CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Clinical Drug List (Pharmacy Coverage)

Governs Blue Cross Blue Shield of Michigan's clinical drug list for pharmacy benefits, describing coverage tiers, restrictions, prior authorization and specialty drug rules that affect prescribers, pharmacists and members.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyClinical Drug List (Pharmacy Coverage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation for drugs marked 'PA' before dispensing to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyupdate frequency

15-dayselect specialty drug fill limit

30-daygeneral specialty drug limit

2,300+in-network retail pharmacies (MI)

1Oncology prior auth pathway

multiple

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entries flagged PA/QL/ST

Coverage Criteria and Exclusions

General coverage criteria

Covered when ALL of the following are met:

Utilization management requirements: Any required utilization management conditions identified in the Notes column are satisfied (for example: prior authorization (PA), step therapy (ST), quantity limits (QL), specialty designation (SP), one-vendor/ program codes such as OVM/15DS).

PA/ST/QL/SP/OVM/15DS markers are defined on the drug list; see Drug list information for meanings.

Specialty drug program and site-of-care: For specialty drugs flagged SP or otherwise managed by the Specialty Drug Program, the drug is dispensed via the designated specialty pharmacy or site-of-care program and any program-specific supply limits (for example, select specialty drugs limited to a 15-day supply) are met.

See Specialty Drug Program instructions and member benefit for permitted fill sites (retail, Walgreens Specialty, Optum home delivery) and supply limits.

Not excluded by drug-list exclusions: The drug is not listed as 'Not covered' or otherwise excluded (excluded categories include OTC equivalents, experimental uses, cosmetic indications, most medical-benefit administered products, certain compounded products, replacements for loss/theft, and drugs not FDA-approved).

If a drug is designated 'Not covered' on the Clinical Drug List it will not be eligible for coverage under the pharmacy benefit.

The Clinical Drug List excludes categories of products from pharmacy benefit coverage. Excluded categories include prescription drugs with an over-the-counter equivalent (in the same strength and dosage form), drugs used for experimental purposes, and drugs prescribed for cosmetic purposes. Products normally covered as a medical benefit (for example, office‑administered injectables and many vaccines) are also excluded from pharmacy coverage except where the plan specifically allows pharmacy benefit coverage. The list also excludes most compounded products (with limited exceptions), replacement prescriptions issued for loss/theft, and drugs not approved by the FDA. Refer to the Notes column and the member’s benefit design for plan‑specific preventive categorizations and exceptions.

Several specific analgesic, NSAID and opioid formulations are designated Not covered in the drug list. Examples shown in the list include branded or formulation entries such as JOURNAVX, diclofenac potassium oral tablet 25 mg (Not covered), ibuprofen oral tablet 300 mg (Not covered), and multiple long‑acting and short‑acting opioid formulations (for example, certain fentanyl patch strengths, OXYCONTIN, TRAMADOL HCL ORAL SOLUTION, and various oxycodone‑acetaminophen solution/tablet preparations) that are explicitly marked Not covered.

The list includes numerous individual products explicitly labeled Not covered. Representative entries include APLENZIN, DRIZALMA SPRINKLE, GIMOTI, LUZU, TAVABOROLE, and other branded agents where the table indicates the Not covered tier for the pharmacy benefit.

Additional examples of products designated Not covered appear throughout therapeutic sections. Sample Not covered entries include topical oncology or dermatology items such as FLUOROURACIL EXTERNAL CREAM 0.5%, oncology formulations and packs (e.g., some XALKORI, VIJOICE, and related therapy packs), and behavioral health or antipsychotic starter packs noted as Not covered in the antipsychotics section.

This segment of the drug list names multiple products as Not covered, including psychiatric and neurologic items as well as certain antidiabetic agents. Examples called out include OPIPZA, COBENFY, and several antidiabetic entries listed as Not covered including ALOGLIPTIN BENZOATE and related combinations in the antidiabetic section.

Several antidiabetic and insulin products are explicitly labeled Not covered in the formulary excerpts. Representative Not covered items shown include INVOKAMET, INVOKAMET XR, INVOKANA and multiple insulin preparations that are listed as Not covered under their Insulins/Antidiabetic headings.

