CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Preferred Drug List (Formulary) — Coverage Criteria

This document is Blue Cross Blue Shield of Michigan and Blue Care Network's 2026 Preferred Drug List describing drug coverage tiers, restrictions, specialty drug handling, and member/provider instructions for prescription benefits in Michigan.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPreferred Drug List (Formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation for drugs marked PA before coverage will be approved.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyupdate frequency

30-daystandard specialty drug supply limit

15-day15-day specialty supply (select drugs)

Walgreenspreferred specialty pharmacy

Optumpreferred mail-order

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Not covered entries in excerpt

Formulary Coverage and Not Covered Products

General coverage stances

Coverage is determined based on tier placement and benefit design. General stances include:

Nonformulary Not Covered: Nonformulary drugs (high-cost with comparable therapeutic alternatives) are not covered under the pharmacy benefit.

Brand-name drugs with generic equivalent are excluded per list.

Preventive Tier Coverage: Drugs designated PV1/PV2/PV3 are covered with no out-of-pocket cost when health care reform/ACA preventive service requirements are met; when those requirements are not met the drug may not be covered or cost-sharing may apply.

Specialty Drug Supply Limits: Specialty drugs are generally limited to a 30-day supply; select specialty drugs are limited to a 15-day supply under the 15-Day Specialty Drug Limitation Program.30-day or 15-day

Members pay half their usual out-of-pocket cost for a 15-day supply for affected drugs.

The Preferred Drug List excludes several broad categories of products from pharmacy coverage. Notable exclusions include: brand-name drugs when a generic equivalent exists; prescription products with an available over‑the‑counter equivalent in the same strength and dosage form (unless designated preventive); drugs used for experimental or cosmetic purposes; many compounded products (with limited exceptions); replacement prescriptions for loss/theft; products considered medical‑benefit items (for example, certain office‑administered injectables and vaccines); and drugs not approved by the FDA.

The formulary extract shows numerous individual products explicitly labeled Not covered. Examples from the analgesics and related sections include JOURNAVX, COMBOGESIC ORAL, select diclofenac and diclofenac potassium tablet formulations, and specific opioid preparations such as certain fentanyl patch strengths and short‑acting oxycodone/aceta minophen solutions and tablets.

Additional Not covered examples appear across local anesthetics, anti‑addiction, antibacterials, tetracyclines and anticonvulsant listings. Representative entries marked Not covered or excluded include ROXYBOND, PROLATE, ZTLIDO, multiple metronidazole oral tablet strengths, and select anticonvulsant products (see BRIVIACT/BRIVIACT formulations and related notes).

The antidepressant, antiemetic and antifungal segments list additional noncovered items. Examples recorded as Not covered include APLENZIN, EXXUA (and its titration pack), DRIZALMA SPRINKLE, and some emetogenic‑therapy adjuncts (e.g., select AKYNZEO ORAL presentations).

Oncology and specialty antineoplastic listings show multiple exclusions. Examples flagged Not covered in this extract include FLUOROURACIL EXTERNAL CREAM 0.5%, INREBIC, and selected agents such as TOLAK and XALKORI (noted in related chunks). Many oncology products are additionally managed with specialty and program notes (PA; SP; 15DS; OVM).

Within neurology, antipsychotic and antiviral/HCV sections, several products are listed as Not covered. Examples in this fragment include XADAGO, ZELAPAR, OPIPZA, and multiple antiviral combinations such as LEDIPASVIR‑SOFOSBUVIR (SOVALDI and related agents appear in the broader extract).

The insulin and blood‑formation sections contain numerous noncovered insulin products and device presentations. Examples explicitly labeled Not covered include ADMELOG, AFREZZA, multiple HUMALOG presentations (vials and KwikPens), and various HUMULIN formulations and other insulin preparations noted as excluded in these chunks.

Other individual specialty and neurologic agents are recorded as Not covered in the extract. Examples include MS and immune‑modulating entries such as MAVENCLAD, PLEGRIDY, and other named products that are either listed as Not covered or transcribed with the phrase 'No t covered' in the fragment.

