Blue Cross Blue Shield MI Clinical Drug List Coverage

General coverage

Coverage and placement are determined by the Clinical Drug List and the member's drug plan; some drugs require additional authorization or special program routing.

General coverage conditions: Drug must be FDA-approved and included on the Blue Cross Blue Shield of Michigan Clinical Drug List for consideration; coverage, tier placement, and member cost-sharing depend on the member's specific drug plan and benefit design.

Drug list overview and plan-dependent placement

Utilization controls may apply: Drugs may be subject to utilization management controls such as prior authorization (PA), step therapy (ST), quantity limits (QL), specialty pharmacy routing (SP), oncology/oral vial management (OVM), age limits (AL), or limited supply programs (e.g., 15DS). Providers must follow the drug list notes and submit required documentation when these controls are indicated.

See drug list notes letters and documentation requirements

Prior authorization requirement: When a drug's Notes include 'PA', prior authorization is required before coverage will be approved; providers must submit clinical information per payer procedures (electronic, phone, fax, or mail) to support the request.

PA requirement and submission methods

Step therapy and alternatives: Where 'ST' is indicated the member must have trial and/or failure of required preferred agents per the plan's step therapy edits before the nonpreferred product is covered.

Step therapy rules are defined in the drug list and prior authorization guidance

Specialty drug routing and limits: Specialty drugs may be managed through specialty pharmacy channels, limited-distribution vendors, or home delivery (Walgreens Specialty Pharmacy or Optum Home Delivery) and select specialty products may be limited to a 15-day supply per program rules.15-day where noted

Site-of-care and specialty supply limitations

Not covered / Exclusions

Drugs not covered under the Clinical Drug List include nonformulary and explicitly excluded categories.

Exclusions — categories: Prescription drugs that have an over-the-counter equivalent in the same strength and dosage form (unless USPSTF preventive), drugs used for experimental purposes, drugs prescribed for cosmetic purposes, products covered under the medical benefit (e.g., certain office-administered injectables and vaccines), most compounded products (with exceptions), replacement prescriptions for loss/theft/mishandling, and drugs not approved by the FDA.

Explicit exclusion categories from the Nonformulary drugs section

Nonformulary high-cost alternatives: High-cost brand drugs that have comparable therapeutic alternatives available at substantially lower cost, and select brand-name drugs with available generics, are designated nonformulary and are not covered under the drug list in applicable benefit designs.

Nonformulary designation for cost-effective alternatives

GLP-1 weight-loss agents (commercial group limitation): Glucagon-like peptide-1 (GLP-1) agonist drugs used for weight loss (for example, Saxenda, Wegovy, Zepbound) are not covered for commercial members of fully insured large groups and some self-funded groups per the drug list exclusions.

The drug list excludes several categories of medications from pharmacy coverage. Not covered are prescription drugs that have an over‑the‑counter equivalent in the same strength and dosage form, drugs used for experimental purposes, and drugs prescribed for cosmetic indications. Products normally covered under the medical benefit — for example, injectable drugs and vaccines administered in a clinician's office — are also excluded from the pharmacy list (note: many common vaccines remain available at network retail pharmacies). In addition, the formulary generally excludes most compounded products (with limited exceptions), replacement prescriptions for loss/theft/mishandling, and any drugs not approved by the FDA.

The Clinical Drug List contains many individual entries explicitly designated Not covered. Examples documented in the listing include ZUNVEYL and multiple antiemetic/antifungal entries (for example, listed as Not covered in the Alzheimer’s/antidepressant and antifungal sections). These explicit not‑covered entries indicate the drug is excluded from coverage under the pharmacy benefit and may be denied if submitted for reimbursement.

Additional specific examples shown as Not covered in the oncology and related sections include topical and systemic agents such as FLUOROURACIL EXTERNAL CREAM 0.5%, and antineoplastic/oncology‑related listings like TOLAK and RUBRACA. The table entries clearly mark these products as noncovered within the drug list.

