CurrentUnitedHealthcarePolicy N/A

Comprehensive pharmacy medication list (formulary attributes)

List of medications included in UnitedHealthcare pharmacy benefit programs with per-drug attributes (therapeutic use, quantity limits, notifications, step therapy, prior authorization/medical necessity, designated specialty network, permanent exclusion, Oxford-only flags). Applies to plans using this pharmacy list; inclusion does not guarantee coverage by any particular plan.

Policy Summary

PayerUnitedHealthcare

PolicyComprehensive pharmacy medication list (formulary attributes)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug entry lists Prior Authorization/Medical Necessity = x.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4/1/2026effective date stated

3/26/2026last update

multipleitems flagged PA

severalpermanent exclusions

20+distinct entries in excerpt

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Exclusions

Inclusion in this list does not by itself guarantee that a medication will be covered under any particular UnitedHealthcare plan. The formulary excerpt is an administrative listing of medications and per-drug attributes; individual products may be subject to plan-level controls such as Exclude at Launch, Review at Launch, or other utilization management rules that can affect coverage decisions.

Many per-drug entries include an explicit coverage attribute labeled Permanent Exclusion and other qualifiers such as Brand Only or Non‑Formulary. These markers indicate that specific brands, formulations, or the product itself may be excluded from coverage for plans that use this listing.

The listing contains multiple examples of the pattern Permanent Exclusion + = Brand Only (or similar qualifiers) that restrict coverage to particular formulations or exclude branded versions. For instance, some lines explicitly show the higher-strength or brand forms designated as Brand Only exclusions.

Across the excerpt several drugs are noted with entries such as Permanent Exclusion + = x or Permanent Exclusion + = Brand Only, demonstrating explicit formulary exclusions for certain products or brands (for example, Balcoltra shows Permanent Exclusion + = x and Baqsimi is listed as Permanent Exclusion + = Tablets Brand Only).

Multiple entries explicitly indicate branded-version restrictions with values like Permanent Exclusion + = Brand Only or blanket exclusions noted as Permanent Exclusion + = x, meaning submission of excluded branded products may result in denial for plans that adopt these settings.

The document shows examples of products with Permanent Exclusion + annotations, including topical products (e.g., Cloderm cream marked Brand Only) and specialty agents (e.g., Copaxone entries flagged with brand and non‑Mylan generic qualifiers).

In this section many products carry a Permanent Exclusion + flag with observed values including x, Brand Only, or Generic only. These designations identify which brands or generics are excluded (for example, Coxanto shows Permanent Exclusion + = x; Cozaar lists Permanent Exclusion + = Brand Only; Cuprimine lists Permanent Exclusion + = Generic only).

Several agents are annotated with Permanent Exclusion flags that include brand‑only or non‑formulary designations (examples in the excerpt include Envarsus XR = Non‑Formulary and Epclusa/EpiCeram = Permanent Exclusion, with other agents listed as Brand Only).

Numerous products in the F–H segments are marked as Permanent Exclusion or Brand Only (for example, Firazyr listed as Permanent Exclusion + = Brand Only; Flector with Permanent Exclusion + = x; Flomax noted as Permanent Exclusion + = x; and several specialty agents such as Forteo and Galafold flagged for permanent exclusion).

The listing continues to show Permanent Exclusion + settings including Brand Only, Non‑Formulary, or x qualifiers across multiple products, signaling explicit exclusion of certain brands or formulations from coverage in this formulary extract.

Several entries identify products as permanently excluded or restricted to generics/authorized generics only (e.g., Jakafi Permanent Exclusion + = x; Jatenzo Permanent Exclusion + = x; Jynarque = Brand Only; Keppra XR Permanent Exclusion + = x; and Lialda = Brand Only in other lines).

Additional product lines are marked with Permanent Exclusion + = Brand Only or = x, indicating explicit exclusion of specific brands or forms (examples appear throughout the list and include common drug classes and specialty therapies).

Multiple drugs shown in these chunks are listed with Permanent Exclusion markers or Brand Only permanent exclusions — examples include topical and systemic products such as Metrogel 1% (Permanent Exclusion + = x), Micort HC (Permanent Exclusion + = x), Mircette / Mirvaso (Permanent Exclusion + = Brand Only), Minivelle (Permanent Exclusion + = Brand Only), and many others identified as brand‑restricted or permanently excluded.