Dermatology sections list numerous noncovered topical and biologic products. Sample items annotated Not covered include ADAPALENE EXTERNAL PAD, ADAPALENE EXTERNAL SOLUTION, AKLIEF, ANZUPGO, and other branded dermatologic biologics or specialty presentations (many dermatology agents also carry PA/SP/QL notes).

Gastrointestinal and related classes include multiple excluded formulations. Examples marked Not covered in this fragment include dicyclomine hcl oral tablet 40 mg, certain ursodiol capsule strengths, and other GI specialty products; several entries concurrently note quantity‑limit (QL) or step‑therapy (ST) controls.

Reproductive and specialty biologic listings also show excluded products. Representative Not covered entries include CRINONE and SLYND in the contraceptive/progestin area, as well as multiple biosimilars and specialty immunologic products that the extract records as not covered or managed under specialty program rules (PA; SP; QL).

Ophthalmic and otic sections list several excluded topical eye products. Examples shown as Not covered include UPNEEQ, ZERVIATE, and multiple ophthalmic anti‑inflammatory or steroid preparations (e.g., ACUVAIL, FLAREX, ILEVRO) recorded as not covered in these chunks.

The respiratory, pulmonary fibrosis and skeletal muscle relaxant fragments include additional noncovered examples. Items listed Not covered include YUTREPIA, DUAKLIR PRESSAIR, and certain skeletal muscle relaxant strengths such as chlorzoxazone oral tablet 250 mg, 375 mg, 750 mg (and other muscular relaxant presentations) in this extract.

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required for Select Branded/Specialty Drugs

Prior authorization (PA) is required for many select branded, specialty, and device items listed in the drug list. When a product has a PA or OVM flag, the prescriber must submit clinical information and meet clinical criteria before coverage is approved. Missing or insufficient documentation can cause a denial.

Examples: specialty antineoplastics and supportive care through the Oncology Value Management (OVM) program; branded specialty agents annotated 'PA; SP; QL' in the formulary.
Devices requiring PA: select diabetes sensors, receivers, and transmitters (e.g., DEXCOM G6/G7 sensor and receiver entries flagged PA; QL).

Prior Authorization

Prior Authorization Requirement and Clinical Criteria

Prior authorization may be necessary whenever a drug is marked with the PA flag. The member must satisfy the plan's clinical criteria or provide additional information before claims will be approved. Clinical criteria are reviewed by Pharmacy and Therapeutics or program administrators (for OVM products).

PA applies across therapeutic areas — oncology OVM entries, specialty biologics, oral specialty agents, and some nonpreferred branded products.

Drugs Subject to Step Therapy Requirements

Summary	Supporting note
Drugs marked 'ST' on the Preferred Drug List are subject to step therapy and require a trial of one or more preferred drugs before a higher-cost medication will be covered.
See the Preferred Drug List Prior Authorization and Step Therapy Coverage Criteria for the specific preferred alternatives and documentation requirements.

Drug / example	Step therapy note (from PDL)
Varenicline tartrate (starter and continuation)
Notes = PV2; QL; AL (Min 18 Years) — varenicline entries appear in sections indicating step/coverage designations on the PDL (see Step therapy section).

Drug / example	Step therapy note (from PDL)
Selected anticonvulsants (examples in epilepsy/GABA‑augmenting class) — gabapentin entries and others
Table listings include gabapentin and related anticonvulsant products; DIACOMIT is noted PA; SP; QL and other seizure agents include ST or QL where indicated in the PDL Table of Contents.

Drug / example	Step therapy note (from PDL)
Selected antidepressants (e.g., DESVENLAFAXINE ER, FETZIMA)
DESVENLAFAXINE ER — Notes = ST; FETZIMA — Notes = ST; QL (antidepressant table shows ST annotations).

Drug / example	Step therapy note (from PDL)
FANAPT (and FANAPT titration packs A/B/C)
FANAPT and FANAPT TITRATION PACKS A/B/C — Notes = ST (PDL Table of Contents shows ST for these FANAPT entries).

