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Currentblue cross blue shield - michiganPolicy N/A

Medicare Plus Blue PPO Core Formulary (2026) — Prescription Drug Coverage Criteria

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Defines the Medicare Plus Blue PPO 2026 core prescription drug formulary, coverage rules (prior authorization, step therapy, quantity limits), and member processes for exceptions and transitions; applies to Medicare Plus Blue PPO members using network pharmacies.

Policy Summary

Payerblue cross blue shield - michigan

PolicyMedicare Plus Blue PPO Core Formulary (2026) — Prescription Drug Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2026

Last ReviewFeb 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' to avoid denial of coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

02/01/2026formulary effective date

31 daystemporary transition supply

31 tabletsexample QL (pioglitazone)

Monthlyformulary updates

26449formulary id

PA/QL/ST/NDSutilization types

Formulary Coverage Rules

General coverage criteria

Covered when ALL of the following are met

General formulary coverage: Drug is listed on the Medicare Plus Blue PPO formulary and is medically necessary, the prescription is filled at a Medicare Plus Blue PPO network pharmacy, and other plan rules are followed.

See Evidence of Coverage for filling rules and transition supplies (temporary 31-day supply for new/restricted drugs).

Prior authorization: If a drug requires prior authorization (PA) as noted in the formulary Requirements/Limits column, the prescriber must obtain approval before the prescription is filled.

Failure to obtain prior authorization may result in the plan not covering the drug; submit prescriber supporting statement per exception process (standard 72 hours; expedited 24 hours).

Step therapy: If a drug is subject to step therapy (ST), the member must try and fail (or be intolerant to) the specified preferred alternative(s) documented by the prescriber before the requested drug is covered.

Policy Summary

Payerblue cross blue shield - michigan

PolicyMedicare Plus Blue PPO Core Formulary (2026) — Prescription Drug Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2026

Last ReviewFeb 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' to avoid denial of coverage.

SourceLink

On This Page

Providers may request an exception with supporting clinical rationale; see Evidence of Coverage for exception timelines.

Quantity limits (QL) published on the formulary apply (for example, pioglitazone = 31 tablets per prescription); prescribing or dispensing quantities exceeding listed QL require documentation or an approved exception.

Some products have one‑month (31 days) or three‑month (90 days) supply rules; claims exceeding QL may be denied without approval.

Coverage by tier with utilization management

Formulary coverage is provided by tier with utilization management conditions applied as listed

Formulary coverage logic: Coverage and member cost‑share depend on the drug's assigned formulary tier (Tier 1–5 and Specialty) and are subject to utilization controls indicated in the Requirements/Limits column, including Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Oncology Value Management (OVM), and Non‑Extended Day Supply (NDS).

See Evidence of Coverage for member cost‑share charts and supply limits (Tier‑specific supply rules; Tier 5 typically limited to 31‑day fills).

Formulary coverage overview

Formulary coverage is denoted by drug tier and may include quantity limits (QL) and prior authorization (PA).

Formulary entries: Each formulary line shows the drug name, strength/form, assigned tier and any Requirements/Limits (e.g., QL, PA). Coverage and member cost‑share follow the listed tier and any PA/QL noted.

This formulary excerpt includes many drug lines with QL and PA annotations; consult the entry for specific QL values and PA flags.

Formulary Coverage with Requirements

Formulary coverage with utilization management applies as listed

Formulary adherence: Coverage of a listed drug is subject to the product‑specific Requirements/Limits shown (for example, QL values and PA noted next to products such as TRULICITY, SOLIQUA, PROCRIT).

Follow product‑specific QL and PA processes; some specialty or high‑cost agents are subject to OVM or PA plus QL.

Formulary coverage

Formulary coverage is determined by assigned drug tier and any listed quantity limits; coverage is implied for listed drugs within their tier subject to quantity limits and plan rules.

Formulary listing: Drug is listed with an assigned Tier (1–5) and may have an associated Quantity Limit expressed as QL (e.g., EA or mL per a defined period).

Tiers indicate formulary placement and relative cost‑share; QLs restrict dispensed amounts and are enforced at dispensing.

Formulary listing with QL/PA/ST

Formulary coverage and controls

Formulary listing: Drugs are listed with a formulary tier and may include Requirements/Limits such as quantity limits (QL), prior authorization (PA), and step therapy (ST) which control coverage and dispensing.

Examples of QL/PA/ST are shown in formulary lines; specific clinical PA criteria are maintained in the payer's authorization process rather than in the formulary table.

Formulary entries (tiers, QL, PA)

Coverage and conditions where specified in formulary lines

Formulary coverage entries: Each drug line presents drug name/strength, assigned tier and Requirements/Limits (e.g., QL, PA, OVM). Coverage is determined by the plan formulary tier and any listed utilization controls.

Many entries in these sections show PA and/or QL flags; clinical documentation is required when requesting exceptions or PA approvals.

Prior authorization for specialty and select hormonal agents

Coverage and utilization management indications recorded as formulary administrative rules

PA required drugs: Drugs marked 'PA' or 'PA; OVM' require prior authorization before coverage (examples include lanreotide acetate injection, leuprolide depot formulations, octreotide acetate injections, ORGOVYX, SIGNIFOR, SOMATULINE DEPOT, SOMAVERT).

Provider must follow the payer's PA submission process; oncology antineoplastics require OVM via OncoHealth where indicated.

Quantity limits

Quantity limits applied to specific products

Quantity-limited drugs: Certain products specify QL values limiting units per time period (examples from the formulary: REZDIFFRA QL(31 EA per 31 days); COSENTYX QL(8 ML per 28 days); DUPIXENT QL(4.56 ML per 28 days); RINVOQ QL(31 EA per 31 days)).see QL values in formulary lines

Claims exceeding QL may require prior authorization or be denied; see specific line for exact QL value.

