CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Medicare Plus Blue Group PPO and Prescription Blue Group PDP Formulary (Drug List) — Coverage Criteria

Customize your policy alerts

Sign up for all blue cross blue shield - michigan policy alerts

Know when blue cross blue shield - michigan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs the 2026 Medicare Part D formulary for Medicare Plus Blue Group PPO and Prescription Blue Group PDP members, describing covered drugs, utilization controls (prior authorization, quantity limits, step therapy), exceptions, and transition supplies.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyMedicare Plus Blue Group PPO and Prescription Blue Group PDP Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative update (no material clinical changes)

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateN/A

Key ActionObtain required prior authorization and provide supporting documentation when a formulary entry lists PA or requests exceed QL.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

06/01/2026Formulary effective date

31 daysTransition supply

72/24 hrsException decision time

90-day availability90-day fills (T1–4)

31-day limitSpecialty tier fill limit

Multiple QLsQuantity limits present

Formulary Coverage, Restrictions, and Controls

Formulary coverage overview and restrictions — coverage when on formulary, medical necessity note, network pharmacy, exceptions/transition supply references

What is covered and general formulary rules:

A formulary (drug list) is a list of covered drugs selected by Medicare Plus Blue Group PPO and Prescription Blue Group PDP in consultation with health care providers. The plan will generally cover drugs listed on the formulary when: (1) the drug is medically necessary; (2) the prescription is filled at a Medicare Plus Blue Group PPO and Prescription Blue Group PDP network pharmacy; and (3) other plan rules are followed. See the Evidence of Coverage for details and contact information.

Some covered drugs have additional requirements or limits on coverage. Common controls include prior authorization (PA), quantity limits (QL), and step therapy (ST). Specific coverage for a listed drug is subject to the Requirements/Limits noted in the formulary table. Examples:

- Prior Authorization: The plan requires approval from the plan (or delegated program) before the drug will be covered. If approval is not obtained, the plan may deny coverage.

- Quantity Limits: The plan may limit the amount of a drug covered (e.g., a 31-day supply or specific tablet count per days' supply).

- Step Therapy: The plan may require trial of specified medications (first-line agents) before covering alternative drugs.

If a drug is not on the formulary and a formulary exception is not approved, the plan will not cover the drug. Members may request an exception (including tiering, coverage restriction waivers, or coverage of a non-formulary drug). To request an exception, the prescriber must provide medical rationale; standard decisions are made within 72 hours and expedited decisions within 24 hours when applicable.

Transition and temporary coverage: For new or continuing members taking drugs not on the 2026 formulary or with new restrictions, the plan may cover a temporary 31-day supply during the first 108 days of membership while an exception or coverage decision is pursued. Long-term care residents may be eligible for a 31-day emergency supply while pursuing an exception. Transition assistance (waiver of early refill limits) applies when moving into/out of a long-term care facility, skilled nursing facility, or on hospital discharge.

Formulary coverage with utilization management — covered when listed subject to plan-specific requirements/limits

Formulary coverage is subject to plan-specific utilization management controls. Covered when listed, but only when all applicable requirements/limits are met:

The formulary table lists drugs and, in the Requirements/Limits column, any coverage controls applicable to that drug. Coverage for the listed drug is contingent on meeting those controls.

Common Requirements/Limits codes and meanings:

- PA (Prior Authorization): The plan or its designee requires prior approval before coverage will be provided. Examples in the formulary include many oncology agents (e.g., entries marked PA and/or OVM) and select specialty drugs.

- QL (Quantity Limit): The plan limits the quantity covered per designated time period (e.g., QL(31 EA per 31 days), QL(180 GM per 90 days), QL(3720 ML per 31 days)). The formulary specifies the exact limit for each product when applicable.

- ST (Step Therapy): The plan requires trial of specified medications before covering certain alternatives. See the formulary and the plan’s step therapy policy for details.

- OVM (Oncology Value Management): Prior authorization for antineoplastics and oncology supportive care drugs is required through the Oncology Value Management program (administered by OncoHealth); physicians must submit additional information to determine coverage.

