Blue Cross Blue Shield NM drug list — Coverage

Product listing with associated requirements

Coverage entries listed with qualifications; products are covered per their drug tier but may require authorization or have limits as shown.

Listed vaccine/biologic entries: Each product is enumerated with Drug Tier and Requirements/Limits; many vaccines have Requirements/Limits = AC (authorization/criteria).

No further decision tree present in excerpt

Selected oncology/specialty lines: Individual specialty and oncology products are listed with Drug Tier and may include Requirements/Limits such as PA, QL and SP (examples: dasatinib, cyclophosphamide entries).

See per-line entries for exact QL values and SP/PA flags

General coverage condition

Covered when prescription meets payer-defined utilization requirements

Formulary entry requirement: Drug must be on formulary with any specified PA, QL, SP requirements satisfied

Examples: obtain PA when 'PA' specified; do not exceed QL; dispense via SP when 'SP' specified

Formulary entries with utilization controls

Coverage and utilization rules as listed for specific products (excerpt):

ORIAHNN (elagolix-estradiol-norethindrone pack) — Drug Tier = P; Requirements/Limits = PA, QL (56 capsules/28 days)

Based on formulary line

ANNOVERA (segesterone acetate-ethinyl estradiol vaginal ring) — Drug Tier = NP; Requirements/Limits = AC, QL (1 ring/365 days)

Based on formulary line

ELLA (ulipristal acetate 30 mg) — Drug Tier = P; Requirements/Limits = AC, QL (2 tablets/365 days)

Based on formulary line

LEVONORGESTREL (emergency): Levonorgestrel 1.5 mg — Drug Tier = P; Requirements/Limits = AC, QL (2 tablets/365 days)

Based on formulary line

Formulary coverage with utilization management

Coverage stance is indicated per drug line and is subject to indicated requirements/limits.

Formulary Coverage Indicators: Each drug line shows Drug Tier and Requirements/Limits. Coverage follows plan formulary when requirements (PA, QL, SP, ST) are met.

No patient-specific clinical criteria provided in these chunks.

Formulary listing — coverage entries

Drugs listed with Drug Tier and Requirements/Limits govern coverage and utilization controls.

Formulary entries: Each listed drug line includes product name, strengths, Drug Tier designation and any Requirements/Limits such as PA, QL, SP.

No additional clinical criteria provided in this segment.

Formulary coverage annotations

Coverage status varies by product and is expressed via Drug Tier and Requirements/Limits flags.

coverage_flags: Products are annotated with Drug Tier (P, NP, NP+) and may have Requirements/Limits: PA (prior authorization), QL (quantity limits with explicit quantities/timeframes), SP (specialty).

These annotations dictate coverage controls per product in the formulary listing.

Product-level utilization controls

Coverage and utilization controls are applied at the product level as listed below; provider must meet specified control to obtain coverage.

Product-level controls: Individual drug lines list Drug Tier and Requirements/Limits fields — examples include PA (prior authorization), QL (quantity limits), SP (specialty product), ST (step therapy)

See product entries in chunks 216-235 for specific values

Coverage conditional on PA/QL/SP/ST

Coverage for the listed outpatient drugs is conditional and follows the stated utilization management flags per product (examples below).

General coverage conditions: Drug coverage is provided when benefit tier permits and when any specified Prior Authorization (PA), Quantity Limit (QL), Specialty Pharmacy (SP), and Step Therapy (ST) requirements for that product are met.

Applies product-by-product as listed

Drugs that are not listed on this formulary are generally not covered by the pharmacy benefit; examples called out in the document include non–FDA‑approved products, repackaged medications and some compounded preparations. Coverage may also be limited for products indicated for cosmetic use (for example, hair‑growth agents) or for members outside an approved age range. When a line item includes a utilization control such as PA (prior authorization), coverage requires approval before the medication will be paid; lack of required PA may result in a claim denial. Refer to the member’s benefit materials or the phone number on the ID card for plan‑specific exceptions and to request an exception.

Several formulary entries in this excerpt show an empty Requirements/Limits field. An absence of listed PA/QL/SP/ST on a drug line in this window indicates there are no special utilization controls documented here and the product is presented as standard formulary coverage subject to the member’s plan terms and tier placement.

