Blue Cross Blue Shield Michigan drug coverage & PA

Tier-based coverage

Coverage and tier placement determine member out-of-pocket costs and may exclude drugs with available lower-cost alternatives.

Formulary inclusion: Drugs are placed into tiers (Preferred generic, Nonpreferred generic, Preferred brand, Nonpreferred brand, Preferred specialty, Nonpreferred specialty, Preventive, Covered $0, Not covered) and coverage is determined by the member's specific drug plan benefits.

Tier definitions and cost implications are plan- and benefit-specific; generics are typically placed to lower tiers and brand products may be moved off-formulary when a generic becomes available.

Tiering effects on coverage: When a generic version of a brand-name drug becomes available the generic is generally added to a lower tier (Tier 1) and the original brand version may no longer be covered.

See 'New generics' policy for automatic tiering behavior.

Cost-sharing and preventive tiers: Select drugs in Preferred generic/Nonpreferred generic/Preferred brand/Nonpreferred brand tiers may be covered with no out-of-pocket cost when health care reform (ACA) preventive requirements are met; such products are marked PV1, PV2 or PV3 in the drug list.

Coverage with no out-of-pocket cost applies only when plan-specific preventive criteria are satisfied.

Nonformulary / Not covered rules: Nonformulary (Not covered) tiers include high-cost, FDA-approved prescription drugs for which comparable therapeutic alternatives exist at substantially lower cost; drugs in the 'Not covered' tier may be denied when billed under the pharmacy benefit.

Not covered status and nonformulary placement are defined by the plan's tier structure (4-tier or 6-tier) and may trigger claim denials if submitted without an approved exception.

Utilization management flags: Drugs may have utilization controls (PA, ST, QL, SP, 15DS, ABA, OVM) noted in the drug list; these controls affect coverage and must be satisfied for approval.

Providers must follow the plan's prior authorization, step therapy, and quantity limit processes where indicated.

The formulary excludes several broad categories of products from coverage. Examples include brand-name drugs when a generic equivalent exists, prescription products that have an over-the-counter equivalent (unless designated preventive), routine over-the-counter medications, lifestyle drugs (e.g., weight loss, erectile dysfunction), prenatal vitamins, most cough/cold products, experimental or cosmetic uses, certain drugs normally covered under the medical benefit (e.g., office-administered injectables/vaccines), many compounded products (with exceptions), replacement prescriptions for loss/theft, and drugs not FDA-approved.

Multiple individual entries across the drug list are explicitly designated Not covered or show restrictive Notes (e.g., QL, ABA). The table of contents and line listings show numerous analgesics, NSAID preparations, extended‑release opioids, and other agents flagged as Not covered in their tier column.

Specific product examples listed as Not covered in the extract include PROLATE, ROXYBOND, lidocaine external ointment 5%, lidocaine external patch 5%, PLIAGLIS EXTERNAL CREAM 7-7%, and a nitrofurantoin oral suspension formulation noted as Not covered.

Additional excerpts mark several formulations as Not covered, such as certain extended‑release anticonvulsant formulations (e.g., eslicarbazepine acetate entries), NAMZARIC ER extended‑release capsule, and other anticonvulsant or antidepressant formulations listed with Not covered status.

Migraine and specialty/oncology segments also contain Not covered designations: examples in the excerpt include ONZETRA XSAIL, sumatriptan‑naproxen sodium, TOSYMRA, ZEMBRACE SYMTOUCH, and multiple specialty oncology agents with Not covered lines in the cancer agent sections.

The antiparasitic and antiparkinson sections show products explicitly marked Not covered, for example SOVUNA, EMVERM, NEUPRO, ONAPGO and other agents cited as Not covered in the listed entries.

The antidiabetic and insulin listings include numerous specific products marked Not covered (for example several ALOGLIPTIN formulations and many insulin presentations are listed with Not covered tier status in the excerpt).

Within the anticoagulant and blood product segments multiple items are Not covered; explicit examples shown include FRAGMIN, ARANESP (albumin‑free) and EPOGEN identified as Not covered in the extract.

