization management conditions that can trigger coverage denials or additional administrative actions if not satisfied.
PA required for select ophthalmic/respiratory agents — denial risk
Certain high‑tier or specialty ophthalmic and respiratory agents are listed with PA and may be denied if prior authorization is not obtained; obtain PA for these select agents to avoid denial.
Specialty respiratory agents require PA/QL/SP — risk of denial
Many pulmonary hypertension and specialty respiratory agents (examples: ADEMPAS, OPSUMIT, TYVASO) are annotated with PA, QL, and SP; claims may be denied without meeting those program requirements.
Utilization management enforcement may cause denials
Requests may be denied if the payer’s utilization management rules (PA, QL, SP) are not followed for listed drugs; providers should ensure compliance with these requirements.
Key Terms & Abbreviations
Step Therapy Policies & Affected Products
| Requirement | What provider must document |
|---|---|
| Step therapy (ST) enforced via prior authorization | |
| Documentation of trials (and failure or intolerance) of the required lower‑cost/preferred agent(s) as specified in the formulary prior to approval |
| Product / Entry | Step designation |
|---|---|
| NICORETTE MOUTH/THROAT LOZENGE (B NICORETTE) - formulary lines show nicotine step 1 | |
| NICORETTE STARTER KIT / nicotine polacrilex mouth/throat - entries reference step designations including step 1 and step 2 (and step 3 in related mapping) |
| ST flag context | Required documentation |
|---|---|
| Formulary entries annotated with 'ST' (e.g., fluconazole oral listed with Requirements & Limits = PA, ST, QL) | |
| Provider must document trial and failure or intolerance to the specified preferred agent(s) when submitting prior authorization |
| Example product | ST noted / action |
|---|---|
| HARVONI ORAL TABLET - Requirements & Limits = PA, ST, QL, SP | |
| LANOXIN ORAL TABLET (certain strengths) - Requirements & Limits = PA, ST, QL (ST applies to listed strengths) |
| General observation | Implication for prior trials |
|---|---|
| Multiple formulary lines include an 'ST' flag indicating step therapy applies | |
| When 'ST' is present, coverage is contingent on documented trials of required preferred therapies submitted with the prior authorization request |
| GI agent / example | ST annotation |
|---|---|
| esomeprazole magnesium oral packet - Requirements & Limits = PA, ST, QL | |
| pantoprazole sodium oral tablet (delayed release) - Requirements & Limits include PA, ST, QL, SP on some lines |
| Where ST appears | How applied |
|---|---|
| ST appears in the Requirements & Limits field on formulary entries across therapeutic classes | |
| ST is enforced via the prior authorization process; providers must document required prior therapy when ST is listed |
| Agent examples (biologic/specialty) | ST presence |
|---|---|
| OMNITROPE - Requirements & Limits = PA, ST, QL, SP (ST noted on some lines) | |
| ORIAHNN and other specialty biologics - entries include ST among other requirement flags indicating step therapy may apply prior to approval |
| Ophthalmic agent | ST flag / other limits |
|---|---|
| tafluprost (pf) and similar ophthalmic glaucoma agents - listed under Ophthalmic Agents - Drugs for Glaucoma | |
| Formulary shows QL and ST for select ophthalmic lines (ST noted where applicable) — step therapy applies when ST is present |
Quantity Limits & Affected Products
Specialty Pharmacy & Site-of-Care Management
Background & Rationale
Specialty medications are high-cost agents used to treat rare or complex conditions and are commonly managed through a specialty pharmacy. These products often require special handling, distribution channels, and additional administrative requirements such as prior authorization or specialty program management; consult the plan's specialty pharmacy processes when prescribing or dispensing specialty agents.
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