Within the provided excerpt there are no discrete exclusion rules tied to specific clinical conditions — the content is an itemized formulary listing showing Drug Tier and any Requirements/Limits per product. Where exclusions exist they are described elsewhere; this fragment contains product lines with PA/QL/SP annotations but no standalone exclusion clauses.

No explicit clinical‑exclusion statements (for example, ‘not covered for diagnosis X’) are included in the excerpted lines. The listing focuses on product, tier and utilization controls (e.g., PA, QL, SP, AC), not clinical exclusion criteria.

This window of the formulary does not include specific conditional exclusions tied to patient characteristics or diagnoses. Entries are presented as drug lines with tier assignment and any associated Requirements/Limits rather than as exclusion policies.

No explicit exclusion language appears in the segments cited; instead, product coverage is expressed through Drug Tier assignment and utilization controls. Providers should follow the Requirements/Limits listed per product to determine coverage applicability.

The excerpted text does not state specific exclusions; it lists medications with Drug Tier and Requirements/Limits (for example, quantity limits or prior authorization). Absence of an explicit exclusion in these lines means coverage considerations are determined by the line‑level annotations and the member’s benefit plan.

No clinical exclusions are explicitly stated in this segment. Several analgesic and specialty lines include PA and QL annotations (e.g., QL for opioid patches, sodium oxybate) but the document does not present exclusion rules tied to clinical diagnoses in these chunks.

In the provided excerpt there are no explicit ‘Not Medically Necessary’ declarations for specific therapies. The policy does note that some product categories (for example, cosmetic indications or OTC equivalents) may not be covered and that coverage determinations follow FDA labeling, evidence‑based guidance and benefit plan terms.

The document highlights that products used for cosmetic purposes are commonly excluded from coverage. It also states some medications may be limited by age for safety or cosmetic reasons. Where a product is excluded for cosmetic use this will be reflected in plan materials or the formulary coverage rules.

Across the excerpt there are no explicit ‘Not Medically Necessary’ statements attached to individual line items. The formulary instead uses tiering and utilization controls; absence of an NMN statement in these chunks means no such determination is declared here.

The excerpt does not include explicit ‘not medically necessary’ language. Individual contraceptive and metabolic therapy lines show AC or PA and QL annotations, but no NMN findings are presented in these chunks.

No explicit ‘Not Medically Necessary’ statements appear in these sections. Coverage determinations for the listed products depend on meeting any stated utilization controls and the member’s plan terms rather than on NMN declarations in this excerpt.

The provided lines do not contain NMN determinations. They document product tiers and controls such as PA, QL, and SP, which govern coverage and potential denial risks if not satisfied.

No explicit ‘Not Medically Necessary’ language is present in the cited excerpt. The policy notes that non‑FDA‑approved, repackaged or OTC‑equivalent products may not be covered and that cosmetic uses are commonly excluded — these are programmatic exclusions rather than NMN statements tied to specific clinical scenarios in the excerpt.

There are no explicit NMN statements in these product lines. Vaccine and contraceptive rows show AC or blank Requirements/Limits entries; absence of NMN language here indicates no NMN determinations are provided in this portion of the formulary.

This excerpt does not list specific ‘Not Medically Necessary’ conditions for the products shown. Coverage is controlled by tier assignment and any per‑product utilization requirements noted in the Requirements/Limits field.

Authorization, Documentation & Denial Risk

Prior Authorization

Prior Authorization Required

Prior Authorization (PA) may be required for many medications listed in this document. When PA applies it will be indicated in the medication entry (Special Requirements column) with a 'PA' flag. Some plans may require PA for additional drugs not shown here; always verify member-specific benefits before dispensing.

PA flag shown next to affected medications in the formulary
PA may be required in addition to other controls (QL, SP, ST)

Prior Authorization

Prior Authorization Required for Select Products

PA is required for many specialty and oncology oral agents, hepatitis C antivirals, vaccines (when noted), CFTR modulators, biologics and other specialty injectables. Example products noted in the formulary that require PA include EPCLUSA, SOVALDI, TRIKAFTA, many cancer oral therapies (ALK, RET, TRK inhibitors), and selected hepatitis C agents.

Selected hepatitis C antivirals (e.g., EPCLUSA, SOVALDI) = PA, QL, SP
Many specialty/oncology oral agents listed with PA + QL + SP (examples in formulary)

Prior Authorization

Prior Authorization Required Where Listed

Where the formulary indicates 'PA' or lists PA in the Requirements/Limits column, providers must obtain authorization before the drug will be covered. PA requirements may be combined with Quantity Limits (QL), Specialty Pharmacy (SP) designation, or Step Therapy (ST).