Cardiovascular and lipid‑management sections also include Not covered entries. Examples include branded calcium‑channel or niche cardiovascular products such as CONJUPRI, NYMALIZE, SDAMLO, and other Not covered items listed under those therapy groups or dyslipidemic entries marked Not covered in the table.

Multiple specialty and dermatology agents are marked Not covered in portions of the list. Examples include starter or limited packs and branded topical products such as PLEGRIDY STARTER PACK, AKLIEF, ARAZLO, as well as certain newer topical formulations (e.g., items showing Not covered or Not covered + QL in the dermatology entries).

Nutritional and gastrointestinal sections show numerous Not covered items. Representative examples include a range of prenatal and vitamin products (e.g., PRENATE formulations listed as Not covered), RANITIDINE HCL (Not covered), and various agents for bowel or motility disorders such as TRULANCE, MOVANTIK marked Not covered or with QL restrictions in the table.

Topical corticosteroids and related dermatologic products include specific Not covered entries. Examples in the table include CLOBETASOL PROPIONATE EXTERNAL CREAM 0.025 %, HALOBETASOL PROPIONATE EXTERNAL FOAM, and other topical products identified as Not covered under the dermatology section.

Several biologic, immunologic and specialty injectable products are listed as Not covered in portions of the immunology and immunosuppressant sections. Representative Not covered entries include certain formulations and starter packs such as ABRILADA (1 PEN) and OMVOH SUBCUTANEOUS, along with biosimilar or specific branded variants identified as Not covered in the table.

This segment contains additional Not covered topical and branded examples across multiple classes. Items listed as Not covered here include specific branded injectables or topical agents and contraceptive formulations that the table flags as Not covered in their tier (for example, some entries shown near USTEKINUMAB listings and contraceptive/multivitamin examples reported as Not covered).

The ophthalmic and otic sections include several products designated Not covered. Notable examples from the list include RESTASIS MULTIDOSE, VEVYE, UPNEEQ, ZERVIATE, BYQLOVI, CLOBETASOL PROPIONATE OPHTHALMIC, ILEVRO, EYSUVIS, NEVANAC and related ophthalmic agents shown as Not covered in the table.

Respiratory and inhalation therapy entries show multiple Not covered products. Examples in this section include inhaled agents and devices such as FLUTICASONE‑SALMETEROL INHALATION AEROSOL 45‑21/115‑21 MCG/ACT (Not covered), XHANCE, INCRUSE ELLIPTA, TUDORZA PRESSAIR, UMECLIDINIUM ELLIPTA, and select nasal products like NEFFY NASAL SOLUTION that are explicitly listed as Not covered.

Provider Responsibilities, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required for PA‑Annotated Products

Prior authorization (PA) is required for many products annotated with "PA" in the drug list. Providers must obtain authorization before dispensing or submission to avoid claim denials.

PA-flagged drugs: many specialty and branded agents throughout the formulary list are annotated "PA".
Oncology antineoplastics and supportive care require PA via the Oncology Value Management (OncoHealth) pathway (see OVM entries).
Devices and diabetes CGM/sensor items (e.g., DEXCOM G7 Sensor, FREESTYLE LIBRE items) list PA; obtain PA prior to dispensing.

Step Therapy

Step Therapy and Specialty Program Requirements

Prior authorization and step therapy are common utilization management controls across the drug list. Drugs annotated "ST" require trials of preferred alternatives before coverage; those annotated "SP" require specialty-channel processing. Review the formulary notes before prescribing.

Key Definitions and Note Codes

Specialty medication — brief definition entry

DefinitionSpecialty medications are drugs that treat complex conditions and may require special handling or administration; they are subject to specialty program rules and site-of-care restrictions.

Supply limitsGenerally limited to a 30-day supply; select specialty drugs are managed under a 15-day Specialty Drug Limitation Program (members pay half usual OOP for a 15-day supply).

Program referenceSee the Specialty Drug Program Pharmacy Benefit Member Guide and bcbsm.com/pharmacy for program details and which drugs are included in the 15-day program.