Drugs that are not listed on the Medicare Plus Blue PPO Core formulary are not covered by the plan unless an exception is granted. Members or prescribers may request a formulary exception from Customer Service; the document directs members to contact Customer Service for coverage options and to request an exception when a needed drug is not on the formulary.

Out-of-network pharmacy coverage is limited and applies only in specific situations. Members should consult their Evidence of Coverage for the conditions under which the plan allows fills from out-of-network pharmacies and for any cost‑sharing differences or prior authorization requirements that may apply.

Within the excerpt provided there are no explicit exclusion statements listing drugs or categories that are categorically excluded from coverage; the formulary lines shown instead indicate tiering and utilization-management flags (PA, QL, OVM) rather than named exclusions.

The excerpt does not state specific exclusionary rules for products or classes; formulary content in these chunks focuses on tier assignments and quantity limits rather than listing items that are expressly excluded.

No explicit medical-exclusion statements (for example, clinical scenarios or diagnoses that render a drug ineligible for coverage) are present in the provided excerpt. The listing shows tiers and requirement/limit fields but does not define medical exclusions in these chunks.

The provided excerpt does not include any statements labeling drugs or uses as 'Not Medically Necessary.' Listings instead show formulary tiers, quantity limits, and prior‑authorization flags; NMN determinations are not included here.

This excerpt does not list any conditions or uses designated as 'not medically necessary.' Coverage details shown are limited to tier assignments, quantity limits, and prior authorization indicators; NMN determinations are not present in these sections.

No 'not medically necessary' (NMN) determinations or formal NMN policy statements are provided in the excerpt. The page includes formulary metadata (Formulary ID, Version, Effective Date) and a note to consult the introduction for symbol definitions, but does not contain NMN decision criteria.

Formulary Drug Listings and Code Groups

Drug listings (no billing codes provided in this section)mixed

No codes listed

Formulary drug entries (partial list from chunks 54-73)mixed

SUBVENITE SUSPENSION 10MG/ML	Tier 5; PA
subvenite tablet 100mg, 150mg, 200mg, 25mg	Tier 2
topiramate capsule sprinkle 15mg, 25mg, 50mg	Tier 3
topiramate solution 25mg/ml	Tier 4; PA
topiramate tablet 100mg, 200mg, 25mg, 50mg	Tier 2
valproic acid capsule 250mg	Tier 3
ethosuximide capsule 250mg	Tier 4
clobazam suspension 2.5mg/ml	Tier 4; QL(480 ML per 30 days); PA; NDS
clobazam tablet 10mg, 20mg	Tier 4; QL(60 EA per 30 days); PA; NDS
clonazepam odt tablet disintegrating 0.125mg-1mg	Tier 3; QL(120 EA per 30 days); NDS

1–10 of 59

1/6

No CPT/HCPCS/ICD codes in this excerptmixed

No codes listed

Formulary product listings (no procedure/diagnosis codes present in this part)mixed

No codes listed

Formulary drug entries in this excerptmixed

TIVICAY PD TABLET SOLUBLE 5MG	Tier 5; QL(372 EA per 31 days)
TIVICAY TABLET 50MG	Tier 5; QL(62 EA per 31 days)
COMPLERA TABLET 200MG; 25MG; 300MG	Tier 5
DELSTRIGO TABLET 100MG; 300MG; 300MG	Tier 5
EDURANT PED TABLET SOLUBLE 2.5MG	Tier 5
EDURANT TABLET 25MG	Tier 5
efavirenz/emtricitabine/tenofovir disoproxil fumarate tablet 600mg; 200mg; 300mg	Tier 4
EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOPROXIL FUMARATE TABLET 400MG; 300MG; 300MG	Tier 5
INTELENCE TABLET 25MG	Tier 4
PIFELTRO TABLET 100MG	Tier 5

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1/2

Formulary drug listingsmixed

SOLIQUA 100/33 INJECTION 100UNIT/ML; 33MCG/ML	Formulary listing (Tier 3) with QL(60 ML per 90 days)
TRADJENTA TABLET 5MG	Tier 3; QL(90 EA per 90 days)
TRULICITY INJECTION 0.75MG/0.5ML, 1.5MG/0.5ML, 3MG/0.5ML, 4.5MG/0.5ML	Tier 3; QL(2 ML per 28 days); PA
XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR	Tier 3; various strengths with QL(180 EA per 90 days) or QL(90 EA per 90 days)
BAQSIMI ONE PACK POWDER 3MG/DOSE	Tier 3
GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR INJECTION 1MG/ML	Tier 3
GVOKE HYPOPEN (various presentations)	Tier 3
HUMALOG, HUMULIN, INSULIN ASPART, INSULIN LISPRO, LANTUS, LYUMJEV, NOVOLIN, NOVOLOG, TOUJEO (multiple formulations)	Mostly Tier 3; some concentrated formulations Tier 5 with PA (e.g., HUMULIN R U-500)
ELIQUIS (various formulations)	Tier 3 with multiple QL values per formulation
dabigatran etexilate capsule 150mg, 75mg	Tier 3; QL(180 EA per 90 days)

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Formulary drug items (examples)mixed

lisinopril 5mg	lisinopril tablet 5mg
moexipril 15mg	moexipril hydrochloride tablet 15mg
moexipril 7.5mg	moexipril hydrochloride tablet 7.5mg
perindopril 8mg	perindopril erbumine tablet 8mg
quinapril 5mg	quinapril hydrochloride tablet 5mg
ramipril 1.25mg	ramipril capsule 1.25mg
trandolapril 4mg	trandolapril tablet 4mg
amiodarone 200mg	amiodarone hydrochloride tablet 200mg
digoxin solution 0.05mg/ml	DIGOXIN SOLUTION 0.05MG/ML
dofetilide 500mcg	dofetilide capsule 125mcg, 250mcg, 500mcg

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Formulary quantity limits and flagsmixed

