Sierra Health and Life Advantage 4‑Tier PDL

Coverage notes and plan-determined coverage

Class-level coverage notes and other coverage determinations

Where differences exist between this PDL and benefit plan documents, the benefit plan documents rule.

Coverage for certain drug classes (for example: central nervous system sedatives/hypnotics; continuous glucose monitors and sensors; growth hormone; infertility treatments; medications for sexual dysfunction) is determined by the member's prescription drug or medical benefit plan; members should review their plan documents for coverage and cost-share.

Coverage for drugs related to termination of pregnancy is set by the member's medical benefit plan; members should review plan documents or call the number on their member ID card for details.

Coverage and utilization overview

Coverage stance and routing for specific classes and individual drugs

Certain classes (CNS sedatives/hypnotics; continuous glucose monitors/sensors; growth hormone; infertility; medications for sexual dysfunction; termination of pregnancy) are governed by the member's prescription drug or medical benefit plan and members should consult their plan documents or call member services.

Many medication entries are presented with a formulary tier and may include utilization controls such as PA (prior authorization) and QL (quantity limits); these flags affect coverage routing and may require provider action.

For the most current list of covered medications or questions about coverage and participating pharmacies, members should call the toll-free number on their ID card or visit the member website to view benefit details.

partial coverage entries

Partial formulary entries indicating coverage tier and utilization controls for listed medications.

buprenorphine hcl-naloxone hcl sublingual tablet — Tier 2 (entry shown in extract).

diclofenac sodium external gel 1% — Tier 2; Requirements & Limits = QL.

bupropion hcl er (smoking det) — entries include Tier 1 and Tier 4 listings; Requirements & Limits flag = H on some entries.

various naloxone formulations — Tier 1 with Requirements & Limits flags QL and/or H on some entries.

Numerous antibiotics and other agents in the extract are assigned tiers ranging from 1–4 or E; some entries include PA, QL, or H as utilization flags.

Formulary entries (partial)

Formulary entries indicating tier and requirement/limit for individual products.

Eliquis — varies by entry, examples show Tier 2 with QL and Tier 3 with PA noted.

Enoxaparin (prefilled syringe / Lovenox) — entries show variable tiers (1–4 or E depending on branded/generic) and Requirements & Limits including QL and PA for some formulations.

Gabapentin (various formulations) — entries span Tier 1 to Tier 4/E; some branded formulations show PA as a requirement.

Libervant buccal film (multiple strengths) — Tier 3; Requirements & Limits = PA, QL (multiple strengths listed).

Ondansetron (various forms) — entries in extract show tiers from 1 to E and QL for some ODT strengths.

Partial formulary entries

Partial mapping of drugs to formulary tiers and any stated Requirements & Limits.

Ciclopirox external shampoo — Tier 2 (entry shown).

Itraconazole oral capsule — Tier 1; Requirements & Limits = QL.

JUBLIA (berberine topical branding examples) — appears in extract with mixed tiering (examples include Tier 4 or Tier 2 depending on entry) and utilization flags such as PA, ST, QL.

Everolimus oral tablet — shown with Tier 2 and utilization flags PA, QL, SP on some entries.

Formulary coverage indicators

Coverage stance is presented via tier assignment and requirement codes per drug entry; specific medical necessity criteria are not included in this excerpt.

Formulary tiers observed in the extract include values 1, 2, 3, 4 and E (exception/excluded); these tier assignments communicate formulary placement and typical member cost-share differences.

Utilization flags observed across entries include PA (prior authorization), QL (quantity limits), ST (step therapy), SP (specialty), H-PA/H (plan-specific or hierarchical prior authorization), which indicate additional coverage controls may apply.

No explicit clinical medical-necessity eligibility criteria (clinical inclusion/exclusion lists) are provided in the excerpt — coverage is signaled via tier plus Requirements & Limits flags.

Sample coverage entries from excerpt

Coverage status for each drug is indicated by a tier and may be subject to requirements/limits.

Enalapril maleate oral solution — Tier 4; Requirements & Limits = PA (example from extract).

Enalapril maleate oral tablet — Tier 1; no Requirements & Limits listed in extract for this form.

Entresto oral tablet — Tier E in extract with Requirements & Limits = PA, QL for some entries.

Fenofibrate micronized oral capsule (various strengths) — Tier 4 in extract with Requirements & Limits = PA, QL for some entries.

Multaq (dronedarone) — shown as Tier 4 with PA in extract.

Nexletol — shown as Tier 2 with Requirements & Limits = PA, ST, QL in the extract.

formulary_criteria_partial

Formulary entries indicate coverage tier and whether utilization management applies.

Methylphenidate HCl ER (LA) extended release capsule — Tier 2 in extract; Requirements & Limits include PA, QL, SP on some entries.