PA — Prior authorization definition

DefinitionPrior authorization (PA) — the prescriber must provide additional information to the plan to determine coverage before the drug is approved for benefit payment.

Step Therapy Rules and Affected Products

Overview
Step therapy (ST) may be required; drugs subject to ST require trial of one or more preferred medications before coverage of higher‑cost or nonpreferred products is approved. Specific step sequences depend on the drug and the member's plan; consult the Blue Cross Clinical Drug List and the Prior Authorization and Step Therapy Coverage Criteria for details.

Detail
Drugs subject to step therapy require previous treatment with one or more preferred drugs before coverage is approved. For the current list and specific step requirements, refer to the Prior Authorization and Step Therapy Coverage Criteria and the Blue Cross Clinical Drug List.

Nonpreferred brand (Notes)
Some nonpreferred brands are annotated with 'ST' in the Notes column indicating step therapy applies (examples in the antidepressants and triptan sections such as EXXUA and selected triptan nasal products).

ST annotated items
Several antipsychotics and related CNS agents carry 'ST' in the Notes column, indicating step therapy is required prior to coverage of the listed product.

Specific drug examples
CAPLYTA, FANAPT, LYBALVI, SECUADO, VRAYLAR, MOUNJARO, OZEMPIC and RYBELSUS appear in the list with 'ST' notes indicating step therapy requirements may apply to these products.

Enforced ST examples
MOUNJARO, OZEMPIC, TRULICITY and RYBELSUS are listed with 'ST' (and in many cases 'QL'), indicating step therapy is enforced for these antidiabetic agents per the drug list notes.

Cladribine / MS examples
Cladribine entries (e.g., cladribine tablets) and related multiple sclerosis products such as MAVENCLAD and REBIF are annotated 'ST' in the Notes column, indicating step therapy applies prior to coverage.

Select products with ST
Additional products carry 'ST' in their Notes (for example, REBIF and certain topical agents show ST flags), meaning applicable prior steps must be met before coverage is approved.

Other ST examples
Some gastrointestinal and pancreatic enzyme products (e.g., PANCREAZE, PERTZYE) and agents such as dexlansoprazole are shown with 'ST' notes in the list, indicating step therapy requirements apply for these items.

Sequencing note
The drug list flags products with ST but does not provide explicit step sequencing within these chunks; specific step sequences and required prior agents are available in the Prior Authorization and Step Therapy Coverage Criteria and program materials.

Specialty + ST interactions
Several specialty agents are marked 'SP' and may also have 'PA' or 'QL' notes; when ST appears alongside specialty designations, follow specialty distribution and prior authorization processes as part of the step/program requirements.

Operational instruction
Follow step therapy and program restrictions where noted (examples include entries with 'SP', '15DS' and other program abbreviations that imply additional enrollment or supply rules).

'ST' requirement statement
Items annotated 'ST' require members to try applicable prior step(s) (preferred medications) per the policy notes before the nonpreferred or higher‑cost product will be covered.

Additional ST examples
Examples of products with 'ST' in the Notes include antipsychotics and CNS agents (CAPLYTA, FANAPT, LYBALVI, SECUADO, VRAYLAR), insomnia agents and nasal/sleep products in other sections, and select antidepressant/nonpreferred brand entries—these indicate step therapy must be met prior to coverage.

Quantity Limits and Fill Restrictions

Select specialty drugs — 15-day supply special fill limit

Program15-Day Specialty Drug Limitation Program — select specialty drugs are limited to 15-day supply for all fills to reduce OOP costs and waste.

Member costMembers pay half their usual out-of-pocket cost for a 15-day supply when drugs are included in the 15DS program.

ReferenceSee the Specialty Drug Program Member Guide and bcbsm.com/pharmacy for the list of drugs included in the 15DS program.

Various drugs annotated with QL — reference to Quantity Limit Program

General noteMany drugs are annotated with 'QL' in the Notes column; see the Quantity Limit Program for specific per-fill limits for each product.