Other Not covered examples in the listing include a spironolactone oral suspension line, DYANAVEL XR, and certain multiple sclerosis or specialty pack items such as PLEGRIDY and its starter pack labeled Not covered.

The dermatology segment in the extract lists many topical agents as Not covered, including ADAPALENE EXTERNAL PAD, AKLIEF, AMZEEQ, certain adapalene‑benzoyl peroxide combinations, and additional branded topical products noted as Not covered.

A broad gastrointestinal and supportive care segment contains many Not covered entries. Examples shown in this segment include GLYCATE; GLYCOPYRROLATE oral tablet 1.5 mg; LEVBID/LEVSIN formulations; HELIDAC therapy oral; loperamide oral capsule; MOVANTIK and MYTESI listed as Not covered (some with QL); and multiple topical corticosteroids or other agents flagged Not covered.

The formulary excerpt identifies numerous topical corticosteroids and related agents as Not covered, including clocortolone pivalate, CORDRAN, CORTISONE ACETATE (oral), halcinonide, and other high‑potency topical products, plus specialty items such as ACTHAR and ACTHAR GEL flagged Not covered.

Reproductive and hormonal entries show several Not covered listings in the extract, for example ORIAHNN, TWIRLA, CRINONE, ERMEZA oral solution, and MYCAPSSA are each shown as Not covered in the posted lines.

The biologics and specialty biologic listing includes many products explicitly labeled Not covered, for example OTREXUP auto‑injector products, OTULFI, RASUVO, SKYRIZI pen presentations, and multiple other specialty biologics identified as Not covered in the extract.

The excerpted device, allergy and ophthalmic sections list numerous specific Not covered items: examples include ODACTRA, RAGWITEK, PALFORZIA (noted elsewhere as PA; SP; QL), CYSTADROPS, RESTASIS MULTIDOSE, TRYPTYR, TYRVAYA, VERKAZIA, VEVYE, ILEVRO, INVELTYS, LOTEMAX SM, NEVANAC, IYUZEH, VYZULTA, UPNEEQ, ZERVIATE and others called out as Not covered in the product lines.

Several topical and oral agents appear with a Not covered status in the extract's Not Medically Necessary / exclusions listing; this indicates these specific formulations are excluded from pharmacy coverage per the drug list extract.

Formulary annotations and non‑code modifiers used through the drug list include plan-specific shorthand (e.g., PA, QL, SP, ST and preventive codes PV1/PV2). These annotations appear adjacent to many entries and guide utilization controls and claims adjudication.

Formulary notes / modifiersmixed

PV2	Prior verification/review or formulary shorthand
QL	Quantity Limit
AL	Age Limit (Min/Max specified where present)

Utilization management notesmixed

PA	Prior Authorization
SP	Specialty drug designation
ST	Step Therapy
ABA	Appears as a formulary note (context-specific)

Provider Responsibilities, Authorization & Documentation

Prior Authorization

Prior authorization and program indicators — high-level

Prior authorization (PA) may be required for coverage of many medications and devices listed on the drug list. PA and program indicators shown next to drugs (PA, SP, QL, ST, ABA, OVM, PV1/PV2/PV3, 15DS, AL) signal administrative or clinical requirements that providers must satisfy before a claim will be approved.

PA = Prior authorization required from prescriber; clinical criteria or additional information must be provided.
SP = Specialty medication — may require specialty pharmacy dispensing and additional handling.
QL = Quantity limits apply.
ST = Step therapy — trial of preferred drug(s) may be required before coverage.
OVM = Oncology Value Management — antineoplastics require PA through OncoHealth.
PV1/PV2/PV3 = Preventive tiers with specific coverage and out-of-pocket rules.

Documentation Required

Prior authorization requirement — submission routes and methods

Prior authorization requests may be submitted electronically, by phone, fax or mail. For oncology antineoplastics and supportive care, use the Oncology Value Management (OncoHealth) submission routes.

Electronic prior authorization: via EHR systems or CoverMyMeds for commercial pharmacy members.
Phone: 1-800-437-3803 (general pharmacy).
Fax: 1-866-601-4425 (general pharmacy).
Mail: Pharmacy Services — Mail Code 512C, Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Detroit, MI 48226-2998.
OncoHealth (antineoplastics/supportive care): submit via OncoHealth OneUM portal through the BCBSM/BCN payer space, or call 1-888-916-2616, fax 1-800-264-6128, or mail OncoHealth, 7000 Central Parkway, Ste 1750, Atlanta, GA 30328.

