Blue Cross Blue Shield MI formulary tiers & PA

Coverage Summary (Part 2 — Formulary Annotations)

This file is Part 2 of a multi-part Medicare Plus Blue Group PPO and Prescription Blue Group PDP formulary, effective 05/01/2026. It lists drugs by therapeutic class in an alphabetical/indexed part of the overall drug list and shows each product’s formulary tier (1–5) plus any line-level requirements or limits such as Quantity Limits (QL), Prior Authorization (PA), and plan annotations (e.g., NDS, B/D, OVM). It is intended to guide prescribing, dispensing and claims processing for Medicare Plus Blue Group PPO and Prescription Blue Group PDP.

Formulary metadata

Effective Date2026-05-01

Last Review2026-05-01

Next Review

StatusCURRENT

PartPart 2 of multi-part formulary

Scope SummaryPart 2 listing drugs by therapeutic class with tiers and requirements/limits (QL, PA, NDS). Applies to Medicare Plus Blue Group PPO and Prescription Blue Group PDP effective 05/01/2026.

Coverage / Utilization Controls

Annotations used in the Requirements/Limits column in this part are defined as: QL = Quantity Limit (units allowed in the specified time period); PA = Prior Authorization (plan requires approval before dispensing); ST = Step Therapy (try specified alternative(s) first); NDS = Non‑Drug‑Specified (formulary annotation); B/D = Billing/Dispense flag; OVM = Oncology Value Management/oversight. The document’s introduction pages contain the full symbol legend and expanded definitions.

Coverage stance: this part is informational and lists covered products and program controls. Drugs in the part are assigned to tiers 1–5; tier placement influences member cost‑sharing and benefit adjudication per the plan’s Evidence of Coverage and benefit charts. This part itself does not change medical necessity policy wording — it shows placement and annotations that drive claims processing.

Prior Authorization (PA) and Oversight (OVM)

Prior Authorization

Prior Authorization Required

Prior authorization is required before prescribing or dispensing certain specialty, oncology, cystic fibrosis, and other high-cost agents. Prescribers must obtain PA for the plan to consider coverage; failure to secure PA may lead to claim denial. Follow formulary tier, drug coverage symbols, and introduction guidance when selecting alternatives.

Prior authorization required for specific agents and many specialty/oncology agents (examples below).
PA applies to listed drugs including ERLEADA, XTANDI, lenalidomide, pomalidomide, THALOMID, JYNARQUE, PALYNZIQ, GATTEX, and other specialty therapies.
PA is required for cystic fibrosis and other specialty therapies as noted on the formulary.

Documentation Required

OVM / Specialty verification for oncology agents

Quantity Limits (QL) — Prescribing & Billing Constraints

Billing Rule

Quantity limits must be followed when prescribing & billing

Prescriptions and claims must adhere to the plan's listed quantity limits (QL) for the specified timeframe. Bill only for quantities within the QL and include supporting medical-necessity documentation when prescribing or dispensing amounts that exceed the QL; failure to follow QL enforcement may result in claim denial. See provider_actions for QL enforcement details and denial risk.

Bill within the QL time/unit shown on the formulary line.
Document medical necessity for any exception requests or when dispensing beyond the QL.
Exceeding the listed QL without prior authorization/exception risks claim denial.

Operational note: QL timeframes vary by product (examples include 28, 30, 31, 90, and 365 days). Always consult the specific formulary line for the exact QL unit and timeframe and for claims adjudication rules.

Step Therapy (ST) Requirements

Step Therapy

Step Therapy Required for Certain Products

Products marked ST (step therapy) require that specified prior steps be tried and documented before the plan will cover the requested product. If step criteria are not met, obtain approval per the plan’s step edits or document why prior steps are clinically inappropriate.

oxcarbazepine er
DESVENLAFAXINE ER
EXXUA
RYTARY
TRINTELLIX

Drugs with Step Therapy (ST) - selectedmixed

oxcarbazepine er tablet	ST (step therapy required)
DESVENLAFAXINE ER TABLET EXTENDED RELEASE	ST
EXXUA TABLET and TITRATION PACK	ST; QL noted for titration/maintenance
TRINTELLIX TABLET	ST
RYTARY CAPSULE EXTENDED RELEASE	ST; QL(360 EA per 30 days) noted