Scope

Fulfillment Channels and Specialty Pharmacy Requirements

Documentation Required

Follow PA/SP/QL requirements and specialty dispensing rules

Coverage may be contingent on prior authorization (PA), specialty pharmacy (SP), and quantity limits (QL) for listed products; providers must obtain PA and follow specialty distribution requirements when these flags appear.

Billing Rule

Specialty drug fill channels — retail, home delivery or limited-distribution specialty

Specialty drugs may be filled at local retail pharmacies (Walgreens preferred), limited-distribution specialty pharmacies per drug, or via home delivery (Walgreens Specialty Pharmacy or Optum Home Delivery).

Walgreens is the preferred specialty pharmacy; home delivery available via Optum Home Delivery.
Retail pharmacies in-network (>2,300 in Michigan) can be used for local fills unless limited-distribution is specified.

Policy Background

Background: The Clinical Drug List is a reference compiled and regularly reviewed by the plan’s Pharmacy and Therapeutics Committee to reflect FDA‑approved medications and to guide safe, effective, and cost‑conscious prescribing. The committee reviews new drugs prior to consideration for formulary placement and coverage decisions consider clinical safety, effectiveness and cost‑effectiveness. The list is intended to support prescribers, pharmacists and members by documenting tier placement, utilization management flags (for example, PA, QL, ST, SP), and any program‑specific supply limits or specialty distribution requirements.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyClinical Drug List (Pharmacy Coverage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation for drugs marked 'PA' before dispensing to avoid claim denials.

SourceLink

On This Page

ST = Step therapy — member must try preferred drug(s) first (examples: MOUNJARO, OZEMPIC, TRULICITY, certain antipsychotics).
SP = Specialty medication — may require special handling and specialty pharmacy channel.
OVM = Oncology Value Management — PA for antineoplastics administered through OncoHealth.

Documentation Required

Submission, Notification and Required Documentation

Providers must submit clinical information and required documentation when requesting prior authorization. Incomplete or missing documentation may lead to denial of coverage. When PA, QL, SP, or ST markers are present, provide the clinical rationale and supporting records.

Submission methods: electronic prior authorization (via EHR or CoverMyMeds), phone (1-800-437-3803), fax (1-866-601-4425), or mail (Pharmacy Services - Mail Code 512C, 600 E. Lafayette Blvd., Detroit, MI 48226-2998).
Oncology PA via OncoHealth: submit through OncoHealth OneUM portal, call 1-888-916-2616, fax 1-800-264-6128, or mail OncoHealth address.
Provide documentation supporting medical necessity and any quantity-limit (QL) justification when QL noted.

Denial Risk

Denial Triggers for PA and Not‑Covered/Restricted Drugs

Claims for drugs that are "Not covered" or otherwise excluded will be denied at adjudication. Coverage may also be denied if PA criteria are not met or required additional information is not provided.

Not covered = excluded from drug benefit and will be denied if billed under the pharmacy benefit (examples appear throughout the formulary).
Denial reasons include: unmet PA criteria, lack of submitted supporting documentation, drug excluded by plan design, or failure to meet step therapy requirements.

Note

Utilization Management Flags and Their Meaning

Utilization management flags appear throughout the formulary — common annotations include PA (Prior authorization), ST (Step therapy), QL (Quantity limit), SP (Specialty), OVM (Oncology Value Management), ABA (Authorized Brand Alternative), and PV1/PV2/PV3 (Preventive tier definitions). Understand the implication of each flag before prescribing.

QL = Quantity limit — requests exceeding limits require justification.
ABA = Authorized Brand Alternative — may affect member cost-share and coverage.
PV1/PV2/PV3 = Preventive coverage designations — coverage and member cost may vary by plan and regulatory requirements.

Documentation Required

Documentation Expectations and Quantity‑Limit Evidence

When PA, SP, or QL markers are present, include specific documentation such as prior treatment history (for ST), clinical test results, diagnosis codes, and rationale for the requested dose/quantity. Lack of these documents is a common denial cause.

For ST: document prior use/failure of preferred agents and dates of therapy.
For QL: provide clinical justification for quantities or extended days' supply.
For SP/OVM: follow specialty or oncology program submission guides and include required clinical forms.

