Currentblue cross blue shield - michiganPolicy Formulary 25351

Medicare Plus Blue PPO Core Formulary (Drug List)

This document is the Medicare Plus Blue PPO Core formulary listing covered prescription drugs, coverage rules (prior authorization, quantity limits, step therapy), and member instructions for Medicare Plus Blue PPO plans. It affects Medicare Plus Blue PPO members and their prescribers and pharmacies.

Policy Summary

Payerblue cross blue shield - michigan

PolicyMedicare Plus Blue PPO Core Formulary (Drug List)

Policy CodePolicy Formulary 25351

Change TypeNo material change

Effective DateDec 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests and supporting clinical documentation for drugs marked 'PA' to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12/01/2025Effective

21Version

25351Formulary ID

31 daysTransition supply

PresentSpecialty tier

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Utilization controls

Coverage Criteria and Formulary Rules

inv-01: General Coverage — Medicare Plus Blue PPO will generally cover drugs listed in the formulary when ALL of the following are met:

Medicare Plus Blue PPO will generally cover drugs listed in the formulary when ALL of the following are met:

Coverage conditions: (1) Drug is listed on the formulary; (2) Drug is medically necessary; (3) Prescription is filled at a Medicare Plus Blue PPO network pharmacy; (4) Other plan rules (prior authorization, step therapy, quantity limits) are followed.

See formulary chart for drug-specific Requirements/Limits entries and consult Evidence of Coverage for filling instructions.

inv-02: Formulary Change Impacts — Mid-year changes and member protections

Mid-year changes and member protections

Immediate change scenarios: Drugs may be immediately removed or moved if replaced by a generic or certain biosimilars, or if withdrawn from market for safety/effectiveness; members currently taking a drug may request an exception to continue coverage.

When other mid-year changes (tier moves, added restrictions) are made, affected members will be notified at least 30 days prior or may receive a 31-day temporary supply and notice when they request a refill.

inv-03: Transition Policy — Temporary coverage for new members or members affected by formulary changes

Temporary coverage for new members or members affected by formulary changes

Temporary supply rules: New members or members whose drug is newly non‑formulary or newly restricted will be provided a temporary 31‑day supply; long‑term care residents past 108 days may receive a 31‑day emergency supply while pursuing an exception.31 days

Limits on early refills may be waived during transitions into/out of facilities; plan will notify member within 3 business days after filling a temporary transition supply.

inv-04: General coverage rules on these pages — Coverage, utilization management, and quantity limits for listed drugs as indicated in the formulary rows

Coverage, utilization management, and quantity limits for listed drugs as indicated in the formulary rows

Formulary entries with utilization requirements: Drugs listed include a tier and may include one or more requirements: Quantity Limit (QL), Prior Authorization (PA), Step Therapy (ST), or B/D flags. Coverage is subject to those requirements and to definitions on the introduction pages.

Refer to each product row for exact QL values, PA, ST, or B/D indications (examples: lacosamide QL(3600 ML per 90 days); XCOPRI QL and PA).

inv-05: Formulary coverage annotations — Coverage annotations are presented as drug-level tier and Requirements/Limits entries; coverage is conditional where PA or QL is indicated.

Coverage annotations are presented as drug-level tier and Requirements/Limits entries; coverage is conditional where PA or QL is indicated.

General formulary entries: Drugs are listed with a tier and may include Requirements/Limits such as QL (quantity limit), PA (prior authorization), B/D, ST, or NDS; coverage is subject to those stated requirements.

Examples shown in the formulary: TRIKAFTA (QL; PA), TOBI PODHALER (QL; PA), FASENRA/NUCALA (QL; B/D = PA); see the Requirements/Limits column for specifics.

If a prescribed drug is not listed on the Medicare Plus Blue PPO formulary and an exception is not approved, the plan will not cover the drug. Members should first contact Customer Service to confirm coverage and to request a list of similar covered drugs to discuss with their prescriber. Alternatively, members (or prescribers on their behalf) may request a formulary exception; the prescriber must submit a supporting statement explaining the medical rationale for the exception and decisions are handled per the plan’s exception process.