Some lines specifically show the Permanent Exclusion or Brand Only designation for products in this part of the list (for example, Noritate Norliqva = Permanent Exclusion + = Brand Only and Norvir = Permanent Exclusion + = Brand Only), illustrating explicit brand‑level exclusions.

Later sections continue to annotate products with Permanent Exclusion + = x or Brand Only. For example, Nutropin AQ NuSpin is shown with a Permanent Exclusion + = x flag and NuvaRing / Nuvessa appears with Permanent Exclusion + = Brand Only; other high‑use products (e.g., Ozempic) are also shown with exclusion markers in some rows.

The listing includes instances where specific authorized generics or particular strengths are excluded; for example, fluorouracil 0.5% cream (Carac authorized generic) is shown with Permanent Exclusion + = x, and certain strengths of other agents (e.g., Fluoxetine 60 mg) are similarly annotated as excluded.

Provider Actions, Prior Authorization, and Denial Risk

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many products listed in the formulary when the entry shows PA = x. Providers must obtain prior authorization before dispensing or submitting claims for drugs flagged with a PA indicator; failure to obtain required PA may result in claim denial or delay.

Use the PA flag on each formulary line to determine whether PA is required.
When PA = x is indicated on a product line, submit prior authorization documentation per payer process before dispensing.
Examples: Bimzelx, Cetrotide, Entyvio Pen, Envarsus XR, Epclusa, Humatrope, Humira, Imbruvica, Leqembi, Mavyret, Nucala, Nurtec ODT, Olumiant, and many others are marked with PA = x in the formulary.

Documentation Required

Documentation & Designated Specialty Network

Some agents require additional documentation to support medical necessity or specialty routing. For drugs marked with Designated Specialty Network = x or where the line shows Designated Specialty, follow the designated specialty network and documentation requirements before submission.

Background and Scope

This document is an administrative, formulary‑style listing that maps medications to therapeutic uses and plan‑level controls such as Quantity Limit, Notification, Step Therapy, Prior Authorization / Medical Necessity, Designated Specialty Network, and Permanent Exclusion. It is intended for operational use; providers should verify plan‑specific coverage and follow the per‑drug flags when submitting authorization or claim documentation.

Key Definitions

Permanent Exclusion+

Definition'Permanent Exclusion +' indicates a formulary attribute where a drug or specific formulation is permanently excluded from coverage or restricted (examples in the listing include values like 'x' or 'Brand Only').

Observed valuesValues observed in the source include 'x' (excluded), 'Brand Only' (brand restricted/excluded), and instances where a product line is noted Non-Formulary.

Operational impactDrugs marked with 'Permanent Exclusion +' may be denied at claim adjudication when an excluded product or brand is billed.

Oxford Only*

Flag meaning'Oxford Only*' is a plan-specific availability flag indicating coverage is limited to Oxford product lines or similar plan-specific restriction as shown on per-drug entries.

Examples in source

Step Therapy Flags and Affected Products

Product	Step therapy
Actemra/Actemra ACTpen (subcutaneous)
Step Therapy + = x

Product	Step therapy
Ajovy
Step Therapy = x

Product	Step therapy
Aplenzin
Step Therapy = . (entry shows Step Therapy field present; specific rows vary)

Product	Step therapy
Bimzelx
Step Therapy + = x

Product	Step therapy
Bosulif
Step Therapy + = x

Product	Step therapy
Caphosol
Step Therapy + = x
Caplyta/Caprelsa
Step Therapy + = x (Caplyta/Caprelsa lines)
Cinryze
Step Therapy = . (field present; varies by row)

Product	Step therapy
Contour Diabetes Test Strips Conzip
Step Therapy = x
Cotempla XR-ODT
Step Therapy = x

Product	Step therapy
Crexont
Step Therapy + = x
Crinone Ctexli
Step Therapy + = x
Descovy Desloratadine (generic Clarinex)
Step Therapy + = . (variable)

Product	Step therapy
Extavia
Step Therapy flagged (Step Therapy present in section)
Farxiga
Step Therapy + = x

Product	Step therapy
Invokamet XR/Invokana
Step Therapy + = x
Ibsrela
Step Therapy + = x
Ilumya
Step Therapy + = x (entries show Step Therapy + = x)
Imbruvica
Step Therapy + = x

Product	Step therapy
Journavx Jublia
Step Therapy = x
Ketoconazole 2% cream
Step Therapy = x
Kerydin
Step Therapy = x

Product	Step therapy
Lynkuet/Lynparza
Step Therapy + = . (section shows Step Therapy + flags vary)
Mekinist
Step Therapy + = x
Methodone (generic Dolophine)
Step Therapy + = .