Product examples	Notes / step therapy indication
Selected nonpreferred brands and GLP‑1/SGLT2 examples (e.g., CAPLYTA, MOUNJARO, OZEMPIC)
CAPLYTA — Notes = ST; QL. MOUNJARO — Notes = ST; QL. OZEMPIC — Notes = ST; (PDL lists ST for selected nonpreferred brands and GLP‑1 agents).

Drug	PDL notes
TRULICITY (dulaglutide)
Notes = ST; QL — TRULICITY is annotated with 'ST' on the PDL and also shows a quantity‑limit note.

Drug / class	PDL notes
Multiple sclerosis agents (example: cladribine)
Cladribine (various tablet counts) — Notes = ST; SP; QL. Several MS agents and some fibromyalgia agents are annotated 'ST' in the PDL.

Product example	PDL notes / ST presence
Topical/systemic dermatology examples (e.g., TAZAROTENE EXTERNAL FOAM; doxycycline entries)
TAZAROTENE EXTERNAL FOAM — Notes = ST; ABA; QL. Other topical/systemic agents include 'ST' where noted in the PDL Table of Contents.

GI / constipation agent	PDL notes
Prucalopride succinate; TRULANCE; IBSRELA
Prucalopride succinate — Notes = ST; QL. TRULANCE — Notes = ST; QL. IBSRELA appears in the GI listings where ST is applied to selected agents.

Listing type	Meaning on PDL
'START' or 'STARTER' product listings for biologics
Entries such as ADALIMUMAB CD/UC/HS START or HUMIRA STARTER indicate starter pack distinctions and imply step/entry products for biologic therapies on the PDL.

Observation	Implication
Some agents annotated 'PA; SP; QL' in the PDL may have implied step edits
The Table of Contents shows many PA; SP; QL annotations; where 'ST' is not explicit, step edits may still be implied by formulary placement and are defined in the full PDL step criteria. See full Prior Authorization and Step Therapy Coverage Criteria.

Drug / example	PDL notes
CARBINOXAMINE MALEATE ER; XHANCE
CARBINOXAMINE MALEATE ER — Notes = ST; ABA; QL. XHANCE — Notes = ST; QL (both are specifically annotated 'ST' in the PDL Table of Contents).

Sleep disorder agent	PDL notes
BELSOMRA; DAYVIGO; QUVIVIQ
BELSOMRA — Notes = ST; QL. DAYVIGO — Notes = ST; QL. QUVIVIQ — Notes = ST; QL. The PDL lists these sleep disorder agents with 'ST' indicating step therapy applies where noted.

Per-Fill and Specialty Quantity Limits

Select specialty drugs — 15DS designation

Program name15-Day Specialty Drug Limitation Program (15DS)

ScopeSelect specialty drugs included on a 15DS list are limited to a 15-day supply for all fills

Member cost impactMembers pay half their usual out-of-pocket cost for a 15-day supply for affected drugs

ReferenceSee Specialty Drug Program Pharmacy Benefit Member Guide and bcbsm.com/pharmacy for details

Standard specialty drug supply limit

Standard supply limitSpecialty drugs are limited to a 30-day supply

Applicability

Where Specialty and Other Drugs Are Dispensed

Billing Rule

Use preferred specialty pharmacy or participating retail pharmacies

Walgreens is the preferred specialty pharmacy and participating local retail pharmacies accept member ID; specialty drugs may be obtained at participating retail pharmacies or via Walgreens Specialty Pharmacy as noted.

Walgreens is the preferred specialty pharmacy (Walgreens Specialty Pharmacy).
Optum Home Delivery and Walgreens Specialty Pharmacy are home‑delivery options.

Billing Rule

Use Optum Home Delivery or Walgreens Specialty for home delivery

Home delivery options include Optum Home Delivery and Walgreens Specialty Pharmacy for specialty or home‑delivery services; contact numbers and web portals are provided in the formulary guidance.