QL(90 EA per 90 days)	Quantity limit examples shown for many oral products (90 each per 90 days)
QL(180 EA per 90 days)	Quantity limit example
QL(360 EA per 90 days)	Quantity limit example
QL(2 ML per 28 days)	Quantity limit example for PRALUENT INJECTION
QL(6 ML per 28 days)	Quantity limit example for ADBRY INJECTION 300MG/2ML
PA	Prior authorization required flag
ST	Step therapy required flag

Formulary utilization codes and flagsmixed

QL(90 EA per 90 days)	Quantity limit: 90 each per 90 days
QL(180 EA per 90 days)	Quantity limit: 180 each per 90 days
QL(62 EA per 31 days)	Quantity limit: 62 each per 31 days
QL(12 EA per 30 days)	Quantity limit: 12 each per 30 days
QL(93 EA per 31 days)	Quantity limit: 93 each per 31 days
PA	Prior authorization required
OVM	Other/medical review (OVM) required
QL(90 GM per 90 days)	Quantity limit: 90 grams per 90 days
QL(180 EA per 30 days)	Quantity limit: 180 each per 30 days
QL(24 EA per 90 days)	Quantity limit: 24 each per 90 days

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NDC/CPT/HCPCS not listedmixed

No codes listed

Example quantity limits — multiple QL examples shown

divalproex sodium dr capsule (sprinkle) 125 mgTier 4 — listed as 'divalproex sodium dr capsule delayed release sprinkle 125mg'

divalproex sodium dr tablet delayed releaseStrengths 125 mg, 250 mg, 500 mg — listed as 'divalproex sodium dr tablet delayed release 125mg, 250mg, 500mg' (Tier 3)

divalproex sodium ER tablet (24‑hour)Extended‑release 24 hour strengths 250 mg, 500 mg — listed as 'divalproex sodium er tablet extended release 24 hour 250mg, 500mg' (Tier 4)

gabapentin formulationsCapsules 100 mg, 300 mg, 400 mg (Tier 2; QL 810 EA per 90 days); Solution 250 mg/5 mL (Tier 3; QL 6480 mL per 90 days); Tablets 600 mg and 800 mg (Tier 2; QL 540 EA and 360 EA per 90 days respectively)

LIBERVANT FILMMultiple film strengths listed (5–15 mg) — Tier 4; Requirements/Limits = QL(10 EA per 30 days); PA; NDS

PRIMIDONE and PHENOBARBITALPRIMIDONE tablet 125 mg (Tier 2); PHENOBARBITAL elixir 20 mg/5 mL (Tier 3; QL 4500 mL per 90 days; PA) and PHENOBARBITAL tablets (various strengths; QL 360 EA per 90 days; PA)

Linezolid suspension limit

Linezolid suspension (reconstituted)linezolid suspension reconstituted 100 mg/5 mL — QL(1680 ML per 28 days)

Linezolid injection/tablet entriesLinezolid injection 600 mg/300 mL and linezolid tablet 600 mg are listed in the formulary; tablet QL shown elsewhere

Documentation noteQuantity‑limit requests exceeding listed QL require supporting documentation as noted in formulary guidance

Linezolid tablet limit

Linezolid tablet 600 mgListed with Requirements/Limits = QL(56 EA per 28 days)

Linezolid injectionLinezolid injection 600 mg/300 mL appears in formulary (Tier 4) — check Requirements/Limits for administration settings

Prescriber documentationRequests that exceed QL for tablets should be supported by clinical documentation per formulary instructions

Vancomycin capsule limits

Vancomycin capsule 125 mgRequirements/Limits = QL(360 EA per 90 days)

Vancomycin capsule 250 mgRequirements/Limits = QL(720 EA per 90 days)

Vancomycin injectionsVancomycin injections (multiple vial strengths) listed separately; check Requirements/Limits for each form

IMPAVIDO capsule limit

IMPAVIDO capsule 50 mgRequirements/Limits = QL(84 EA per 28 days)

Tier assignmentIMPAVIDO listed as Tier 5 in formulary extract

Reference guidanceFormulary legend and intro pages describe symbols/abbreviations that accompany QL values

DIFICID (fidaxomicin) limit

DIFICID (fidaxomicin) 200 mg tabletRequirements/Limits = QL(20 EA per 10 days)

Tier assignmentFidaxomicin tablet listed as Tier 5 in formulary extract

Treatment duration implicationQL matches typical 10‑day Clostridioides difficile regimen (20 tablets per 10 days)

Briviact solution/tablet limits

BRIVIACT solution 10 mg/mLRequirements/Limits = QL(620 ML per 31 days)

BRIVIACT tablets (various strengths)Requirements/Limits = QL(62 EA per 31 days)

Prior authorizationBoth solution and tablets are annotated with PA in the formulary listing

Quantity limits examples (multiple exact QL values)

Multiple example QLsExamples shown across formulary: QL(372 EA per 31 days); QL(1860 ML per 31 days); QL(270 EA per 90 days); QL(15 EA per 30 days); QL(84 EA per 28 days)

Supply periodsQuantity limits use per‑day windows (e.g., per 28, 30, 31, 90, or 365 days) reflected in QL notation

Formulary guidanceIntro pages and Requirements/Limits legend should be consulted for interpreting QL syntax and exceptions

Quantity limits examples (CRESEMBA, AIMOVIG, NURTEC)

CRESEMBA capsulesCRESEMBA 74.5 mg — QL(175 EA per 31 days); CRESEMBA 186 mg — QL(70 EA per 31 days)

AIMOVIG injectionsAIMOVIG 140 mg — QL(3 ML per 84 days); AIMOVIG 70 mg — QL(6 ML per 84 days)

NURTEC tabletNURTEC ODT 75 mg — QL(18 EA per 30 days)

Quantity limits (examples)