PA + QL + SP combinations are common for specialty agents (e.g., OMVOH, TREMFYA, SKYRIZI)
Failure to obtain PA may result in claim denial or member financial liability

Prior Authorization

PA Required for Listed Specialty Agents

Many listed specialty agents require prior authorization and are designated for specialty pharmacy (SP). Examples include GENOTROPIN, GALAFOLD, OMNITROPE, and other high-cost biologic or infusible therapies.

GENOTROPIN – Requirements/Limits = PA, SP
GALAFOLD – Requirements/Limits = PA, QL, SP
OMNITROPE – Requirements/Limits = PA, SP

Prior Authorization

PA Required for Many Specialty Drugs

Numerous specialty drugs across therapeutic areas are subject to PA; these entries frequently also include QL and SP flags. Providers should anticipate PA for pulmonary arterial hypertension agents, biologics, CFTR modulators, and many oncology and rare-disease therapies.

PA, QL, SP appear together for many specialty agents (e.g., TYVASO, ALYFTREK, TRIKAFTA)
PA expected for high-cost chronic therapies and rare disease products

Prior Authorization

PA Required for Many Specialty Agents (Pulmonary & Biologics)

Prior authorization is required for selected pulmonary, respiratory, and biologic specialty agents. Examples include ORENITRAM, TYVASO, XOLAIR, and ALYFTREK — check each formulary line for PA, QL and SP annotations.

ORENITRAM – Requirements/Limits = PA, QL, SP
TYVASO and starter kits – PA, QL, SP
XOLAIR – Requirements/Limits = PA, SP

Prior Authorization

PA Required for Specific Products

Certain specific products listed require PA and have explicit quantity limits and specialty designations. Examples include OMVOH, SKYRIZI, TREMFYA, and other high-cost injectables shown with PA, QL and SP annotations.

OMVOH – PA, QL (2 pens/28 days), SP
SKYRIZI – PA, QL (1 cartridge/56 days), SP
TREMFYA – PA, QL (1 syringe/28 days), SP

Denial Risk

Coverage and Prior Authorization Triggers

Coverage and prior authorization triggers: drugs not listed as covered by your plan or lacking required PA/step therapy/quantity-limit compliance may be denied. Plans may also exclude drugs (e.g., non–FDA approved, repackaged, or OTC-equivalent products). Verify member-specific benefits and follow the formulary flags.

Non–FDA approved drugs, repackaged medications, and excluded categories may not be covered
If PA/ST/QL requirements are not met, coverage may be denied and member may be liable

Denial Risk

PA and Limits May Trigger Denial

Failure to follow PA, QL, ST or SP requirements can lead to claim denial or member financial responsibility. Prior authorization and dispensing limits are enforceable; some state laws may further restrict coverage for controlled substances dispensed beyond limits.

Noncompliance with PA/QL/ST may result in denial
Dispensed quantity beyond QL may be excluded from coverage and billed to member

Prior Authorization

PA Required for Selected Hepatitis C Agents

Prior authorization is commonly required for newer hepatitis C agents and combination regimens. Examples in the formulary include EPCLUSA, SOVALDI and other sofosbuvir-containing products — these entries are noted with PA, QL and SP where applicable.

EPCLUSA – Requirements/Limits = PA, QL (28 tablets/28 days), SP
SOVALDI – Requirements/Limits = PA, QL (30 tablets/30 days), SP

Prior Authorization

Authorization Required for Many Vaccines

Authorization is required for many vaccines and preventive products when indicated by the formulary (AC or PA flags). Check the vaccine entries (e.g., ACTHIB, AREXVY, seasonal influenza formulations) for Authorization (AC) or PA requirements.

AC indicates administrative coverage/authorization for vaccines
Some vaccine formulations list AC in Requirements/Limits

Prior Authorization

Prior Authorization / Administrative Criteria Required

When a formulary line includes 'PA' or other administrative criteria, providers must follow the listed authorization process and submit required documentation. For exception or expedited reviews follow BCBSNM procedures; exception requests and responses have defined timelines.