Prior Authorization

Prior authorization required for select specialty/brand drugs examples

Many specialty and branded products require prior authorization and specialty pharmacy dispensing; examples across the list include ARIKAYCE, VIGABATRIN products, LIVTENCITY, EPCLUSA, MAVYRET, and numerous oncology and immunologic agents.

ARIKAYCE — Notes: PA; SP; QL.
VIGAFYDE / vigabatrin — Notes: SP; QL / PA; SP; QL for some formulations.
LIVTENCITY — Notes: PA; SP; QL.
EPCLUSA, MAVYRET, SOFOSBUVIR-VELPATASVIR — Notes: PA; SP; QL.
Many oncology agents (e.g., CABOMETYX, CALQUENCE, CAPRELSA) flagged PA; 15DS; SP; OVM.

Prior Authorization

Prior authorization required for certain drugs (examples: LIVTENCITY, EPCLUSA, PAXLOVID)

Certain widely used or high-cost drugs are explicitly listed with utilization controls; examples include oral antivirals and other agents that may require PA, QL, or age limits.

PAXLOVID (various pack sizes) — Notes: QL; age limits.
LAGEVRIO — Notes: QL; age limits.
Antivirals and some hepatitis C regimens (EPCLUSA, HARVONI, MAVYRET) — Notes: PA; SP; QL.

Prior Authorization

Prior authorization required for select CGM devices

Continuous glucose monitoring (CGM) devices and related supplies on the list are frequently flagged for PA and quantity limits. Providers should verify device-specific requirements prior to dispensing.

Dexcom G6/G7 sensors and transmitters — Notes: PA; QL.
FreeStyle Libre sensors and readers — Notes: PA; QL.
Some blood glucose devices are covered $0 but still require PA and have QL flags.

Prior Authorization

Prior authorization required for many specialty agents

A large portion of specialty agents across categories (oncology, immunology, genetic disorders, blood-formation modifiers, etc.) require prior authorization and specialty pharmacy handling; examples are pervasive throughout the drug list and carry PA, SP and often QL flags.

Oncology agents: many entries flagged PA; 15DS; SP; OVM (e.g., CABOMETYX, CALQUENCE).
Immunoglobulins and biologics: GAMMAGARD, HIZENTRA, HYQVIA, etc., flagged PA; SP.
Rare-disease and enzyme-replacement therapies: multiple entries flagged PA; SP; QL.

Denial Risk

Noncovered items / Not covered products may be denied

Drugs marked Not covered or listed as Nonformulary will typically be denied if billed to the pharmacy benefit. Providers and members are notified in writing when requests are denied, including reasons and appeal rights.

Nonformulary/excluded categories include brand drugs with generic equivalents, OTC equivalents, cosmetic or experimental uses, products covered under medical benefit, compounded products (with exceptions), and drugs not FDA-approved.
When a requested drug is Not covered, claims may be denied; the plan will send written notification to the member and prescriber with denial reason and appeals process.
If a product is covered as a medical benefit (e.g., certain injectables or vaccines administered in-office), do not bill under the pharmacy benefit.

Documentation Required

Quantity limit / PA documentation; documentation implied by flags

Utilization controls and annotations (PA, QL, SP, ST, ABA, OVM, PV1/PV2/PV3, 15DS, AL) imply specific documentation and administrative steps. Providers should include clinical rationale, prior drug trials, dosing, duration, and relevant labs or diagnostics with PA submissions.

Documentation implied by flags: evidence of prior therapy for ST; diagnosis and severity for PA; quantity justification for QL; specialty indications for SP.
Supporting documentation: chart notes, prior medication history, relevant lab results, and rationale for non-preferred or off-formulary use.
Authorization-related notes: some products require specialty pharmacy dispensing (SP) or OncoHealth routing for oncology (OVM).

