CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Blue Care Network Custom Select Drug List — Coverage Criteria

Governance of pharmacy drug coverage, formulary tiers, specialty drug limits, and utilization management requirements for Blue Cross Blue Shield of Michigan / Blue Care Network members enrolled in participating plans.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyBlue Care Network Custom Select Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Coverage Request Form or electronic prior authorization via EHR/CoverMyMeds when a drug is noted 'PA' to obtain prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlydrug list update frequency

15-/30-dayspecialty drug fill limits referenced

OncoHealthdesignated oncology prior auth program

multipleentries marked Not covered

120+drug entries in excerpt

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Formulary Coverage & Tiering

Formulary tiering and coverage

Drugs are assigned to formulary tiers which determine coverage status and member cost-sharing. Coverage decisions reflect safety, clinical effectiveness, and cost as reviewed by the Pharmacy & Therapeutics Committee.

Formulary inclusion and tiering: Drugs are placed into tiers (e.g., Preferred generic, Nonpreferred generic, Preferred brand, Nonpreferred brand, Preventive, Preferred specialty, Nonpreferred specialty, Not covered). Tier placement determines member out-of-pocket cost and whether a product is covered or denied at claim adjudication.

Tier definitions and coverage implications are defined in the formulary (see Tier information).

Nonformulary (not covered) drugs

The plan designates specific categories and products as nonformulary (Not covered); such items will be denied if submitted for coverage unless an exception is granted.

Excluded categories: The following categories are excluded from coverage: brand-name drugs when a generic equivalent exists; prescription drugs with an OTC equivalent in the same strength and dosage form (unless considered preventive by USPSTF); over-the-counter medications (unless preventive); lifestyle drugs (e.g., erectile dysfunction, weight loss); prenatal vitamins; most heartburn/acid reflux drugs (except select generics); most cough/cold drugs; experimental or cosmetic uses; products covered as a medical benefit; certain compounded products; replacement prescriptions for loss/theft; and drugs not approved by the FDA.

Specific excluded products are listed in the formulary and table of contents as 'Not covered'.

Specific Not covered products: Individual drugs and formulations explicitly labeled 'Not covered' in the formulary (see formulary table of contents) are excluded from coverage and will trigger denial if billed (examples appear throughout the formulary excerpts).

Refer to the full formulary listing for complete product-level 'Not covered' entries.

Specialty drugs

Specialty drug dispensing and fill limits are subject to program rules and quantity limits.

Specialty drug day-supply limits: Most specialty drugs are limited to a 30-day supply. A subset of specialty drugs are managed under a 15-Day Specialty Drug Limitation Program and are limited to a 15-day supply for all fills; members pay half their usual out-of-pocket cost for a 15-day supply for those drugs.15-day or 30-day

See the Specialty Drug Program Pharmacy Benefit Member Guide and the 15-Day Specialty Drug Limitation Program for details.

Program management and distribution: Specialty drugs may require specialty pharmacy routing (SP) and utilization management controls (PA, QL, ST) per formulary notes; site-of-care and designated dispensing vendors (e.g., specialty or home-delivery pharmacies) may be required based on the drug and plan rules.

Follow formulary Notes (PA, SP, QL, 15DS) and Specialty Drug Program guidance when requesting coverage or dispensing specialty agents.

Excluded categories: The formulary explicitly excludes several broad categories of products from coverage. Examples include brand-name drugs when a generic equivalent exists, prescription drugs with an OTC equivalent in the same strength and dosage form, most over-the-counter medications, lifestyle drugs (for example erectile dysfunction or weight-loss agents), prenatal vitamins, many heartburn/acid reflux drugs except select generics, most cough/cold agents, therapies used for experimental or cosmetic indications, many compounded products (with exceptions), replacement prescriptions for loss/theft/mishandling, products normally covered as a medical benefit, and drugs not approved by the FDA.

Selected examples of drugs shown as Not covered in the table of contents include analgesic and anesthetic formulations such as NALOCET, branded abuse-deterrent opioid tablets (e.g., OXYCODONE HCL ORAL TABLET ABUSE-DETERRENT), and specialty branded products such as ROXYBOND and ZTLIDO which are listed as Not covered or flagged with utilization notes.

Formulary excerpts show many product-level Not covered entries across therapeutic areas. Representative Not covered listings include SUBVENITE ORAL SUSPENSION, extended-release/topiramate ER preparations marked Not covered, certain formulations of memantine/donepezil ER and other branded dementia agents, multiple antidepressant and antipsychotic items (e.g., specific titration packs or extended‑release strengths), and antineoplastic entries where select oncology agents or kits are identified as Not covered.