PA is required for certain drugs and devices as noted in the Notes column (items flagged 'PA').

SubmissionProviders must submit clinical information or a Coverage Request Form per the prescription drug benefit packet when PA is requested.

Common administrative note codes

PAPrior authorization — requires provider submission of clinical information before coverage.

QLQuantity limit — limits on amount dispensed per fill or timeframe (see Quantity Limit Program for specifics).

STStep therapy — requires trial of one or more preferred drugs before a higher-cost medication is covered.

SPSpecialty — indicates specialty medication handling, specialty pharmacy or site-of-service program requirements.

OVMOncology Value Management — prior authorization pathway for antineoplastics administered via OncoHealth.

ABAAdministrative/billing adjudication abbreviation used in Notes (document uses but does not further define).

15DS15-day supply — program limiting certain specialty drugs to a 15-day supply (members pay half their usual OOP for 15-day fills).

PA — prior authorization flag definition (annotation)

PA flagIndicates the item requires prior authorization — provider must submit supporting clinical documentation before coverage is approved.

Use in listPA appears in the Notes column next to many drugs and devices; claims may be denied if PA is not obtained when required.

Oncology noteFor antineoplastics, PA may be routed via the Oncology Value Management program (OncoHealth).

QL — quantity limit flag definition

QL flagQuantity Limit — denotes restrictions on quantity dispensed per fill or timeframe; refer to the Quantity Limit Program for exact per-fill limits.

PurposeLimits are set based on clinical appropriateness and manufacturer-recommended dosing.

DocumentationPrescribers may need to document prescribed quantity and days supply during PA review when QL is noted.

ST — step therapy flag definition

ST flagStep Therapy — requires trial and failure of one or more preferred medications before coverage of the listed (usually higher-cost) product.

ApplicationST appears for select nonpreferred brands and other products (examples: certain antipsychotics, antidiabetics).

ReferenceRefer to Prior Authorization and Step Therapy Coverage Criteria and the Clinical Drug List for specific step sequences.

SP — specialty designation definition

SP flagSpecialty designation — indicates the drug is a specialty medication and may require specialty pharmacy fulfillment or site-of-service program enrollment.

ImplicationSP items often have additional requirements such as PA, QL, or program enrollment and may be dispensed through limited-distribution specialty pharmacies.

Site-of-careSpecialty drugs may be fulfilled via Walgreens Specialty Pharmacy, Optum Home Delivery, or other designated specialty sites per plan rules.

ABA — administrative/billing abbreviation usage note

ABA usageABA appears as an administrative/billing adjudication abbreviation in the Notes column; the document references it but does not define it further.

ContextABA is used alongside other note codes (e.g., PA; QL) on select entries, indicating administrative actions or billing considerations may apply.

Provider actionWhere ABA appears, follow payer adjudication instructions and submit required documentation as indicated elsewhere in the benefit packet.

AL — age limit note example

ExampleAL (Min 18 Years) — age-limit note shown for LAGEVRIO indicating a minimum age requirement applies.

FunctionAL denotes age limits or adult/minimum age restrictions for specific drugs.

ActionConfirm member age meets AL requirements when submitting claims or PA requests for agents with AL noted.

PV2 / PV1 — plan-preventive designation example

PV2 examplePV2/PV1 — preventive tiers used in formulary tiering and shown for contraceptives and vaccines (e.g., many contraceptive products listed as PV2).

MeaningPV1/PV2/PV3 indicate preventive coverage categories with specific out-of-pocket implications when health care reform requirements are met or not met.

ReferenceSee Notes column for PV1/PV2 flags on contraceptives and vaccines; coverage and OOP depend on benefit design and reform criteria.

PA — Prior Authorization definition (additional reference)

DefinitionPrior Authorization (PA) — a utilization management requirement where the plan reviews and approves a medication before benefit payment.

OccurrencePA flags appear repeatedly in the Notes column for many drugs and devices across the drug list.

ConsequenceClaims submitted without required PA risk denial; providers must follow PA submission instructions in the benefit packet.