Step Therapy

Step therapy requirement and examples (including GLP‑1 agents)

Step therapy (ST) rules require trial and failure or intolerance to specified preferred agents before a nonpreferred or higher-cost agent will be approved. Several product categories show step therapy or step-therapy-related notes.

Examples: TRINTELLIX — Notes: ST; QL.
Antipsychotics and some GLP-1/GLP analogues show ST flags (e.g., CAPLYTA, FANAPT, MOUNJARO, OZEMPIC, RYBELSUS, RYBELSUS notes ST on some agents).
For GLP-1 agents and similar high-cost diabetic agents, check the full formulary for specific ST sequences and exceptions.

Denial Risk

Denial triggers, tiering/notes and preventive/noncovered denial risk

If prior authorization is required and the necessary documentation is not provided or criteria are unmet, claims or coverage requests will be denied. Denials can also result from noncompliance with quantity limits, specialty dispensing requirements, or if a product is Not covered on the formulary.

Denial triggers: Not covered status, unmet PA clinical criteria, QL exceeded, required step(s) not completed, or wrong benefit (medical vs pharmacy).
Tiering/notes (e.g., Not covered, ABA, PV2) may also cause denial when an item is off-formulary or excluded.
Preventive designations (PV1/PV2) have coverage conditions — if reform requirements aren’t met, the item may not be covered through the pharmacy benefit.

Documentation Required

Prior authorization documentation & supporting documentation for PA

Providers should include complete supporting documentation with PA requests and keep copies for appeals. The plan will communicate approvals and denials in writing and provides appeal instructions in denial notices.

Include clinical notes, prior medication trials (dates and outcomes), labs, imaging, and rationale for the requested therapy.
If a PA request is denied, the written notice will state the reason and explain appeal rights and process.
When in doubt about a drug's coverage status or required documentation, contact Pharmacy Services using the phone or fax numbers listed or consult bcbsm.com/pharmacy and the Prior authorization and step therapy coverage criteria.

Prior Authorization

Prior authorization & specialty pharmacy flags; PA and SP documentation

Specialty pharmacy (SP) flags indicate items that must be dispensed via a specialty pharmacy; prior authorization and specialty dispensing requirements often occur together. Providers must follow the SP routing and any 15-day supply (15DS) limits where indicated.

PA + SP examples: many biologics, oncology agents and rare-disease therapies are flagged PA; SP; QL.
15DS indicates a 15-day supply limit for certain specialty drugs — billing or dispensing beyond this without authorization may be denied.
Providers should coordinate with the designated specialty pharmacy and follow OncoHealth routing for oncology PA where applicable.

Terms and Abbreviations

PA definition

TermPA (Prior authorization)

DefinitionYour doctor is required to give more information to determine coverage.

Where shownDisplayed in the drug list 'Notes' column as 'PA' to indicate prior authorization is required.

ST definition

TermST (Step therapy)

DefinitionRequires you try one or more preferred drugs before a higher-cost medication can be covered.

Where shownDisplayed in the drug list 'Notes' column as 'ST' to indicate a step edit applies.

QL definition

TermQL (Quantity limit)

DefinitionThe quantity of medication dispensed at one time is limited (per-fill limits set by BCN based on clinical appropriateness and manufacturer dosing).

Where shownDisplayed in the drug list 'Notes' column as 'QL' to indicate quantity limits apply.

SP definition

TermSP (Specialty)

DefinitionSpecialty medication — treats complex conditions and may require special handling or administration and routing via a specialty pharmacy.

Where shownDisplayed in the drug list 'Notes' column as 'SP' to indicate specialty pharmacy routing is indicated.

15DS definition

Term15DS (15-day supply)

DefinitionLimits the amount of certain specialty drugs to a 15-day supply for all fills (managed by the 15-Day Specialty Drug Limitation Program).

Plan impactMembers pay half their usual out-of-pocket cost for a 15-day supply per program description.

PV1/PV2/PV3 preventive designations

TermPV1 / PV2 / PV3 (Preventive designations)

DefinitionPreventive categories covered with no out-of-pocket costs when Affordable Care Act requirements are met (shown as PV1, PV2 or PV3 in the drug list 'Notes' column).

Where shownOften applied to vaccine and contraceptive entries in the Notes column (e.g., many vaccines labeled PV1; QL).