The formulary also lists behavioral health and antiviral products as Not covered in places. Documented examples include psychiatric/antipsychotic entries and antiviral protease inhibitors such as OPIPZA and VIRACEPT, which are shown in the table-of-contents excerpts as excluded.

Several antidiabetic and insulin items are explicitly designated Not covered. Examples shown in the insulin/glycemic sections include agents and presentations such as ZITUVIMET and numerous insulin presentations (multiple Humalog, Humulin, Novolin, and other branded pen/vial forms) that the list marks as not covered in the pharmacy benefit.

Cardiovascular and related product listings include several specific formulations shown as Not covered. Examples from those table excerpts include INDERAL XL, INNOPRAN XL, KAPSPARGO SPRINKLE, and other entries that the document marks as excluded from pharmacy coverage.

Dermatologic and specialty dermatology products are also represented among noncovered items. The document lists multiple topical and systemic dermatologic products as Not covered, including examples such as ABSORICA LD, several adapalene external formulations (e.g., ADAPALENE EXTERNAL PAD, ADAPALENE EXTERNAL SOLUTION), and other branded topical agents noted in the table excerpts.

Numerous prenatal and vitamin products are included in the list of noncovered brand items. Documented examples shown as Not covered include brand prenatal/multivitamin products such as GESTYRA, JENLIVA PRENATAL/POSTNATAL, MATERNACEL, and other named prenatal preparations.

The formulary marks a variety of topical corticosteroid and endocrine replacement products as Not covered in specific formulations. Examples from the table excerpts include ALKINDI SPRINKLE, CLOBETASOL PROPIONATE EXTERNAL CREAM 0.025%, HYDROCORTISONE ACETATE EXTERNAL CREAM 2.5%, and specialty products such as ACTHAR GEL and CORTROPHIN listed as excluded.

The contraceptive transdermal system TWIRLA is explicitly listed with Drug Tier = Not covered in the contraceptives section, signifying exclusion from the pharmacy benefit for that product.

Multiple biologic and biosimilar immunomodulators are documented as Not covered in the biologics sections. Examples shown in the table include many adalimumab products and biosimilars (for example, entries such as HADLIMA, HULIO, and branded HUMIRA presentations) which are marked as excluded in the listing.

Additional biologic and specialty products are listed as Not covered in other sections. Representative examples include subcutaneous biologic preparations such as PYZCHIVA SUBCUTANEOUS, SELARSDI SUBCUTANEOUS, and certain presentations of STELARA, as well as ophthalmic agents like RESTASIS MULTIDOSE and weight‑management or specialty agents where the table explicitly marks the product as noncovered.

The ophthalmic and respiratory product listings contain specific noncovered entries as well. For example, the table marks RESTASIS MULTIDOSE as Not covered, and various ophthalmic agents (including select formulations and brand products) are shown as excluded from pharmacy coverage in the provided excerpts.

The policy notes that nonformulary drugs which have therapeutically comparable alternatives available at lower cost may be designated Not covered. This reflects the plan’s approach to exclude higher‑cost, nonpreferred products when lower‑cost therapeutic equivalents exist.

Prior authorization, step therapy, documentation, and denial risks

Prior Authorization

Prior authorization required

Prior authorization is required for many drugs listed on the Blue Cross Blue Shield of Michigan Clinical Drug List. When a drug entry includes the Notes flag 'PA', the prescriber must request and obtain prior authorization before coverage will be approved. Authorization requests must demonstrate that the member meets the plan's clinical criteria; failure to provide required clinical information may result in a denial.

Applies to multiple branded drugs and specialty products annotated 'PA' across the drug list (examples include NUPLAZID, LIVTENCITY, DEXCOM G6 sensors and devices, CAMZYOS, BYLVAY, TRIKAFTA).
Drugs with combined flags (e.g., 'PA; SP; QL; OVM') require PA plus specialty routing, quantity justification, or program-specific review (Oncology Value Management for oncology agents).
If PA is required and not obtained prior to dispensing, the claim may be denied or reversed.