Additional specific Not covered examples noted in the listing include pyridostigmine bromide oral tablet 30 mg, the antimycobacterial product TRECATOR oral tablet 250 mg, and the oncology agent TAZVERIK 200 mg, each explicitly designated Not covered in the table of contents.

Parkinson and related neurologic agents show Not covered designations in this excerpt: for example, GOCOVRI and OSMOLEX ER 129 mg are listed as Not covered, and other agents used in movement disorders (such as DUOPA, RYTARY, and VYALEV) are listed with Not covered or utilization flags.

Several diabetes-related products and devices are flagged Not covered in the insulin and glucose-regulating section. Examples shown include specific insulin presentations and related products (multiple insulin entries are designated Not covered in the table extract), and some glucagon/emergency rescue presentations are similarly listed with noncoverage or administrative notes.

Hematology and supportive care products include Not covered listings for particular brands and formulations: examples include ARANESP (albumin free), EPOGEN, GRANIX, and multiple other growth‑factor or supportive biologic products shown as Not covered in this segment.

Cardiovascular/lipid therapy examples designated Not covered include certain specialty lipid agents and formulation variants: for instance, JUXTAPID and other named products are listed as Not covered or carry utilization restrictions in the formulary excerpt.

Dermatology and related specialty agents show multiple Not covered entries: examples in these chunks include LEQSELVI, NORITATE, SOFDRA, and various topical or specialty dermatologic products listed as Not covered or subject to specialty/quantity controls.

Gastrointestinal and genetic/enzyme disorder product listings include explicit Not covered designations: notable examples are PRILOSEC (omeprazole brand), multiple pantoprazole/omeprazole packet forms and several enzyme replacement or cystic fibrosis–related products like PROCYSBI shown as Not covered in the excerpts.

Endocrine and hormone sections include numerous Not covered items. Examples in the extract include topical steroid brand ULTRAVATE, pituitary/hormonal products such as ACTHAR and ACTHAR GEL, and several contraceptive or hormone replacement formulations (e.g., BIJUVA) that appear with Not covered or quantity-limit annotations.

Immunology, biologic and immunosuppressant sections show many Not covered entries for specific biologics and starter kits. Representative Not covered products include certain adalimumab biosimilars and branded biologic presentations (multiple ADALIMUMAB entries) and listed monoclonal antibody products such as USTEKINUMAB and other biologics flagged Not covered in the table of contents.

The formulary table of contents lists additional Not covered ophthalmic and gastroenterology products. Examples include VELSIPITY and the rectal mesalamine product SFROWASA RECTAL ENEMA 4 GM/60ML, both called out as Not covered in the table excerpts.

Ophthalmic and cystic fibrosis sections contain multiple Not covered items: notable ophthalmic products listed as Not covered include CYSTADROPS, RESTASIS MULTIDOSE, TRYPTYR, TYRVAYA, and other named topical/ocular agents; cystic fibrosis and inhaled antibiotic entries such as TOBI PODHALER are also shown as Not covered or managed via specialty/PA/QL processes.

Table of Contents Note Codes & Abbreviations

TOC note codesmixed

PA	Prior Authorization
SP	Specialty
QL	Quantity Limit
PV1	Preventive note variant 1
PV2	Preventive note variant 2
15DS	Note code appearing with IWILFIN (context-specific, likely days supply)
OVM	Note code appearing with IWILFIN (context-specific)

Prior Authorization, Step Therapy, Documentation & Denials

Prior Authorization

Prior Authorization & Specialty Routing

Prior authorization may be required for many drugs listed on the Custom Select Drug List. Prior authorization (PA) and specialty routing (SP) indicate that the prescriber must submit supporting clinical information before coverage will be approved; drugs marked PA, SP, OVM, ABA, QL, ST, PV#, and related notes in the list reflect utilization management controls that affect coverage and dispensing. Specialty distribution routing means medications will be handled through a specialty pharmacy network and may require specific supply arrangements.

PA — Prior authorization required; provider must submit clinical documentation.
SP — Specialty medication routing; may require special handling/dispensing through specialty pharmacy.
OVM — Oncology Value Management routing for antineoplastics; requests routed to OncoHealth (see submission instructions).
ABA — Authorized brand alternative; administrative designation that can affect coverage.
QL — Quantity limits applied; claims may deny if quantity exceeds limits.
ST — Step therapy; member may need to trial preferred drugs before higher-cost therapy is covered.
PV1/PV2/PV3 — Preventive flags; certain preventive and smoking-cessation products are covered under preventive benefits when criteria met; age limits may apply.