Optum Home Delivery phone numbers are listed for members in the formulary excerpt.

Abbreviations and Notes Used on the Formulary

About the Preferred Drug List (PDL)

Background: The Preferred Drug List groups medications by therapeutic class and tier to guide prescribers, pharmacists, and members toward clinically appropriate and cost‑effective options. Tier placement and benefit design determine coverage and member cost‑sharing; the Pharmacy & Therapeutics Committee reviews new FDA approvals and selects medications based on safety, effectiveness, and cost considerations.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPreferred Drug List (Formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation for drugs marked PA before coverage will be approved.

SourceLink

On This Page

When PA is required and not obtained, the claim may be denied and the member and prescriber will be notified with reasons and appeal rights.

Prior Authorization

PA Required for Select Specialty and Device Items

Some specialty and device items are explicitly marked with PA and may also require specialty channel dispensing (SP) and/or quantity limits (QL). Providers should anticipate documentation beyond a standard prior authorization for specialty items.

Examples: Specialty biologics and injectables (PA; SP; QL) and diabetes sensors/receivers (PA; QL).
Specialty channel may be required for distribution and adherence to handling/administration requirements.

Prior Authorization

PA Required for PA‑Marked Drugs

When a formulary entry includes the notes field with 'PA' or similar shorthand, prior authorization is required for that specific product. Providers must follow the documented submission process for that PA type.

Many formulary rows show combined flags (e.g., 'PA; SP; QL', 'PA; 15DS; OVM') — each flag carries an actionable requirement.
Products marked 'Not covered' or listed on the Nonformulary tier are not covered under the pharmacy benefit.

Prior Authorization

Prior Authorization Required When Noted

PA is required when indicated by notes on the drug list. Providers must obtain authorization before billing the pharmacy benefit for specialty or nonpreferred brands flagged with PA to avoid denial.

If coverage criteria are not met or documentation is incomplete, the request will be denied and an explanation and appeal rights will be provided.
Providers should verify benefit-specific coverage (plan-level differences may apply).

Prior Authorization

PA Required for Selected Specialty and Nonpreferred Agents

Selected specialty and nonpreferred agents are subject to prior authorization; these are commonly annotated in the Notes field. Confirm PA requirements before prescribing or dispensing.

Examples across the formulary include oncology agents (OVM), specialty biologics (PA; SP; QL), pulmonary and cystic fibrosis agents (PA; SP; QL).
Nonpreferred branded specialty products frequently require PA and may require specialty distribution.

Prior Authorization

Prior Authorization Required for Selected Agents

Prior authorization is required for a broad set of selected agents across therapeutic areas. Review the formulary notes to determine whether PA, SP, QL, ST or OVM apply and plan documentation accordingly.

Pulmonary, cystic fibrosis, and other specialty agents marked with 'PA; SP; QL' will need PA and likely specialty-pharmacy dispensing.
Some agents are 'Not covered' or 'Nonformulary' and will be denied under the pharmacy benefit.

Denial Risk

Nonformulary Drugs Not Covered

Nonformulary (Nonpreferred tier) high-cost drugs are not covered by the pharmacy benefit when designated as Nonformulary. Providers should select covered therapeutic alternatives when possible or pursue coverage review prior to dispensing.

Nonformulary examples: high-cost brand drugs with therapeutically comparable generics or preferred alternatives; some weight‑loss GLP‑1 agents (coverage exclusions apply for certain groups).
If a drug is not on the list or coverage status is unclear, contact Customer Service using the member ID card number for clarification.

Documentation Required

Prior Authorization / Administrative Notes Present

Administrative flags in the Notes column (PA, QL, SP, ST, OVM, ABA, PV1/PV2/PV3, 15DS) indicate utilization management controls that require provider action. Treat each annotation as a required step before coverage will be approved.

PA = prior authorization; QL = quantity limit; SP = specialty medication; ST = step therapy; OVM = Oncology Value Management; ABA = age-based/other age limits; 15DS = 15-day supply restriction.
Combined annotations (e.g., 'PA; SP; QL; OVM') imply multiple concurrent requirements — follow all applicable processes.

