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CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2025 Drug List (Pharmacy Formulary) — Coverage Criteria

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This document is Blue Cross and Blue Shield - New Mexico's 2025 pharmacy drug list describing preferred drugs, tiers, special requirements, and general coverage policies that affect members and prescribing providers under the plan.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2025 Drug List (Pharmacy Formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change (routine update)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a listed drug is marked 'PA' before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~150+distinct drugs listed in segment

manyentries with PA/QL/SP flags

6member payment tiers described

100+specialty/oncology entries

MultipleRequirements/Limits flags present

Coverage Criteria and Product Controls

General pharmacy coverage conditions

Covered when plan provisions and utilization management requirements are met.

Formulary coverage general conditions: Drug is FDA-approved or supported by recognized evidence-based guidelines; drug is included on the plan drug list or approved via prior authorization or coverage exception; dispensing and quantity limits adhere to plan rules and benefit design; site-of-care/specialty pharmacy routing is followed when indicated.

Many agents have PA, ST, or QL noted in Special Requirements (see product listings).

Examples of PA/QL/SP Controlled Agents

Selected formulary coverage controls in this segment (examples):

ATTRUBY (acoramidis): Listed with Prior Authorization and Quantity Limit and Administrative Coverage as indicated; subject to specialty routing where shown.QL (30 tablets/30 days)

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2025 Drug List (Pharmacy Formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change (routine update)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a listed drug is marked 'PA' before dispensing.

SourceLink

On This Page

ENTRESTO (sacubitril-valsartan): Requires Prior Authorization and Quantity Limit; specialty designation applies for some formulations.QL (112 tablets/28 days or 2 cartridges/30 days)

chunk 61

UPTRAVI (selexipag) titration pack: Requires Prior Authorization and Quantity Limit; specialty designation applies to titration pack and pack-based dispensing.QL (1 pack/180 days or 30 tablets/30 days)

chunk 63

VERQUVO (vericiguat): Requires Prior Authorization and Quantity Limit; specialty designation where noted.QL (30 tablets/30 days)

chunk 63

VYNDAMAX / VYNDAQEL / tafamidis formulations: Listed with Prior Authorization, Quantity Limit and specialty designation for indicated formulations.QL (120 capsules/30 days)

chunk 63

FASENRA (benralizumab): Requires Prior Authorization, Quantity Limit and Specialty Pharmacy routing for indicated presentations.QL (1 pen/28 days)

chunk 68

NUCALA (mepolizumab): Requires Prior Authorization, Quantity Limit and Specialty Pharmacy routing; limits vary by presentation (syringe vs vial).QL (1 syringe/28 days or 3 ml/28 days)

chunk 69

TEZSPIRE (tezepelumab): Requires Prior Authorization, Quantity Limit and Specialty Pharmacy routing for subcutaneous presentations.QL (1 pen/28 days)

chunk 70

XOLAIR (omalizumab): Requires Prior Authorization and Specialty Pharmacy routing; formulation-specific limits apply.

chunk 70,71

Coverage with utilization management

Coverage for listed drugs is governed by the presence of utilization management controls; items are covered subject to the listed PA and QL requirements where present.

Coverage rule: Drugs listed are covered under the payer's pharmacy benefit when billed within the member's benefit design and when any listed requirements (PA, QL, SP, AC, ST) are met.

PA/QL/SP/AC flags in the product listing are the controlling coverage rules; no additional clinical entry criteria are provided in these chunks.

Product coverage designations

Coverage and utilization management designations presented per product/formulation:

Per-product designations: Each listed product line includes a Requirements/Limits field with designations such as PA (prior authorization), QL (quantity limit), SP (specialty pharmacy), AC (administrative coverage) and ST (step therapy) where applicable.

Product-level flags define coverage controls; the policy lists these designations per formulation without additional nested clinical criteria.

General coverage conditions for listed drugs

Products are covered subject to listed requirements and limits when the provider obtains any required prior authorization and adheres to quantity limits, specialty routing, and other administrative conditions.