Policy Background & Scope

The formulary groups drugs by major class and assigns tier placement to communicate coverage and member cost responsibility. The policy also defines specialty drug supply limits: specialty drugs are generally limited to a 30‑day supply, while select specialty agents are limited to a 15‑day supply under the 15‑Day Specialty Drug Limitation Program; members pay reduced out-of-pocket cost for a 15‑day supply for those drugs. These tiering and supply rules are intended to guide prescribing, dispensing site (retail, home, specialty) and utilization management such as PA, QL and ST controls.

Abbreviations & Note Code Definitions

PA definition

DefinitionPA = Prior authorization — prescriber must submit additional clinical information for coverage determination.

When usedAppears as a Notes code next to many drugs to indicate an administrative approval is required before coverage.

Related processProviders must submit clinical information consistent with Pharmacy & Therapeutics–approved criteria when PA is required (see Coverage Request Form).

SP / 15DS definition

DefinitionSP = Specialty medication — drugs treating complex conditions that may require special handling or administration.

15DS meaning15DS = 15-day supply — limits certain specialty drugs to a 15-day supply for all fills under the 15-Day Specialty Drug Limitation Program.

Step Therapy Rules & Affected Agents

Requirement	What it means
Member must try one or more preferred drugs before a higher-cost medication is approved
Drugs subject to step therapy require prior treatment with preferred alternatives; coverage of nonpreferred/step agents is conditional on documented trial or failure of preferred therapy (see BCN Custom Select Drug List).

Requirement	Implication
Must trial preferred drugs before coverage of step therapy agents
Prior trial/failure of one or more preferred drugs is required and must be documented on prior authorization per the Prior authorization and step therapy coverage criteria.

Program flag	Details / Age or quantity limits
Preventive (PV) designation on smoking cessation products
Several nicotine and smoking cessation products are marked PV1/PV2 with QL and age limits (AL Min 18 Years), suggesting preventive designation and program or step-edit implications for coverage.

Example drug	Step therapy note
TRINTELLIX
TRINTELLIX is listed as Nonpreferred brand and is identified in the table of contents as having an ST note, indicating it is subject to step therapy requirements.

Note code	Implication for dispensing/edits
15DS / OVM / 15DS appears with oncology and specialty agents
Entries annotated 15DS (15-day supply) or OVM imply specific dispense day-supply limits or oversight; follow plan step/dispense edits where noted (e.g., agents under Oncology Value Management).

Flag	Policy implication
ST (Step therapy) flag on products
Items annotated 'ST' require documented trial/failure of preferred alternatives before coverage of the ST‑flagged drug is approved (see drug-specific notes).

Drug group / examples	Step therapy annotation
GLP-1 agonists and related agents (examples)
Agents such as liraglutide, MOUNJARO, OZEMPIC, RYBELSUS and TRULICITY are listed with 'ST' in Notes, indicating step therapy requirements apply to these GLP-1 / related products.

Drug	ST note
EDARBYCLOR
EDARBYCLOR is listed as Nonpreferred brand with Notes = ST; QL, indicating step therapy may be required before coverage and quantity limits apply.

Drugs	Step therapy annotation
Cladribine (various tab counts) and REBIF
Cladribine entries are noted ST; SP; QL (starter/pack variants listed) indicating step therapy and specialty routing; REBIF is cited among MS agents with ST noted — step therapy applies per Notes.

Products	ST annotation
CREXONT; CAPLYTA; FANAPT and FANAPT titration packs
These products are listed with 'ST' (and often QL) in the Notes, indicating they are subject to step therapy protocols before coverage.

Preventive-designated products	Indication / limits
Colorectal prep / laxative products (PEG 3350, milk of magnesia, PLENVU, SUTAB) marked PV1/PV2
Several bowel preparation and laxative products are marked PV1/PV2 with QL and AL (Min 45 Years and Max 75 Years), indicating preventive designation and indication/age limits influence coverage and may require specific program criteria.

Observation	Source note
No explicit step therapy sequences listed in these chunks
The provided table of contents entries show tiering and utilization management flags (PA, SP, QL, ST) but do not define step-by-step algorithms in this excerpt; specific step sequences are in detailed criteria elsewhere.

Starter/induction items	Program implication
Starter / induction kits (e.g., CD/UC/HS STARTER; CIMZIA-STARTER; ADALIMUMAB starters)
Starter and initiation packs are listed with SP/QL notes and may be managed under starter/induction program rules or step edits; follow product-specific starter/induction guidance noted in the formulary.