Denial Risk

Denial Triggers from Notes

Notes such as PA, SP, ABA, ST, QL, OVM and similar are common denial triggers if requirements are not met. Ensure all required information and prior authorizations are in place to avoid delays or denials.

Denial triggers: missing PA, failure to meet step‑therapy requirements, exceeding QL without exception, wrong channel for SP products, or prescribing a noncovered/nonformulary product.
Denial notifications will include the reason and the member’s appeal rights.

Denial Risk

Noncovered Drugs May Be Denied

Drugs listed as 'Not covered' or placed on a Nonformulary tier may be denied at claim adjudication. Providers should verify coverage and consider covered alternatives or submit an exception request when clinically justified.

Not covered examples appear throughout the formulary (various topical, oral, and branded products).
Denials for noncovered drugs are administrative and appeals can be pursued per the plan's process.

Denial Risk

Prior Authorization / Quantity Limit Risk

Prior authorization and quantity-limit flags indicate a risk of denial when requirements are unmet. Confirm allowed quantities and secure PA before dispensing to reduce claim reversals and member cost exposure.

Examples: many specialty agents have QL limits tied to dosing schedules; diabetes sensors and supplies show QL flags alongside PA.
When submitting PA, include dosing rationale and expected duration to address QL concerns.

Prior Authorization

Authorization and Utilization Controls

Formulary notes and flags (PA, SP, QL, ST, OVM, ABA) are the plan’s authorization and utilization controls. Providers must follow these controls to obtain coverage — failure to do so may result in claim denial or out-of-pocket liability for the member.

Authorization and utilization controls apply across therapeutic classes including oncology, dermatology, rheumatology, pulmonary, and others.
Specialty items commonly require both PA and specialty pharmacy fulfillment.

Prior Authorization

Specialty / Prior Authorization Items

Specialty products and many biologics require prior authorization and often specialty pharmacy handling (SP). Plan entries marked 'PA; SP; QL' indicate both an authorization and a specialty dispensing requirement.

Examples include many injectables, biosimilars, and specialty oral agents shown in the formulary.
Ensure specialty pharmacy routing and PA approvals are arranged prior to shipment.

Prior Authorization

Prior Authorization and Utilization Controls Noted

Prior authorization and utilization controls are consistently noted in the formulary by shorthand flags. Providers should interpret these flags as actionable steps and confirm plan-specific submission requirements before prescribing or dispensing.

Common flag patterns: 'PA; SP; QL; OVM', 'PA; 15DS; SP; OVM', and 'ST; QL'.
Check the Preferred Drug List and Coverage Request Form for product‑specific criteria.

Denial Risk

Denial Triggers in Formulary Fragments

Some formulary fragments show noncovered products or short-form notes that indicate immediate denial risk if billed; pay close attention to fragments marked 'Not covered' or 'SP; QL' without PA.

Fragment examples: YUTREPIA and DUAKLIR PRESSAIR are listed as Not covered or Not preferred in portions of the formulary — these can be denied at claim time.
When in doubt, contact Customer Service or submit a Coverage Request Form prior to dispensing.

Note

How to Request Authorization

To request prior authorization, follow the plan's submission channels and include required clinical documentation. Electronic, phone, fax, and mail routes are available depending on the drug and program (for oncology OVM use the OncoHealth portal).

Online Coverage Request Form: bcbsm.com (Coverage Request Form).
Provider submission options: electronic prior authorization via EHR or CoverMyMeds, phone (1-800-437-3803), fax (1-866-601-4425), or mail to Pharmacy Services (Mail Code 512C).
Oncology OVM submissions: use OncoHealth OneUM via the payer space on availity.com; OVM phone: 1-888-916-2616; fax 1-800-264-6128.

Documentation Required

Prior Authorization and Specialty Documentation

Prior authorization for specialty and OVM-managed drugs often requires additional specialty or program documentation. Submit full clinical notes, diagnosis codes, prior treatments, and any program‑specific forms to support medical necessity determinations.