Example QLs (antiretroviral/prep)TIVICAY PD soluble 5 mg — QL(372 EA per 31 days); TIVICAY 50 mg — QL(62 EA per 31 days); PREZISTA suspension 100 mg/mL — QL(414 ML per 31 days); TRIUMEQ PD soluble — QL(180 EA per 30 days)

Formulary tiersThese HIV agents appear across Tiers 4–5 with QLs specified per formulation

Refer to Requirements/Limits legendConfirm dispensing rules and PA requirements via the formulary introduction pages

Examples of quantity limits

Diabetes/GLP‑1 and related QLsSOLIQUA 100/33 — QL(60 ML per 90 days); TRADJENTA 5 mg — QL(90 EA per 90 days); TRULICITY injection (various strengths) — QL(2 ML per 28 days) and marked PA

Insulin and GLP‑1 listingsMultiple insulin and GLP‑1 products are listed with tier and QL/PA annotations (see formulary lines for specific strengths)

PA annotationsSeveral GLP‑1 and antidiabetic injectables are annotated with PA in the Requirements/Limits column

Quantity limits examples (examples)

ELIQUIS tablet soluble 0.5 mgRequirements/Limits = QL(1164 EA per 90 days) (multiple QL variants shown for different dosing scenarios)

rivaroxaban suspension reconstituted 1 mg/mLRequirements/Limits = QL(2700 ML per 90 days)

Dabigatran etexilate capsulesListed with QL(180 EA per 90 days) in the anticoagulant class entries

Quantity limits examples (examples)

Common QL patternsExamples include QL(720 EA per 90 days), QL(360 EA per 90 days), QL(180 EA per 90 days), QL(90 EA per 90 days), QL(1350 ML per 90 days)

Topical dermatologic QLsclobetasol propionate cream/ointment/gel — QL(180 GM per 90 days); clobetasol shampoo — QL(354 ML per 90 days)

Specialty injectable QLsVarious biologic/injectable QLs shown (e.g., glatiramer acetate QL values; DUPIXENT and COSENTYX QLs in other sections)

Example quantity limit

Topical quantity examplesQL examples include QL(180 GM per 90 days), QL(360 ML per 90 days), QL(354 ML per 90 days), QL(300 GM per 90 days)

Dispensing implicationQuantity limits for topical products specify GM or ML units per 90‑day windows — exceeding these may require PA or be denied

Formulary legendRefer to introduction pages for symbol definitions and QL interpretation

Quantity Limits examples

Sample QL entriesExamples include QL(31 EA per 31 days); QL(8 ML per 28 days); QL(360 ML per 30 days) as shown for various hormonal and biologic agents

PA associationMany of these QL entries for high‑cost hormonal/biologic agents are accompanied by PA flags in the Requirements/Limits column

Provider actionObtain PA where indicated to avoid coverage denial; documentation requirements referenced in formulary guidance

Shingrix quantity limit

SHINGRIX vaccineRequirements/Limits = QL(2 EA per 999 days)

Mesalamine capsule 400 mg delayed releaseRequirements/Limits = QL(1080 EA per 90 days)

Mesalamine tablet 1.2 g delayed releaseRequirements/Limits = QL(360 EA per 90 days)

Mesalamine capsule limit

Mesalamine DR capsule 400 mgRequirements/Limits = QL(1080 EA per 90 days)

Mesalamine DR tablet 1.2 gRequirements/Limits = QL(360 EA per 90 days)

Mesalamine DR tablet 800 mgRequirements/Limits = QL(540 EA per 90 days)

Mesalamine 1.2 g tablet limit

Mesalamine 1.2 g tablet (delayed release)Requirements/Limits = QL(360 EA per 90 days)

Related mesalamine entriesCapsules and enemas have separate QLs; see formulary lines for mesalamine suppository/enema values

Supply periodQL expressed per 90‑day window in these entries

Mesalamine 800 mg tablet limit

Mesalamine 800 mg tablet (delayed release)Requirements/Limits = QL(540 EA per 90 days)

Class noteMesalamine formulations (capsule, tablet, enema) each have specific QLs; confirm formulation when applying QL

Exception processPrescribers may request quantity‑limit exceptions with supporting documentation per formulary instructions

Mesalamine enema limit (ml)

Mesalamine enema 4 gRequirements/Limits = QL(5400 ML per 90 days)

Unit of measureEnema QL expressed in mL for the 4 g preparation — check product specifics when dispensing

Formulary referenceRefer to the formulary introduction for symbol/QL interpretation and exception submission guidance

Alendronate 35/70 mg limit

Alendronate 35 mg / 70 mg tabletsRequirements/Limits = QL(12 EA per 84 days)

Supply implicationQL allows a 12‑count supply covering roughly a three‑month period (84 days)

Related alendronate 10 mg entrySee separate QL for alendronate 10 mg (QL 90 EA per 90 days)

Alendronate 10 mg limit

Alendronate 10 mg tabletRequirements/Limits = QL(90 EA per 90 days)

Tier assignmentAlendronate 10 mg listed in formulary with Tier 2 assignment

Dispensing noteQL reflects a 3‑month supply limit; exceptions can be requested per formulary procedures

What Providers Must Do

Prior Authorization

Prior authorization required

Prescriber or pharmacy must obtain prior authorization (PA) from Medicare Plus Blue PPO before dispensing drugs that are marked with the PA requirement; failure to obtain PA may result in the plan not covering the drug.

Obtain PA prior to initial fill for any product with 'PA' in Requirements/Limits.
If PA is not approved, expect non‑coverage and advise patient of exception process.

Prior Authorization

PA required for oncology/supportive care via OVM

Oncology antineoplastics and supportive care drugs require prior authorization through the Oncology Value Management (OVM) program administered by OncoHealth; prescribers must submit required clinical information to the OVM process prior to coverage.

Submit OVM/PA documentation per OncoHealth instructions for antineoplastics and supportive care agents.
Claims lacking OVM/PA may be denied.