- EX (Excluded): Drugs marked EX are not normally covered by the PDP; amounts paid for EX-coded drugs do not count toward total drug costs and, if applicable, do not count toward extra help qualification. Examples include some topical combination products and other specific items throughout the formulary.

- NDS (Non-Extended Day Supply): Certain controlled substances and other products are restricted to shorter maximum day supplies (e.g., many opioids and benzodiazepines limited to 30–31 day supplies).

The formulary contains many line-item examples showing these flags. For example:

- Oncology and targeted therapies (multiple entries) are commonly listed with PA; many are also flagged OVM (e.g., REVUFORJ = PA; OVM; VONJO = PA; OVM; ZOLINZA = PA; OVM).

- Quantity limits are specified for numerous products (e.g., celecoxib QL(180 EA per 90 days); diclofenac sodium external solution QL(600 ML per 30 days); ketorolac tablet QL(360 EA per 90 days); tramadol ER QL(31 EA per 31 days)).

- EX examples appear (e.g., HYDROCORTISONE/IODOQUINOL CREAM Requirements/Limits = EX; various combination topical products and select oral preparations are marked EX).

Coverage determinations will follow the Requirements/Limits shown; where PA, ST, QL, OVM or other controls are indicated, the plan may deny coverage if those requirements are not satisfied.

Members and prescribers should consult the formulary table for the specific product entry to determine the exact Requirements/Limits (including numeric quantity limits and program-specific notes such as generic equivalents or alternative listings). For full details on how to request prior authorization, step-therapy exceptions, or formulary exceptions, contact Customer Service or review the Evidence of Coverage and the plan’s prior authorization/step therapy documentation posted online.

Coverage controls (PA, QL, OVM) for listed drugs — coverage contingent on Requirements/Limits column

Coverage controls (examples) — listed drugs are subject to the Requirements/Limits noted; if requirements are not met, coverage may be denied:

PA and OVM: Several oncology and specialty agents require prior authorization and enrollment in the Oncology Value Management program (OVM). Examples from the formulary include REVUFORJ (PA; OVM), VONJO (PA; OVM), ZOLINZA (PA; OVM), and many molecular targeted agents listed with PA; OVM.

PA alone: Many specialty and high-cost drugs require prior authorization (e.g., RYLAZE injection listed with PA; numerous oral targeted agents and specialty medications are flagged PA).

QL examples: The formulary specifies precise numeric quantity limits for many products (e.g., QL(31 EA per 31 days); QL(62 EA per 31 days); QL(180 GM per 90 days); QL(3720 ML per 31 days)). These limits are binding for coverage unless a limit is successfully appealed or an exception is granted.

EX examples: Some products are marked EX (excluded) and are not normally covered. EX-coded drugs do not count toward total drug costs for benefit phase calculation and may not be eligible for extra help.

NDS examples: Several opioid analgesics and other controlled substances are designated NDS (Non-Extended Day Supply), limiting them to shorter fills (e.g., 30–31 day supplies).

Formulary listings and plan controls — drugs listed with tier and explicit Requirements/Limits

Formulary listings and plan controls — representative examples:

Therapeutic classes and individual products are presented with drug tier and explicit Requirements/Limits in the formulary (e.g., Antiarrhythmics showing digoxin tablet with QL(90 EA per 90 days); Diuretics with furosemide listed without limits; Diuretics, Thiazide entries with standard tiers and no limits).

Opioid analgesics (long-acting and short-acting) include many NDS and QL entries (e.g., fentanyl patch QL(15 EA per 30 days); methadone solution QL with ML limits; morphine ER products with QL and NDS designations).

Coverage contingent on formulary Requirements/Limits — PA, QL, EX, OVM, NDS examples

Coverage contingent on specific Requirements/Limits — examples and operational notes:

Some specialty therapies require both QL and PA (e.g., tolvaptan tablet therapy pack noted with QL(56 EA per 28 days); PA, and other tolvaptan strengths listed with QL; PA).

Certain renal and phosphate binders are listed with PA or QL (e.g., AURYXIA listed with PA; sevelamer carbonate packet with QL numeric limits).