QL — Quantity Limit definition (additional reference)

DefinitionQuantity Limit (QL) — indicates limits on the amount or frequency of the dispensed product per fill or timeframe.

Where usedQL markers are used for many products (devices, medications, inhalers, statins, etc.); consult the Quantity Limit Program for specifics.

Provider noteWhen QL is noted, documentation of prescribed quantity and days supply may be required during PA or claim adjudication.

ST — Step Therapy definition (additional reference)

DefinitionStep Therapy (ST) — requires trial/failure of preferred alternatives before the requested medication is approved for coverage.

ExamplesST is noted for select antipsychotics and antidiabetic GLP-1 agents (e.g., CAPLYTA, MOUNJARO, OZEMPIC, RYBELSUS) and others per the Clinical Drug List.

InstructionRefer to the Prior Authorization and Step Therapy Coverage Criteria for required prior steps and documentation needed to meet ST requirements.

SP — Specialty Program definition (additional reference)

DefinitionSpecialty Program (SP) — indicates specialty pharmacy handling, site-of-service program requirements, or limited-distribution arrangements for specialty drugs.

ImplicationSP items commonly require PA and may have QL; fulfillment is often through designated specialty pharmacies or infusion/clinic settings.

ExamplesSP appears on many biologics, oncology, and high-cost agents (examples: IMBRUVICA, GAMMAGARD, USTEKINUMAB entries).

ABA — administrative/billing abbreviation reference

ABA referenceABA is used as an administrative/billing adjudication abbreviation in the Notes column; the policy references ABA but does not provide a detailed definition.

UsageAppears alongside other markers (e.g., QL, PA) indicating administrative or billing actions may be relevant for adjudication.

Provider actionFollow adjudication guidance and submit required documentation where ABA is present to avoid claim issues.

PA — repeated PA flag definition reference

PrevalencePA markers appear frequently across the drug list; absence of PA when required may result in denial.

See alsoOncology antineoplastics follow OncoHealth/OVM PA pathway where noted.

SP — specialty designation reference

SP (repeat)Specialty pharmacy designation — indicates specialty fulfillment or site-of-service program; often linked with PA and QL.

Program impactDrugs flagged SP may require enrollment in specialty programs and limited-distribution channels.

ExamplesSeen on biologics, immunoglobulins, and certain oncology or rare-disease therapies (e.g., GAMMAGARD, USTEKINUMAB).

QL — quantity limit reference

QL (repeat)Quantity Limit — denotes limits on amount dispensed; check Quantity Limit Program for per-fill values and product-specific limits.

Common itemsQL commonly applies to devices, inhalers, statins, and many maintenance medications listed in the Clinical Drug List.

ActionEnsure prescribed quantity aligns with QL restrictions when submitting PA or claims to avoid denials or adjustments.

PV2 / PV1 — preventive coverage tier indicators

Preventive tiersPV1/PV2 — preventive coverage tier indicators used for contraceptives and vaccines; these determine preventive benefit treatment and member cost when reform criteria apply.

ImplicationPV1/PV2 items may be covered with no out-of-pocket cost when health care reform requirements are met; otherwise coverage and cost depend on benefit design.

ExamplesMany contraceptives are labeled PV2 (e.g., multiple oral contraceptives and patches) and some vaccines are PV1/PV2 in the list.

PA — prior authorization reference (later segments)

PA referencePA note indicates the item requires prior authorization for benefit payment; providers must follow PA processes in the benefit packet.

Common usePA is annotated across many therapeutic classes including immunologics, biologics, and specialty agents.

Denial riskClaims may be denied at adjudication if PA is required but not obtained when the item is flagged 'PA'.

QL — quantity limits reference (later segments)

QL referenceQuantity limits are applied to many products and devices; refer to the Quantity Limit Program and the Notes column for per-fill and time-based limits.

Device examplesCGM devices and supplies (Dexcom, FreeStyle Libre, Omnipod kits) show QL markers in the list indicating per-fill limits.