Product	Step therapy
Nexletol
Step Therapy + = x x
Nexlizet
Step Therapy + = x
Novolin/Novolog mixes
Step Therapy + = x

Product	Step therapy
Nurtec ODT
Step Therapy + = x
Nuedexta
Step Therapy + = .

Product	Step therapy
Olumiant
Step Therapy + = x

Product	Step therapy
Palynziq
Step Therapy + = x

Quantity Limit Flags and Examples

Abilify discmelt tablets — Quantity Limit

Abilify discmelt tabletsQuantity Limit = x (Quantity limit flagged in formulary entry).

ContextListed under therapeutic use = Mental health; providers should check specific QL rules in the full formulary for numeric limits.

Related flagsNotification/PA fields for Abilify discmelt are present in the entry; use those fields when submitting documentation.

Accu-chek diabetes test strips — Quantity Limit

Accu-chek diabetes test stripsQuantity Limit = x (Quantity limit flagged in the entry).

Therapeutic useDiabetic supplies — QL applies to test strips per formulary entry.

Specialty Distribution and Site-of-Care Requirements

Note

Policy Summary

PayerUnitedHealthcare

PolicyComprehensive pharmacy medication list (formulary attributes)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug entry lists Prior Authorization/Medical Necessity = x.

SourceLink

On This Page

Designated specialty network applies to select specialty agents (examples: Forteo, Galafold, Entyvio Pen, Cyltezo, Granix).
When Designated Specialty Network = x is present, additional specialty documentation or routing may be required.

Documentation Required

Verify Per-Drug Attributes & Documentation Elements

Per-drug coverage attributes are recorded on each formulary line and must be verified when submitting PA requests or claims. Verify Therapeutic Use, Quantity Limit, Notification, Step Therapy, Prior Authorization/Medical Necessity, Designated Specialty, Permanent Exclusion, and Brand-only or Oxford-only notes.

Required coverage attribute fields: QL (Quantity Limit), Notification, Step Therapy, PA, Designated Specialty, Permanent Exclusion/Brand Only, Oxford Only.
Use the PA flag on the formulary line as the trigger to submit PA documentation.
Documentation elements to verify include clinical indication, prior therapies (for step edits), quantities/dosing, and any specialty routing information.

Step Therapy

Step Therapy May Apply

Step therapy requirements apply when a product line shows Step Therapy = x or Step Therapy + = x. Providers must follow step edits where indicated before PA or coverage will be approved.

Step therapy may require trial of preferred agents before higher-cost or specialty products are authorized (examples in the formulary: Bimzelx, Extavia, Farxiga, Fruzaqla, Gomekli, Olumiant).
When Step Therapy + = x is indicated, ensure supporting documentation of prior therapy trials is included with PA submission.

Denial Risk

Permanent Exclusion / Brand-Only Restrictions — Denial Risk

Permanent exclusions and brand-only restrictions are noted on formulary lines. Products marked as Permanent Exclusion, Brand Only, or Non-Formulary may be denied if a non-covered brand or excluded item is submitted.

Presence of Permanent Exclusion or Brand Only on the formulary line indicates the product may be excluded from coverage.
Exclusion may cause claim denial — confirm whether a generic or covered alternative is available prior to filling.
Examples: products flagged Brand Only or Non-Formulary at line (e.g., Basaglar, Canasa, Caprelsa Carafate, Freestyle test strips) may not be covered in certain plans.

Documentation Required

Submit PA Documentation When Flagged

When submitting PA requests, include clinical documentation addressing the coverage criteria: therapeutic use, previous therapies (for step edits), dosing/quantity limits, and any specialty network routing. Use the PA flag as the submission cue.