General coverage conditions for listed drugs: Coverage for each listed drug is conditioned on: (1) prior authorization when 'PA' is indicated; (2) dispensing through specialty pharmacy when 'SP' is indicated; and (3) adherence to the specified quantity limit (QL) per time period. Providers must submit PA documentation as required by Blue Cross Blue Shield - New Mexico.

Apply product-specific PA, QL and SP as listed in the product entries (examples: REBINYN QL 1 vial/30 days; ADDBRY QL 2 pens/28 days or 4 mLs/28 days).

Non-covered items may include non–FDA‑approved drugs, repackaged medications, and certain prescription products that have an available over‑the‑counter (OTC) equivalent. The policy directs providers and members to review the member's benefit documents for specific exclusions and notes that repackaged medications are not covered under the pharmacy benefit.

Within the provided excerpt there are no standalone, generalized coverage exclusions listed beyond the product‑level entries. Instead, the document presents drug listings with their associated Requirements/Limits (e.g., PA, QL, SP, AC) for each product; callers should consult the specific line item for any management flags.

This segment does not provide explicit clinical exclusion criteria for agents. The content is primarily formulary product listings with management flags and Requirements/Limits fields; clinical contraindications or patient‑level exclusion rules are not specified in these chunks.

The formulary notes that anti‑obesity / weight‑management drugs may be excluded depending on the member's benefit plan. The document states: “Anti‑obesity/weight loss/weight management drugs may be excluded, please see your benefit plan materials for coverage.” Therefore coverage for these agents depends on the member's specific plan terms.

No explicit coverage exclusions appear in this portion; the pages list products and their product‑level management designations (for example, PA and QL) rather than broad categorical exclusions.

The excerpt does not contain explicit clinical exclusion statements. Product lines (including specialty injectables and coagulation factors) are shown with Requirements/Limits such as PA and QL, but no separate clinical exclusion rules are provided in these chunks.

The policy indicates that drugs that are not FDA‑approved for the indicated use or those prescribed for cosmetic purposes (for example, some hair‑growth products or age‑related cosmetic uses) may be considered not covered under the pharmacy benefit and may be denied unless otherwise specified in the member’s plan.

There are no explicit not medically necessary (NMN) declarations in the referenced section. The excerpt focuses on product entries with Requirements/Limits rather than formal NMN policy language.

These chunks do not contain explicit statements labeling products or uses as Not Medically Necessary. The document lists per‑product management flags (PA, QL, SP) but does not provide NMN determinations in this segment.

The excerpted pages do not present specific not‑medically‑necessary conditions. Coverage guidance in this section is delivered via product‑specific Requirements/Limits rather than NMN listings.

Product Listings and Coding / Quantity Examples

Drugs and formulations (no procedure codes)mixed

list	This section lists drug products and strengths rather than procedure codes; no CPT/HCPCS/ICD codes present in these chunks.

Drug formulations (no procedural codes)mixed

NDC not listed

Document lists drug products and formulations but does not provide NDCs in these chunks.

Product listings without codesmixed

NDC/HCPCS not listed

No procedure/billing codes (CPT/HCPCS/ICD-10/NDC) are provided in this excerpt; products are listed by name and strength/packaging.

Quantity limits examples

Example QL — oral tabletsQL 60 capsules/30 days (example shown for macrolides/other chronic tablets)

Example QL — pensQL 2 pens/28 days (example shown for biologic autoinjectors/syringes)

Example QL — kitsQL 1 kit/28 days (example shown for starter/therapy kits)

Quantity limits examples

Example QL — tabletsQL 60 tablets/30 days (example shown for multiple oral chronic therapies)

Example QL — injectionQL 1 injection/28 days (example shown for select injectable migraine/biologic products)

Example QL — liquidsQL 360 mls/30 days (example shown for oral suspensions/suspension formulations like XARELTO suspension)

Ophthalmic quantity limits (examples)

Latanoprost / LumiganQL 2.5 mls/20 days (latanoprost and bimatoprost listed with this limit)

Tobramycin ophthalmicQL 15 ml/30 days (tobramycin ophthalmic solution 0.3% listed with this limit)

Lumigan (bimatoprost)QL 2.5 mls/20 days (Lumigan specifically shown with same ophthalmic limit and ST flag for some presentations)