OVM: Antineoplastics and oncology supportive care drugs require PA through the Oncology Value Management program administered by OncoHealth.
Specialty biologics: include prior biologic history, dosing plan, and monitoring strategy when requesting PA.

Documentation Required

Specialty and Utilization Management Documentation

Specialty and utilization management flags seen across the formulary indicate required documentation and handling steps. Providers should gather relevant clinical records and use the designated submission channels to avoid processing delays.

Common combined flags: PA; SP; QL; OVM; 15DS — each requires adherence to a specific process.
For specialty drugs, include indication, prior therapies, labs, and provider specialty information where applicable.

Documentation Required

Documentation Requirements Indicated by Notes

The formulary uses shorthand flags to indicate documentation requirements. Learn the abbreviations and follow the corresponding submission expectations to ensure complete prior authorization requests.

Administrative annotations explained: PA (prior authorization), QL (quantity limit), SP (specialty), ST (step therapy), OVM (Oncology Value Management), ABA (age limits), PV1/PV2/PV3 (preventive categories), 15DS (15‑day supply restriction).
Use the Coverage Request Form and provide referenced documentation to map notes to required actions.

Documentation Required

Documentation for PA‑Listed Devices

Devices and PA-listed durable medical items on the formulary often require supporting documentation demonstrating medical necessity. When devices are flagged with PA/QL, include clinical justification, device model, and expected duration of use.

Examples: CGM sensors, receivers, and transmitters (DEXCOM G6/G7 entries flagged PA; QL) — provide clinical indication and prior authorization paperwork.
Readers and test strips may be subject to QL and require justification for frequency of replacement.

Billing Rule

Administrative Annotations

The formulary's administrative annotations (PA, QL, SP, ST, OVM) denote required administrative controls. Treat these annotations as operative rules and ensure PA or prior steps (like ST) are completed before dispensing.

Administrative annotations are present at product level throughout the drug list — follow flagged requirements to prevent denial.
If a starter pack or 'START/STARTER' designation is shown, note starter/step product distinctions and related PA or ST implications.

Documentation Required

PA / SP / QL Documentation

When PA, SP, or QL appear together in the Notes field for dermatology or other specialty agents, providers should submit specialty documentation and obtain PA prior to dispensing to avoid denial.

Dermatology examples: agents like COSENTYX, SKYRIZI, TALTZ often show 'PA; SP; QL'.
Include prior topical/systemic therapy history and relevant diagnostic information with the PA.

Documentation Required

Documentation Needed per Drug Notes

Multiple shorthand flags across drug entries imply distinct documentation needs. Providers must respond to each flagged requirement (for example, supply proof for QL, specialty pharmacy routing for SP, or clinical criteria for PA).

Review each flagged requirement on a product row — do not assume one form of documentation satisfies all flags.
Failure to satisfy any required flag can result in partial or full claim denial.

Note

Utilization Management Abbreviations

Utilization management abbreviations appear throughout the drug list and map directly to required actions. Learn these abbreviations to interpret formulary entries quickly and to assemble complete authorization requests.

Common abbreviations: PA, QL, ST, SP, ABA, AL, PV1/PV2/PV3, OVM, 15DS.
These abbreviations instruct whether PA, quantity limits, step therapy, specialty handling, age limits, preventive coverage, or oncology program routing apply.

Documentation Required

Required Documentation and Channels

Required documentation and submission channels vary by flag. Use the Coverage Request Form and the electronic prior authorization options when available; for oncology products use the OncoHealth OneUM portal as directed.

Electronic PA: preferred for speed — use EHR-integrated ePA or CoverMyMeds for commercial pharmacy members.
Paper/fax/mail: addresses and fax numbers are provided for Pharmacy Services and OncoHealth in plan materials; include all supporting clinical records with submissions.

Step Therapy

Step Therapy Requirement

Step therapy (ST) requirements exist for many higher‑cost agents. When ST is noted, the plan requires documented trials of specified preferred drugs before the nonpreferred or higher‑cost medication will be covered.