Prior Authorization

PA indicated for specified formulations (e.g., VOQUEZNA)

Some specific products in the formulary (for example, VOQUEZNA Dual and Triple Pak therapy packs) are annotated with 'PA' and require prior authorization before coverage; lack of PA may trigger a denial.

Check product Requirements/Limits for 'PA' (e.g., VOQUEZNA Dual/Triple Pak show QL and PA).
Obtain PA before dispensing to avoid coverage denial.

Prior Authorization

Prior authorization required for listed products

Many listed products are marked 'PA' in the Requirements/Limits column; providers must obtain prior authorization for those drugs before dispensing to ensure coverage.

Review the formulary Requirements/Limits column for 'PA' flags (examples include topiramate solution, DIACOMIT, rufinamide).
Provide clinical documentation with the PA request as required.

Prior Authorization

PA required for selected specialty drugs (CRESEMBA, AIMOVIG, EMGALITY)

Selected agents such as CRESEMBA, AIMOVIG, EMGALITY and numerous antineoplastics are marked 'PA' (often with QL or OVM) and require prior authorization; providers must follow PA procedures for these specialty agents.

For CRESEMBA, AIMOVIG, EMGALITY confirm PA and any QL before prescribing.
For oncology agents, follow OVM submission requirements in addition to PA.

Prior Authorization

PA required for listed specialty/oncology drugs

Many Tier 5 specialty and oncology oral agents and injectables are labeled 'PA' (and some 'PA; OVM'); prescribers must obtain prior authorization for these high‑cost specialty products prior to coverage.

Confirm PA (and OVM where indicated) for Tier 5 specialty agents before dispensing.
Failure to secure PA may result in claim denial.

Billing Rule

Obtain PA and comply with quantity limits (PA + QL)

Some products require both prior authorization and adhere to quantity limits (QL) — for example LORBRENA and ROZLYTREK list QL(93 EA per 31 days) plus PA; VENCLEXTA starting pack has QL(84 EA per 365 days).

When requesting PA, include documentation supporting the requested quantity when it approaches or exceeds the QL.
Claims exceeding QL without an approved override/PA may be denied.

Prior Authorization

PA and/or Step Therapy for high‑tier agents

High‑tier agents and certain long‑acting injectables are subject to prior authorization or step therapy as noted; providers must check Requirements/Limits for 'PA' or 'ST' and follow the specified authorization or step process.

Confirm whether an agent is marked 'ST' (step therapy) and document prior trial of preferred agents when required.
Submit PA documentation for long‑acting injectables where 'PA' is listed.

Prior Authorization

PA required for select diabetes/weight‑management agents

Certain diabetes and weight‑management agents are annotated with 'PA' and QL (examples: MOUNJARO QL(2 ML per 28 days); OZEMPIC QL(3 ML per 28 days); TRULICITY QL(2 ML per 28 days); RYBELSUS entries include PA).

Obtain PA for GLP‑1 and related agents when 'PA' is indicated.
Ensure dispensing does not exceed the listed QL periods.

Prior Authorization

PA required for certain insulin products (e.g., HUMULIN R U‑500)

Select products such as HUMULIN R U-500 (concentrated insulin) are listed with 'PA'; prescribers must obtain prior authorization for these specific insulin formulations before coverage.

Check Requirements/Limits for concentrated insulin entries (HUMULIN R U-500 shows 'PA').
Provide clinical rationale and dosing details in the PA submission.

Prior Authorization

High‑tier drugs require additional prior review

Many Tier 5 or high‑cost drugs are assigned to higher tiers and require additional review processes (PA/OVM) before coverage; providers should anticipate program‑level reviews for Tier 5 items.

For Tier 5 agents, verify PA and OVM requirements prior to prescribing.
Expect additional documentation and longer review workflows for specialty agents.

Prior Authorization

PA required for listed cardiovascular/metabolic agents (NEXLETOL, NEXLIZET, PRALUENT)

Some formulary entries (e.g., NEXLETOL, NEXLIZET, PRALUENT) are labeled 'PA' in the Requirements/Limits column; obtain prior authorization for these therapies before dispensing.

Review the specific formulary line for each product to confirm PA and any QL.
Submit PA requests with relevant clinical supporting information.

Prior Authorization

PA required for products like EUCRISA and deferasirox

Selected products such as EUCRISA OINTMENT 2% and deferasirox tablets are marked 'PA' in the formulary; prescribers must request prior authorization and supply required documentation for these products.

For topical EUCRISA, note QL and PA (EUCRISA QL(300 GM per 90 days); PA).
For deferasirox, submit PA per Requirements/Limits before dispensing.

Prior Authorization

PA required for GI/specialty agents (VOWST, XIFAXAN, XERMELO)

Products including VOWST, XIFAXAN 550 mg, XERMELO and other select specialty/high‑cost agents are annotated with 'PA' (some also show QL/OVM); providers must obtain PA prior to coverage to avoid denial.

Check Requirements/Limits for PA and QL for these gastrointestinal and specialty agents.
Submit PA with clinical indication and dosing to support coverage.

Prior Authorization

Obtain PA for numerous formulary entries marked 'PA'

Multiple agents in the formulary excerpt are marked 'PA' in the Requirements/Limits column; providers must obtain prior authorization for those listed drugs before dispensing to ensure coverage.

Always verify the 'PA' flag on the formulary line prior to prescribing.
If PA is required, include all requested clinical information to support the authorization.

Prior Authorization

PA required for named injectables (JYLAMVO, JUBBONTI, TYMLOS)

Certain additional examples (JYLAMVO, XATMEP, JUBBONTI, TYMLOS and others) are listed with 'PA'; prescribers must follow the PA process and supply any program‑specific documentation requested.

Confirm PA and OVM where listed (e.g., JYLAMVO shows PA; OVM).
Include dosing, diagnosis, and prior therapies as requested in the PA submission.