Injectable vial quantity limits (examples)

REBINYN (coagulation factor IX)QL 1 vial/30 days (also listed as 1 ml/30 days for some presentations)

TAKHZYRO (lanadelumab)QL 2 vials/28 days (also shown as 2 mls/28 days for syringe presentation)

Hemophilia/coagulation factors (examples)Commonly listed QL = 1 ml or 1 vial/30 days for many factor products

Authorization, Documentation, and Denial Risk

Prior Authorization

Prior Authorization Required

Prior Authorization (PA): Many drugs listed in this document require prior authorization. When PA is commonly required for a medication it is noted with 'PA' in the Special Requirements column. Providers must submit a prior authorization request and receive approval before the medication will be covered; claims may be denied without an approved PA.

PA flagged products are subject to review before coverage is granted.
Some plans may impose PA on additional medications beyond those shown — verify benefit plan materials.

Prior Authorization

Prior Authorization for Select Antivirals and Hepatitis Agents

Certain antiviral and hepatitis agents (examples: EPCLUSA, HARVONI, MAVYRET) and other agents listed in the antiviral classes require PA and often have quantity limits (QL) and specialty pharmacy (SP) dispensing noted. Documentation supporting medical necessity, diagnosis, and treatment history should accompany PA requests for these agents.

EPCLUSA, HARVONI, MAVYRET are marked PA, QL, SP where applicable.
Prescribers should include pertinent clinical documentation (e.g., genotype, prior therapies, lab results) with PA submissions.

Prior Authorization

PA Required for Specialty / High‑Cost Drugs

Many specialty, high-cost, and oncology agents require prior authorization and are frequently limited by quantity limits and specialty pharmacy dispensing. Examples include (but are not limited to) TAGRISSO, TALZENNA, TASIGNA, VERZENIO, VITRAKVI and many others in the specialty drug listings.

Specialty agents are often coded PA, QL, and SP in the Requirements/Limits column.
Lack of PA or exceeding QL may result in claim denial or member financial responsibility.

Prior Authorization

Prior Authorization for Listed Biologics and Specialty Injectables

Prior authorization is required for many listed specialty biologics, coagulation factors, injectables, and other specialty products (examples: REBINYN, RIXUBIS, TAKHZYRO, ADBRY, COSENTYX, ADALIMUMAB products, ENBREL). These products are commonly noted with PA and SP designations.

Providers must request PA for biologics and specialty injectables prior to dispensing.
Specialty dispensing (SP) may be required and affects where the product can be obtained.

Note

Index — Prior Authorization and Listing Notes

Some index pages in this section list medications but do not include explicit prior authorization rules or clinical criteria. The index entries provide page references only and are not a substitute for the Requirements/Limits details found next to product listings.

Index pages show product names and page numbers but may omit PA/QL/SP flags—refer to the main formulary listings for requirements.

Denial Risk

Denial and Financial Risk Triggers

Denial and financial risk triggers: coverage may be denied if PA, step therapy (ST), quantity limits (QL), dispensing limits (DL), or specialty pharmacy (SP) requirements are not met. Non‑FDA approved products, repackaged medications, and compounded products may be excluded from coverage. Dispensing beyond a listed quantity limit may result in full member financial responsibility for the excess units.

Claims for products listed with 'PA' may be denied without an approved prior authorization.
If a prescriber requests a quantity above a QL, the member may be responsible for costs beyond the allowed amount; some state laws prohibit coverage for controlled substances dispensed beyond limits.

Prior Authorization

PA/QL Required for Specialty Cardiovascular Agents

PA and QL are required for many specialty cardiovascular agents (examples: ATTRUBY, ENTRESTO, VERQUVO, VYNDAMAX/VYNDAQEL). These medications are often subject to both prior authorization and specific quantity limits.

ATTRUBY, ENTRESTO, VERQUVO, VYNDA products are shown with PA and QL in the Requirements/Limits column.
Requests exceeding QL or lacking PA may be denied; providers should confirm required documentation for cardiac specialty agents.