Step therapy is used across multiple classes including antidepressants, triptans, antipsychotics, and GLP‑1/SGLT2/GLP‑1 weight‑management agents.
Check the Preferred Drug List Prior Authorization and Step Therapy Coverage Criteria for the required prior agents and trial durations.

Step Therapy

Step Therapy / Designation — Smoking Cessation

Certain products (particularly smoking-cessation therapies) use PV1/PV2 and other preventive designations that interact with step or age‑based designations. Confirm the step or preventive tier designation before prescribing.

Smoking cessation examples: nicotine replacement products are annotated PV1 or PV2 and may include QL and age limits.
Prescriptions for preventive-designated products must meet health reform and plan-specific criteria to be covered at $0.

Step Therapy

Step Therapy Noted

Step therapy appears throughout the formulary. When present, providers must document prior therapies tried and justify moving to a higher‑tiered product if requesting an exception.

Examples: many triptans and certain antidepressants are marked ST; QL.
For some agents, starter/titration packs are separately listed and may be subject to ST rules.

Step Therapy

Step Therapy Requirements

Step therapy criteria can require specific prior drugs or classes to be tried and documented. Providers should consult the plan’s step therapy coverage criteria to know the acceptable prior regimens and evidence needed for exceptions.

Antipsychotics and some GLP‑1 agents show ST flags; documentation of trial duration and outcomes is commonly required.
When a product shows 'ST; QL' include prior trial records and dosing history with any PA request.

Step Therapy

Step Therapy Indicated

When an entry shows 'ST' with another flag (for example, 'ST; QL' or 'ST; ABA; QL'), ensure both the step-therapy conditions and any age/quantity constraints are met or documented with the PA/exception request.

Example: TRULICITY is listed with 'ST; QL' — both a prior trial and quantity justification may be required.
Provide complete prior-treatment documentation to expedite coverage decisions.

Step Therapy

Step Therapy Present

Many product groups show ST flags (topical, systemic, neurologic, metabolic agents). When step therapy is present, it must be satisfied or an exception must be requested with supporting rationale.

Examples across formulary: antipsychotic titration packs, starter packs for biologics, and GLP‑1 agents flagged ST.
Starter/titration packs are often listed separately and may have different coverage or PA requirements.

Step Therapy

Starter / Step Product Distinctions

Where starter packs or 'START/STARTER' product listings appear, they can represent initial dosing/packaging that differs administratively from regular supply. These starter distinctions may affect PA or ST processing.

Starter packs for oncology or specialty biologics (e.g., VENCLEXTA STARTING PACK) are annotated with PA and SP — ensure correct pack routing and authorization.
Document initial dosing and planned transition to maintenance supply when submitting PA.

Applies to specialty drugs not managed under the 15DS program

Member guidanceSee Specialty Drug Program Pharmacy Benefit Member Guide for exceptions and program details

Quantity limits — program overview

PolicyBlue Cross and BCN set per-fill quantity limits based on clinical appropriateness and manufacturer dosing

Where to find detailsRefer to the Quantity Limit Program for the current list and limits (column labeled BCBSM and BCN Preferred Drug List)

VariationLimits vary by drug; some entries show QL in the Notes column indicating a specific per-drug limit

Notes: 'QL' annotation

Notation meaningEntries annotated 'QL' in the Notes column indicate a quantity limit applies to that drug

Where used'QL' appears across numerous therapeutic sections (see individual drug Notes)

Provider actionFollow the per-drug QL specification when dispensing or requesting authorization

Memantine HCl tablet — specific QL example

Drug examplememantine HCl oral tablet — listing shows '28 x 5 mg & 21 x 10 mg' with Notes = QL

InterpretationQuantity limit defined as specific tablet counts/strengths for the course shown

ActionAdhere to the listed QL when processing fills or PA requests

15DS or QL — Notes usage

Annotation practiceMultiple entries are flagged with '15DS' or 'QL' where noted in the Notes column