Supply limits and pack-specific rules are included in Requirements/Limits (e.g., PYRUKYND taper packs have QL per 28-day limits and PA; PALYNZIQ injection listed with PA).

For products marked PA, documentation requirements and plan or vendor-specific prior authorization processes apply (see Oncology Value Management notes where OVM is indicated).

Formulary Codes, Tiers, and Quantity Rules

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Prior Authorization

Prior authorization required for listed drugs

Certain drugs listed on the formulary require prior authorization (PA); providers or prescribers must obtain plan approval before the prescription is filled or the plan may not cover the drug.

Prior Authorization

OVM/OncoHealth prior authorization for oncology drugs

Oncology antineoplastics and oncology supportive care drugs require prior authorization through the Oncology Value Management (OVM) program administered by OncoHealth; the physician must submit additional information to determine coverage.

Prior Authorization

PA flagged for specific products (examples)

Some products in the formulary are flagged 'PA' (for example, lidocaine/prilocaine cream and VOQUEZNA therapy packs), indicating prior authorization is required before coverage.

Prior Authorization

Obtain PA when 'PA' is indicated

When a product row in the formulary shows 'PA' in the Requirements/Limits column, the provider must obtain prior authorization from the plan prior to dispensing to ensure coverage.

Prior Authorization

PA required for selected products (examples)

Selected products are designated 'PA' in the formulary (examples include ZTALMY suspension, rufinamide products, and memantine ER); providers must submit prior authorization requests for these items.

Prior Authorization

PA required for select high‑tier/specialty drugs

Several high‑tier or specialty formulary drugs are labeled 'PA' (examples include VECAMYL, VYNDAMAX); prior authorization must be obtained before coverage is approved.

Prior Authorization

PA required for many listed drugs

Many drugs in the formulary display 'PA' in the Requirements/Limits column; providers must secure prior authorization prior to dispensing to avoid claim denial or noncoverage.

Prior Authorization

PA and/or step therapy required for select agents (examples)

Some agents require prior authorization and/or step therapy; examples in the formulary include LIVTENCITY, PREVYMIS, NUPLAZID, OPIPZA FILM and RYTARY where 'PA' or 'ST' is indicated.

Prior Authorization

PA required for select GLP‑1 / tirzepatide agents

Select GLP‑1 receptor agonists and tirzepatide products (e.g., MOUNJARO, OZEMPIC, RYBELSUS, liraglutide) are designated 'PA' and require prior authorization for coverage.

Prior Authorization

PA required for listed specialty/high‑tier agents (examples)

Prior authorization is required for specific high‑tier or specialty agents (examples include HUMULIN R U‑500, ARANESP, EPOGEN, NEULASTA, PROCRIT, FULPHILA); providers must submit PA requests per formulary entries.

Prior Authorization

Prior authorization plus quantity limits may apply

Some products include both prior authorization (PA) and quantity limits (QL) in their Requirements/Limits; providers must obtain PA and ensure dispensed quantities meet the specified QL.

Prior Authorization

PA required for additional listed drugs (examples)

Examples of drugs requiring prior authorization appear throughout the formulary (for example, NUEDEXTA, tetrabenazine, multiple MS agents and OTEZLA entries); providers must follow the PA process before dispensing.

Prior Authorization

Combined PA and QL for specialty drugs (examples)

Several specialty drugs combine PA and QL flags (e.g., PRALUENT, NEXLETOL/NEXLIZET, KERENDIA, VERQUVO); providers must request PA and adhere to the listed quantity limits.

Prior Authorization

PA required for tier 5 specialty products (examples)

Certain tier‑5 specialty products such as OTEZLA and tolvaptan/JYNARQUE are marked 'PA' in the Requirements/Limits; prior authorization must be obtained for coverage.

Prior Authorization

Prior authorization required — general statement

Formulary entries annotated with 'PA' indicate the plan requires prior authorization; providers are responsible for obtaining PA to secure coverage.