Billing Rule

Adhere to quantity limits for vaccines and listed products

Vaccines and certain topical/other products in the formulary include quantity limits (QL) that must be observed (for example SHINGRIX QL(2 EA per 999 days); mesalamine formulations have QL per 90 days).

Do not exceed the stated QL when dispensing; request a QL exception with supporting documentation if clinically necessary.
For SHINGRIX, note the QL of 2 doses per 999 days.

Step Therapy

Step therapy requires documented prior trial(s)

Step therapy (ST) may require the member to try specified alternative(s) first and document failure or intolerance before the requested drug is covered; providers must document prior trials when ST applies.

If a drug is marked 'ST' in Requirements/Limits, document prior trial of the required preferred agent(s).
Prescribers may request an exception with a supporting statement if ST is not clinically appropriate.

Step Therapy

ST required for select products (EXXUA, TRINTELLIX)

Some formulary lines explicitly indicate step therapy (ST) — e.g., EXXUA titration pack and TRINTELLIX entries show 'ST' — providers must follow the step edits listed in Requirements/Limits.

For EXXUA and TRINTELLIX, confirm the ST requirement on the formulary line before prescribing.
Provide evidence of trial and failure/intolerance if requesting bypass of ST.

Note

ST sequences not always specified; follow PA/QL controls

The excerpt primarily shows PA and QL controls rather than detailed step‑therapy sequences; when ST is not listed, PA and QL are the primary utilization controls to follow.

Where step therapy sequences are not specified, check for PA or QL flags that control coverage.
Submit PA documentation as required for products with 'PA'.

Step Therapy

Entries marked 'ST' indicate step therapy (e.g., EXXUA, TRINTELLIX)

Examples in the formulary show step‑therapy flags for products such as EXXUA and TRINTELLIX — entries marked 'ST' indicate a step‑therapy requirement that must be satisfied for coverage.

When 'ST' appears, ensure documented trial and failure/intolerance of required agents prior to approval of the requested drug.
Use the exception process if ST cannot be met for clinical reasons.

Step Therapy

Follow ST or OVM flags where indicated (e.g., febuxostat)

Some agents are noted with 'ST' or other utilization flags (for example febuxostat shows 'ST') or OVM signals for oncology items; providers must adhere to those utilization requirements per the formulary legend.

For febuxostat and similar entries, follow the ST requirement noted in Requirements/Limits.
For OVM items, submit oncology documentation per OncoHealth requirements.

Step Therapy

RYTARY and select products show ST — document prior therapy

Certain formulations of RYTARY and other products list 'ST' in Requirements/Limits indicating step therapy may apply; prescribers must confirm and document required prior therapy.

For RYTARY strengths showing ST, document prior use of preferred agents before requesting coverage for the ST product.
Include relevant clinical notes with any exception request.

Step Therapy

'ST' flag requires adherence to step/site rules

Entries marked 'ST' (step therapy) in the Requirements/Limits column indicate the member must meet step rules per the formulary legend; providers must follow the ST/site rules when present.

Adhere to the ST/site restrictions indicated in the formulary legend when 'ST' is present.
If ST cannot be met, submit prescriber supporting statement with exception request.

Note

When ST not specified, follow PA/QL requirements shown

Where the formulary excerpt does not specify step therapy sequences, providers should rely on the Requirements/Limits flags (PA, QL, ST) shown and follow standard PA/QL processes for coverage determination.

When step sequences are absent, confirm PA/QL requirements on the formulary line.
Use the exception process and prescriber supporting statement when necessary.

Documentation Required

OVM/ONPRO and program‑level utilization management require extra documentation

Some products include OVM or other utilization management signals (for example NEULASTA ONPRO Kit is listed with 'PA; OVM'); providers must submit the additional clinical information specified for program‑level reviews.

For items marked 'PA; OVM' include oncology documentation and site‑of‑care details per OVM requirements.
Claims without required OVM/PA documentation may be denied.

Note

No detailed ST algorithms in excerpt — follow 'ST' flag and exception process

No explicit step‑therapy algorithms are provided in this excerpt; when step therapy applies, follow the 'ST' flag in Requirements/Limits and document prior therapy or request an exception with a prescriber supporting statement.

If ST is required, document prior trial and outcome before seeking coverage for the next step.
Use the expedited exception process if medically necessary.

Step Therapy

FARXIGA and JARDIANCE show 'ST' — document prior therapy

Formulary entries show specific products (e.g., FARXIGA, JARDIANCE) marked 'ST' — confirm and document step therapy requirements before requesting coverage for these agents.

Provide documentation of prior preferred agent trials if 'ST' is indicated for FARXIGA or JARDIANCE.
If clinical reasons exist to bypass ST, submit a prescriber supporting statement with the exception request.

Note

Specialty agents: PA and QL common; step sequences often not listed

High‑tier specialty agents commonly display PA and QL controls but often no step sequences; providers must obtain prior authorization and adhere to quantity limits for these agents.

Confirm PA/QL flags for specialty agents and provide required supporting documentation with PA requests.
Expect OVM or program reviews for many oncology/specialty items.

Documentation Required

Follow PA and QL flags as primary utilization controls

The formulary excerpt lists 'PA' and 'QL' as primary utilization controls across many products; providers must follow those flags when submitting claims or PA requests.

Check the Requirements/Limits field for each product to determine whether PA, QL, ST, or OVM applies.
Include Formulary ID/Version/Effective Date when referencing the formulary in documentation.

Step Therapy

'ST' items require adherence to formulary legend step/site rules

Items marked 'ST' require adherence to step/site rules per the formulary legend; providers must consult the legend and document compliance when submitting authorization requests.

When 'ST' appears on a line, follow the step/site rules per the introductory legend.
Include documentation demonstrating compliance with site‑of‑care or step requirements.