Exception requests: standard response within 3 business days; expedited within 24 hours if life/health threatened
Contact number on member ID card for PA or exception submissions

Prior Authorization

PA and QL Entries for Specialty Drugs

Formulary PA entries frequently appear alongside QL (quantity limits) and SP (specialty pharmacy) flags for specialty drugs. Providers should confirm whether an agent requires specialty pharmacy dispensing and adhere to the stated QL.

PA + QL + SP are combined controls for many agents (examples throughout the formulary)
Specialty agents often have per‑period quantity limits that must be observed

Documentation Required

Required Documentation for PA/SP Drugs

Required documentation: when PA or SP is indicated, providers must supply clinical documentation supporting medical necessity (diagnosis, prior therapies tried, lab results, dosing plan). Specialty products in particular require thorough documentation at submission.

Provide clinical rationale, prior-treatment history, and relevant labs/imaging as applicable
Specialty pharmacy submissions may require additional forms or manufacturer support documentation

Billing Rule

Follow Requirements / Limits

Follow requirements and limits exactly: prescriptions must match the formulary QL and any PA instructions. If the prescribed quantity exceeds the formulary QL, the extra amount may be non‑covered and billed to the member unless an approved exception exists.

Match dispensed quantity to formulary QL
Request exception or prior authorization if a larger quantity is clinically required

Documentation Required

Prior Authorization Documentation & Clinical Details

Prior authorization documentation expectations: include drug name, dosage, diagnosis, prior treatment(s) and outcomes, anticipated duration, and any specialty‑pharmacy enrollment details. For CFTR and specialty respiratory agents include genotype, weight/age, and prior CF‑directed therapies where required.

CFTR/respiratory agents (e.g., TRIKAFTA, KALYDECO) often require genotype and prior therapy documentation
Quantity limits and refill schedules must be documented for chronic specialty therapies

Billing Rule

Match Prescription Quantity to Formulary QL

Match prescription quantity to the formulary QL and the approved PA. Examples: many biologics and specialty injectables specify induction and maintenance quantities (e.g., TREMFYA induction/maintenance packs). Dispense strictly within those limits unless PA/exception authorizes otherwise.

TREMFYA – induction and maintenance QL specified (induction packs and maintenance pens)
OMVOH, SKYRIZI, TREMFYA examples show induction/maintenance QLs

Documentation Required

Documentation Expectations for PA/SP Drugs

Documentation for PA/SP drugs must be maintained and submitted with the authorization request. Specialty products typically require more extensive documentation and may require ongoing documentation at reauthorization intervals.

Ongoing reauthorization may require updated clinical data
Keep records of prior authorizations and approvals for claims and refills

Documentation Required

Specialty Products Require Documentation

Specialty products require documentation at initial authorization and often at renewal. Be prepared to provide therapy plans, monitoring schedules, and evidence of benefit for continuation approvals.

Many specialty agents list PA and SP with QL and require periodic review
Reauthorization timelines vary by product and clinical program

Documentation Required

Documentation and Limits for PA/QL/SP Items

Documentation and limits for PA/QL/SP items: follow the exact formulary annotations for each line item — PA, QL and SP are enforceable controls. For high-cost, rare-disease, or weight‑management agents (e.g., WEGOVY, SAXENDA, MOUNJARO) expect PA plus QL and possible SP handling.

MOUNJARO – Requirements/Limits = PA, QL (4 pens/28 days)
WEGOVY – Requirements/Limits = PA, QL (8 pens/180 days)
SAXENDA – Requirements/Limits = PA, QL (15 mls/30 days)

Billing Rule

Required Claim Documentation Aligns with QL and SP

Required claim documentation must align with the approved PA and the formulary QL/SP designation. Submit authorization identifiers and supporting clinical records as required to avoid claim denials or delays.

Include PA approval number on claims where applicable
Ensure claim quantities and NDCs match the authorized product and QL

Step Therapy

Step Therapy Requirement

Step Therapy (ST) requirements apply where indicated — the formulary will flag medications with 'ST' when a preferred first‑line agent must be tried prior to coverage of the listed drug. Providers may submit a step therapy exception with clinical justification if the preferred agent is unsuitable.