Selected ophthalmic / glaucoma agents	Step therapy / notes
RHOPRESSA; ROCKLATAN; (other ophthalmic agents)
RHOPRESSA and ROCKLATAN are listed with ST; QL in Notes indicating step therapy may apply to selected glaucoma agents; other ophthalmic agents have corresponding Notes (PA/SP/QL) guiding utilization management.

Quantity Limits & Day-Supply Rules

select specialty drugs — 15-day supply callout

Specialty — 15DS calloutSelect specialty drugs listed on the 15‑Day Specialty Drug Limitation Program are limited to a 15‑day supply for all fills.

Member cost impactMembers pay half their usual out‑of‑pocket cost for a 15‑day supply of drugs on the 15DS list.

ReferenceSee the Specialty Drug Program Member Guide and bcbsm.com/pharmacy for details on which products are subject to 15DS.

specialty drugs (general) — 30-day supply note

General specialty supply ruleSpecialty drugs are limited to a 30‑day supply unless otherwise specified (e.g., 15DS products).

Program referenceSee the Specialty Drug Program Pharmacy Benefit Member Guide for distribution and supply rules.

Dispensing Channels & Specialty Pharmacy

Note

Preferred retail, specialty and home delivery vendors

Walgreens is the preferred specialty pharmacy and Optum Home Delivery is the designated home‑delivery vendor; specialty drugs may be dispensed at local retail (including Walgreens) or routed to Walgreens Specialty Pharmacy or Optum Home Delivery per the Specialty Drug Program.

Walgreens is listed as preferred specialty pharmacy
Optum Home Delivery is available for mail‑order specialty

Note

Specialty pharmacy designation (SP) for many specialty drugs

Many specialty drugs in the formulary are designated 'SP' which indicates they must be dispensed via the specialty pharmacy channel; providers should route prescriptions accordingly.

Note

SP designation applies to additional specialty drug examples

Specialty pharmacy routing (SP) is indicated for numerous specialty agents across the list (including cystic fibrosis and other specialty therapies); obtain PA and route dispensing per SP instructions.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyBlue Care Network Custom Select Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Coverage Request Form or electronic prior authorization via EHR/CoverMyMeds when a drug is noted 'PA' to obtain prior authorization.

SourceLink

On This Page

Documentation Required

Required Documentation & Denial Risk

Providers must supply clinical justification and documentation when a drug is marked with PA, SP, OVM, ABA, or other utilization flags. The PA/SP/QL/ST and Notes fields in the drug list indicate the specific administrative requirements. Failure to provide required documentation or to meet noted criteria may result in claim denial.

Documentation should demonstrate medical necessity, prior treatment history (for ST), dosing and intended quantity (for QL), and diagnosis or relevant test results as applicable.
Oncology antineoplastics/supportive drugs marked OVM must follow the OncoHealth submission process.
Devices and CGM components (notes QL/PA) may also require PA and administrative documentation.
Not covered (Not covered tier) entries will deny at adjudication; claims for drugs listed as Not covered are subject to immediate denial.

Note

How to Request Prior Authorization

How to submit prior authorization requests and where routing applies: providers can submit electronically (EHR or CoverMyMeds), by phone, fax, or mail. Oncology OVM submissions use the OncoHealth OneUM portal or the OncoHealth contact channels. Approved authorizations are processed and the prescriber notified; denials are sent in writing with reasons and appeal rights.

Electronic prior authorization: via EHR or CoverMyMeds for commercial pharmacy members.
Phone: 1-800-437-3803 for general PA requests; oncology OncoHealth phone 1-888-916-2616.
Fax: 1-866-601-4425 for general PA; 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.
Oncology OVM: submit via OncoHealth OneUM™ through the BCBSM payer space on availity.com, or use OncoHealth contact details above.

Note

Utilization Management Flags & Notes

Utilization management flags appearing in the Notes column (PA, SP, QL, ST, OVM, ABA, PV#, 15DS, AL, etc.) indicate specific administrative programs or clinical controls. Review the Notes field for each product to determine required actions before dispensing.

PA/SP — prior authorization and specialty routing requirements.
QL — quantity limits; check the Notes for permitted quantity and interval.
ST — step therapy sequences are not fully listed in the drug list; consult the Prior Authorization and Step Therapy coverage criteria for detailed sequences.
OVM — oncology drugs marked OVM must be routed to Oncology Value Management administered by OncoHealth.
PV1/PV2/PV3 — preventive medication indicators; coverage and member cost-sharing depend on whether federal preventive requirements are met.
15DS/ABA/AL — other administrative edits (starter/induction products, authorized brand alternatives, age limits) may apply.