Most maintenance medications on Tiers 1–4 may be dispensed for up to a 90‑day supply at participating pharmacies. Medications on Tier 5 are limited to a maximum 31‑day supply per fill. Out‑of‑network pharmacy coverage is available only in limited situations; members should consult the Evidence of Coverage for details.

These formulary pages do not set out specific clinical exclusions. The table lists drugs, tiers, and any Requirements/Limits flags (e.g., QL, PA, ST, B/D); where clinical exclusions apply they are defined elsewhere in the plan documents. Providers should consult other formulary sections or the plan’s policy introduction for any explicit exclusion language.

This excerpt does not include a list of conditions or services explicitly labeled as "Not Medically Necessary." Absence of such listings on these pages does not imply none exist elsewhere in plan materials; refer to the broader policy documents or the Evidence of Coverage for any Not Medically Necessary definitions or examples.

Coding, Drug Listings, and Quantity Limit Examples

No codes listed

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Prior Authorization Required — Some drugs require prior authorization

Some covered drugs listed in the formulary require Prior Authorization (PA) before the prescription is filled. Where a drug line lists "PA" (or PA; OVM/B/D combinations), the prescriber or member must obtain approval from Medicare Plus Blue PPO prior to dispensing — failure to obtain required PA may result in the plan denying coverage for the drug.

PA flags appear throughout the formulary (e.g., BRIVIACT, EPIDIOLEX, FINTEPLA, LIVTENCITY, EPCLUSA, HARVONI, NEULASTA, PRALUENT, REPATHA, TRIKAFTA, COSENTYX, DUPIXENT, many biologics and specialty injectables).
Some agents are subject to Oncology Value Management (OVM) — antineoplastics and oncology supportive drugs require additional oncology prior authorization via OncoHealth; entries show "PA; OVM".
B/D indicates drugs that may be covered under Part B or Part D depending on setting; supporting documentation about use/setting may be required to determine coverage and PA responsibility.

Denial Risk

Quantity Limits by Drug and Presentation

Drug	Quantity limit
pioglitazone (example)
31 tablets per prescription

inv-117: Multiple listed drugs (see drug_names)

Multiple product QL examplesVaries by product — examples include QL(270 EA per 90 days), QL(372 EA per 31 days), QL(124 EA per 31 days), QL(15 EA per 30 days)

Methadone solution/tablet examplesQL(3720 ML per 31 days); QL(372 EA per 31 days) for tablet strengths

Vancomycin capsule QLsQL(360 EA per 90 days) and QL(720 EA per 90 days) depending on strength

inv-118: DIFICID TABLET

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

Site-of-Care and Benefit Determination

Note

Abbreviations and Definitions

Background and Scope

The formulary groups drugs by therapeutic category and provides each entry with the brand and generic name, assigned tier, and any Requirements/Limits (for example: Quantity Limits (QL), Prior Authorization (PA), Step Therapy (ST), or B/D designation indicating possible Part B vs Part D coverage). These annotations indicate utilization management that may affect coverage and claims processing; providers should consult the individual product row and the formulary introduction pages for the precise interpretation and any documentation or prior authorization processes required.

Note

Policy Summary

Payerblue cross blue shield - michigan

PolicyMedicare Plus Blue PPO Core Formulary (Drug List)

Policy CodePolicy Formulary 25351

Change TypeNo material change

Effective DateDec 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests and supporting clinical documentation for drugs marked 'PA' to avoid coverage denial.

SourceLink

On This Page

PA and Quantity Limits — Denial risk when PA or QL not met

Prior authorization requirements often coexist with Quantity Limits (QL) and other verification programs. When a drug row lists PA and a QL, the plan may deny claims where PA is not obtained or where the requested quantity exceeds the QL. Providers should confirm both PA and QL before prescribing or dispensing.