Lisdexamfetamine dimesylate — Tier 3 in extract with Requirements & Limits = QL on some entries.

Jornay PM — listed in extract as Tier E with Requirements & Limits = QL, ST for certain entries.

Mayzent starter pack — shown as Tier 3 with Requirements & Limits = PA, QL, SP in the extract.

Ingrezza oral capsule — Tier 2 entry with Requirements & Limits = PA, QL, SP in the extract.

Various dermatologic agents in the extract are assigned mixed tiers and often include PA or QL flags.

Formulary coverage entries (excerpt)

Formulary listing with per-product tier assignment and coverage-controls; no explicit clinical criteria are included in this excerpt beyond flags.

The extract lists multiple topical and related agents (for example: adapalene external gel, clindamycin external, clobetasol propionate external, tretinoin external, isotretinoin oral) with a tier value per entry (1,2,3,4 or E) and Requirements & Limits flags such as PA, QL, ST, SP or blank.

Some entries note alternate drug name mappings or generic equivalents; utilization flags indicate whether prior authorization or quantity limits may apply rather than providing clinical eligibility criteria in this fragment.

Per-item coverage stance

Per-item coverage indicators shown as Tier and Requirements & Limits fields.

Zenatane (tretinoin oral or isotretinoin-related entry) — shown as Tier 4 with Requirements & Limits = PA, QL in the extract.

Tremfya (various formulations) — entries show tiering that varies by formulation (Tier 2 or Tier 4) and Requirements & Limits including PA, QL and in some cases ST.

Dexcom G6/G7 components (sensors, transmitters, receivers) — entries in the extract show Tier 3 with Requirements & Limits = PA, QL for some SKUs.

FreeStyle Libre sensors/readers and related supplies — entries show tiers (2–3) and Requirements & Limits including PA and QL for some items.

Various pen needles, insulin syringes, and CGM supplies — listings show mixed tier assignments (E/1/2/3) with QL or PA indicated for some items.

Formulary item-level coverage indicators

Coverage stance is expressed per item via tier and Requirements & Limits codes.

FreeStyle Libre 2 Plus sensor — Tier 2; Requirements & Limits = QL as shown in extract.

FreeStyle Libre 2 reader — Tier 3; Requirements & Limits = PA, QL for some entries.

FreeStyle Libre 3 Plus sensor — Tier 3 with PA indicated for some entries.

Omnipod/Dexcom pods and related devices — examples in extract show tiering and Requirements & Limits such as PA and QL for certain products.

Examples of insulin product listings show combinations of utilization controls (ST, QL, PA) depending on product and formulation.

Formulary listing with utilization management

Drugs are listed with Tier and Requirements & Limits values which determine coverage and utilization management.

The extract uses Tier values (1,2,3,4,E) to indicate formulary placement; 'E' is used for some items in the listing.

Requirements & Limits flags shown include PA, QL, ST, SP or blank — these flags indicate prior authorization, quantity limits, step therapy, specialty designation or no additional controls respectively.

Representative drugs appearing in the extract include Farxiga (Tier E with PA/ST/QL flags for some entries), Glimepiride (Tier 1), Trulicity (Tier 2 with PA/QL in some entries), demonstrating that tier plus flags determine plan utilization management routing rather than clinical criteria in this fragment.

Formulary tier entries with requirement flags

Drugs listed with tier and requirement flags indicating coverage conditions.

Lansoprazole oral tablet (delayed release dispersible) — example entry showing Tier 3 with Requirements & Limits including PA, ST, QL in the extract.

Misoprostol oral — example entry shown as Tier 1 with no Requirements & Limits indicated in the extract.

Bylvay — example listed as Tier 4 with Requirements & Limits = PA, QL, SP in the extract.

IQIRVO (Viberzi) — example entry shown as Tier 4 with Requirements & Limits including PA, ST, QL, SP.

Formulary tier and requirement entries (partial)

Coverage stance is expressed via tier and requirement/limits codes per drug entry.

Selected contraceptive and related products in the extract are assigned Tier values (for example Tier 1) with Requirements & Limits flags such as H on many entries indicating plan-specific handling.

Across the listed examples (altavera, alyacen 1/35, aurovela 1.5/30), tier assignments and requirement flags (H, QL, PA) are used to indicate coverage and utilization handling rather than clinical eligibility criteria in this fragment.

Sample coverage entries

Selected drug entries with tier and requirements

Loestrin FE 1/20 — Tier E in the extract with no Requirements & Limits shown.

Lojaimiess (norethindrone variant) — Tier 1 with Requirements & Limits = H as shown.

PHEXXI — listed in extract as Tier E with Requirements & Limits = PA (prior authorization) for some entries.