Denial Risk

Prior Authorization Required — Examples & Alerts

Examples and implications: many specialty and biologic products (e.g., numerous oncology, immunologic, genetic disorder, and biologic therapies) are PA and SP; selected devices and CGM components are PA/QL; some drugs are listed Not covered and will deny. Check product Notes for exact routing and restrictions.

Oncology agents: many cancer therapies carry PA; SP; OVM flags (see Antineoplastics sections).
Immunologics/biologics: multiple entries flagged PA; SP; QL — expect specialty pharmacy handling.
CGM/devices (e.g., DEXCOM G6/G7 sensors, receivers, transmitters) are noted PA; QL — prior authorization may be required for coverage.
Not covered examples: drugs listed as Not covered (e.g., select brands, formulations) will be denied at adjudication; providers should verify coverage before prescribing.

Supply ruleSpecialty drugs are generally limited to a 30-day supply; select specialty drugs on the 15-Day program are limited to 15 days and members pay half their usual out-of-pocket cost for a 15-day supply.

PV1/PV2/PV3 definitions

PV1/PV2/PV3Preventive designation codes indicating drugs covered with no out-of-pocket costs when health care reform requirements are met (PV1, PV2, PV3).

Usage examplesApplied to vaccines, colorectal prep and some smoking-cessation products (e.g., nicotine kits marked PV1; PEG 3350 marked PV1/PV2).

Effect if requirements unmetWhen health care reform requirements aren't met, coverage and applicable out-of-pocket costs depend on the member's benefit design.

PA (alternate reference)

PA (alternate ref)Prior Authorization — note code requiring prescriber to provide additional information to determine coverage; appears across the formulary Notes column.

ImplicationDrugs marked PA require prior approval before coverage; failure to obtain PA may result in denial and written notification with appeal rights.

Provider actionSubmit Coverage Request Form or electronic PA per payer instructions to request authorization.

QL definition

DefinitionQL = Quantity limit — the quantity of medication dispensed per fill is limited based on clinical appropriateness and manufacturer dosing.

Where shownAppears as 'QL' in the Notes field next to many drugs and devices (e.g., CGM sensors, insulin products).

ReferenceCurrent limits and full list available in the BCN Quantity Limit Program and BCN Custom Select Drug List.

SP definition

DefinitionSP = Specialty Pharmacy — indicates the product is managed through a specialty drug channel and may require dispensing via specialty pharmacy.

Common notesOften combined with PA and QL (e.g., 'PA; SP; QL') to signal prior authorization, specialty routing, and quantity limits apply.

Site of careSpecialty drugs may be dispensed at local retail (Walgreens preferred) or specified home delivery vendors depending on distribution requirements.

PV definition (smoking cessation)

DefinitionPV (preventive) — preventive designation applied to certain smoking-cessation products and other preventive therapies (e.g., nicotine patches/kits).

Age limitsSome PV-designated smoking-cessation products include age limits (AL Min 18 Years) and QL annotations.

Coverage impactWhen preventive requirements of health reform are met the drug may be covered with no out-of-pocket cost; otherwise coverage depends on benefit design.

Tier definition (formulary tiers)

Tier designationFormulary tiers include Preferred generic, Nonpreferred generic, Preferred brand, Nonpreferred brand, Preferred specialty, Nonpreferred specialty and Not covered — tier determines member cost-sharing and coverage status.

ExamplesNot covered tier indicates no benefit and will trigger claim denial if billed; PV2/PV3 may modify cost-sharing for preventive generics as shown for statins and others.

ImplicationTier placement and Notes codes (PA, SP, QL, ST, PV) guide coverage rules and required administrative steps.

PA (notation explanation)

Notation usePA in the Notes column denotes Prior Authorization is required prior to coverage; appears throughout the table of contents as a shorthand code.

Common combinationPA is frequently listed with SP and QL (e.g., 'PA; SP; QL') to indicate combined requirements for specialty drugs.

Provider requirementProviders must follow PA submission instructions (Coverage Request Form, electronic PA portals, phone/fax) when PA is present.

SP (notation explanation)

Notation useSP in the Notes column indicates the drug is managed and dispensed via specialty pharmacy and may require specialty routing.

Associated controlsSP is often paired with PA and QL to signal that prior authorization, specialty distribution, and quantity limits apply.

ExamplesMany biologics and specialty agents (e.g., AQVESME, DOPTELET, XOLAIR) show SP in their Notes entries.

QL (notation explanation)

Notation useQL denotes a Quantity Limit on the amount dispensed per fill; appears next to many drugs and devices (e.g., CGM supplies, injectables).