PA documentation note: attach relevant chart notes, prior therapy history, lab results, and specialist notes as applicable.
Failure to include required documentation for specialty or PA products may delay review or result in denial.

Denial Risk

Denial Risk When Exclusion or PA Indicated

Denial risk increases when a product is subject to PA or is permanently excluded/brand-only. Confirm PA requirements and exclusion status before dispensing to reduce claim denials and member disruption.

If a drug is listed but marked as Permanent Exclusion or Brand Only, coverage is not guaranteed — check plan-specific coverage.
If PA = x and no authorization is obtained prior to claim submission, expect potential denial or delayed payment.

Note

Provider Action Summary

Consolidated operational guidance: follow per-line utilization management flags (QL, Notification, Step Therapy, PA, Designated Specialty, Permanent Exclusion) and include all relevant documentation in PA submissions. Contact UnitedHealthcare payer support for plan-specific questions.

Check each formulary line for required actions prior to dispensing.
When in doubt, verify plan-specific coverage and PA process with the payer to avoid denial.

Appears repeatedly in entries such as Abbott Diabetic Meter, Absorica, Azstarys and many others where Oxford Only* is shown next to the product line.

Operational noteExact operational details for Oxford-only handling are not defined in this excerpt; treat as an availability restriction tied to Oxford products.

Permanent Exclusion + = Brand Only

Definition'Permanent Exclusion + = Brand Only' indicates the brand formulation is excluded from coverage while generics (when available) may remain allowed.

ExamplesSource examples include Abilify tablets (Permanent Exclusion + = Brand Only), Canasa (Brand Only), Baqsimi (Tablets Brand Only).

Provider impactSubmitting an excluded brand when a generic or allowed formulation exists may result in denial; use this flag to determine allowable product forms.

Designated Specialty Network = x

Definition'Designated Specialty Network = x' denotes that the product must be obtained through the payer's designated specialty pharmacy or specialty distribution network.

ExamplesCetrotide, Emverm, Galafold and other specialty agents in the listing show Designated Specialty Network = x or designated specialty assignment.

Operational impactClaims or dispensings for products with this flag should follow the plan's specialty network/channel requirements (e.g., specialty pharmacy procurement).

Permanent Exclusion +

Summary'Permanent Exclusion +' is used across the formulary with observed values 'x', 'Brand Only', and occasionally 'Generic only' to indicate products or specific formulations excluded from coverage.

ExamplesEntries showing this pattern include Coxanto (Permanent Exclusion + = x), Cozaar (Brand Only), and multiple others listed in the source slices.

Actionable guidanceWhen 'Permanent Exclusion +' is present, do not submit claims for excluded brands/forms — verify allowed alternatives before dispensing.

Oxford Only

Occurrence'Oxford Only' appears frequently as a per-drug flag in the source; examples include Abbott Diabetic Meter and many other product lines.

MeaningThe excerpt does not provide full operational detail for 'Oxford Only*'; it functions as an availability designation tied to Oxford product lines.

ImplicationTreat entries marked 'Oxford Only*' as plan-specific availability notes — confirm with payer formulary operations for covered populations.

Therapeutic Use

FieldTherapeutic Use identifies the clinical condition or indication associated with the drug in the formulary (examples: 'Diabetic supplies', 'Inflammatory conditions', 'Asthma').

Examples from sourceAbbott Diabetic Meter = Diabetic supplies; Actemra ACTpen = Inflammatory conditions; Flovent Diskus = Asthma.

UseTherapeutic Use guides clinical categorization and supports utilization management decisions (e.g., step therapy or PA criteria).

Quantity Limit Notification

Definition'Quantity Limit Notification' (or Quantity Limit/Quantity Limit Notification) is a utilization flag indicating that a quantity limit or notification may apply to dispensing; specifics (exact limits) are not provided in this excerpt.

ExamplesEntries showing this flag include Abilify discmelt tablets (Quantity Limit = x), Accu-chek test strips (Quantity Limit = x), and Bactroban cream (Quantity Limit Notification = x).

Operational noteWhen Quantity Limit/Notification is marked, check the full formulary or prior authorization system for the specific numeric limit or notification process before dispensing.