Applicable Codes & Billing Designations

Drugs with Prior Authorization (PA)NDC|drug_name|mixedCovered

DIACOMIT CAPSULE/PACKET	Requirements/Limits = PA
rufinamide suspension/tablet	Requirements/Limits = PA
XCOPRI (tablets/therapy packs)	Requirements/Limits = PA; QL on therapy packs
CRESEMBA CAPSULE 74.5/186MG	Requirements/Limits = PA; QL(...)
ERLEADA / XTANDI / NUBEQA / YONSA etc.	Requirements/Limits = PA; OVM for many oncology agents
AIMOVIG / EMGALITY / NURTEC / QULIPTA / UBRELVY	Requirements/Limits = QL(...); PA
PRALUENT INJECTION 150MG/ML	Requirements/Limits = QL(2 ML per 28 days); PA
VERQUVO TABLET 10MG	Requirements/Limits = QL(30 EA per 30 days); PA
MANY MS AGENTS (BETASERON, COPAXONE, REBIF)	Requirements/Limits = QL per product; PA
VENCLEXTA STARTING PACK / VENCLEXTA	Requirements/Limits = QL(...); PA; OVM

Drugs with Quantity Limits (QL)NDC|drug_name|mixedCovered

clobazam suspension 2.5mg/ml	QL(480 ML per 30 days)
clobazam tablet 10/20mg	QL(60 EA per 30 days)
RYTARY CAPSULE EXTENDED RELEASE	QL(360 EA per 30 days)
OPIPZA FILM (2/5/10mg)	QL(60/180/90 EA per 30 days)
paliperidone er tablets	QL(180 EA per 90 days) for 6mg; QL(90 EA per 90 days) for other strengths
risperidone solution	QL(720 ML per 90 days)

Drugs with Billing/Dispense (B/D) or OVM notesmixed

ondansetron products	Requirements/Limits = B/D (billing/dispense noted)
amphotericin / ABELCET / select injectables	Requirements/Limits = B/D for select injectable agents
many oncology agents	Requirements/Limits = PA; OVM (Oncology Value Management) noted where applicable

Guidance for billing/dispensing: tier (1–5) influences adjudication and member cost-share. Many entries in this part are listed by product name and NDC; billing teams should map NDCs to local systems. Where entries include B/D or packaging notes, check product lines for prefilled syringe versus vial distinctions before submitting claims.

Documentation & Operational Notes

Documentation Required

Documentation: Medical Necessity and Formulary Symbols

Document medical necessity when requesting exceptions to QL or PA and follow the formulary introduction for meanings of plan symbols (PA, QL, ST, OVM, B/D, NDS). Keep relevant records and clinical rationale available when submitting PA/exception requests.

clobazam suspension — QL(480 ML per 30 days)
clobazam tablet — QL(60 EA per 30 days)
lenalidomide capsule — QL(31 EA per 31 days)

For formulary questions contact Customer Service at 1-866-684-8216 (TTY 711) or visit www.bcbsm.com/medicare. For symbol meanings and the full product lists see the formulary introduction pages and other parts of the drug list.

Clinical Evidence & Rationale

This part contains no formal clinical‑evidence citations (the evidence array for this part is empty). Utilization controls shown here (PA, QL, ST) are program and policy driven; for drug‑specific medical necessity criteria, consult the plan’s clinical policy or medical coverage guidelines referenced elsewhere in the formulary.

Background & Definitions

Background: this file is part 2 of a multi‑part formulary effective 05/01/2026 and lists drugs by therapeutic class, tier and any requirements/limits (for example, quantity limits QL, prior authorization PA). It is intended to help guide prescribing, dispensing and claims processing.

Term	Definition (exact wording from source)
QL	Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.
PA	Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don't get approval, we may not cover the drug.
ST	Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your condition before we will cover another drug for that condition.
NDS	NDS, Drug Notes Code Definitions. Definition = Non-Extended Day Supply. Most opioid analgesics are available for up to a 31-day supply and benzodiazepines are available for up to a 30-day supply through retail and mail.
B/D	B/D, Drug Notes Code Definitions. Definition = This prescription drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
B/D (alternate wording)	Listed in Requirements/Limits as 'B/D' as shown in source (meaning not defined in this part).
OVM	OVM, Drug Notes Code Definitions. Definition = Oncology Value Management. Prior authorization for antineoplastics and oncology supportive care drugs is required through the Oncology Value Management program, which is administered by OncoHealth. Your physician is required to submit more information to determine coverage.
EA	Each (unit).
ML	Milliliter unit seen in QL entries (Quantity Limit specified as ML per time period in table entries).

Unproven / Exclusions

This part does not list explicit 'not medically necessary' or investigational agents; no explicit not‑covered criteria are included in Part 2. Coverage exclusions and detailed non‑coverage determinations are defined elsewhere in the formulary and Evidence of Coverage.

Revision History

2026-05-01effective_dateLatest

Part 2 formulary effective/last updated

OpenPayer

Medicare Plus Blue Group PPO and Prescription Blue Group PDP formulary — Part 2 (drug list by therapeutic class; effective 05/01/2026)