Policy actionWhen QL is present, ensure claims and dispensed amounts comply with documented limits to prevent claim adjustments or denials.

SP — specialty pharmacy reference (later segments)

SP referenceSpecialty pharmacy (SP) indicates specialty distribution or site-of-service program requirements; many specialty agents are flagged SP in the list.

Fulfillment channelsSP drugs may be dispensed through Walgreens Specialty Pharmacy, Optum Home Delivery, or other limited-distribution specialty pharmacies per plan rules.

Associated notesSP frequently appears with PA and QL and may require program enrollment or specialty-site dispensing (infusion, clinic, home infusion).

PV1/PV2 — preventive tier notations used in formulary tiering

PV1 / PV2 categoriesPV1/PV2 denote preventive-designation categories used for vaccines and contraceptives that affect coverage and member cost when reform requirements apply.

Coverage effectPV1/PV2 items may be covered with no OOP when health care reform criteria are met; otherwise coverage depends on the member's benefit design.

Where shownPV1/PV2 appear in the Notes column for numerous contraceptive and vaccine entries in the Clinical Drug List.

PA — prior authorization definition (another repeat)

PA definition repeatPrior Authorization — the payer requires review and approval before coverage; indicated by 'PA' in the Notes column.

Provider requirementProviders must submit required documentation per the benefit instructions to obtain PA prior to dispensing when PA is noted.

AppealsDenials for lack of PA will be communicated with reasons and appeal rights as described in the benefit materials.

SP — specialty pharmacy/site-of-service program definition (repeat)

SP — site-of-service programSpecialty Pharmacy or site-of-service program — indicates specialty handling, possible limited-distribution, and program enrollment requirements for fulfillment.

Associated requirementsSP items commonly require PA and may carry QL; they may also be restricted to specific specialty pharmacies or infusion centers.

ExamplesSP used on many biologics, immunoglobulins, and high-cost specialty therapies (see GAMMAGARD, USTEKINUMAB entries).

QL — quantity limit definition (repeat)

QL — definition repeatQuantity Limit — restriction on amount dispensed per fill or time period; check the Quantity Limit Program and Notes for product-specific limits.

Common occurrenceQL appears widely across the list including statins, inhalers, devices, and many chronic medications.

Provider tipVerify QL before authorizing refills to ensure dispensed quantities conform to plan limits.

PV1 / PV2 — preventive designation categories

PV1 / PV2 usePV1/PV2 — preventive categories used for vaccines and contraceptives; determine preventive benefit treatment and cost-sharing per member benefits.

Annotation examplesMultiple contraceptives and vaccines in the list are annotated PV1 or PV2 to indicate preventive tiering.

Impact on coverageWhen health care reform requirements are met, PV1/PV2 items may be covered with no out-of-pocket cost; otherwise coverage and cost depend on benefit design.

QL applies across multiple therapeutic classes including devices, inhalers, statins, topical agents, and specialty agents.

ActionCheck product-specific QL entries when planning fills or prior authorization requests to ensure compliance with limits.

Multiple entries with QL — general note

QL marker — generalThe document marks numerous entries with 'Notes = QL' indicating quantity limits apply; consult the specific entry for exact limits.

Examples includeDevices and injectables (e.g., Dexcom sensors, infusion kits) and many outpatient medications show QL flags.

Provider implicationWhen QL is present, documentation may be required to support quantities dispensed during PA review or claim processing.

Many listed drugs note 'Notes = QL' — consult list

Notes = QL — many drugsSeveral drug entries include 'Notes = QL' in the Clinical Drug List; these indicate plan-specific quantity restrictions per fill or month.

Where to confirmConfirm per-fill limits in the Quantity Limit Program and in the Notes column of the specific drug entry.

ExamplesStatins, inhaled corticosteroids, ophthalmic agents, and topical/systemic dermatologic agents are among those with QL notes.

Device and antiviral examples showing QL flag

Device and antiviral QL examplesExamples showing QL include LIVTENCITY (PA; SP; QL), EPCLUSA (PA; SP; QL), and Dexcom/FreeStyle Libre devices (PA; QL).