PA (definition repeat)

TermPA (Prior authorization)

DefinitionPrior authorization — prescriber must submit clinical information demonstrating the member meets the plan's coverage criteria.

Usage noteShown as 'PA' in the drug list 'Notes' column; required documentation/process described in the plan's PA procedures.

QL (definition repeat)

TermQL (Quantity limit)

DefinitionMaximum allowed quantity per time period; BCN sets per-fill limits based on clinical appropriateness and manufacturer dosing.

Where shownDisplayed as 'QL' in the Notes column; see Quantity Limit Program and BCN Custom Select Drug List for specifics.

SP (definition repeat)

TermSP (Specialty)

DefinitionSpecialty — agent dispensed through the specialty pharmacy channel and may require specialty dispensing and documentation.

Where shownShown as 'SP' in the Notes column; specialty routing and requirements detailed in site-of-care and PA instructions.

ST (definition repeat)

TermST (Step therapy)

DefinitionStep therapy — requires trial of one or more preferred drugs before a higher-cost medication can be covered.

Where shownMarked as 'ST' in the drug list 'Notes' column; consult BCN Custom Select Drug List for specific step requirements and sequences.

ABA definition (administrative authorization)

TermABA (Authorized brand alternative)

DefinitionApproved brand medication marketed without the brand name on its label; considered brand‑name for cost purposes and may not have generic equivalents.

Plan impactAuthorized brand alternatives are treated as brand‑name drugs for member out-of-pocket costs and may not be covered in some cases.

PA (definition — multiple entries)

TermPA (Prior authorization)

DefinitionPrior authorization required — prescriber must supply additional clinical information for coverage determination.

NoteAppears widely across specialty and branded entries in the drug list 'Notes' column as 'PA'.

SP (definition — multiple entries)

TermSP (Specialty)

DefinitionSpecialty pharmacy routing indicated — drug is handled through specialty channels and may require SP vendor processing.

Where shownNoted as 'SP' in the Notes column; many biologics and infused/complex therapies include this flag.

QL (definition — multiple entries)

TermQL (Quantity limit)

DefinitionQuantity limit — maximum quantity dispensed at one time; appears as 'QL' in the Notes column and may be time‑period specific.

Where to find detailsSee BCN Quantity Limit Program and the BCN Custom Select Drug List for per‑drug limits.

PV1/PV2/PV3 (definition — plan-specific codes)

TermPV1 / PV2 / PV3 (Plan-specific preventive codes)

DefinitionPlan-specific preferred/coverage codes used in the listing to indicate preventive coverage (no out-of-pocket cost when ACA requirements are met).

Common useApplied to vaccines and select preventive drugs in the Notes column (e.g., many vaccines labeled PV1; QL).

PA (definition reference)

TermPA (Prior authorization)

DefinitionYour doctor is required to give more information to determine coverage; widely used for specialty and certain branded drugs.

Operational noteProviders must follow BCN's PA submission procedures (electronic or via Coverage Request Form).

SP (definition reference)

TermSP (Specialty)

DefinitionSpecialty designation — indicates specialty pharmacy dispensing and handling requirements.

ImplicationEntries with 'SP' often also show 'PA' and 'QL' and require specialty routing per the formulary notes.

PV1 (Preventive vaccine designation)

TermPV1 (Preventive vaccine designation)

DefinitionIndicates a vaccine is covered as preventive with no out-of-pocket cost when health care reform (ACA) requirements are met.

Where shownAppears in the 'Notes' column (e.g., many vaccine entries labeled PV1; QL).

QL (definition reference)

TermQL (Quantity limit)

DefinitionQuantity limit — the plan limits how much of a drug can be dispensed per fill; BCN publishes these limits in the Quantity Limit Program.

ReferenceSee the BCN Custom Select Drug List/Quantity Limit Program for specific per‑drug QL values.

Step therapy table reference (trial requirement)

TermST (Step therapy) — trial requirement

DefinitionDrugs labeled 'ST' require a trial of one or more preferred drugs before coverage of the listed higher‑cost medication is approved.

