CurrentBaylor Scott & White Health PlanPolicy N/A

2026 Formulary (Drug List) for BSW SeniorCare Advantage Plans

This formulary lists covered drugs, tiers, and utilization controls (prior authorization, quantity limits, step therapy, billing directives) for BSW SeniorCare Advantage Medicare Part D plans and explains how to use the formulary, change notifications, and exception/transition processes.

Policy Summary

PayerBaylor Scott & White Health Plan

Policy2026 Formulary (Drug List) for BSW SeniorCare Advantage Plans

Policy CodePolicy N/A

Change TypeRevised formulary (updated 04/01/2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization for drugs marked PA before dispensing and follow quantity limits and network pharmacy requirements when prescribing or dispensing.

POLICY UPDATE CHANGES

Formulary updated on 04/01/2026.

04/01/2026Formulary Last Updated

5Defined Tiers

30Specialty days supply

72/24 hrsException decision times

ManyProducts with PA

ManyProducts with QL

Coverage Summary

Formulary Coverage and Restrictions

Covered when ALL of the following are met:

ALL of the following

Drug is listed on the Baylor Scott & White Health Plan formulary (Drug List) current as of the effective date and has not been removed from the market.
Prescription is filled at a Baylor Scott & White Health Plan network pharmacy, or other pharmacy arrangements allowed by the plan (e.g., mail-order) are followed as specified in the Evidence of Coverage.
Other plan rules are followed, including prior authorization, quantity limits, step therapy requirements, and formulary tier cost‑sharing rules when applicable.
Drug is determined to be medically necessary for the member by the prescriber and documentation supports the clinical indication.

Policy Summary

PayerBaylor Scott & White Health Plan

Policy2026 Formulary (Drug List) for BSW SeniorCare Advantage Plans

Policy CodePolicy N/A

Change TypeRevised formulary (updated 04/01/2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization for drugs marked PA before dispensing and follow quantity limits and network pharmacy requirements when prescribing or dispensing.

On This Page

Prior Authorization / Quantity Limits / Step Therapy

Coverage is subject to utilization controls. The plan may require prior authorization, enforce quantity limits, and apply step therapy. Requests for exceptions may be submitted per the plan's exception process.

ALL of the following

Prior Authorization
- Prior authorization is required for drugs that the plan has designated as PA — prescriber must obtain approval before the drug will be covered; absence of approval may result in denial of coverage.
- PA criteria will specify required clinical information, trials of preferred therapies when applicable, and duration of approval; prescribers should follow the plan’s prior authorization submission instructions.
Quantity Limits
- Quantity limits (QL) restrict the amount of drug the plan will cover for a given time period (e.g., tablets per 30 days).
- QLs may apply in addition to standard one‑month or three‑month supply rules and are enforced at the pharmacy; examples (illustrative) include limits like 60 tablets/30 days for certain strengths of a medication.
Step Therapy
- Step therapy (ST) requires trial and failure, intolerance, or contraindication of specified step agents before a non‑preferred agent will be covered.
- Documentation of prior trials and outcomes is required for coverage of higher‑tier or non‑preferred agents when ST is applicable.
The plan’s utilization controls and clinical criteria are published in the formulary and related documents; providers and members may request exceptions if clinically appropriate.

Transition and Temporary Supplies

Temporary coverage and transition fill rules ensure short‑term access when coverage changes or upon plan enrollment.

ALL of the following

New members transitioning to the plan may receive temporary (transition) supplies for drugs they are currently taking even if the drug is not on the formulary or is subject to new restrictions; transition fill availability and duration follow plan procedures.
When a formulary change affects a member, the plan will provide a 30‑day notice or allow a one‑time 30‑day refill at a network pharmacy when the member requests a refill, as required by Medicare rules.
Long‑term care (LTC) emergency supplies and other short‑term fills are available per plan policies (e.g., a 31‑day emergency supply for LTC residents) consistent with state and CMS requirements.
Members and prescribers should contact Customer Service or follow the Evidence of Coverage to initiate transition fills or request assistance during a coverage change.

Formulary Coding & Tier Definitions

Tier definitionsmixed

Tier 1	Preferred generic drugs — lowest member cost-share when available.
Tier 2	Generic drugs — standard generic tier with low cost-share.
Tier 3	Preferred brand drugs — brand-name products with moderate cost-share.
Tier 4	Non-preferred brand drugs — higher cost-share brand products.
Tier 5	Specialty drugs / high-cost therapies — highest cost-share; may include specialty pharmacy handling.

Column Abbreviations / Requirement codesmixed

PA	Prior Authorization required before coverage is approved.
QL	Quantity Limit — limits on amount or day supply allowed per fill.
ST	Step Therapy — trial of one or more drugs required before coverage.
BD	Brand Dispense as Written — brand-only coverage; generic substitution not allowed.
>	Indicates a range or greater-than threshold for tiering or quantity (used within formulary tables).

Representative Formulary Examples (not exhaustive) - representative rows only; see master formulary for full NDC mappingNDCCovered

BELBUCA	Buprenorphine buccal film — included as example opioid partial agonist product (may have PA/QL/ST as indicated in master formulary).
buprenorphine td patch	Transdermal buprenorphine patch — representative opioid analgesic delivery form; check master formulary for specific strengths and restrictions.
fentanyl td patch	Transdermal fentanyl patch — opioid analgesic; often subject to QL/PA — see master formulary NDC mapping.
ZTLIDO	Lidocaine topical system (ZTLIDO) — topical analgesic product; coverage details in master formulary.
ARIKAYCE	Amikacin liposome inhalation suspension (ARIKAYCE) — covered specialty inhaled antibiotic; PA/QL may apply.
VIVITROL	Naltrexone extended-release injectable suspension (VIVITROL) — coverage for opioid/alcohol dependence; may require PA and site-of-care rules.
posaconazole (example)	Antifungal agent (e.g., posaconazole oral suspension/tablet) — representative systemic antifungal entries; check master formulary for formulations and QL/PA codes.
dordaviprone hcl cap 125 mg	Example specialty oral agent — refer to master formulary for PA/QL and NDC-level pricing.
neratinib maleate tab 40 mg	Oral oncologic agent — see master formulary for specific coverage, PA requirements, and NDCs.
nilotinib hcl cap 50 mg	Oral tyrosine kinase inhibitor — specialty tiering and PA likely; consult master formulary.

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This fragment contains numerous additional product line items not shown in the representative examples above. For billing, clinical rules, exact NDC-level identifiers, and pricing, reference the master formulary/pricing table (document part: Master Formulary / NDC Index). The master formulary provides complete NDC mappings, PA and QL codes, and up-to-date pricing — use it for claims submission and clinical prior authorization requests.

OpenPayer

2026 Formulary (Drug List) for BSW SeniorCare Advantage Plans

Coverage Summary

Utilization Controls (PA / QL / ST / BD)

Provider Requirements and Billing Rules

Formulary Coding & Tier Definitions

Revision History