ST flags are shown in the Special Requirements column when applicable
Submit ST exception requests with clinical rationale and prior drug history

Specified Quantity Limits (QL) by Product

Standard supply duration summary

Standard policy on supply durationStandard: up to 30-day supply for most prescriptions; some maintenance medications permitted up to 90 days

Quantity limits (QL) enforce dispensing limitsQL entries specify maximum quantity and time period (e.g., '60 tablets/30 days', '1 kit/180 days') and are noted on each drug line

Prior Authorization (PA)PA flag indicates clinician must obtain approval before coverage; absence may lead to denial

Specialty Pharmacy (SP)SP designation requires specialty pharmacy dispensing where indicated

azithromycin tab 250 mg (Zithromax z-pak) — QL 60 tablets/180 days

Productazithromycin tab 250 mg (Zithromax z-pak)

Quantity LimitQL (60 tablets/180 days)

Source noteListed with QL on formulary

BAXDELA - delafloxacin tab 450 mg — QL 28 tablets/180 days

ProductBAXDELA - delafloxacin tab 450 mg

Quantity LimitQL (28 tablets/180 days)

Source noteListed with QL on formulary

ARIKAYCE — QL 28 vials/28 days

ProductARIKAYCE - amikacin liposome inhalation suspension

Quantity LimitQL (28 vials/28 days)

Special RequirementsSP indicated for product

KITABIS PAK — QL 280 mls/56 days

ProductKITABIS PAK - tobramycin nebulization solution 300 mg/5 ml

Quantity LimitQL (280 mls/56 days)

Special RequirementsSP indicated where listed

TOBI PODHALER — QL 224 capsules/56 days

ProductTOBI PODHALER - tobramycin inhalation capsules 28 mg

Quantity LimitQL (224 capsules/56 days)

Special RequirementsSP indicated where listed

itraconazole cap 100 mg — QL 120 capsules/30 days

ProductItraconazole cap 100 mg (Sporanox)

Quantity LimitQL (120 capsules/30 days)

Alternate formItraconazole oral solution QL (1200 mls/30 days)

EPCLUSA — QL 28 tablets/28 days

ProductEPCLUSA (sofosbuvir-velpatasvir)

Quantity LimitQL (28 tablets/28 days) — packs also listed as QL (28 packs/28 days)

Special RequirementsPA, SP for some presentations

EDURANT PED (rilpivirine) — QL 180

ProductEDURANT PED (rilpivirine) oral suspension tablets 2.5 mg

Quantity LimitQL (180 tablets/30 days)

Source noteListed with QL on formulary

efavirenz tab 600 mg — QL 30

ProductEfavirenz 600 mg tab

Quantity LimitQL (30 tablets/30 days)

Source noteListed with QL on formulary

EPCLUSA (duplicate listing) — QL 28

ProductEPCLUSA (repeated listing)

Quantity LimitQL (28 tablets/28 days)

NoteListed as PA/QL/SP where applicable

TRIUMEQ — QL 30

ProductTRIUMEQ (abacavir-dolutegravir-lamivudine)

Quantity LimitQL (30 tablets/30 days)

Source noteListed with QL on formulary

VIREAD — QL 30

ProductVIREAD (tenofovir disoproxil fumarate) 300 mg tab

Quantity LimitQL (30 tablets/30 days)

Source noteListed with QL on formulary

Examples across multiple specialty drugs (varies)

Specialty drug examplesMany specialty oncology and high-cost drugs have PA, QL and SP designations with varying numeric limits (examples shown across entries)

Examples includeALUNBRIG QL (30-120 tablets/30-180 days); ALECENSA QL (240 capsules/30 days); IMBRUVICA QL (30 tablets/30 days or 216 mls/30 days for suspension)

Maintenance oncologySome therapy packs and starter kits are limited by pack/kit counts (e.g., COMETRIQ kits QL (1 kit/28 days))

vandetanib tab 100 mg — QL 60 tablets

ProductVandetanib (CAPRELSA) 100 mg tab

Quantity LimitQL (60 tablets/30 days)

Special RequirementsPA, SP as listed

everolimus tab 2.5-10 mg — QL 30 tablets

ProductEverolimus (Afinitor) 2.5–10 mg tabs

Quantity LimitQL (30 tablets/30 days)

NotesHigher-dose or alternative presentations may have 60–90 tablet QLs as listed

MEKINIST trametinib soln — QL 13 bottles

ProductMEKINIST (trametinib) solution 0.05 mg/ml

Quantity LimitQL (13 bottles/28 days)