Step Therapy

Step therapy: try first‑line drug(s) before alternatives

Step therapy may require trying specified first‑line formulary drugs before coverage is allowed for alternative drugs; providers should confirm whether 'ST' is shown for a product and document trials accordingly.

Step Therapy

Step therapy applies to some listed drugs

Some drugs are explicitly subject to step therapy (ST) as shown in the Requirements/Limits column; providers must follow the ST edits (e.g., oxcarbazepine ER, febuxostat and certain long‑acting injectables marked 'ST').

Step Therapy

Step therapy: follow plan edits when 'ST' flagged

No detailed step therapy algorithms are provided in the formulary excerpts; when 'ST' is shown the provider must follow the plan's step edits and document prior therapy and treatment failure as needed.

Step Therapy

Step therapy indicators (examples)

Products with 'ST' shown (examples include oxcarbazepine ER, REXULTI, ABILIFY long‑acting injectables) indicate step therapy edits apply; providers should confirm required prior steps before prescribing alternatives.

Step Therapy

Step therapy present for select drugs (example febuxostat)

Some formulary entries show 'ST' for specific products (for example, febuxostat lists 'ST'), indicating the plan requires step therapy prior to coverage of alternatives.

Step Therapy

ST for long‑acting injectables and specialty agents

Certain long‑acting injectable antipsychotics and specialty injectable agents are marked 'ST' (e.g., ABILIFY MAINTENA, ARISTADA, INVEGA products); providers must meet the step therapy edits prior to coverage.

Step Therapy

Step therapy for select insulin products

Some insulin products (APIDRA SOLOSTAR, APIDRA) are designated 'ST' in the Requirements/Limits and are subject to step‑therapy edits; providers must follow the ST requirements when requesting coverage.

Step Therapy

ST indicated for some SGLT2 inhibitors

Step therapy markers are shown for certain SGLT2 inhibitors (e.g., FARXIGA, JARDIANCE) indicating a step therapy requirement may apply; providers should verify and document prior treatment steps.

Step Therapy

When step therapy details are not shown, consult plan step rules

Some products are labeled 'ST' while many entries do not include explicit step therapy program language; absence of detail means providers must consult the plan's step therapy documentation for specific rules.

Note

Documentation Required

Exception request: prescriber supporting statement and timeframes

When requesting an exception to the formulary (to override PA, ST, or QL), the prescriber's supporting statement explaining the medical reasons must be submitted; standard decision timeframes are 72 hours, and expedited requests are decided within 24 hours when appropriate.

Prescriber must explain the medical reasons for the exception.
Standard decision timeframe: 72 hours; expedited: 24 hours.

Documentation Required

Provide B/D and site‑of‑care information when applicable

For drugs that may be covered under Part B or Part D (B/D designation) or where site of administration affects coverage, providers should submit information describing the drug's use and setting to help determine whether coverage falls under Part B or Part D.

Documentation Required

Document justification when requesting quantities above QL

When prescribing quantities that exceed the formulary's specified quantity limits (QL), providers should include supporting documentation and dosing rationale with the prior authorization or exception request to justify the additional quantity.

Document the requested strength/form and the clinical rationale for exceeding QL.
Refer to the product's QL value (e.g., DIFICID QL(136 ML per 10 days)).

Documentation Required

Include dosing/quantity justification with PA/QL requests

When a product is designated 'PA' or 'QL' the provider should include dosing, quantity, and clinical justification in the PA request to support approval; lack of supporting documentation may result in denial.

Documentation Required

Follow Requirements/Limits codes and provide required supporting documentation

Formulary entries use the symbols PA, ST, QL and NDS; providers should follow the Requirements/Limits codes and the document's introduction pages for symbol definitions when preparing authorizations and documentation.

Note

Documentation Required

Adhere to explicit quantity limits or document exceptions (examples)

For products with explicit QL values (for example RUBRACA QL(124 EA per 31 days) or VENCLEXTA STARTING PACK QL(84 EA per 365 days)), providers must adhere to those limits or submit documentation supporting a quantity exception.