Documentation Required

Prescriber supporting statement required for exceptions

Providers must include a prescriber supporting statement explaining the medical reasons for an exception request; Medicare Plus Blue PPO generally requires this statement to make a decision within standard or expedited timeframes.

Prescriber's supporting statement should describe why the formulary alternative is ineffective or would cause harm.
Standard decision timeframe is 72 hours; expedited requests may be decided within 24 hours when appropriate.

Documentation Required

Submit setting/use details for coverage determinations (Part B vs Part D, OVM)

Plans may require submission of information that describes drug use and setting (for example, whether Part B or Part D applies) or additional clinical details for OVM prior authorizations; include this information when requested to support coverage determinations.

For OVM/antineoplastic PA, include clinical regimen, diagnosis, and site‑of‑care details.
Indicate whether the drug is expected to be covered under Part B or Part D when applicable.

Documentation Required

Document clinical justification when requesting QL exceptions

When requesting a quantity‑limit exception, prescribers must supply documentation to support the requested quantity (examples: linezolid suspension QL(1680 ML per 28 days)); without supporting documentation, requests to exceed QL may be denied.

Include rationale and dosing schedule when requesting QL overrides.
Provide prior treatment history and clinical justification for higher quantities.

Documentation Required

Supply required documentation for PA and QL requests

For drugs marked 'PA' or with specific QL limits, prescribers must supply prior authorization information and supporting medical documentation consistent with plan requirements; failure to supply required documentation may lead to denial.

Attach relevant medical records, prior therapy history, and rationale with PA submissions.
Use formulary Requirements/Limits as the source of required submission elements.

Documentation Required

Follow Requirements/Limits field on formulary entries

Formulary rows include 'Requirements/Limits' fields (PA, OVM, QL, ST); providers must follow these indicators when requesting coverage or submitting claims — e.g., where 'PA' is present the provider must obtain authorization prior to fill.

Always check the Requirements/Limits field for each formulary line before prescribing or dispensing.
If 'PA' is listed, do not dispense expecting coverage without prior approval.

Documentation Required

Include formulary ID/version/effective date in submissions

Providers should include the formulary metadata (Formulary ID 26449, Version 11, Effective Date 02/01/2026) when referencing the formulary in PA or exception requests to ensure reviewers apply the correct formulary version.

Cite Formulary ID: 26449 and Version: 11, Effective Date: 02/01/2026 in submissions.
Include last updated date if available.

Prior Authorization

Obtain PA for high‑cost hormonal/pituitary injectables

Where 'PA' appears alongside high‑cost injectables (for example lanreotide, leuprolide depot, octreotide, somatostatin analogs, SOMATULINE DEPOT), providers must obtain prior authorization per the formulary before dispensing.

Confirm PA for pituitary/hormonal injectables and include required clinical documentation with PA requests.
Claims without PA will likely be denied.

Denial Risk

Denial risk if PA not obtained

Failure to obtain required prior authorization may result in the plan not covering the drug; providers should secure PA before dispensing to avoid non‑coverage for the member.

Do not assume coverage for drugs marked 'PA' without finalized authorization.
Advise patients about the exception request process if PA cannot be obtained in time.

Denial Risk

Denial risk for PA/QL/OVM items without required authorization

Medications listed with 'PA' or with QL/OVM designations are subject to utilization management reviews and may be denied without required authorization or if QLs are exceeded; providers must complete PA/OVM steps to reduce denial risk.

For PA; OVM items include full clinical regimen and site‑of‑care details.
Monitor QL enforcement and request overrides with documentation when clinically necessary.

Denial Risk

Quantity‑limit enforcement and denial risk

Medications with QL entries are subject to quantity checks; exceeding listed QL without an approved override may trigger denial or limit dispensing (examples include multiple QLs shown across the formulary).

Confirm the QL on the formulary line prior to dispensing.
If higher quantity is clinically indicated, submit QL exception with supporting documentation.

Note

Initial Coverage Notes

Initial coverage notes for specialty/high-tier agents

Some specialty/high-cost agents list PA and quantity limits.

PA and QL for specialty/high-tier agents: High‑tier and specialty agents are frequently annotated with Prior Authorization (PA) and Quantity Limits (QL) — coverage requires meeting PA criteria and dispensing within specified QL (examples include VOWST, XIFAXAN 550 mg, XERMELO, GENOTROPIN, SOMATULINE DEPOT, DUPIXENT).

Specific clinical PA criteria are managed through the plan's authorization process (OVM for oncology agents where noted).

Step Therapy Rules and Flags

Requirement	Description
Step therapy (ST)
Member must try specified preferred drug(s) first before the plan will cover an alternate drug for the same condition; prescriber must document trial and failure or intolerance to the preferred agent.

Product	Tier / Requirements
EXXUA titration pack / EXXUA tablets
Tier 5; Requirements/Limits = QL(32 EA per 14 days) for titration pack; QL(31 EA per 31 days) for tablets; ST
TRINTELLIX (various strengths)
Tier 4; Requirements/Limits vary by strength (examples QL(180), QL(360), QL(90) EA per 90 days); ST indicated for listed strengths

Product	Requirement/Note
VOQUEZNA Dual Pak / Triple Pak therapy packs
Tier 4; Requirements/Limits = QL(336 EA per 90 days); PA required for coverage

Product	Requirement/Note
EXXUA (titration pack and tablets)
Requirements/Limits include QL per pack/strength and ST (step therapy) indicated
TRINTELLIX (5 mg, 10 mg, 20 mg)
Tier 4; Requirements/Limits = QL per strength (examples QL(180), QL(360), QL(90) EA per 90 days); ST indicated for listed strengths

Product	Requirement/Note
febuxostat tablet 40mg, 80mg
Tier 3; Requirements/Limits = QL(90 EA per 90 days); ST indicated