Medrol oral tablet 16 mg — example shown as Tier 4 with Requirements & Limits = PA, QL, SP in the extract.

Codes, Tiers, and Utilization Flags

Insulin syringe gauges/volumesmixed

27G x 1/2" - 0.5 mL	Insulin syringe gauge 27G with 1/2 inch length, 0.5 mL volume (listed)
27G x 1/2" - 1 mL	Insulin syringe gauge 27G with 1/2 inch length, 1 mL volume (listed)
28G x 1/2" - 0.5 mL	Insulin syringe gauge 28G with 1/2 inch length, 0.5 mL volume (listed)
28G x 1/2" - 1 mL	Insulin syringe gauge 28G with 1/2 inch length, 1 mL volume (listed)
29G x 1/2" - 0.5 mL	Insulin syringe gauge 29G with 1/2 inch length, 0.5 mL volume (listed)
29G x 1/2" - 1 mL	Insulin syringe gauge 29G with 1/2 inch length, 1 mL volume (listed)
30G x 1/2" - 1 mL	Insulin syringe gauge 30G with 1/2 inch length, 1 mL volume (listed)
30G x 5/16" - 0.5 mL	Insulin syringe gauge 30G with 5/16 inch length, 0.5 mL volume (listed)
31G x 5/16" - 0.5 mL	Insulin syringe gauge 31G with 5/16 inch length, 0.5 mL volume (listed)

Utilization Codes (excerpt)mixed

PA	Prior Authorization indicated on multiple entries
QL	Quantity Limit indicated on multiple entries
ST	Step Therapy indicated on select entries

Formulary Drug-Tier Entries (examples)mixed

Tier 1

Lower-cost / generics (examples present throughout list)

Utilization Control Flags (examples)mixed

PA	Prior Authorization
ST	Step Therapy
QL	Quantity Limits
SP	Specialty/Single-source product flag

Formulary drug-tier mapping (partial)mixed

Tier 2

Mid-range cost (examples present)

Observed Formulary Tiersmixed

Tier 1	Lowest-cost tier
Tier 2	Mid-range tier
Tier 3	Mid/high tier
Tier 4	Highest-cost tier
E	Excluded or external categorization in source

Formulary tiers (additional)mixed

Tier 3

Example entries such as LIBERVANT BUCCAL FILM listed in Tier 3

Formulary entries (singular examples)mixed

MEDROL 16 mg

Listed with PA, QL, SP flags in source

Formulary entries (no billing codes)mixed

Naloxone (various forms)

Naloxone nasal, injection listed with QL; includes OTC Narcan reference

Device specifications (examples)mixed

CarePoint Poly Hub Needle sizes	18G x 1", 21G x 1", 22G x 1", 23G (listed)
FREESTYLE LIBRE sensors/readers	Associated insulin syringe sizes listed in device entries

Formulary tiers & requirement flags (observations)mixed

H-PA	Hybrid Prior Authorization / medical necessity flag seen on some entries (H-PA)

Formulary tiers (additional observed)mixed

E (external)

External or excluded designation present in source

Miscellaneous formulary tiers presentmixed

Tier 4	Highest-cost examples such as some injectables and specialty products
Tier E	External/excluded category noted
Tier 2	Mid-range examples
Tier 3	Mid/high examples
Tier 1	Lower-cost examples

Formulary tiers (single)mixed

Tier 1

Lower-cost generics highlighted across list

What Providers and Pharmacists Must Do

Prior Authorization

Prior Authorization & Utilization Controls

Drug list entries use short requirement codes to indicate utilization management controls. Common codes you will see in the formulary include: PA (Prior authorization — provider must submit clinical information before coverage can be determined), QL (Quantity limits — maximum covered quantity per fill or time period), ST or SP (Step therapy / Step program — may require trials of other agents before coverage), H (Health care reform preventive or other special handling), E (Excluded), and RS (Refill & Save). These codes may appear next to many drugs or devices (examples in the drug list include B JUBLIA, B CAPLYTA, B HARVONI, B LEDIPASVIR-SOFOSBUVIR, TREMFYA products, FREESTYLE LIBRE sensors/readers, DEXCOM G7 sensor, PHEXXI, MEDROL items, MEDROL ORAL TABLET 16 MG).

PA = Prior authorization: requires clinician to provide information prior to plan decision; may be listed alone or with other flags (e.g., H-PA).
QL = Quantity limits: maximum covered quantity per copayment or defined period.
ST / SP = Step therapy / Step program: may require trial(s) of other medications before coverage; often combined with PA.
H = Health care reform preventive or special handling indicator; H-PA indicates preventive with prior authorization.
E = Excluded from coverage.
RS = Refill & Save program (copay savings on timely refills).
Many formulary drug lines include Requirements & Limits fields showing these codes (examples: B JUBLIA = PA, ST, QL; B CAPLYTA = PA, ST, QL; B HARVONI = PA, ST, QL, SP; TREMFYA entries = PA, ST, QL; FREESTYLE LIBRE readers/sensors = PA, QL or QL-only; DEXCOM G7 sensor lines = PA, QL).