Where to find specificsStep therapy sequences and required agents are published on the BCN Custom Select Drug List and prior authorization/step therapy coverage criteria.

Step Therapy Rules and Affected Agents

Requirement	Source excerpt
Trial of one or more preferred drugs required before coverage of a listed drug labeled 'ST'
'Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved.' (See BCN Custom Select Drug List for current list)

Preventive / Age note	Source excerpt
Many nicotine replacement and smoking cessation products are annotated PV1/PV2 indicating preventive tier designation
Entries include age limit notes such as 'AL (Min 18 Years)' for nicotine replacement products (e.g., ft nicotine, goodsense nicotine products)

Example drug	ST annotation / Notes
TRINTELLIX
Notes = ST; QL (listed as Nonpreferred brand with ST flag)

Example drug	ST annotation / Notes
CAPLYTA
Notes = ST; QL (listed as Nonpreferred brand)
FANAPT (including titration packs)
Notes = ST (FANAPT and FANAPT titration packs listed with ST)

Example GLP‑1 / weight/diabetes agent	ST annotation / Notes
liraglutide
Notes = ST; QL (listed as Nonpreferred generic)
MOUNJARO; OZEMPIC; RYBELSUS; TRULICITY
Notes = ST; QL for multiple GLP‑1/weight/diabetes agents (listed in Antidiabetic Agents section)

Example drug	ST annotation / Notes
EDARBYCLOR
Notes = ST; QL (listed as Nonpreferred brand)

Example drug	ST annotation / Notes
cladribine (various pack sizes)
Notes = ST; SP; QL (listed as Preferred specialty with ST; SP; QL)
MAVENCLAD
Notes = ST; SP; QL (MAVENCLAD listed as Nonpreferred specialty with ST; SP; QL)

Instruction	Source excerpt
When a drug line shows 'ST' in the Notes column, follow the plan's step therapy requirements (trial of one or more preferred agents is required prior to coverage)
'Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved.' Consult the BCN Custom Select Drug List for specifics.

Example drug	ST / QL annotation
prucalopride succinate
Notes = ST; QL (listed as Nonpreferred generic)

Program flags	Source excerpt
Many specialty products show 'PA; SP' indicating prior authorization and specialty pharmacy routing; some also include 'QL'
Examples in the listing include multiple preferred/nonpreferred specialty agents annotated 'PA; SP; QL' (see Antidiabetic/ specialty sections)

Finding	Source excerpt
No explicit step therapy sequences (i.e., the specific preferred-step agents or step order) are listed in this excerpt
'This extract does not explicitly list step therapy sequences; consult full formulary for step therapy rules.'

Example ophthalmic agent	ST annotation / Notes
RHOPRESSA
Notes = ST; QL (listed as Nonpreferred brand)
ROCKLATAN
Notes = ST; QL (listed as Nonpreferred brand)

Quantity Limits and Supply Restrictions

select specialty drugs — 15-day or 30-day supply depending on program

Supply limitSelect specialty drugs limited to a 15-day supply; general specialty drugs limited to a 30-day supply.

Program name15-Day Specialty Drug Limitation Program manages the 15-day limits for drugs on that list.

Member cost impactMembers pay half their usual out-of-pocket cost for a 15-day supply per program description.

per-fill limits set by BCN based on clinical appropriateness and manufacturer dosing

PolicyBCN sets quantity limits based on clinical appropriateness and manufacturer‑recommended dosing.

Where publishedSpecific per‑fill limits are listed in the Quantity Limit Program and the BCN Custom Select Drug List.

ScopeApplies to certain medications where BCN limits the quantity dispensed per fill.

QL noted for ZTLIDO; ARIKAYCE

ExamplesZTLIDO and ARIKAYCE are listed with Notes indicating QL (quantity limit).

Source entriesZTLIDO marked 'Notes = QL' (chunk 38); ARIKAYCE marked 'Notes = PA; SP; QL' (chunk 41).

ImplicationQuantity limits apply to these products and will affect allowable dispensed amounts per fill.

perampanel oral tablet — see QL

Drugperampanel oral tablet

NotesTier = Nonpreferred generic; Notes = QL (quantity limit applies).