Prior Authorization

Prior authorization required when Notes = PA

Drugs and devices annotated with 'PA' on the drug list (including certain continuous glucose monitoring components, specialty biologics, and select branded agents) require submission of clinical documentation supporting medical necessity. Prior authorization approvals are contingent on meeting the plan-specific clinical criteria and any applicable program requirements (e.g., OVM for oncology).

Examples of devices/drugs with PA: DEXCOM G6 receiver/sensor/transmitter (Notes = PA; QL).
Select branded specialty drugs (e.g., LIVTENCITY, EMPAVELI, CAMZYOS, BYLVAY) show PA; SP; QL and need both PA and specialty pharmacy routing.
Oncology antineoplastics require PA via the Oncology Value Management (OncoHealth) process.

Prior Authorization

Prior authorization required for select branded drugs and devices

Several high-cost branded drugs, specialty products, and devices are subject to prior authorization and additional utilization controls. Providers should check the 'Notes' column for PA, SP, ST, QL, OVM and follow the listed routing — specialty products often require specialty pharmacy fulfillment.

Examples include NUPLAZID (PA; QL), LIVTENCITY (PA; SP; QL), DEXCOM G6 components (PA; QL), and multiple specialty biologics listed as PA; SP; QL.
Specialty biologics and immunosuppressant entries often show 'Not covered', 'SP', and/or 'PA' — verify coverage and required routing prior to prescribing.

Prior Authorization

Prior authorization required for annotated drugs

Many annotated products across therapeutic classes require prior authorization; the annotation legend (PA, SP, QL, ST, ABA, OVM, PV1/PV2/PV3, AL) defines the applicable utilization control and any age or preventive benefit considerations. Providers must supply supporting documentation as indicated.

Legend items: PA = Prior authorization; ST = Step therapy; QL = Quantity limit; SP = Specialty medication; OVM = Oncology Value Management; ABA = Authorized brand alternative; PV1/PV2/PV3 = Preventive benefit classifications; AL = Age limits.
When Notes include PA; SP; QL — provide PA clinical documentation and quantity justification; specialty products may require limited distribution or specialty pharmacy dispensing.

Denial Risk

Not covered items and denial risk

A subgroup of listed products is explicitly identified as Not covered or excluded. Prescriptions for Not covered items may be denied if billed under the pharmacy benefit; contact Customer Service or review the benefit packet for member-specific coverage.

Examples of Not covered items: FLUOROURACIL EXTERNAL CREAM 0.5% (Not covered), TWIRLA (Not covered), numerous biologic/biosimilar entries marked 'Not covered'.
Some high-cost brand drugs with available generics or therapeutically equivalent alternatives are excluded from coverage.
Members and providers will be notified in writing of denials and given appeals information.

Documentation Required

Prior authorization documentation and submission methods

Prior authorization requests must include the clinical information required by the plan. Providers can submit requests electronically (EHR, CoverMyMeds, OncoHealth OneUM for oncology), by phone, fax, or mail. For oncology drugs, PA is managed through OncoHealth with separate submission channels.

Electronic prior authorization: via provider EHR, CoverMyMeds, or OncoHealth OneUM (access through Availity payer space for oncology).
Phone: 1-800-437-3803 (general pharmacy PA); Oncology: 1-888-916-2616.
Fax: 1-866-601-4425 (general); Oncology fax: 1-800-264-6128.
Mail: Pharmacy Services - Mail Code 512C, Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Detroit, MI 48226-2998.

Documentation Required

Required documentation and utilization controls

Utilization control flags (PA, QL, ST, SP, OVM, ABA, PV1/PV2/PV3, 15DS, AL) indicate required documentation, quantity limits, age restrictions, step-therapy requirements, specialty routing, or program-based review. Ensure supporting documentation is included with PA requests to avoid processing delays or denials.