Prior Authorization

PA/QL Required for Specialty Respiratory Agents

Many respiratory biologics and specialty respiratory agents require PA and are subject to quantity limits and specialty pharmacy dispensing (examples: NUCALA, TEZSPIRE, XOLAIR, TRELEGY entries). PA and QL details are listed alongside each product.

NUCALA, TEZSPIRE, XOLAIR are commonly flagged PA, QL, SP.
Provider-submitted documentation should support diagnosis, prior controller therapy, and clinical response for respiratory biologics.

Prior Authorization

PA for Weight‑Management Injectables

Weight‑management injectables (e.g., WEGOVY, ZEPBOUND, SAXENDA, MOUNJARO when used for weight management) are frequently subject to prior authorization and quantity limits. PA must be obtained per plan rules; QL entries specify limits (pens/period) where noted.

WEGOVY, ZEPBOUND, SAXENDA and tirzepatide weight‑management formulations are marked PA and QL where applicable.
Confirm indication (weight‑management vs diabetes) and required documentation when submitting PA.

Documentation Required

Supporting Documentation for Prior Authorization

Providers must supply supporting documentation when submitting PA requests. Documentation should be consistent with the product's Requirements/Limits and may include clinical history, diagnosis, prior therapies tried (for ST), relevant labs, and rationale for the requested agent. Antiviral and specialty drug PAs commonly require disease‑specific data and prior therapy details.

Include drug name, dose, duration, diagnosis, prior medications and response, and relevant labs or imaging as applicable.
For antivirals (e.g., EPCLUSA, HARVONI) include genotype/viral load and prior treatment history when relevant.

Documentation Required

Documentation and Specialty Pharmacy Requirements (PA/QL/SP)

Documentation, specialty pharmacy (SP) designation, and quantity limit (QL) information are documented per product. For products marked 'PA' or 'SP', providers should follow payer submission instructions and indicate whether specialty pharmacy dispensing is required.

PA submissions should indicate if SP dispensing is required and include contact information for the dispensing pharmacy if known.
Quantity limit exceedance requests must be supported with clinical justification to be considered.

Step Therapy

Step Therapy Requirements

Step Therapy (ST): Some benefit plans include step therapy requirements; medications commonly subject to step therapy are noted with 'ST' in the Special Requirements column. Where present, ST requires trial of specified alternatives before the requested agent will be covered.

At least some products (e.g., KERENDIA, selected antipsychotics) are labeled with ST.
Step therapy sequencing details are not always provided in the index — consult the plan-specific criteria or the formulary product listing for the required prior steps.

Step Therapy

Step Therapy — Flags and Operational Note

Step therapy flags are present for select products, but explicit step sequences are not always specified in this section. When 'ST' is shown, the plan may require trial and failure of preferred alternatives before approving the requested medication.

Providers should consult plan-specific criteria for the required prior agents and documentation needed to demonstrate attempted therapy.
If step therapy is required and not met, PA may be denied or coverage limited.

Note

Index Pages — No Authorization or Denial Criteria Provided

Some index pages and segments in this section are index-only and do not include explicit authorization, documentation, or denial criteria. These pages provide product name references and page numbers; they do not substitute for the Requirements/Limits entries in the main listings.

When the index does not list PA/QL/SP flags, review the referenced formulary pages for full coverage rules and submission requirements.
No explicit denial triggers or authorization criteria are presented on index‑only pages.

Denial Risk

Quantity Limit Exceedance — Risk and Process

Quantity limits (QL): Products with QL entries specify permitted quantity per time period (e.g., tablets/30 days, pens/180 days). Dispensing beyond these limits can trigger denial or require prior approval; members may be financially liable for excess quantities.

QL examples: QL (30 tablets/30 days), QL (4 pens/28 days), QL (1 kit/180 days).
Requests to exceed QL should include clinical rationale and supporting documentation.

Definitions and Tiering

The formulary lists preferred drugs selected by a committee of physicians and pharmacists; selections and coverage designations are informed by FDA regulation, drug safety, efficacy and cost considerations. Specialty drugs and clinician‑administered products may be handled under the medical benefit rather than the pharmacy benefit, and utilization management controls (PA, QL, SP) are applied to manage appropriate use.