Examples: fentanyl oral transmucosal lozenges (QL + PA); BRIVIACT (QL + PA); EXXUA and other titration/therapy packs (QL + ST + PA flags in places).
HCV and HBV regimens (EPCLUSA, HARVONI) list QL and PA; failure to obtain PA or to adhere to QL may result in denial.
Specialty high-cost biologics and injectables frequently show both QL and PA (e.g., COSENTYX, DUPIXENT, SKYRIZI, many immunologics).

Documentation Required

PA plus OVM/B/D — Additional documentation may be required

Some drugs are marked with PA plus other program flags (OVM, B/D). When PA is combined with OVM or B/D, additional documentation or clinical records must be submitted to determine medical necessity and coverage responsibility. Do not assume PA alone is sufficient — follow the documentation guidance in the introduction.

OVM entries (e.g., many antineoplastics) require oncology-specific submission via the Oncology Value Management program administered by OncoHealth.
B/D entries indicate Part B vs Part D coverage determination may require supporting information about administration setting and indication.

Step Therapy

Step Therapy — Indicators present but full rules not shown in this excerpt

Step therapy (ST) edits appear in the formulary but are not broadly described in this extracted segment. Where "ST" is present on a drug row, the plan may require trying a preferred alternative before covering the requested drug. This excerpt does not contain full step therapy sequences or rules; consult the formulary introduction or the plan's online prior authorization/step therapy documents for full requirements.

Examples of ST flags in the listing include EXXUA TITRATION PACK, certain long‑acting injectables (e.g., ABILIFY ASIMTUFII, ARISTADA products), and select oral products.
No explicit step therapy sequences are present in this extracted segment — providers should refer to the plan's step therapy policy and the formulary introduction for operational rules and allowed exceptions.

Documentation Required

Documentation and Version Tracking — Submit prescriber supporting statement and confirm formulary version

Follow the formulary's Requirements/Limits column and the introduction pages for documentation instructions. When submitting PA or exception requests, the prescriber must provide a supporting statement explaining the medical necessity; expedited (24-hour) review is available when waiting could seriously harm the member. The formulary version and effective date are listed on table pages and should be used to confirm policy currency.

Prescribers should include clinical rationale and relevant records for PA or tiering/formulary exceptions; typical decision timeframe is 72 hours (or 24 hours for expedited requests).
Formulary ID: 25351, Version: 21, Effective Date: 12/01/2025; Last Updated: 12/01/2025 — use these to verify you are following the current requirements.

Note

Index Note — This excerpt is a formulary listing; consult the introduction for complete rules

This section is an index/listing of formulary entries and flags (PA, QL, ST, B/D, OVM). It is not a complete policy narrative — providers must consult the formulary introduction and the plan's PA/step therapy program documents for full operational rules and how to submit requests.

The Requirements/Limits column is the operational indicator for PA, QL, ST, OVM, and B/D — treat the abbreviations as instruction to check the introduction or contact the plan for next steps.
A drug line with no flags does not imply there are no coverage conditions elsewhere — always confirm via the introduction pages or the plan website.

inv-119: DIFICID SUSPENSION RECONSTITUTED

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

inv-120: gabapentin capsule

gabapentin capsule (various)QL(810 EA per 90 days)

gabapentin tablet 800 mgQL(360 EA per 90 days)

inv-122: lacosamide solution

lacosamide solutionQL(3600 ML per 90 days)

lacosamide tablets (100/150/200 mg)QL(180 EA per 90 days)

inv-123: lacosamide tablets 100/150/200mg

lacosamide tablets (100/150/200 mg)QL(180 EA per 90 days)

inv-124: ZONISADE

ZONISADEQL(2700 ML per 90 days)

inv-125: AIMOVIG injection 140mg/ml

AIMOVIG injection 140 mg/mLQL(3 ML per 84 days)

AIMOVIG injection 70 mg/mLQL(6 ML per 84 days)

EMGALITY injection 120 mg/mLQL(5 ML per 84 days)