Quantity limits (QL) and age limits (AL) are enforced where annotated (e.g., DEXCOM G6 components = PA; QL; some statins have AL ranges).
ST (step therapy) entries require trial of preferred agents first (examples include GLP-1 agents: MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY show ST; QL).
OVM indicates Oncology Value Management review for antineoplastics and supportive care agents.

Step Therapy

Step therapy required when Notes = ST

Step therapy (ST) is required for specified products. When Notes include 'ST', members may need to have trialed one or more preferred drugs before a higher-cost medication will be approved. Providers should confirm step requirements before prescribing to minimize denials or delays.

GLP-1 and other agents: MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY show ST; QL — step edits apply.
Select psychiatric and other nonpreferred brands (e.g., FANAPT, CAPLYTA, LYBALVI) have ST flags.
If step therapy criteria are not met or documented, coverage may be denied.

Denial Risk

Denial triggers and appeal notification

Denials can occur when prior authorization is not requested, required clinical criteria are not met, or submission lacks required documentation. The plan will notify the prescriber and member in writing with the reason for denial and appeal rights.

Common denial triggers: missing PA; failure to meet clinical criteria; prescribing a Not covered product; missing specialty routing (SP) or OVM requirements.
Denial notices include reason and instructions for submitting an appeal or additional information.

Denial Risk

Coverage denial risk for Not covered products

Coverage may be denied or restricted when a drug is marked 'Not covered' on the drug list, or when utilization management requirements (PA, ST, QL, SP, OVM) are not satisfied. Verify member benefit design and drug-list status prior to dispensing.

Examples of Not covered items that may be denied: RESTASIS MULTIDOSE, TWIRLA, selected formulary exclusions and certain high-cost branded products.
Claims for Not covered items submitted without an approved exception are at risk of denial.

Note

Excluded and nonformulary items

Some products are excluded from the pharmacy benefit entirely (e.g., drugs with a therapeutically equivalent OTC alternative, cosmetic uses, experimental therapies, drugs payable under the medical benefit). Confirm whether an item is covered under the pharmacy or medical benefit and advise members accordingly.

Excluded categories include OTC-equivalent prescription products, experimental drugs, cosmetic-use agents, products billed as medical benefit (office-administered injectables/vaccines).
Members with questions should call the Customer Service number on their BCBS member ID card.

Key abbreviations and tier definitions

Drug tiers (member cost-sharing and coverage)

GenericTier for generic medications; lower member cost-sharing

Preferred brandTier for preferred brand-name medications with moderate cost-sharing

Nonpreferred brandTier for nonpreferred brand-name medications, often higher cost-sharing

Preventive (PV1/PV2)Designated preventive tier for vaccines and select products; may be covered with no out-of-pocket cost when reform requirements met

Nonformulary / Not coveredDrugs listed as Not covered are excluded from coverage and may be denied if billed

Specialty medication (SP, 15DS)

Designation codeSP (Specialty medication)

Supply limitsSelect specialty drugs limited to a 15-day supply under the 15-Day Specialty Drug Limitation Program; most specialty drugs limited to 30-day supply

HandlingSpecialty medications may require special handling, administration, and routing via specialty pharmacy programs

Prior authorization definition

DefinitionPrior authorization (PA) — the prescriber must provide additional clinical information and obtain payer approval before coverage is allowed

When requiredApplied to many branded drugs, specialty products, and devices as noted in the drug list (Notes = PA)

How to requestSubmit Coverage Request Form online or follow payer instructions (electronic/phone/fax/mail) as referenced in drug list guidance

Utilization note codes (Notes column shorthand)

PAPrior authorization — approval required before coverage

QLQuantity limit — limits on amount dispensed per fill or time period

STStep therapy — trial of preferred drug(s) required before higher-cost alternative