Documentation Required

Submit documentation to support PA and QL requests

Providers must supply documentation supporting prior authorization requests for products marked 'PA' and provide rationale when requesting quantities above QL; failure to submit required documentation may lead to denial.

Denial Risk

Denial risk: no PA may result in noncoverage

Drugs labeled 'PA' in the Requirements/Limits can be denied if prior authorization is not obtained; providers are responsible for obtaining PA to avoid noncoverage.

Denial Risk

Denial risk: unmet PA or QL requirements

Claims for drugs listed with 'PA' or 'QL' may be denied if prior authorization is not obtained or if the dispensed quantity exceeds the formulary quantity limit without an approved exception.

Obtain PA before dispensing drugs marked 'PA'.
Do not exceed QL unless an exception is approved.

Denial Risk

Denial triggers from PA/ST/NDS flags

Items marked with PA, ST, or NDS in the formulary may trigger claim denials if the corresponding authorization or step therapy requirements are not met; providers should confirm flags and follow the plan's processes.

Denial Risk

PA required for tolvaptan/JYNARQUE — denial risk without PA

Requests for tolvaptan (including JYNARQUE) are shown with 'PA' and may be denied without prior authorization; providers must obtain PA for these formulations.

Denial Risk

PA required for select specialty injectables (examples)

Coverage for specialty injections (examples: PALYNZIQ, PROLASTIN‑C, RAVICTI, REVCOVI) is listed as PA; claims may be denied if PA is not obtained prior to administration or dispensing.

Denial Risk

Denial risk for exceeding quantity limits

Providers must respect formulary quantity limits (QL) — requests exceeding a product's QL (for example oseltamivir QL(168 EA per 180 days) or DIFICID limits) may be denied unless supported by documentation and approved exception.

Note

Step Therapy Indicators and Affected Products

Coverage note
Step therapy (ST) requires that specified formulary first‑line drugs be tried and found ineffective or not tolerated before the plan will cover an alternative drug for the same condition.

Example ST designations / context
The formulary uses the 'ST' (Step Therapy) code to indicate that a specified first‑line agent must be tried first; see the Requirements/Limits code definitions in the introduction pages.

Anticonvulsant / specialty PA context
Several anticonvulsant and specialty products include utilization controls: examples include brivaracetam (Requirements/Limits = QL(...); PA) and multiple levetiracetam formulations marked PA in the listing.

ST label meaning / examples
Entries labeled 'ST' indicate step therapy must be met prior to coverage; examples in the formulary include oxcarbazepine ER (Requirements/Limits = ST) and several products with ST noted in their Requirements/Limits fields.

febuxostat (example)
Febuxostat tablets (40 mg, 80 mg) are listed with Requirements/Limits including QL and 'ST', indicating a step therapy requirement may apply to febuxostat prescribing.

Specialty injectables / oral agents with ST
Multiple long‑acting injectable antipsychotics and specialty agents are marked 'ST' in the formulary (examples include ABILIFY ASIMTUFII, ABILIFY MAINTENA, ARISTADA, ARISTADA INITIO, CAPLYTA, REXULTI and risperidone long‑acting injectables), indicating step therapy edits apply.

APIDRA insulin — ST designation
APIDRA SOLOSTAR injection 100 unit/mL and APIDRA injection 100 unit/mL are listed with Requirements/Limits = ST, indicating step therapy edits apply to these insulin products.

Requirements/Limits = ST (APIDRA examples)
Formulary rows for APIDRA (APIDRA SOLOSTAR and APIDRA injection) explicitly show 'ST' in the Requirements/Limits column, meaning the plan requires step therapy be satisfied per the formulary coding.

Step therapy context where steps not detailed
The formulary indicates when step therapy (ST) applies via the Requirements/Limits column, but no explicit step‑by‑step algorithms or sequences are provided in the listing; specific clinical step rules are referenced on the introduction pages or separate program documents.

SGLT2 inhibitors (example FARXIGA, JARDIANCE)
Certain SGLT2 inhibitors are marked 'ST' in the formulary; for example, FARXIGA and JARDIANCE entries include ST in their Requirements/Limits, indicating step therapy requirements apply to these agents.