ImplicationDrugs with '15DS' are limited to 15-day fills; drugs with 'QL' have specified quantity controls

Where to verifyCheck the Notes column in the Preferred Drug List and the Quantity Limit Program for specifics

Drugs and devices — QL note

ScopeVarious drugs and devices (e.g., sensors, monitors, specialty agents) show 'See QL note' — quantity limits apply as listed

ExamplesDEXCOM sensors/receivers and many diabetes devices include QL and PA in Notes — see device listings for limits

Provider actionConfirm device/drug-specific QL when ordering or requesting authorization

Specialty biologics and QL annotations

PrevalenceMultiple specialty biologics and other agents are annotated 'QL' in Notes indicating quantity controls

ExamplesCOSENTYX, EMPAVELI, CAMZYOS and many specialty biologics include 'PA; SP; QL' in Notes — see listing for specifics

ActionFollow listed QL when requesting PA or specialty distribution

Generics and brands — QL references

Notation across brandsMultiple agents across generics and brands reference 'QL' in the Notes column — check per-drug notes

Where to confirmRefer to each drug's Notes entry on the Preferred Drug List for the specific quantity limit

ImplicationCoverage and dispensing are subject to the stated QL; PA may also be required

COSENTYX — QL example

Example drugCOSENTYX entries show Notes = PA; SP; QL for multiple presentations (e.g., 150 mg and 300 mg presentations)

ImplicationQuantity limits for COSENTYX are specified in the formulary Notes — check the QL for dose/packaging limits

Provider actionObtain PA and follow specialty distribution and QL when prescribing COSENTYX

Isotretinoin — QL indicated

DrugIsotretinoin oral capsule (various strengths)

AnnotationNotes indicate 'QL' applies for some strengths; certain strengths may be Not covered

ActionReference the specific isotretinoin strength entry and Notes for applicable quantity limits or coverage status

MOVANTIK — quantity limits

Drug exampleMOVANTIK — Notes = QL (quantity limits apply)

LocationListed under Gastrointestinal Agents with Notes indicating QL

Provider actionAdhere to the QL when prescribing or dispensing MOVANTIK

PEG 3350 / polyethylene glycol 3350 — PV and QL

DrugsPEG 3350 and polyethylene glycol 3350 oral

DesignationListed as Preventive (PV1/PV2) with QL noted in Notes column

ImplicationPreventive designation and QL/age limits (AL) apply — check Notes for dispensing limits

Various specialty biologics — QL annotations

ScopeVarious specialty biologics (e.g., ENBREL, HUMIRA, STELARA, TREMFYA) are annotated with PA; SP; QL

ImplicationThese products require specialty handling and have quantity limits specified in the Notes

Provider actionSubmit required PA documentation and follow specialty pharmacy/channel requirements and QL

Condoms — quantity limits noted

ItemCondoms (e.g., DUREX products, FC2 female condom)

DesignationPreventive-tier items with Notes = PV1 and QL (quantity limits noted)

ActionObserve QL when dispensing preventive contraceptive supplies

Per-drug QL notes — follow Notes column

PracticePer-drug QL notes are used throughout the formulary — follow the Notes column for each drug's quantity limit

ExamplesOphthalmic agents, inhaled corticosteroids, respiratory devices and others show QL annotations in Notes

Provider actionVerify QL and any concurrent PA or ST requirements listed in the Notes before dispensing

Multiple agents — QL in Notes

PrevalenceMultiple listed agents (pulmonary hypertension, pulmonary fibrosis, sleep agents, etc.) reference 'QL' in the Notes column

ImplicationQuantity limits are commonly paired with PA and SP flags in specialty agents — check all Notes fields

Where to checkReview the Preferred Drug List entries for each agent to determine applicable QL

Documentation Required

Route SP‑flagged products through specialty pharmacy channel

When an entry is annotated 'SP' (specialty), the product is managed via a specialty distribution channel and may require specialty pharmacy dispensing and additional authorization/documentation.