SPSpecialty pharmacy — routing/management through specialty channel

Other codesOVM = Oncology Value Management; ABA = Administered benefit/authorized brand alternative; PV1/PV2 = Preventive designations; 15DS = 15-day specialty supply limit

PA — Prior authorization (notes)

PA (notes)Indicates prior authorization is required; prescriber must submit clinical information for coverage determination

ContextUsed next to many drug and device entries in the Clinical Drug List to flag PA requirement

Related actionsFailure to obtain PA when noted may result in claim denial

ST — Step therapy (notes)

ST (notes)Step therapy — requires trial and documented failure or contraindication to preferred agent(s) before coverage

ApplicationAppears on many nonpreferred branded drugs and certain therapeutic classes (GLP‑1 agents, others)

DocumentationPrescribers must document prior treatment history per plan step edits when ST is listed

QL — Quantity limit (notes)

QL (notes)Quantity limit — plan limits quantity dispensed per fill or time period as indicated in Notes

Where listedApplied to many products (e.g., donepezil 23 mg; memantine ER; inhaled agents; device supplies)

ReferenceRefer to the Quantity Limit Program for exact per‑product limits

SP — Specialty pharmacy (notes)

SP (notes)Specialty pharmacy — drug must be obtained via specialty pharmacy channel and may have additional management

ImplicationsOften accompanies PA and QL flags; may require specialty routing or restricted distribution

Supply rulesSpecialty products may be limited to shorter supply (15DS) where noted

ABA — Administered benefit / alternative administration

ABA (notes)Administered benefit / authorized brand alternative notation — document‑specific meaning used in some insulin and related entries

UsageAppears alongside certain products to indicate alternative administration or billing instructions

ActionProviders should follow plan guidance when ABA is shown in product Notes

PA — alternate references

PA (alt ref)Prior authorization — plan requires approval before coverage (alternate references in drug list confirm PA meaning)

SP (alt ref)Specialty — managed under specialty pharmacy program (alternate references reinforce SP definition)

QL (alt ref)Quantity limit — plan limits quantity/time period as noted (alternate references reinforce QL meaning)

SP — alternate references

SP (alt ref)Specialty — drug managed under specialty pharmacy program (alternate reference)

ImplicationMay require specialty routing and additional documentation when listed

Common pairingOften appears together with PA and QL on biologic and high‑cost agents

QL — alternate references

QL (alt ref)Quantity limit — plan limits quantity/time period as noted in product entries

Where to confirmSee per‑product QL notes in the Clinical Drug List and Quantity Limit Program

EffectMay restrict dispense quantity or frequency to align with clinical dosing

ST — alternate references

ST (alt ref)Step therapy — requires trial of alternative(s) first; alternate references confirm ST usage

Typical useApplied to select nonpreferred brands and specialty therapies (see product Notes)

Provider actionDocument prior treatment history when requesting PA for ST‑flagged products

PV1 / PV2 — Preventive designation indicators

PV1Preventive 1 — covered with no out‑of‑pocket cost when health care reform requirements are met

PV2Preventive 2 — preventive designation that may be covered with no out‑of‑pocket cost when reform rules met; otherwise coverage/costs depend on benefit design

UsageApplied to vaccines, certain devices, and select products (noted alongside product entries)

Common UM abbreviations

Common abbreviationsPA = Prior authorization; QL = Quantity limit; SP = Specialty; ST = Step therapy; AL = Age limits; OVM = Oncology Value Management; 15DS = 15‑day specialty supply

Where shownThese appear in the Notes column next to drug/device entries to indicate utilization controls

Provider implicationFollow plan documentation and authorization processes when these flags appear

Example shorthand explanation

Example shorthandPA; SP; QL; PV2 — indicates prior authorization required, specialty pharmacy routing required, quantity limits apply, and PV2 preventive designation

InterpretationEach code stacks to represent combined utilization controls on a product entry

ActionProviders should supply PA documentation and follow specialty routing when this shorthand appears