Where to find detailsSpecific QL values and program rules are maintained in the BCN Quantity Limit Program and BCN Custom Select Drug List.

Effect on dispensingQuantity limits determine allowable amount/frequency per fill and may be enforced at claim adjudication when QL appears in Notes.

15DS definition

Definition15DS = 15-day supply — limits certain specialty drugs to a 15-day supply for all fills as part of the 15-Day Specialty Drug Limitation Program.

Member cost impactMembers pay half their usual out-of-pocket cost for a 15-day supply of drugs on the 15DS list.

Program referenceSee the Specialty Drug Program Member Guide and formulary Notes for which products are subject to 15DS.

OVM definition

DefinitionOVM = Oncology Value Management — a notation indicating oncology antineoplastics and supportive care drugs are subject to OncoHealth–administered prior authorization/verification processes.

How appliedOVM appears with PA/15DS/SP on oncology products to indicate enrollment in the Oncology Value Management program may be required.

Submission pathOncology PA requests are processed through the OncoHealth OneUM portal or the specified phone/fax/mail channels per the formulary guidance.

PA (redundant reference)

Redundant PA notePA (Prior Authorization) — reiterated across the formulary as the primary administrative requirement for many drugs and specialties.

ConsequenceClaims for PA-marked drugs may be denied if prescriber fails to obtain approval or supply required documentation.

Provider actionProviders will be notified in writing if a PA request is not approved and may use appeal rights per plan guidance.

ST definition

DefinitionST = Step Therapy — requires trial and documented failure or contraindication of one or more preferred drugs before a higher-cost medication will be approved.

Where shownAppears as 'ST' in the Notes next to select drugs (e.g., some GLP‑1 agonists and other agents) indicating step edits apply.

Provider requirementProviders must document prior therapy trials per the step therapy criteria when submitting PA for ST‑marked drugs.

QL definition (alternate)

Alternate QL definitionQL = Quantity Limit — restricts amount or frequency covered per fill; used across devices, diabetes supplies and drug entries.

ExamplesQL applied to CGM sensors/readers, lancets, insulin products and many oral medications indicating limits per plan policy.

Reference listSee BCN Quantity Limit Program for current limits and product-specific QL values.

Tier designation explanation

Tier designation explanationTier labels (Preferred generic, Nonpreferred generic, Preferred brand, Nonpreferred brand, Preferred specialty, Nonpreferred specialty, Not covered) indicate coverage status and member cost-share implications.

Not covered meaning'Not covered' tier indicates the drug is excluded from the formulary and will trigger denial if billed without an exception.

Preventive tier linkagePV-tier flags (PV1/PV2/PV3) interact with tiering to determine out-of-pocket costs for preventive drugs under health reform rules.

PA definition (alternate)

Alternate PA definitionPA = Prior Authorization — prescriber must provide additional information and obtain approval before coverage for PA‑marked drugs.

Common consequenceFailure to obtain PA may lead to claim denial; denials are communicated with reasons and appeal rights.

DocumentationProviders should submit clinical justification consistent with Pharmacy & Therapeutics–approved criteria when requesting PA.

SP (alternate)

SP (alternate)SP indicates Specialty Pharmacy routing — used for many biologics, immunologics and specialty agents requiring specialty dispensing.

Associated notesOften combined with PA and QL (e.g., 'PA; SP; QL') to indicate prior authorization, specialty distribution, and quantity limits apply.

ExamplesEntries like XOLAIR, TREMFYA, many adalimumab biosimilars and cystic fibrosis therapies are annotated SP in the formulary list.

QL (alternate)

QL (alternate)Quantity Limit — plan restricts the quantity dispensed per fill for certain products; appears as 'QL' alongside drug entries.

Program guidanceSpecific limits are set based on clinical appropriateness and manufacturer dosing; refer to the BCN Quantity Limit Program for details.

EnforcementQuantity limits are applied at claim adjudication and may require PA or override if exceeded.

Not covered (definition)

Not covered definitionNot covered — drugs listed as 'Not covered' in the formulary are excluded from benefit coverage and claims will be denied if billed without an exception.

ExamplesNumerous products in the TOC are labeled Not covered (e.g., ULTRAVATE, ACTHAR, many others), indicating explicit exclusion.

Provider implicationProviders should check formulary tiering prior to prescribing to avoid billing for noncovered items or pursue exceptions where applicable.

PV1 / PV2 preventive indicators

PV1 / PV2 indicatorsPV1 and PV2 are preventive tier flags used in the Notes to mark vaccines, colorectal prep/laxatives and other preventive supplies (e.g., PEG‑3350, milk of magnesia).