EMGALITY injection 100 mg/mLQL(9 ML per 84 days)

inv-126: AIMOVIG INJECTION 140MG/ML

AIMOVIG 140 mg/mL (summary)3 ML per 84 days (QL)

inv-127: AIMOVIG INJECTION 70MG/ML

AIMOVIG 70 mg/mL (summary)6 ML per 84 days (QL)

inv-128: EMGALITY INJECTION 120MG/ML

EMGALITY 120 mg/mLQL(5 ML per 84 days)

inv-129: EMGALITY INJECTION 100MG/ML

EMGALITY 100 mg/mLQL(9 ML per 84 days)

inv-130: NURTEC

NURTECQL(18 EA per 30 days)

inv-131: naratriptan hcl tablet 2.5mg

naratriptan HCl tablet 2.5 mgQL(24 EA per 90 days)

naratriptan HCl tablet 1 mgQL(60 EA per 90 days)

inv-133: rizatriptan benzoate ODT 5mg

rizatriptan ODT 5 mgQL(162 EA per 90 days)

rizatriptan ODT 10 mgQL(81 EA per 90 days)

inv-135: sumatriptan succinate tablet 50mg

sumatriptan succinate tablet 50 mgQL(108 EA per 90 days)

sumatriptan succinate tablet 25 mgQL(216 EA per 90 days)

sumatriptan succinate tablet 100 mgQL(54 EA per 90 days)

inv-138: sumatriptan solution

sumatriptan solution (injectable)QL(36 EA per 90 days)

inv-139: PANRETIN

PANRETIN (topical retinoid)QL(60 GM per 30 days)

Other retinoids/related agentsPA and QL annotations present for multiple products

inv-140: CALQUENCE (tablet/capsule)

CALQUENCE (tablet/capsule)QL(124 EA per 31 days)

inv-141: EXKIVITY / RUBRACA

EXKIVITY / RUBRACAQL(124 EA per 31 days)

inv-142: Multiple listed products

Multiple LAI and specialty productsVaries by product; examples include QL(300 EA per 30 days), QL(360 EA per 30 days), QL(2.4 ML per 56 days) for select injectables

RYTARY examplesQL(300 EA per 30 days) and QL(360 EA per 30 days) depending on strength

inv-143: EPCLUSA PACKET 200MG; 50MG

EPCLUSA packet (200/50 mg)QL(62 EA per 31 days)

inv-144: EPCLUSA TABLET 400MG; 100MG

EPCLUSA tablet (400/100 mg)QL(31 EA per 31 days)

inv-145: HARVONI TABLET

HARVONI tabletQL(31 EA per 31 days)

inv-146: TIVICAY PD

TIVICAY PDQL(372 EA per 31 days)

inv-147: PREZISTA SUSPENSION

PREZISTA suspensionQL(414 ML per 31 days)

inv-148: MOUNJARO

MOUNJAROQL(2 ML per 28 days)

inv-149: OZEMPIC INJECTION (various presentations)

OZEMPIC (various presentations)QL(1.5–3 ML per 28 days) depending on presentation

inv-150: RYBELSUS TABLET (various strengths)

RYBELSUS (various strengths)QL(90–540 EA per 90 days) depending on strength

inv-151: TRULICITY

TRULICITYQL(2 ML per 28 days)

inv-152: dabigatran etexilate capsule

dabigatran etexilate capsuleQL(180 EA per 90 days)

inv-153: ELIQUIS TABLET (2.5 mg, 5 mg)

ELIQUIS tablets (2.5 mg, 5 mg)QL(180 EA per 90 days); QL(194 EA per 90 days for 5 mg)

inv-154: XARELTO TABLET (various)

XARELTO (various)QL(51 EA per 30 days) starter pack; QL(180 EA per 90 days); QL(90 EA per 90 days)

inv-155: tranexamic acid tablet

tranexamic acid tabletQL(90 EA per 63 days)

clopidogrel 75 mg tabletQL(90 EA per 90 days)

inv-157: atorvastatin calcium tablet 40mg

atorvastatin calcium 40 mgQL(180 EA per 90 days)

inv-158: REPATHA (various presentations)