Preferred generic / reference brand

Preferred generic notationGeneric drugs are shown in lower-case boldface; reference brand often shown in parentheses

Reference brand usageReference brand is provided in parentheses as a non-preferred brand reference when applicable

Visual cue for genericsLower-case boldface indicates preferred generic products in the list

Formulary tiers

Number of tiersUp to six member payment tiers: Preferred Generic (Tier 1) through Non-Preferred Specialty (Tier 6)

Tier examplesPreferred Generic (Tier 1), Preferred Brand (Tier 3), Preferred Specialty (Tier 5)

Tier effectTier placement determines member cost-sharing; verify plan-specific tier at MyPrime.com or ID card number

Prior Authorization (PA)

DefinitionPA = Prior Authorization: approval required prior to coverage/dispensing

When usedPA is indicated in the Requirements/Limits column for many specialty and high-cost agents

Effect of missing PAClaims for products listed with 'PA' may be denied if PA is not obtained

Quantity Limit (QL)

DefinitionQL = Quantity Limit: maximum quantity allowed per specified time window (e.g., 30 days, 28 days, 180 days)

Common examplesExamples include limits expressed as tablets/30 days, pens/28 days, mLs/30 days depending on formulation

ConsequenceExceeding the listed QL can trigger denial or require prior approval

Specialty Pharmacy (SP)

DefinitionSP = Specialty Pharmacy: designation indicating medication is managed/dispensed through a specialty pharmacy channel

Where shownMany specialty injectables and high-cost agents are flagged 'SP' in the Requirements/Limits column

ImplicationSP designation may require provider to use designated specialty distributor or pharmacy for dispensing

Administrative/Clinical coverage condition (AC)

DefinitionAC = Administrative/Clinical coverage condition: an administrative code/flag used for select products (e.g., some contraceptives, Golytely)

UsageAC appears in Requirements/Limits to denote administrative coverage conditions or access flags

EffectProducts with AC may have special administrative handling or exceptions; consult plan materials

Prior Authorization (alternate)

Alternate PA entryPrior Authorization — approval required prior to coverage/dispensing (alternate wording in list)

ContextPA noted next to many specialty biologics and high-cost oral agents

ActionProviders must submit PA documentation per payer processes when 'PA' is indicated

Quantity Limit (alternate)

Alternate QL entryQuantity Limit — maximum quantity allowed per time period as specified (e.g., 30 tablets/30 days)

ExamplesQL entries vary by product: tablets/30 days, pens/28 days, vials/30 days, mLs/30 days

EnforcementDispensing beyond QL may result in full member financial responsibility or denial

Specialty (alternate)

Alternate SP entrySpecialty — designation indicating specialty pharmacy distribution or management

ExamplesPegfilgrastim, coagulation factors, biologic dermatology and gastroenterology agents commonly marked SP

Provider noteSpecialty products may require routing to a designated specialty pharmacy

Administrative Coverage (alternate)

Alternate AC entryAdministrative Coverage code — often used for contraceptives and other products listed with AC

MeaningIndicates administrative/access handling rather than clinical PA/QL in some cases

Where seenAC appears next to items such as folic acid, certain laxative preparations, and contraceptives

PA / QL / SP / AC (combined)

Combined definitionsPA = Prior Authorization; QL = Quantity Limit; SP = Specialty Pharmacy; AC = Administrative Code/coverage designation

ApplicationThese flags appear in the Requirements/Limits column and control coverage/dispensing

Provider actionProviders must follow the indicated PA/QL/SP/AC requirements to avoid claim denials

Index entry

Index definitionIndex entries map drug/product names to page numbers within the full drug list document

PurposeUsed for navigation; index-only pages do not include clinical criteria or submission instructions

Location noteIndex entries are shown in the Index section of the document

Initial Therapy Requirements

Initial utilization controls for GLP-1/GIP agents

Selected diabetes and obesity agents have initial utilization controls.

Initial controls for GLP-1/GIP agents: Initial coverage for specified GLP-1/GIP agents requires prior authorization where indicated and is subject to quantity limits on pens/tablets per dispensing period.

Examples: MOUNJARO entries show PA and QL (4 pens per relevant period); OZEMPIC and RYBELSUS entries show PA and specified QLs (see listings).