PA and/or QL listed; step rules absent
Some products are shown with prior authorization (PA) and/or quantity limits (QL) in their Requirements/Limits fields; where PA/QL are listed there may be step implications, but explicit step therapy rules are not provided in these chunks.

Branded specialty products with PA/QL (examples)
Branded specialty agents such as OTEZLA (OTEZLA, OTEZLA XR and therapy packs) and tolvaptan (including JYNARQUE and tolvaptan tablets) are listed with Requirements/Limits = PA and QL, indicating prior authorization and quantity limits apply and may interact with step/coverage processes.

No explicit ST requirements in some chunks
Several formulary segments show PA, QL, or OVM flags but do not include explicit step therapy ('ST') entries; where ST is not present the listing does not describe step requirements in the available excerpt.

Quantity Limit Values and Examples

Example pioglitazone prescribing limit (31 tablets per prescription example)

Pioglitazone prescribing example31 tablets per prescription (example provided in formulary guidance)

Related QLsPioglitazone entries also show QL(90 EA per 90 days) for some strengths elsewhere; check product row.

ImplicationSome products are limited to a 31‑tablet prescription even if other QLs exist for different strengths.

acetaminophen/codeine solution QL example

Acetaminophen/codeine solution QLQL(5167 ML per 31 days)

FormulationAcetaminophen/codeine solution 120mg/5mL (Tier 2)

Dispensing noteQuantity limited to 5167 mL per 31 days per formulary row.

acetaminophen/codeine tablet QL example

Acetaminophen/codeine tablet QLQL(186 EA per 31 days)

Formulation examplesVarious acetaminophen/codeine tablet strengths listed with 186 EA per 31 days QL.

NoteTablets use EA unit limits; verify specific strength row for exact QL.

lidocaine patch 5% QL example

Lidocaine patch 5% QLQL(270 EA per 90 days)

FormulationLidocaine patch 5% listed with form‑specific QL and PA flags in some rows.

DispensingLimit applies over a 90‑day period as shown in formulary.

KLOXXADO liquid QL example

KLOXXADO liquid QLQL(12 EA per 90 days)

FormulationKLOXXADO liquid 8mg/0.1mL listed with 12 EA per 90 days QL.

ImplicationOpioid reversal agent dispensing limited to 12 units per 90 days.

linezolid suspension QL example

Linezolid suspension QLQL(1680 ML per 28 days)

Linezolid tablet QLQL(56 EA per 28 days) for 600mg tablet

FormulationLinezolid suspension reconstituted 100mg/5mL and 600mg tablet rows include QLs.

linezolid tablet QL example

Linezolid tablet QLQL(56 EA per 28 days)

FormulationLinezolid 600mg tablet listed with 56 each per 28 days limit.

NoteFollow the 28‑day window for dispensing linezolid tablets per listing.

VOQUEZNA therapy packs QL example

VOQUEZNA therapy pack QLQL(336 EA per 90 days)

ProductVOQUEZNA dual and triple pack therapy packs listed with same QL and PA.

ImplicationTherapy pack dispensing governed by the 336 EA per 90 days limit and PA.

DIFICID suspension QL example (repeat)

DIFICID suspension QL (repeat)QL(136 ML per 10 days)

DIFICID tablet QL (repeat)QL(20 EA per 10 days)

TierDIFICID entries assigned to Tier 5 with specified QLs.

DIFICID tablet QL example (repeat)

DIFICID tablet QL (repeat)QL(20 EA per 10 days)

FormulationFidaxomicin tablets listed with 20 each per 10 days limit in formulary.

Dispensing noteAdhere to the 10‑day course limits for both suspension and tablets.

MINOCYCLINE ER QL example (repeat)

MINOCYCLINE ER QL (repeat)QL(90 EA per 90 days)

Formulation noteMultiple ER strengths listed with same 90‑day QL.

TierListed at Tier 2 (and Tier 4 for some strengths) with consistent QL.

brivaracetam solution/tablet QL examples

Brivaracetam solution/tablet QLsQL(620 ML per 31 days) for solution; QL(62 EA per 31 days) for tablets

PAPA indicated alongside QL for brivaracetam entries.