ImplicationRefer to BCN Quantity Limit Program for the specific QL value applied to perampanel tablets.

AIMOVIG, EMGALITY, NURTEC, QULIPTA, UBRELVY and others — PA; QL indicated

ExamplesAIMOVIG, EMGALITY, NURTEC, QULIPTA, UBRELVY and other antimigraine/CGRP and acute agents show 'PA; QL' in Notes.

NotesThese products are subject to prior authorization and quantity limits per the drug list entries.

ActionProviders should submit PA and check QL limits when prescribing these agents.

Various products — Notes = QL

ObservationVarious listed products include 'Notes = QL' indicating quantity limits apply.

Where to confirmSee the BCN Quantity Limit Program or the BCN Custom Select Drug List for per‑drug QL specifics.

EffectQuantity limits will restrict the amount dispensed per fill and may require prior authorization for overrides.

Various products — See QL annotation

NoteMultiple products in antiviral/antiviral-associated sections include QL annotations.

ReferenceEntries such as LAGEVRIO and PAXLOVID include QL; many hepatitis/HIV agents include PA; SP; QL notes.

Provider actionCheck QL and PA requirements when prescribing these agents to ensure coverage and appropriate dispensing.

CGM sensors/receivers and many drugs — QL applied as noted

ScopeCGM sensors, receivers and many diabetes devices are flagged with PA and QL (e.g., DEXCOM G6 SENSOR, FREESTYLE LIBRE sensors/readers).

ImplicationPA and quantity limits apply to these devices; check device-specific Notes for QL values.

ReferenceSee device listings in the drug list (chunks 110–111) and BCN device policies for details.

Specialty products — see QL notes

ObservationMany specialty products (biologics, injectables) are noted with PA; SP and QL where applicable.

Example entriesOTREXUP, SIMLANDI, REZUROCK, SIMPONI and others show SP; QL or PA; SP; QL in Notes.

Provider stepFollow PA and specialty pharmacy routing when Notes indicate SP and check QL for dispensing limits.

Multiple specialty drugs — see QL notes

ExamplesMultiple listed drugs (FIRDAPSE, PALFORZIA, VEOZAH, VYKAT XR, ZILBRYSQ, etc.) are annotated with QL in their Notes.

ReferenceSee the individual drug entries in the BCN Custom Select Drug List for exact QL values.

Provider actionConfirm QL and PA requirements prior to dispensing to avoid claim denials.

Multiple specialty drugs — QL indicated per drug note

ObservationNumerous specialty and immunoglobulin products display PA; SP; QL or SP; QL flags.

ExamplesGAMMAGARD, GAMMAKED, HYQVIA, XEMBIFY and many immunomodulators show PA/SP/QL in Notes.

ActionFollow specialty pharmacy processes and document PA where required; check quantity limits in the QL program.

Listed specialty products — QL applied where noted

ObservationListed specialty products include QL annotations where applicable (e.g., OTREXUP marked SP; QL).

ImpactQuantity limits affect allowable dispensing and may require PA for exceptions.

Provider stepReview Notes column for each specialty drug to determine QL and PA requirements prior to submission.

Quantity limits applied where 'QL' appears

SummaryWhere 'QL' appears in the Notes column, BCN applies a quantity limit to that product.

Where documentedSpecific QL values and timeframes are published in the Quantity Limit Program and BCN Custom Select Drug List.

Provider adviceCheck the BCN resources for exact QL values before authorizing fills or submitting PA requests.

Various listed drugs — see QL note

ExamplesVarious CNS and migraine agents, among others, show 'Notes = QL' indicating quantity limits on dispensing.

ReferencePerampanel (chunk 55) and many antimigraine agents (chunk 70) are examples; consult BCN QL listings for exact limits.

Provider actionConfirm QL and submit PA if an override is clinically indicated and allowed by BCN policy.

OpenPayer

Blue Care Network Custom Select Drug List - Coverage Criteria

Coverage Criteria and Formulary Tiering

Provider Responsibilities, Authorization & Documentation

Terms and Abbreviations

Step Therapy Rules and Affected Agents

Quantity Limits and Supply Restrictions

Dispensing Channels and Specialty Pharmacy

Policy Background and Scope