PA — additional reference

PA definition (additional)Prior authorization — product requires payer approval before coverage as indicated in product Notes

Common pairingOften paired with SP and QL on biologic/immunomodulator entries

DocumentationRequests must include clinical rationale and supporting records per payer guidance

SP — additional reference

SP definition (additional)Specialty pharmacy — routing through specialty channel; often used for injectables and complex therapies

ImplicationMay require distribution through specialty vendors and additional management steps

Associated notesFrequently shown with PA and QL on high‑cost specialty agents

PV1 / PV2 — preventive vaccine/device notes (additional)

PV1 / PV2 notes (additional)Preventive vaccine/device annotations — PV1/PV2 indicate preventive coverage status and may carry quantity limits (QL)

ExamplesMultiple vaccines listed with PV1 and QL (e.g., COMIRNATY, FLUARIX) show how PV codes are applied

Provider noteCoverage/costs depend on whether reform requirements are met for PV designations

QL — additional reference

QL (additional)Quantity limit — enforces per‑fill or per‑period limits; common across many drug classes

Where to verifyCheck the Clinical Drug List QL notes and the Quantity Limit Program for exact numeric limits

Effect on dispensingMay restrict days' supply or units per fill, requiring PA for overrides

PA shorthand (additional)

PA shorthand (additional)PA — indicates prior authorization required; used consistently across product entries

Provider actionObtain PA before dispensing to avoid denials when PA is listed

DocumentationInclude clinical criteria and prior therapy history as applicable

QL shorthand (additional)

QL shorthand (additional)QL — quantity limits; seen on statins and many other drug classes to limit dispense quantity or frequency

Common applicationApplied to generics, brands, devices, and specialty products where clinical or safety reasons support limits

ReferenceQuantity Limit Program for per‑product specifics

ST shorthand (additional)

ST shorthand (additional)ST — step therapy; requires trial/failure of preferred alternatives as indicated

Common examplesUsed with GLP‑1 agents, select respiratory and neuropsychiatric drugs in the list

ActionDocument prior trials when submitting PA for ST‑flagged agents

SP shorthand (additional)

SP shorthand (additional)SP — specialty pharmacy requirement; indicates specialty channel and management for the product

Operational impactMay restrict dispensing location and require specialty vendor enrollment

Associated controlsFrequently appears with PA and QL

ABA abbreviation (document‑specific meaning)

ABA abbreviation noteABA appears in Notes to denote administered benefit / authorized brand alternative; used in insulin and select formulations with document‑specific meaning

ImplicationMay affect how product is billed or substituted; follow payer guidance when ABA is shown

VerificationCheck product entry Notes for ABA usage and associated instructions

Step therapy rules and affected products

Overview	Source note
Step therapy requires trying one or more preferred drugs before a higher-cost medication will be covered.
Per drug list definitions: 'ST = Step therapy - Requires you try one or more preferred drugs before a higher-cost medication can be covered.' See 'Step therapy' section for operational details.

Statement	Example / placement in drug list
Some drugs require prior treatment with preferred agents before coverage will be approved (step therapy applies).
The 'Step therapy' notice directs providers to the Prior Authorization and Step Therapy Coverage Criteria and the Blue Cross Clinical Drug List for the current list of affected drugs.

Observation	Drug-list evidence
'ST' is noted on many brand and nonpreferred entries in the Clinical Drug List, indicating step therapy is applied to multiple products.
Examples in the table of contents show entries with Notes = ST (e.g., AUVELITY Notes = ST; CAPLYTA Notes = ST; FANAPT Notes = ST).

Policy implication	Supporting excerpt
Step edits apply where 'ST' is listed in the Notes column; prior steps or documentation of trial/failure of preferred agents may be required before coverage of the listed product.
Table excerpts list many products with Notes = ST (for some antipsychotics and related agents), indicating that step edits apply when ST is present.

Note	Examples
Certain nonpreferred branded drugs are labeled 'ST' indicating step therapy is required prior to coverage.
Examples called out in the list include FANAPT products and several antipsychotic entries marked 'ST'.