ImplicationDevices and certain antivirals carry QL and may also require PA and specialty handling.

Provider tipVerify device-specific QL and PA requirements before dispensing or ordering to avoid claim issues.

Atorvastatin 10 mg & 20 mg — QL indicated

Specific statin strengthsAtorvastatin calcium oral tablets 10 mg and 20 mg are annotated with QL in the Clinical Drug List excerpt.

Annotation detailNotes for these strengths include PV2; QL; and age-limit (AL) entries in related statin listings.

ActionConfirm quantity limits for these strengths when processing fills or prior authorization requests.

Various topical and systemic agents — QL indicated

Topical/systemic agentsVarious topical and systemic dermatologic agents are noted with QL in the Clinical Drug List excerpt.

ExamplesEntries include ENSTILAR, EMROSI, tazarotene products and others with QL or ST/ABA annotations.

Provider actionCheck each product's Notes for exact QL values and any associated step or specialty requirements prior to dispensing.

MYTESI — QL indicated in Notes

MYTESIMYTESI is listed with Notes = PA; QL indicating a quantity limit applies and prior authorization is required.

ImplicationPrescribers should obtain PA and confirm QL parameters when prescribing MYTESI to ensure coverage.

ReferenceSee the Clinical Drug List entry for MYTESI for specific QL and PA instructions.

MYFEMBREE — quantity limit reference

MYFEMBREEMYFEMBREE appears in the Clinical Drug List excerpt with Notes indicating PA; QL (MYFEMBREE listed as Nonpreferred brand with PA; QL).

ActionConfirm PA and quantity restrictions for MYFEMBREE before dispensing or submitting claims.

Where listedSee the contraceptives/menstrual agents section of the Clinical Drug List for full details on PA/QL for MYFEMBREE.

Various entries — see QL marker in these chunks

QL markers presentMultiple entries across the Clinical Drug List are marked with QL; consult each drug's Notes field for the applicable limit.

ExamplesTopical agents, ophthalmic products, inhalers, statins and many other classes show QL annotations in the list.

Provider guidanceUse the Quantity Limit Program to identify precise per-fill or per-month limits when planning therapy or prior authorization requests.

Mesalamine 1.2 g — per plan QL applies

Mesalamine 1.2 gMesalamine oral tablet delayed release 1.2 gm is listed with a plan-specific QL (per plan quantity limit applies).

ImplicationConfirm the plan QL when authorizing or dispensing mesalamine 1.2 gm tablets to ensure compliance with limits.

ReferenceSee the Clinical Drug List Notes and the Quantity Limit Program for the exact per-fill/period limit for mesalamine 1.2 gm.

CEQUA — QL noted

CEQUACEQUA is listed in the Clinical Drug List excerpt with Notes indicating QL applies (entry shows ophthalmic agents with QL markers).

ActionVerify CEQUA's quantity restriction before dispensing and when submitting PA or claims.

Where to checkRefer to the ophthalmic section of the Clinical Drug List for CEQUA's specific QL details.

Fluticasone propionate HFA 44 mcg/act — AL (Max 5 Years) noted

Fluticasone HFA 44 mcg/actFluticasone propionate HFA aerosol 44 mcg/act inhalation is annotated with QL and an age limit (AL Max 5 Years) in the Clinical Drug List excerpt.

Age noteAL (Max 5 Years) indicates a maximum age-related restriction applies to that formulation per the Notes field.

Provider actionConfirm both QL and AL restrictions when prescribing or dispensing this inhaler to pediatric patients.

Billing Rule

Use specialty pharmacy for SP‑flagged products

Specialty items flagged 'SP' indicate specialty pharmacy or site-of-service program requirements for fulfillment; providers must direct patients to the appropriate specialty channel per the drug entry.

Examples: Many biologics (XOLAIR, USTEKINUMAB) and specialty injectables show SP and require specialty distribution.

Documentation Required

Enroll in specialty program and follow SP guidance for SP-marked drugs

Items annotated 'SP' in the drug list require specialty pharmacy handling or program enrollment — follow the plan's specialty program instructions and PA/QL steps when ordering or dispensing.