Permanent Exclusion

Meaning'Permanent Exclusion' denotes the plan designation that the drug (or specific formulation/brand) is excluded from coverage, typically shown as 'x' or 'Brand Only'.

Observed valuesSource shows 'x' (excluded), 'Brand Only' (brand restricted/excluded), and examples where Non-Formulary is indicated for exclusion at launch.

Clinical/administrative impactSubmission of claims for permanently excluded products may result in denial; verify allowed alternatives and prior authorization requirements when present.

Designated Specialty Network

Definition'Designated Specialty Network' marks drugs that must be obtained through the payer's specialty pharmacy or designated specialty distribution channel.

ExamplesCetrotide, Emverm, Galafold and other specialty agents are listed with Designated Specialty or Designated Specialty Network = x in the source.

Actionable guidanceFor drugs with this flag, providers should use the plan's designated specialty pharmacy/network and follow specialty dispensing procedures to avoid claim disruption.

Permanent Exclusion +

Definition'Permanent Exclusion +' indicates a product is permanently excluded from coverage; entries may qualify this as 'Brand Only' or 'Non-Formulary' in specific cases.

ExamplesGalafold shows Permanent Exclusion + = x; Humatrope shows Permanent Exclusion + = x; multiple oncology and specialty products are similarly flagged.

Provider impactProducts marked 'Permanent Exclusion +' should not be expected to be covered; confirm alternatives or coverage exceptions before prescribing/dispensing.

Designated Specialty Network

Meaning'Designated Specialty Network' indicates the product is managed through the payer's designated specialty distribution network (flagged as = x in many entries).

Representative entriesCetrotide (Designated Specialty Network = x), Emverm (Designated Specialty Network = x), Galafold (Designated Specialty = x) are examples from the source.

ActionUse the designated specialty channel for dispensing and prior authorization processes for these products to ensure proper handling and reimbursement.

Designated Specialty Network flag

ObservationA 'Designated Specialty Network' flag is repeatedly observed in later chunks for specialty products and growth-hormone/biologic agents (e.g., Nutropin AQ NuSpin, Omnitrope, Palforzia).

Source examplesNutropin AQ NuSpin (Designated Specialty Network = x), Omnitrope Pen entries (Designated Specialty Network = x), Palforzia (Designated Specialty Network = x).

Practical noteConfirm specialty network routing and any associated prior authorization requirements when the flag is present.

Permanent Exclusion / Brand Only

Flag meaning'Permanent Exclusion / Brand Only' marks products that are either permanently excluded or only the brand form is excluded/restricted per the formulary entry.

ExamplesCozaar (Permanent Exclusion + = Brand Only), Firazyr (Permanent Exclusion + = Brand Only), Morgidox Kit Morphine sulfate ER (Permanent Exclusion + = Brand Only) are shown in source.

Clinical/administrative impactWhen this flag is present, dispensing or billing an excluded brand can result in denial — verify allowed generic/authorized generic alternatives.

Designated Specialty Network

Designation'Designated Specialty Network' entries are observed across table segments indicating certain products are managed via specialty networks (examples present in the F–N segments).

ExamplesNiaspan Nilotinib D-Tartrate (Designated Specialty Network = x), Nuwiq (Designated Specialty Network = x), Nutropin AQ NuSpin (Designated Specialty Network = x).

Provider actionFollow specialty network procurement and authorization pathways for products flagged as Designated Specialty Network to avoid coverage issues.

Permanent Exclusion / Brand Only

Definition'Permanent Exclusion / Brand Only' indicates the brand product is excluded or coverage is restricted to brand only in the formulary listing.

ExamplesFlomax (Permanent Exclusion + = x), Flovent Diskus (Quantity Limit flagged and Permanent Exclusion entries nearby), Metrogel 1% (Permanent Exclusion + = x) illustrate variations of exclusion/brand-only flags.

Operational impactClaims for excluded brands may deny; check the formulary for allowed generics or required substitutions before dispensing.

Operational noteConfirm the allowed quantity per time period in the full formulary or claims system prior to dispensing.

Amicar Amitiza — Quantity Limit

Amicar AmitizaQuantity Limit = x (quantity limit flag present).

Therapeutic useListed therapeutic use = Constipation.