Initial therapy requirements

Initial coverage requires meeting the PA and QL rules where present.

Initial therapy general rule: If a product is marked 'PA', prior authorization must be obtained before initial dispensing; if a Quantity Limit (QL) is stated, the initial dispensed quantity must not exceed the listed limit.

The policy does not provide product-specific clinical entry criteria in these chunks; follow product-level PA/QL flags.

Initial therapy — Initial dispensing for listed biologics

Initial dispensing for listed biologics requires prior authorization when indicated and adherence to product-specific limits.

Initial dispensing for biologics: Initial fills of biologic and specialty injectables require prior authorization when 'PA' is indicated and must conform to quantity limits and specialty pharmacy routing where 'SP' is listed.

Examples include dermatologic biologics (Adbry, Cosentyx, Dupixent) listed with PA, QL and SP designations.

Continuation and Maintenance Therapy

Continuation therapy

Continuation/maintenance supplies are subject to the same QL and PA requirements.

Continuation: Refills and maintenance dispensing must remain within the product-specific quantity limits and any active prior authorization approvals; continuing therapy will be denied or subject to full member financial responsibility if these conditions are not met.

Example: REBINYN continuation limited to QL 1 vial/30 days; PYRUKYND taper packs have annual QL constraints (7 or 14 tablets/365 days).

Step Therapy Flags and Notes

Step therapy overview
No explicit step therapy sequences or required prior agents are stated in this excerpt; the document segment provides per-drug requirement flags (e.g., PA, QL, SP, AC) rather than detailed step algorithms.

Product	Step therapy flag
KERENDIA (finerenone) — 10 mg, 20 mg
ST (step therapy) indicated for KERENDIA in the Requirements/Limits field

Step therapy note
No explicit step therapy entries in this segment; listings show prior authorization (PA), quantity limits (QL), specialty pharmacy (SP) and other per-product controls, but do not define step sequences.

Item	ST flag present?
Select oral agents (examples: aripiprazole entries) are annotated with 'ST' indicating step therapy flags
Detailed step therapy rules or required prior agents are not provided in these chunks; only the 'ST' annotation is shown where present

Observation
No explicit step therapy steps are defined for products in this segment; product lines are presented with Requirements/Limits flags (PA, QL, SP, AC) but without step sequencing language.

Summary
No explicit step therapy sequence or mandatory prior agents are specified in this excerpt; the listing format uses per-product flags rather than step algorithms.

Quantity Limits by Product / Examples

azithromycin tablet quantity limit

Azithromycin (tablets)QL 60 tablets (azithromycin tab 250 mg, 500 mg listed with QL 60 tablets/180 days)

FormulationAvailable as suspension and tablets; QL applies to tablet formulation in listing

Typical periodListed example shows 60 tablets per 180 days in this entry

BIKTARVY quantity limit

BIKTARVYQL 30 tablets/30 days

Formulationbictegravir-emtricitabine-tenofovir alafenamide tablets as listed

Provider noteRequires adherence to QL as shown in Requirements/Limits

CIMDUO quantity limit

CIMDUOQL 30 tablets/30 days

Formulationlamivudine-tenofovir disoproxil fumarate tablets

Coverage noteListed under antiviral/antiretroviral group with QL

DELSTRIGO quantity limit

DELSTRIGOQL 30 tablets/30 days

Formulationdoravirine-lamivudine-tenofovir DF tablets

NoteShown with standard 30-tablet QL in Requirements/Limits

DESCOVY quantity limit

DESCOVYQL 30 tablets/30 days

Formulationemtricitabine-tenofovir alafenamide tablets (multiple strengths)

Special noteSome DESCOVY presentations also list AC plus QL in Requirements/Limits

MAVYRET quantity limit

MAVYRETQL 90 tablets/30 days

Formulationglecaprevir-pibrentasvir tablets (100-40 mg)

PA statusListed with PA and SP in Requirements/Limits

PAXLOVID quantity limit

PAXLOVIDQL 11/20/30 tablets (pack configurations: 11 tablets/30 days; 20 tablets/90 days; 30 tablets/90 days)