Product	Requirement / Quantity Limit
RYTARY capsule extended release (61.25 mg; 245 mg)
Tier 4; Requirements/Limits = QL(300 EA per 30 days); ST indicated
RYTARY capsule extended release (23.75 mg; 95 mg; other strengths)
Tier 4; Requirements/Limits = QL(360 EA per 30 days); ST indicated

Product	Requirement/Limit (includes ST where shown)
RYTARY (multiple strengths)
Requirements/Limits include QL per strength (300 or 360 EA per 30 days) and ST indicated for listed entries
ARISTADA injections (various strengths) / ARISTADA INITIO
Tier 5; Requirements/Limits = QL (e.g., 2.4 mL per 31 days for INITIO) and ST indicated
INVEGA HAFYERA / SUSTENNA / TRINZA (various strengths)
Requirements/Limits include QL per dosing interval (examples 0.25–1.5 mL per dosing period) and ST indicated
REXULTI tablets (various strengths)
Tier 5; Requirements/Limits = QL(31 or 62 EA per 31 days) and ST indicated

Product	PA / Step sequence
MOUNJARO injection (multiple strengths)
Tier 3; Requirements/Limits = QL(2 ML per 28 days); PA indicated (no step sequence specified in excerpt)
OZEMPIC injection / TRULICITY injection / RYBELSUS tablets
Requirements/Limits show QL and PA flags for these diabetes/GLP-1 agents; step therapy sequence not specified in the excerpt

Tier	Notes (PA, QL)
Tier 5 / Specialty agents (examples: VOYDEYA, PROCRIT, NEULASTA, ZARXIO)
Many Tier 5 specialty drugs require prior authorization (PA) and have quantity limits (QL) as listed in Requirements/Limits

Statement	Note
Step therapy sequences
No explicit step therapy sequences or multi-step algorithms are included in the provided excerpt; only individual entries show ST flags where applicable.

Product	Requirement/Flag
FARXIGA (dapagliflozin) tablets 5 mg, 10 mg
Tier 3; Requirements/Limits = QL(90 EA per 90 days); ST indicated
JARDIANCE (empagliflozin) tablets 10 mg, 25 mg
Tier 3; Requirements/Limits = QL(90 EA per 90 days); ST indicated

Observation	Explanation
Step therapy sequences not specified
Formulary lines primarily display tiering plus QL and PA flags; explicit step therapy sequences (ordered steps) are not specified in the excerpt.

Indicator	Implication
ST flag on item rows
Items marked 'ST' require adherence to step therapy/site rules per the formulary legend; where 'ST' appears it indicates a step therapy requirement or site-specific restriction.

Quantity Limits (QL) by Product

inv-147: pioglitazone — 31 tablets per prescription

DrugPioglitazone (example)

Quantity limit31 tablets per prescription

ContextShown in the policy introduction as an example QL per prescription.

inv-148: multiple listed drugs — examples of QL values

Representative QL setMultiple listed drugs show a range of QLs (examples across sections: 180 EA/90 days; 270 EA/90 days; 540 EA/90 days; 372 EA/31 days; 1860 ML/31 days; 12 EA/90 days; 84 EA/28 days).

UseThese example values illustrate the variety of QL formats (EA, ML, GM) and time periods used in the formulary.

Provider actionFollow product-specific Requirements/Limits for dispensing or request exceptions if clinically necessary.

inv-149: IMPAVIDO CAPSULE 50MG — 84 EA

ProductIMPAVIDO capsule 50 mg

Quantity limit84 EA (per 28 days as listed)

Formulary noteTier 5 product with stated QL in the formulary table.

inv-150: linezolid suspension 100mg/5ml — 1680 ML

ProductLinezolid suspension 100mg/5mL (reconstituted)

Quantity limit1680 ML per 28 days

Formulary locationListed under antibacterials with specific QL.

inv-151: linezolid tablet 600mg — 56 EA

ProductLinezolid tablet 600 mg

Quantity limit56 EA per 28 days

Formulary noteQL specified in the antibacterial section.

inv-152: vancomycin capsule 125mg — 360 EA

ProductVancomycin capsule 125 mg

Quantity limit360 EA per 90 days

Related productVancomycin 250 mg capsule QL(720 EA per 90 days)

inv-153: vancomycin capsule 250mg — 720 EA

ProductVancomycin capsule 250 mg

Quantity limit720 EA per 90 days

Formulary noteListed in antibacterials with QL per 90 days.

inv-154: DIFICID (fidaxomicin) 200mg tablet — 20 EA

ProductDIFICID (fidaxomicin) 200 mg tablet

Quantity limit20 EA per 10 days

Tier/NotesTier 5 product with QL matching typical treatment course.

inv-155: BRIVIACT SOLUTION 10MG/ML — 620 ML

ProductBRIVIACT solution 10 mg/mL

Quantity limit620 ML per 31 days

RequirementPA indicated for solution formulation.

inv-156: BRIVIACT TABLET (multiple strengths) — 62 EA

ProductBRIVIACT tablets (multiple strengths)

Quantity limit62 EA per 31 days

RequirementPA indicated for tablet strengths as listed.

inv-157: Multiple per-drug QL values as listed in Requirements/Limits

Various QLsMultiple per‑drug QL values are listed throughout the Requirements/Limits column (see relevant formulary rows for exact unit and period).

ExamplesIncludes QLs for suspensions, tablets, injectables and therapy packs across many classes.

Provider actionReview the specific product row for the correct QL unit and timeframe before dispensing.

Site of Care and Program Indicators

Note

Legend and Abbreviations

Policy Background

This formulary groups drugs by medical condition and lists each product with an assigned Tier and, where applicable, Requirements/Limits such as PA (prior authorization), QL (quantity limits), ST (step therapy) or OVM. Coverage and member cost‑share depend on the assigned tier and adherence to any listed requirements; providers must follow the Requirements/Limits fields and obtain prior authorization when indicated before dispensing.

Biosimilar Substitution and Policy

Note