DocumentationNotification = x is also present for Amicar Amitiza; check notification/PA processes when dispensing.

Apidra / Apidra Solostar — Quantity Limit

Apidra / Apidra SolostarQuantity Limit = x (quantity limit flag present).

Therapeutic useDiabetes — insulin product; QL applies as noted in the insulin product group listings.

Related entriesInsulin pens/cartridges and vials have multiple QL notifications across the formulary — verify product-specific QLs.

Bactroban Cream/Ointment — Quantity Limit Notification

Bactroban Cream/OintmentQuantity Limit Notification = x (flagged in formulary).

Therapeutic useInfections — topical antibiotic preparations.

Operational noteQuantity Limit Notification indicates a QL or notification process applies; consult the full formulary for limits.

Baqsimi — Quantity Limit Notification

BaqsimiQuantity Limit Notification = x (flagged as QL Notification); Permanent Exclusion + = Tablets Brand Only for some entries.

Therapeutic useLow blood sugar rescue product — flagged for both QL and brand-only treatment in source.

Provider impactWhen brand-only or QL flags are present concurrently, verify allowable forms and any prior authorization requirements before dispensing.

Breo Ellipta — Quantity Limit Notification

Breo ElliptaQuantity Limit Notification = x (flagged in listing).

Therapeutic useAsthma/COPD — QL flagged; check formulary for numeric limits.

Additional notesEntry also shows Permanent Exclusion + = Generic Only in source for some lines; confirm allowable products.

Butorphanol NS — Quantity Limit Notification

Butorphanol NSQuantity Limit Notification = x x (multiple QL notifications indicated).

Therapeutic usePain — intranasal formulation flagged for QL notifications in the source.

Operational guidanceMultiple QL markers suggest product-specific limits or different limits by strength/formulation; verify exact limits in full formulary.

Quantity Limit flags — various entries

ObservationMany formulary lines show Quantity Limit flagged as 'x' or blank — QL presence varies by product and formulation.

ExamplesVarious entries across the F–H segments and earlier chunks show QL flags; see individual product lines for specifics.

ActionWhen QL is present, check the formulary's full QL table or claims system for specific numeric limits before dispensing.

Copaxone — Quantity Limits

CopaxoneQuantity Limit = x x x (multiple QL flags noted across product rows).

Therapeutic useMultiple sclerosis — multiple Copaxone product lines show repeated QL markings.

Provider noteConfirm product-specific QLs (by strength/formulation) in the full formulary or claims adjudication system.

Covid-19 Vaccine — Quantity Limits

Covid-19 Vaccine linesQuantity Limit = x x (repeated QL flags for vaccine entries).

Therapeutic useVaccine — QL/Notification flags are present for multiple repeated Covid-19 vaccine listings.

Operational guidanceVaccine entries with QL flags may indicate per-dose or per-course limits; consult plan vaccine guidance for specifics.

Cozaar — Quantity Limit

CozaarQuantity Limit = x (QL flag present in entry).

Therapeutic useHigh blood pressure — QL flagged alongside Notification and Designated Specialty for some rows.

ImplicationCheck the formulary or claims system for specific dispensing limits when QL is flagged.

Cystadrops — Quantity Limit

CystadropsQuantity Limit = x (QL flag present).

Therapeutic useCystinosis/Endocrine disorders — QL and Notification flags also present in entry.

Provider noteConfirm QL numeric limits in the full formulary prior to dispensing specialty ophthalmic products.

D. H. E. 45 — Quantity Limit

D. H. E. 45Quantity Limit = x (QL flag present).

Therapeutic useListed among migraine/neurologic therapy products in the excerpt.

Operational noteWhen QL flagged, confirm allowed quantity per time unit in the complete formulary data before dispensing.

Dawnzera Daxbia — Quantity Limit

Dawnzera DaxbiaQuantity Limit = x (QL flag present in entry).

Therapeutic useInfections — notification and designated specialty flags may also appear for related product lines.

ActionVerify specific QL values in the full formulary or claims system for accurate dispensing.

Emverm — Quantity Limit / Notification (example)

EmvermExample showing Quantity Limit/Notification flagged; entry lists Prior Authorization = x and Designated Specialty = x in the source.