Note

Benefit Routing & Member Directions

Coverage routing: certain product classes may be handled under different benefits (pharmacy vs medical) or have special coverage notes. Examples: sedatives/hypnotics, continuous glucose monitors and supplies, growth hormone, infertility treatments, and medications for sexual dysfunction — check the member’s plan documents (SBC) and the formulary flags to determine if pharmacy or medical benefit applies. For diabetic supplies, sensors, and CGMs, specific SKUs often show PA and/or QL flags (e.g., FREESTYLE LIBRE sensors/readers, DEXCOM G7 sensor entries).

If a drug/device is listed with PA, the provider should submit prior authorization per the plan’s process.
If a product is flagged QL, confirm the allowed quantity and billing unit to avoid denials.
For items that may be medical-benefit routed, contact the plan or consult the member ID resources to confirm benefit assignment.

Billing Rule

Provider / Pharmacist Required Actions

Action checklist for providers and pharmacists: review the formulary Requirements & Limits column on the latest drug list before prescribing or dispensing; anticipate PA submission when PA appears; verify step therapy history when ST or SP is present; and confirm quantity limits to prevent claim denials or interruptions in therapy.

When PA is required, include clinical rationale and pertinent records to meet the plan’s prior authorization criteria.
When ST/SP is present, document prior medication trials and dates — plans commonly require evidence of failure, intolerance, or contraindication to preferred agents.
For QL flags, check the specific numeric limits in the plan drug list or formulary database and write prescriptions aligned with allowed days supply and units.
For specialty medications (SP), coordinate with the plan’s specialty pharmacy requirements and handling instructions.

Key Terms and Abbreviations

PDL — definition

PDL definitionPrescription Drug List (PDL): a list of commonly prescribed medications (brand-name and generic FDA-approved) organized by class and tier.

OrganizationMedications are listed by common categories or classes and placed in tiers that represent member out-of-pocket cost.

PurposeServes as a guide; benefit plan documents govern final coverage decisions when differences exist.

Tier — definition and guidance

Tier meaningTier: a cost level assigned to medications determining member copayment/coinsurance; Tier 1 is lowest-cost and Tier 4 is highest-cost.

Plan variabilityPlans may have multiple or no tiers; high-deductible plans may apply tier cost levels after deductible is met.

Member guidanceUse lower-tier medications to lower out-of-pocket costs and consult your doctor about lower-cost alternatives.

Coverage indicators (PA, ST, QL, SP, H, E, RS)

PAPrior authorization — requires clinician to provide information before plan decides coverage; appears as 'PA' in Requirements & Limits.

QLQuantity limits — largest quantity covered per copayment or within defined time period; appears as 'QL'.

STStep therapy — may require trying one or more other medications first; appears as 'ST' and may require PA.

SP / H / H-PASP = specialty medication designation; H = health care reform preventive or plan-specific flag; H-PA = preventive with prior authorization.

Coverage set by plan

Coverage routing noteCertain drug classes (e.g., CNS sedatives/hypnotics, CGMs, growth hormone, infertility, sexual dysfunction) have coverage set by the member's prescription drug or medical benefit plan; members should review plan documents.

Member actionMembers should consult their plan documents or call member services for coverage and cost-share specifics for these classes.

PDL is a guideWhere differences exist between the PDL and benefit documents, the benefit plan documents rule.

PA — Prior Authorization (abbreviation and examples)

PA abbreviationPA = Prior Authorization — listed as a requirement for select drugs in the Requirements & Limits field.

Action requiredPA typically requires submission of clinical information by the provider prior to coverage approval.

Examples in listENTRESTO (PA, QL), everolimus (PA, QL, SP), LIBERVANT (PA, QL) are entries showing PA in this excerpt.

QL — Quantity Limits (abbreviation and usage)

QL abbreviationQL = Quantity Limit — appears as a Requirements & Limits flag for many drugs and supplies in the excerpt.

MeaningIndicates the largest quantity covered per copayment or within a defined period; numeric limits are not shown in this excerpt.

Common items with QLAnticoagulants, analgesics, dermatologics, CGM sensors/readers and test strips frequently display QL flags in this extract.

OpenPayer

Advantage 4-Tier Prescription Drug List (PDL)

Formulary Coverage and Tiering

Codes, Tiers, and Utilization Flags

What Providers and Pharmacists Must Do

Key Terms and Abbreviations