Associated limitsPV entries commonly include QL and age limits (AL) — e.g., PV1; QL; AL (Min 45 Years and Max 75 Years) for colorectal prep agents.

Coverage effectWhen preventive criteria under health reform are met, PV‑flagged drugs may be covered with no out-of-pocket cost; otherwise coverage depends on plan design.

PA / SP / QL shorthand

ShorthandPA / SP / QL — common Notes shorthand meaning Prior Authorization; Specialty Pharmacy; Quantity Limit.

InterpretationCombined (e.g., 'PA; SP; QL') signals prior authorization is required, dispensing via specialty channel is mandated, and quantity limits apply.

ActionProviders must follow PA and specialty submission processes and respect QL rules when these codes appear together.

Formulary note abbreviations (summary)

Formulary note abbreviationsCommon abbreviations include PA (Prior Authorization), SP (Specialty), QL (Quantity Limit), PV1/PV2/PV3 (Preventive variants), 15DS (15‑day supply), OVM (Oncology Value Management), ST (Step Therapy), AL (Age Limit), ABA (Authorized Brand Alternative).

Where shownThese annotations appear in the Notes column across the table of contents to signal utilization controls and program requirements.

Provider implicationReview Notes annotations in the BCN Custom Select Drug List to determine administrative steps required for coverage.

Notes flags (example)

Notes flags (example)PV# = preventive category flag; PA = prior authorization required; SP = specialty pharmacy required; QL = quantity limit; 15DS = 15‑day specialty supply; OVM = Oncology Value Management.

Example entryIWILFIN shown with PA; 15DS; SP; OVM in the TOC demonstrating multiple simultaneous flags for a specialty oncology product.

UseThese flags provide concise administration instructions on the formulary listing for providers and pharmacies.

PA (TOC-level)

TOC-level PAPA — indicated at table‑of‑contents level to flag products requiring prior authorization across sections of the formulary.

ScopeApplies to many specialty and non‑specialty drugs as noted in the TOC; detailed clinical criteria are maintained in PA documentation and forms.

Next stepProviders should consult the Coverage Request Form and PA submission channels when PA appears at the TOC level.

SP (TOC-level)

TOC-level SPSP — table‑of‑contents flag indicating products managed through specialty pharmacy; appears across biologic and specialty drug listings.

DistributionSP-marked products commonly require dispensing through preferred specialty vendors or designated home‑delivery channels.

Associated annotationsOften listed with PA and QL to indicate combined administrative controls.

QL / PV1 / PV2 definitions (TOC)

QL / PV (TOC-level)QL and PV1/PV2 appear at the TOC level to indicate quantity limits and preventive designations for groups of products (e.g., vaccines, laxatives, nicotine products).

ExamplesPEG‑3350 and milk‑of‑magnesia entries show PV1 and QL at TOC level with age limits for preventive coverage.

ActionRefer to the detailed drug listing and BCN program documents for specific QL values and preventive coverage rules.

ExceptionsCertain specialty oncology and select products may have different day‑supply rules noted in the formulary (15DS).

various QL program reference (BCN Quantity Limit Program)

BCN Quantity Limit ProgramBCN limits quantity dispensed per fill based on clinical appropriateness and manufacturer dosing; see the Quantity Limit Program for current product‑specific limits.

EnforcementQuantity limits are applied at claim adjudication and may require PA or override if exceeded.

Where listedA current list of QL products is maintained in the BCN Custom Select Drug List and Quantity Limit Program documents.

Multiple listed products — see QL note in formulary list

Multiple products noteMultiple listed products in the formulary include QL annotations — refer to the Notes column in the drug list for product‑specific quantity limits.

ExamplesAnticonvulsants, topical creams, and other classes show QL entries in the TOC where limits apply.

ActionCheck the BCN Custom Select Drug List to determine the exact QL for each listed product before prescribing or dispensing.

multiple (see Notes with 'QL')

Multiple entries — QL noteWhere 'QL' appears in Notes for multiple entries, quantity limits apply per the plan's QL program.

Common classesTopiramate formulations, certain starter kits and other products in this section are noted with QL.

Provider checkProviders and pharmacies should check the formulary Notes and BCN QL program for allowable quantities per fill.

VYVGART HYTRULO subcutaneous solution prefilled syringe — QL annotated

VYVGART HYTRULO entryVYVGART HYTRULO subcutaneous solution prefilled syringe — Notes = PA; SP; QL, indicating prior authorization, specialty dispensing and a quantity limit apply.

ImplicationProviders must obtain PA and route dispensing via specialty pharmacy; check QL rules for allowable quantity per fill.