Formulationnirmatrelvir with ritonavir packaged combinations listed with specific QLs

Coverage noteQL tied to pack configuration as shown in Requirements/Limits

TABRECTA quantity limit

TABRECTA (capmatinib)QL 120 tablets/30 days

Formulationcapmatinib 150 mg, 200 mg tablets listed with PA, QL and SP

Provider noteSpecialty oncology oral agent with PA and SP flags

TAFINLAR quantity limit

TAFINLAR (dabrafenib)QL 120 capsules/30 days

Formulationdabrafenib capsules and oral suspension presentations (suspension QL also listed)

Coverage notePA and SP designated in Requirements/Limits

TAGRISSO quantity limit

TAGRISSO (osimertinib)QL 30 tablets/30 days

Formulationosimertinib 40 mg and 80 mg tablets listed with PA and SP

Usage noteStandard 30-tablet monthly QL for oncology oral targeted therapy

VENCLEXTA quantity limit

VENCLEXTA 100 mgQL 180 tablets/30 days

Formulationvenetoclax tablets (multiple strengths) with starter packs and QL variations

Provider notePA and SP indicated for oncology agents like VENCLEXTA

MOUNJARO (2.5 mg) pens quantity limit

MOUNJARO (2.5 mg pens)QL 4 pens (example listing: 4 pens/28 days for some presentations; 4 pens/180 days for 2.5 mg in other entries)

Dose variationsLower-dose pen packings may have different QL periods (examples shown in listing)

PA/QLGLP-1/GIP agents commonly require PA and have pen-count QLs

MOUNJARO (higher doses) quantity limit

MOUNJARO (higher-dose pens)QL 4 pens/28 days (higher-dose pen presentations listed with 4 pens/28 days)

Formulation noteHigher-dose pen strengths have monthly 4-pen QL in the listing

PA requirementPA indicated for many tirzepatide presentations

TRULICITY quantity limit

TRULICITY (dulaglutide)QL 4 pens/28 days

FormulationMultiple pen strengths listed; QL shown as 4 pens per 28 days in Requirements/Limits

PA statusTRULICITY listed with PA and QL

JANUMET quantity limit

JANUMETQL 60 tablets/30 days

Formulationsitagliptin-metformin combinations listed with 60-tablet QL

XR optionJANUMET XR shows 30 or 60 tablets/30 days depending on strength

JANUMET XR quantity limit

JANUMET XRQL 30 or 60 tablets/30 days (strength-dependent)

FormulationExtended-release strengths have either 30- or 60-tablet monthly limits as listed

Provider noteCheck specific strength entry for the applicable QL

ENTRESTO quantity limits

ENTRESTO (tablets)QL 112 tablets/28 days (example for certain packings)

ENTRESTO (cartridge)QL 2 cartridges/30 days (cartridge formulation listed separately)

PA/SPENTRESTO entries show PA and SP designations in Requirements/Limits

UPTRAVI titration pack quantity limit

UPTRAVI TITRATION PACKQL 1 pack/180 days (titration pack example)

Alternate listingSome UPTRAVI entries also list 30 tablets/30 days depending on pack type

PA/SPUPTRAVI titration packs are PA and SP designated

VERQUVO quantity limit

VERQUVO (vericiguat)QL 30 tablets/30 days

FormulationListed with PA and SP designations in Requirements/Limits

Provider noteStandard 30-tablet monthly QL for chronic cardiology agents

Selected biologic injection quantity limits

FASENRAQL 1 pen/28 days (benralizumab shown with this limit)

NUCALAQL 1 syringe/28 days (or 3 ml/28 days depending on presentation)

TEZSPIREQL 1 pen/28 days (tezepelumab listed with this limit)

Inhaler quantity limits (examples)

Inhalers (BREO/TRELEGY/others)QL 1-60 (varies by product; common limits shown as 1 inhaler to 60 blisters/30 days)

ExamplesBREO ELLIPTA QL 60 blisters/30 days; TRELEGY entries vary by strength with 1 inhaler/30 days

Provider noteInhaler QLs depend on product and presentation as listed

TRIKAFTA / CFTR modulators quantity limits

TRIKAFTA / CFTR modulatorsQL 56-90 (varies by formulation/packaging; examples show 90 tablets/30 days or 56-90 per period)