TierListed at Tier 3 with QL and PA.

gabapentin solution QL example

Gabapentin solution QLQL(6480 ML per 90 days)

Gabapentin capsule/tablet QLsCapsule QL(810 EA per 90 days); tablet 800mg QL(360 EA per 90 days)

TierGabapentin entries listed at Tier 2 with form‑specific QLs.

gabapentin capsule QL example

Gabapentin capsule QLQL(810 EA per 90 days)

FormulationCapsules 100/300/400mg show EA limits over 90 days per listing.

ActionApply the capsule QL when dispensing capsule strengths.

gabapentin solution 250mg/5ml QL example

Gabapentin 250mg/5mL solution QLQL(6480 ML per 90 days)

Formulation noteSolution strengths have large ML-based limits reflecting liquid dosing.

ImplicationUse ML-based QL for suspension dispensing and claims.

gabapentin tablet 800mg QL example

Gabapentin tablet 800mg QLQL(360 EA per 90 days)

Formulation800mg tablet row lists 360 each per 90 days limit.

NoteHigher-strength tablets have distinct EA QLs compared with capsules/solutions.

ZTALMY SUSPENSION QL example

ZTALMY suspension QLQL(1116 ML per 31 days)

Formulation/TierZTALMY suspension 50mg/mL listed at Tier 5 with QL and PA.

ImplicationLiquid therapy packs and suspensions often use ML-based QLs over monthly windows.

lacosamide solution QL example

Lacosamide solution QLQL(3600 ML per 90 days)

Lacosamide tablets QLsQL(180 EA per 90 days) for 100/150/200mg; QL(360 EA per 90 days) for 50mg tablets

PA/STSome lacosamide entries include PA or other requirement flags; check row.

lacosamide tablets QL examples

Lacosamide tablet QL (100/150/200mg)QL(180 EA per 90 days)

Lacosamide 50mg tablet QLQL(360 EA per 90 days)

UseSelect the QL matching tablet strength when processing.

lacosamide 50mg tablet QL example

Lacosamide 50mg tablet QL (repeat)QL(360 EA per 90 days)

Formulation noteLower-dose tablet formulations may allow higher EA counts across the period.

ActionApply the listed QL corresponding to strength/formulation.

XCOPRI tablet QL example

XCOPRI tablet QLQL(31 EA per 31 days) for some tablet strengths; therapy pack limits vary

Formulation noteMultiple XCOPRI therapy pack and tablet rows show differing QLs and PA requirements.

ImplicationCheck the specific pack/strength row for the applicable QL.

donepezil various forms QL example

Donepezil QL rangeQL(90-180 EA per 90 days) depending on strength

FormulationsVarious donepezil forms and strengths listed with differing 90‑day EA limits.

ActionUse strength‑specific QL when adjudicating claims.

AUVELITY QL example

AUVELITY QLQL(62 EA per 31 days)

ProductAUVELITY tablet ER 105mg listed with 62 each per 31 days and PA.

ImplicationDispensing limited to the 31‑day pack quantity unless PA allows otherwise.

aprepitant capsule QL example

Aprepitant capsule QLQL(12 EA per 90 days) for 40mg capsule

ContextAprepitant entries also include B/D designation for Part B/Part D determination.

ActionObserve B/D and QL flags when submitting coverage requests.

CRESEMBA QL example

CRESEMBA QLQL(175 EA per 31 days) for 74.5mg capsule

PACRESEMBA entries also list PA alongside QL.

ImplicationCoverage requires adherence to both QL and PA processes.

AIMOVIG injection QL example

AIMOVIG QLQL(3 ML per 84 days)

FormulationAIMOVIG injection 140mg/mL listed with 3 mL per 84 days and PA.

Dispensing noteAdhere to 84‑day ML limit for migraine biologic dispensing.

RUBRACA QL example (repeat)

RUBRACA QL (repeat)QL(124 EA per 31 days)

Product noteRUBRACA tablet quantities limited monthly per formulary row.