ReferenceSee the formulary Notes and BCN specialty program guidance for submission and distribution instructions.

VARIOUS specialty oncology agents — 15DS noted

Specialty oncology 15DSVarious specialty oncology agents are annotated with 15DS in the Notes (e.g., EULEXIN, NUBEQA, INLURIYO) indicating they are subject to the 15‑day supply limitation.

Associated flagsThese oncology agents commonly include PA; SP; OVM alongside 15DS to indicate oncology verification and specialty routing requirements.

Member cost15DS oncology products on the program follow the 15‑day supply cost rules (member pays half usual out‑of‑pocket for a 15‑day fill where applicable).

multiple entries — QL indicated where noted

Multiple — QL indicatedMultiple entries in the formulary are annotated with QL where product‑specific quantity limits apply.

ExamplesAntiparkinson agents, antivirals and others in the TOC show QL flags for selected strengths/forms.

InstructionConfirm product QL values in the BCN Quantity Limit Program prior to dispensing or authorizing fills.

CGM sensors/readers and diabetes drugs — QL references

CGM and diabetes suppliesMany CGM sensors/readers, transmitters and diabetes supplies are annotated with QL and/or PA in the Notes (e.g., DEXCOM G6/G7, FREESTYLE LIBRE), indicating quantity limits and prior authorization requirements.

ExamplesDEXCOM G6 SENSOR and FREESTYLE LIBRE sensors/readers show PA; QL annotations in the TOC.

Provider actionObtain PA where indicated and adhere to QL rules for supplies when arranging durable medical/supplies prescriptions or device coverage.

multiple specialty and branded agents — see QL note

Multiple specialty/branded agentsNumerous specialty and branded agents in the TOC include QL annotations — check the Notes per product for quantity limits.

ExamplesAgents such as AQVESME, DOPTELET, VYNDAMAX show PA; SP; QL in the Notes across the specialty sections.

ActionUse the BCN Custom Select Drug List to verify product‑specific QL values before prescribing or dispensing.

multiple entries — see QL per drug

Multiple entries — per‑drug QLVarious drug entries are flagged with QL in the Notes — QL values and enforcement are drug‑specific.

ExamplesDyslipidemics and certain lipid agents show QL annotations for specific formulations and strengths.

Provider checkVerify QL for the exact product and strength in BCN program documents to ensure appropriate dispensing.

isotretinoin oral capsule — QL annotated

Isotretinoin QLIsotretinoin oral capsules (various strengths) are noted with QL for specified strengths in the formulary Notes.

Associated controlsSome isotretinoin entries also include ST or other program flags; check the Notes for exact requirements per strength.

ActionConfirm QL and any REMS/administrative requirements for isotretinoin formulations prior to dispensing.

VARIOUS listed products — see QL per product

Multiple entries with QLVarious products across sections are annotated QL in the formulary; refer to the Notes for each product to determine limits.

Classes affectedIncludes laxatives, PEG‑3350, proton pump inhibitors, topical agents and others shown with QL flags.

Where to confirmConsult the BCN Quantity Limit Program and specific drug listing for exact QL values and enforcement details.

NOCDURNA sublingual tablet — Not covered and QL flag

NOCDURNA statusNOCDURNA sublingual tablet 27.7 mcg, 55.3 mcg — listed as Not covered with a QL flag in the Notes.

ImplicationAlthough QL appears, the Not covered tier indicates the product is excluded from coverage and would trigger denial if billed.

Provider actionDo not bill through the formulary benefit for Not covered items unless an exception is granted; consider alternative therapies.

mesalamine 1.2 gm — subject to QL

mesalamine 1.2 gm QLMesalamine oral tablet delayed release 1.2 gm — Notes = QL, indicating the product is subject to a quantity limit.

TierListed as Nonpreferred generic with QL annotation in the TOC.

ActionVerify the specific QL for this formulation in the BCN Quantity Limit Program before authorizing fills.

Various listed products — see QL per product

Multiple QL annotationsMultiple ophthalmic, cystic fibrosis and other specialty agents in the TOC are annotated 'QL' — product‑specific quantity limits apply per the formulary Notes.

ExamplesCYSTADROPS, CYSTARAN, OXERVATE, KALYDECO, TRIKAFTA and others show PA; SP; QL or QL annotations in the TOC.

Where to confirmRefer to BCN Custom Select Drug List and Quantity Limit Program for exact QL values and enforcement rules.

Note

Specialty pharmacy routing for cystic fibrosis and other agents

Cystic fibrosis agents and several other specialty products are routed to the specialty pharmacy channel (SP); providers must follow SP routing and PA requirements for these agents.