PA/SPCFTR modulators are PA, QL and SP designated in Requirements/Limits

Provider noteCheck specific product entry for exact QL and pack type

Proton pump inhibitors quantity limit

Proton pump inhibitors (class)QL 60 tablets/30 days (esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole)

Class noteChronic-use GI agents commonly listed with 60-tablet monthly QL

Provider actionDispensing should adhere to the 60-tablet/30-day limit where shown

Multiple quantity limit examples

Assorted QL examples (multiple products)Examples shown across the list include: 90 tablets/30 days; 2 pens/28 days; 1 kit/28 days; 4 pens/28 days; 8 syringes/180 days; 3 packs/180 days; 600 mls/30 days

Range of unitsQLs expressed as tablets, pens, syringes, kits, vials, mLs depending on product type

EnforcementAll QLs in the list are enforced at adjudication and exceeding them can trigger denial or additional authorization

celecoxib quantity limit

celecoxib capsulesQL 60 capsules/30 days (Celebrex example)

Formulationcelecoxib cap 50 mg, 100 mg, 200 mg listed with 60-cap QL

Provider noteChronic NSAID therapy entries may have 60-tablet monthly limits

pregabalin quantity limit

pregabalin 25 mg capsQL 360 capsules/30 days (pregabalin cap 25 mg listed with this limit)

Formulation noteHigh-count QL applies to lower-dose capsule presentation in listing

Provider actionDispensing must conform to the stated 360-cap QL

apremilast (OTEZLA) quantity limit

apremilast (OTEZLA)QL 60 tablets/30 days

FormulationOTEZLA tablets listed with PA and 60-tablet QL

Provider notePA and QL apply per Requirements/Limits entry

QULIPTA quantity limit

QULIPTA (atogepant)QL 30 tablets/30 days

FormulationAtogepant tablet strengths listed with 30-tablet monthly QL

PA statusPA indicated alongside QL for migraine preventive agents

EMGALITY quantity limit

EMGALITY prefilled syr 100 mgQL 9 syringes/180 days

FormulationGalcanezumab prefilled syringes listed with 9-syringe/180-day limit

PA/SPPA and SP designations apply to migraine biologics

XARELTO suspension quantity limit

XARELTO suspensionQL 600 mls/30 days

FormulationRivaroxaban suspension listed with a 600 mL monthly limit

Provider noteLiquid anticoagulant formulations have mL-based QLs as shown

PYRUKYND taper pack quantity limits

PYRUKYND TAPER PACKQL 7 or 14 tablets/365 days (pack-dependent annual QL)

FormulationMitapivat therapy packs listed with 7- or 14-tablet yearly limits depending on pack

PA/SPPA and SP indicated in Requirements/Limits for these packs

REBINYN quantity limit

REBINYNQL 1 vial/30 days (also shown as 1 ml/30 days for specific unit sizes)

FormulationCoagulation factor IX glycopegylated product listed with 1 vial/30-day QL

PA/SPPA and SP apply to REBINYN entries

ADBRY quantity limits

ADBRY (tralokinumab)QL 2 pens/28 days or 4 mls/28 days depending on presentation

FormulationPrefilled pens and syringe presentations have distinct QLs as shown

PA/SPPA and SP indicated for dermatologic biologics

LATANOPROST / LUMIGAN ophthalmic limits

LATANOPROST / LUMIGANQL 2.5 mls/20 days (both latanoprost and bimatoprost listed with this ophthalmic limit)

FormulationOphthalmic solution presentations shown with mL-based QLs

Provider noteST flag present for some Lumigan entries; adhere to QL to avoid denial

TOBRAMYCIN ophthalmic quantity limit

TOBRAMYCIN ophthalmic 0.3%QL 15 ml/30 days

FormulationTobramycin ophthalmic solution 0.3% listed with 15 mL monthly limit

Provider noteObserve the 15 mL/30-day QL when dispensing ophthalmic antibiotics

Specialty Pharmacy and Site-of-Care Notes

Note

Biosimilars and Reference Biologics

Note