ActionFollow the 31‑day EA limit when processing oncology agent claims.

VENCLEXTA STARTING PACK QL example

VENCLEXTA Starting Pack QL (repeat)QL(84 EA per 365 days)

ProductVENCLEXTA starting pack therapy pack limited annually per formulary listing.

ImplicationAnnual QL applies to starter pack dispensing and coverage decisions.

Mixed examples list (various specialty meds)

Mixed specialty examplesOTEZLA QL(31 EA per 31 days) or QL(62 EA per 31 days) depending on formulation; tolvaptan QL(31 EA per 31 days) / QL(62 EA per 31 days)

PA requirementMany of these specialty entries also list PA alongside QL.

ActionVerify both QL and PA before dispensing or submitting prior authorization requests.

DESCOVY tablet QL example (repeat)

DESCOVY QL (repeat)QL(31 EA per 31 days)

Product detailsDESCOVY tablet combinations listed at Tier 5 with 31‑day QL.

DispensingLimit applies per 31‑day period; adhere to listed QL for coverage.

oseltamivir capsule QL example (repeat)

Oseltamivir capsule QL (repeat)QL(168 EA per 180 days)

FormulationsMultiple oseltamivir strengths have QLs over 180‑day windows (e.g., 84 EA per 180 days for other strengths).

ImplicationApply the 180‑day limit across antiviral dispensing as indicated.

RUKOBIA QL example

RUKOBIA QLQL(62 EA per 31 days)

ProductRUKOBIA tablet extended release 600mg listed at Tier 5 with 62 each per 31 days.

DispensingMonthly EA limit applies per formulary row.

liraglutide QL example (repeat)

Liraglutide QL (repeat)QL(27 ML per 90 days)

ContextLiraglutide injection entries include PA and the 90‑day ML limit.

ActionUse ML‑based QL for mL formulations when adjudicating claims.

MOUNJARO QL example

MOUNJARO QLQL(2 ML per 28 days)

FormulationMOUNJARO injection rows list 2 mL per 28 days and PA.

Dispensing noteMonthly or 28‑day ML limits apply for GLP‑1/tirzepatide agents as listed.

dabigatran QL example and related DOAC QLs

Dabigatran QLQL(180 EA per 90 days)

ELIQUIS QLsMultiple ELIQUIS QLs by formulation (e.g., QL(148 EA per 365 days); QL(194 EA per 90 days); QL(1164 EA per 90 days)).

Rivaroxaban suspension QLQL(2700 ML per 90 days)

ELIQUIS QL examples

ELIQUIS multiple QLsQL(148 EA per 365 days); QL(194 EA per 90 days); QL(1164 EA per 90 days) depending on formulation

ImplicationDifferent ELIQUIS formulations use distinct QLs — use exact row value for claims/PA.

ActionVerify the formulation (starter pack, soluble, tablet) to apply correct QL.

Site-of-Care and B/D Coverage Considerations

Documentation Required

Document site‑of‑care for B/D drugs

When a product is labeled 'B/D' or site of care may affect coverage, providers should include details about where and how the drug will be administered (infusion center, office, pharmacy) to support correct coverage determination.

Provide setting and use information for B/D‑designated drugs.

Formulary Symbols and Abbreviations

Formulary Organization and Context

The formulary groups drugs by medical condition and lists both brand‑name and generic products as well as biologicals and biosimilars. Coverage is provided for drugs on the plan formulary when used for a medically necessary indication, dispensed at network pharmacies, and when any listed utilization controls (for example, PA, QL, or ST) are satisfied.

Biosimilar Substitution and Policy Notes

Billing Rule

Biosimilar substitution and tier changes

The plan may substitute an original biological product with a biosimilar (including interchangeable biosimilars) and may reassign tiers or restrictions; providers should expect possible immediate replacement and follow substitution rules per state law.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyMedicare Plus Blue Group PPO and Prescription Blue Group PDP Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative update (no material clinical changes)

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateN/A

Key ActionObtain required prior authorization and provide supporting documentation when a formulary entry lists PA or requests exceed QL.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.