REPATHA (various presentations)QL(3 ML per 28 days) or QL(3.5 ML per 28 days)

PRALUENTQL(2 ML per 28 days)

inv-160: amphetamine/dextroamphetamine (various ER oral capsules)

amphetamine/dextroamphetamine (ER formulations)QL(180 EA per 90 days) or formulation‑specific QLs

dexmethylphenidate HCl ER 20/35 mgQL(30 EA per 30 days)

inv-161: dexmethylphenidate hcl er capsule extended release 24 hour 20mg, 35mg

dexmethylphenidate HCl ER capsule (20mg, 35mg)QL(30 EA per 30 days)

dexmethylphenidate HCl tablet 10/5 mgQL(60 EA per 30 days)

inv-162: dextroamphetamine sulfate tablet 10mg, 5mg

dextroamphetamine sulfate tablets (10 mg, 5 mg)QL(540 EA per 90 days)

inv-167: methylphenidate hydrochloride solution 10mg/5ml

methylphenidate HCl solution 10mg/5mlQL(2700 ML per 90 days)

inv-168: tetrabenazine tablet 12.5mg

tetrabenazine tablet 12.5 mgQL(248 EA per 31 days)

tetrabenazine tablet 25 mgQL(124 EA per 31 days)

inv-170: VEOZAH

VEOZAHQL(90 EA per 90 days)

inv-171: AVONEX PEN/INJECTION 30MCG/0.5ML

AVONEX pen/injection 30 mcg/0.5 mLQL(4 EA per 28 days)

inv-172: fluocinonide cream 0.05%

fluocinonide cream 0.05%QL(360 GM per 90 days)

inv-173: tacrolimus ointment 0.03%, 0.1%

tacrolimus ointment 0.03% / 0.1%QL(300 GM per 90 days)

inv-174: fluorouracil solution 5%

fluorouracil solution 5%QL(10 ML per 30 days)

inv-175: clindamycin phosphate lotion 1%

clindamycin phosphate lotion 1%QL(180 ML per 90 days)

inv-176: Electrolyte / dextrose injections

Electrolyte / dextrose injectionsQL(90 GM per 90 days) — repeatedly stated for multiple IV fluid products

inv-177: LOKELMA PACKET 5GM

LOKELMA packet 5 gmQL(270 EA per 90 days)

inv-178: LOKELMA PACKET 10GM

LOKELMA packet 10 gmQL(94 EA per 90 days)

inv-179: sevelamer carbonate tablet

sevelamer carbonate tabletQL(1620 EA per 90 days)

inv-180: LINZESS

LINZESSQL(90 EA per 90 days)

inv-181: MOVANTIK TABLET 12.5MG

MOVANTIK 12.5 mgQL(180 EA per 90 days)

MOVANTIK 25 mgQL(90 EA per 90 days)

inv-183: eluryng; enilloring; etonogestrel/ethinyl estradiol; haloette

eluryng / enilloring / etonogestrel/ethinyl estradiol / haloetteQL(3 EA per 84 days)

inv-184: levonorgestrel/ethinyl estradiol (certain entry)

levonorgestrel/ethinyl estradiol (selected entry)QL(91 EA per 91 days)

inv-185: DEPO-SUBQ PROVERA 104

DEPO-SUBQ PROVERA 104QL(0.65 ML per 90 days)

inv-186: raloxifene hydrochloride; various immunoglobulins/biologics

Examples for biologics / immunoglobulinsExamples include QL(90 EA per 90 days) and QL(27 ML per 30 days) for various immunoglobulins and biologics

inv-187: RINVOQ; SKYRIZI; XELJANZ; others

RINVOQ / SKYRIZI / XELJANZ examplesExamples include QL(31 EA per 31 days); QL(1 ML per 28 days); QL(30 EA per 30 days) depending on product

inv-188: multiple (see entries)

Miscellaneous QL examplesVarious QLs listed across products — e.g., QL(225 ML per 90 days); QL(360 EA per 90 days); QL(6 EA per 90 days)