Operational contextEmverm is shown with utilization management flags (PA and designated specialty) — check full policy details for numeric QLs and PA criteria.

Provider actionSubmit PA and follow specialty pharmacy routing where indicated to support coverage determination.

Flovent Diskus & Flovent HFA — Quantity Limit

Flovent Diskus & Flovent HFAQuantity Limit = x (Quantity Limit flagged; specific numeric limit not provided in excerpt).

Therapeutic useAsthma — controller inhaled corticosteroids.

Operational noteBecause only a QL flag is shown, consult the full formulary for the precise quantity limit by strength/formulation.

Multiple insulin products — Quantity Limit Notification

ScopeMultiple insulin products and many other listed drugs show Quantity Limit Notification = x across the formulary entries (insulin pens, vials, and related supplies).

ExamplesHumulin N, Humulin R, Humulin 70/30, Apidra Solostar and insulin pen/vial product groups all have QL/QL Notification markers.

Provider guidanceConfirm product- and strength-specific quantity limits (often monthly) in the full formulary prior to dispensing insulin products.

Jynarque — Quantity Limit Notification

JynarqueQuantity Limit Notification = x x (quantity limit/notification flags present).

Therapeutic useEndocrine disorders — PA and designated specialty flags also appear for Jynarque in the entry.

ActionWhen QL/PA are present, follow PA submission and specialty network routing as required for coverage consideration.

Leqembi LQLIK — Quantity Limit Notification

Leqembi LQLIKQuantity Limit Notification = x (QL notification flagged in the entry).

Therapeutic useListed therapeutic use = Alzheimer's disease.

Provider noteQL/notification and PA flags present — verify coverage rules, PA criteria, and numeric limits in the full formulary for this agent.

Various listed products — Quantity Limit flags

ObservationMany products across the listing are flagged with Quantity Limit = x indicating QLs apply broadly across therapeutic classes.

ExamplesEntries in chunks 198–205 (Lipofen, Livdelzi, Livtencity, Lupkynis, Luxiq, etc.) show QL flags for multiple products.

ActionWhen QL marked, consult the full formulary or claims adjudication table to determine the specific numeric quantity limits before dispensing.

Examples with Quantity Limit = x

ExamplesNon-exhaustive examples with Quantity Limit = x include Morgidox Kit Morphine sulfate ER, Miebo Migranal, Naprosyn/Naproxyn, and Nitrofurantoin entries.

VariationQL application varies by product, strength, and formulation — some entries show multiple 'x' markers indicating repeated QL rows.

RecommendationVerify the precise QL values in the complete formulary prior to dispensing to ensure compliance with plan limits.

Various — Quantity Limit flags

General noteNumerous formulary lines are marked with 'x' where quantity limits apply; the source uses 'x' consistently to indicate a QL or QL notification.

Provider actionUse the QL flag as an indicator to look up the numeric limit and any time-period (e.g., per month) in the full formulary or claims system.

ExamplesNiaspan Nilotinib (QL = x), Nystatin/Triamcinolone cream & ointment (QL = x) illustrate the pattern across classes.

Nutropin AQ NuSpin — Quantity Limit

Nutropin AQ NuSpinQuantity Limit = x (QL flag present in formulary entry).

Therapeutic useGrowth hormones — Nutropin AQ NuSpin listed under growth hormones with QL marker and Designated Specialty Network = x.

Operational guidancePA = x is also indicated for Nutropin AQ NuSpin — follow PA and specialty dispensing requirements for coverage.

Ondansetron 16 mg ODT — Quantity Limit

Ondansetron - 16 mg ODTQuantity Limit flagged in the listing (source shows Quantity Limit and Notification entries for the 16 mg ODT).

Therapeutic useNausea & vomiting — higher-strength ondansetron formulations may have QL/notification and PA flags.

RecommendationConfirm the specific numeric QL and PA requirements (entry shows PA = x for some related specialty rows).

Ozempic — Quantity Limit

OzempicQuantity Limit Notification flagged in some entries (source shows QL markers for Ozempic in different rows).

Therapeutic useDiabetes — QL markers appear across Ozempic listings; check product-specific limits.

ActionConfirm numeric QL and any PA requirements for Ozempic in the complete formulary or claims system before dispensing.