Special RequirementsPA, SP indicated

IMBRUVICA oral susp — QL 216 mls

ProductIMBRUVICA oral suspension

Quantity LimitQL (216 mls/30 days)

Special RequirementsPA, SP indicated

Pomalyst — QL 21 capsules

ProductPomalyst (pomalidomide)

Quantity LimitQL (21 capsules/28 days)

Special RequirementsPA, SP indicated

QINLOCK — QL 90 tablets

ProductQINLOCK (ripretinib) 50 mg

Quantity LimitQL (90 tablets/30 days)

Special RequirementsPA, SP indicated

ROZLYTREK — QL 336 packets

ProductROZLYTREK (entrectinib) pellet pack

Quantity LimitQL (336 packets/28 days)

Special RequirementsPA, SP indicated

VITRAKVI oral soln — QL 300 mls

ProductVITRAKVI (larotrectinib) oral solution

Quantity LimitQL (300 mls/30 days)

Special RequirementsPA, SP indicated

XYOSTED — QL 4 pens

ProductXYOSTED testosterone auto-injector pens

Quantity LimitQL (4 pens/28 days)

Special RequirementsPA where listed

ORIAHNN / ANNOVERA / emergency contraception examples

ProductORIAHNN (elagolix-estradiol-norethindrone pack)

Quantity LimitQL (56 capsules/28 days)

ProductANNOVERA (segesterone acetate ring)

Quantity LimitQL (1 ring/365 days)

ProductELLA (ulipristal) and Levonorgestrel emergency contraception

Quantity LimitELL A QL (2 tablets/365 days); Levonorgestrel QL (2 tablets/365 days)

WEGOVY / OZEMPIC / MOUNJARO / oral GLP-1 examples

OZEMPIC (semaglutide pen)QL (1 pen/28 days)

MOUNJARO (tirzepatide)QL (4 pens/28 days or 4 pens/180 days depending on strength)

RYBELSUS (oral semaglutide)QL (30 tablets/30 or 180 days depending on strength)

TRIJARDY XRQL (60 tablets/30 days or 30 tablets/30 days depending on strength)

XIGDUO XRQL (60 or 30 tablets/30 days depending on strength)

Multiple insulin products — QL 100 mls

Multiple insulin products (pens/cartridges/vials)QL (100 mls/30 days) is the common limit across insulin presentations

ExamplesFIASP, HUMALOG, LYUMJEV, NOVOLOG, HUMULIN, NOVOLIN and cartridge/pen presentations all list QL (100 mls/30 days)

Specialty noteSome insulin combination pens (e.g., SOLIQUA, XULTOPHY) have different pen-count QLs as listed

GALAFOLD / IMCIVREE / ISTURISA examples

GALAFOLD (migalastat)QL (14 capsules/28 days)

IMCIVREE (setmelanotide)QL (10 vials/30 days)

FOLLISTIM AQ cartridgesQL varies by presentation (e.g., 15, 8, 5 cartridges/30 days)

ISTURISA (osilodrostat)QL (360 tablets/30 days)

ISTURISA / ORILISSA / TRYNGOLZA / oral solution examples

ORILISSA (elagolix) 200 mgQL (60 tablets/30 days)

TRYNGOLZA injection deviceQL (1 injection device/28 days)

Epaned (enalapril oral solution)QL (1200 mls/30 days)

ALYFTREK / KALYDECO / TRIKAFTA examples

ALYFTREK (CFTR mod) various strengthsQL (84 tablets/28 days or 56 tablets/28 days depending on strength)

KALYDECO (ivacaftor)QL (60 tablets or packets/30 days)

TRIKAFTA (packets/tablets)QL (56 packets/28 days) or QL (84 tablets/28 days) depending on presentation

TRELEGY / VENTOLIN / OFEV examples

TRELEGY ELLIPTA inhalerQL (1 inhaler/30 days)

VENTOLIN HFAQL (2 inhalers/30 days)

OFEV (nintedanib)QL (60 capsules/30 days)

Various biologics, tablets, and kit examples

CIMZIA (certolizumab)QL (4 syringes/28 days) or starter kit QL (1 kit/180 days)

MOVANTIK (naloxegol)QL (30 tablets/30 days)

Sevelamer carbonate formulationsExamples: QL (1530 tablets/365 days) or QL (450 packets/365 days)