Products annotated 'ST'	Listed examples
Multiple GLP‑1 and other glycemic agents are annotated 'ST' in the drug list and are therefore subject to step therapy requirements.
Examples from the glycemic agents section: MOUNJARO; OZEMPIC; RYBELSUS; TRULICITY — each listed with Notes = ST (and often QL).

Agents with 'ST' annotation	Source examples
Certain agents outside diabetes are annotated 'ST', indicating step therapy applies to those products as listed.
Examples in the table of contents: EDARBYCLOR noted ST (cardiovascular segment); cladribine entries show Notes = ST; SP; QL in the neurological therapies section.

General rule	Consequence
Drugs flagged 'ST' require adherence to the plan's step therapy protocols as a condition of coverage for the listed product.
When ST is listed, prior trial/failure of preferred agents or documentation per the plan's step-edit requirements is expected before coverage is granted.

Meaning of 'ST'	Operational impact
'ST' denotes Step therapy — the member must try one or more preferred drugs before coverage of the higher‑cost medication is allowed.
Per drug list directions, providers should consult the Prior Authorization and Step Therapy Coverage Criteria and document prior therapies where ST is indicated to avoid claim denials.

PV2 annotation	Implication
PV2 appears alongside many contraceptive and estrogen products as a formulary/program designation.
The PV2 designation denotes preventive/formulary status in this document and may reflect preferred/program requirements that could imply step or program prerequisites depending on member benefits.

Other utilization flags	Examples of combined notes
Some drug entries include notes such as PA, SP, and QL which indicate prior authorization, specialty pharmacy routing, or quantity limits that may interact with step therapy requirements.
Table excerpts show products annotated with combinations like PA; SP; QL (e.g., PALSONIFY, SIGNIFOR) demonstrating overlapping utilization controls in the list.

Weight-management / specialty products	Step/PA/QL cues
Weight‑management and other specialty products are frequently noted with PA and QL and may be subject to step edits per plan rules.
Examples and cues in the list include WEGOVY (Notes = PA; QL) and other weight‑management agents where PA and QL appear alongside potential step requirements.

Products annotated 'ST' (examples)	Evidence
Products annotated 'ST' require fulfillment of step therapy rules prior to coverage of the listed product.
The glycemic agents section lists liraglutide, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY with Notes = ST (and often QL), indicating step therapy applies to these examples.

ST‑annotated GLP‑1 examples	Source rows
Several GLP‑1 and related products are explicitly annotated 'ST' in the drug list and therefore subject to step therapy edits.
Documented examples: MOUNJARO; OZEMPIC; RYBELSUS; TRULICITY — each listed with Notes = ST (see glycemic agents section).

Quantity limits and supply controls

Select specialty drugs subject to 15-day supply limits

15DS markerSelect specialty drugs identified in the list are subject to a 15‑day supply limit (noted as '15' or '15DS')

Program name15‑Day Specialty Drug Limitation Program — limits fills to 15 days for included products

Member impactMembers pay half their usual out‑of‑pocket cost for a 15‑day supply for these drugs

Quantity Limit Program

Program referenceQuantity Limit Program — Blue Cross sets QL based on clinical appropriateness and manufacturer dosing; see Quantity Limit Program for current list

Where notedQL flags appear in the Notes column next to drug entries throughout the Clinical Drug List

Provider actionRefer to the Quantity Limit Program or product Notes for per‑product dispensing limits or PA requirements to override

donepezil hcl 23 mg — Quantity limit

Productdonepezil hcl oral tablet 23 mg

Quantity controlNotes = QL (quantity limit applies)

TierDrug Tier = Generic (per listing)

memantine hcl ER and select tablet packs — Quantity limit

Productmemantine hcl ER and select tablet packs

Quantity controlNotes = QL on ER and certain tablet pack presentations

TierDrug Tier = Generic (per listing)