TREMFYA induction packQL (3 kits/180 days) and regular QL (1 pen/28 days)

Additional specialty biologic, psychiatric, and weight-management QLs

OMVOH (mirikizumab)QL (2 pens/28 days) or QL (2 syringes/28 days) depending on presentation

ZYMFENTRA infliximab biosimilar pensQL (2 pens/28 days) or QL (2 syringes/28 days)

Aripiprazole ODTQL (60 tablets/30 days)

Hetlioz (tasimelteon) oral suspensionQL (158 mls/30 days)

WEGOVY/ZEPBOUND weight-management pensWEGOVY: QL (8 pens/180 days) or QL (4 pens/28 days); ZEPBOUND: QL (4 pens/180 days) or QL (4 pens/28 days)

Step Therapy Indicators & Expectations

Indicator	Meaning
ST	Denotes drugs commonly requiring step therapy on the drug list; listed when a preferred first‑line medication must be tried prior to coverage of the indicated drug
Examples	If a step therapy is commonly required it is noted with 'ST' under Special Requirements; prescriber may request a step therapy exception if preferred agent is not appropriate

Observation	Source detail
Some products include QL or PA flags	Multiple formulary entries show 'QL' (quantity limits) and 'PA' (prior authorization) in Requirements/Limits, e.g., azithromycin (QL), ARIKAYCE (QL/PA), EPCLUSA (PA)
No explicit step therapy steps in excerpt	The listing shows PA/QL entries but does not provide multi‑step sequences or required first‑line agent names in these chunks

Observation	Source detail
Some products marked SP (specialty) requiring PA	Many specialty agents include 'SP' and 'PA' in Requirements/Limits (examples: oncology and CFTR modulators), but no explicit step sequence provided
Examples of SP/PA lines	Entries such as ORENITRAM, TYVASO, ALYFTREK, KALYDECO show 'PA' and 'SP' designations and quantity limits

Observation	Source detail
AC indicated for many contraceptives	Contraceptive product lines list 'Requirements/Limits = AC' (administrative coverage) and often QL (e.g., 28 tablets/21 days) where applicable
AC used as administrative/coverage step	AC appears in Special Requirements for contraceptives and denotes administrative coverage or criteria; may function as a step/authorization code

Product	Requirement
MOUNJARO (tirzepatide auto‑injector)	Requirements/Limits = PA, QL (4 pens/28 days or 4 pens/180 days depending on strength) — prior authorization required before coverage

Product	Annotation
KERENDIA (finerenone)	Requirements/Limits = QL (30 tablets/30 days), ST — marked 'ST' indicating step therapy may apply

Observation	Source detail
Multiple products annotated 'ST'	Formulary lines include 'ST' for selected agents and formulations (examples in chunks: psychiatric agents, KERENDIA; lipid agents have PA/QL but ST not specified)

Category	Controls noted
New lipid‑lowering agents (examples)	NEXLETOL / NEXLIZET show PA and QL (30 tablets/30 days); step therapy details are not specified in this segment

Step	Instruction
Step 1	(No specific Step 1 instructions provided in the excerpt; step therapy is referenced generally and marked with 'ST' where applicable)

Summary	Implication
No explicit step therapy sequences documented	The excerpt primarily uses PA, QL, and SP flags to control use; formal multi‑step sequences or required prior agents are not listed

Scope	Examples
Step Therapy applied to selected psychiatric agents	Several antidepressant/antipsychotic entries are annotated 'ST' (examples: AUVELITY, TRINTELLIX, CLOZAPINE ODT, FANAPT titration packs show 'ST')

Observation	Source detail
Some products/formulations annotated 'ST'	Psychiatric agents (AUVELITY, TRINTELLIX), clozapine ODT, FANAPT titration packs, and GRALISE entries include 'ST' indicating step therapy must be followed where noted

Requirement	Provider action
Document prior steps as required	When 'ST' is indicated, prior steps should be documented per the step therapy program; prescriber can submit an exception request if preferred agent is inappropriate

OpenPayer

2026 Drug List (pharmacy formulary) — Coverage Criteria

Formulary Coverage & Conditions

Drug Listings & Coding Indicators

Authorization, Documentation & Denial Risk

Dispensing Channel & Administration

Specified Quantity Limits (QL) by Product

Key Terms & Abbreviations

Step Therapy Indicators & Expectations

Policy Background & Scope