Oncology and specialty entries — QL / 15DS notes

ExamplesMultiple oncology and specialty agents (e.g., XROMI, INREBIC, VERZENIO, LYTGOBI) show QL or 15DS flags in Notes

Notes meaningQL indicates quantity limits; 15DS indicates 15‑day specialty supply limit and often pairs with SP and OVM

Provider actionFollow Oncology Value Management (OVM) routing and specialty pharmacy procedures where OVM/SP/15DS are noted

DEXCOM G6 SENSOR — quantity/authorization notes

ProductDEXCOM G6 SENSOR

NotesNotes = PA; QL (prior authorization and quantity limit apply)

CategoryBlood glucose monitoring device — listed with utilization controls

Multiple products — see QL notes

ScopeMultiple listed products across diabetes, blood products, and specialty categories have QL noted in product Notes

ReferenceSee each product entry in the Clinical Drug List for the per‑product QL annotation

ActionProviders should consult the Quantity Limit Program or product Notes when dispensing these items

Various entries marked QL

ScopeVarious entries across therapeutic classes are marked QL in the drug list (see per‑product Notes)

ExamplesCarvedilol phosphate ER, HEMANGEOL, nebivolol show QL flags in their listings

Provider actionCheck product Notes for exact QL details when dispensing or requesting PA to exceed limits

Isotretinoin — quantity limits

ProductIsotretinoin (various strengths)

Quantity controlNotes = QL (quantity limits apply as noted)

ImplicationPrescribers/pharmacies must follow QL constraints in product entry

Laxatives — QL indicated

ProductsLaxatives (bisacodyl EC, clearlax, PEG 3350)

NotesListed with PV1/PV2 and QL; age limits (AL) also applied on select formulations

ActionQuantity limits apply as noted; consult product Notes for exact dispensing restrictions

Various listed products — QL annotations

ScopeVarious specialty and hormonal agents in these sections carry QL annotations

ExamplesACTHAR, GENOTROPIN, ALORA and others appear with PA/SP/QL flags in product Notes

Provider actionFollow PA/SP/QL documentation requirements per product when requesting authorization or dispensing

ORIAHNN and others — QL noted

ExamplesORIAHNN and other contraceptive/hormonal products listed with Notes = PA; QL (ORIAHNN shown with PA; QL)

ImplicationQuantity limits and prior authorization requirements may apply for these products

ReferenceSee product Notes in Clinical Drug List for exact controls

mesalamine 1.2 g — subject to QL

Productmesalamine oral tablet delayed release 1.2 g

Quantity controlNotes = QL (subject to quantity limit)

CategoryAminosalicylate — listed under IBD agents with QL flag

alendronate sodium — subject to QL

Productalendronate sodium

Quantity controlNotes = QL (subject to quantity limit)

CategoryMetabolic bone disease agent — QL indicated in listing

Multiple listed products — per‑product QL noted

ScopeMultiple listed products across ophthalmic, respiratory, and other categories have per‑product QL notes

ActionConsult each product entry for the specific QL annotation and any combined PA/SP requirements

ExamplesCEQUA, OXERVATE, BREO ELLIPTA, PULMICORT FLEXHALER among others show QL in Notes

Inhaled agents — quantity limits where specified

ScopeMultiple inhaled agents (e.g., FLUTICASONE‑SALMETEROL formulations, OMNARIS, QNASL, SYMBICORT)

Quantity controlMany inhaled agents show QL in Notes and some include ABA or ST flags

Provider actionCheck product Notes for QL and any ST requirements before dispensing

OpenPayer

Clinical Drug List (Pharmacy Formulary) Coverage Criteria

Coverage scope and exclusions

Coding and limits

Prior authorization, step therapy, documentation, and denial risks

Policy governance and maintenance

Key abbreviations and tier definitions

Step therapy rules and affected products

Quantity limits and supply controls

Dispensing sites and specialty routing