CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2025 Drug List (Prescription Drug Formulary)

This document is Blue Cross and Blue Shield's 2025 Drug List describing preferred drugs, tiers, coverage considerations, and special program indicators for pharmacy benefits affecting plan members covered by BCBS (including New Mexico).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2025 Drug List (Prescription Drug Formulary)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJanuary 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests when a drug is marked PA in the Requirements/Limits column.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6member payment tiers

30/90supply limits

PA, QL, SP, ACrequirement flags

REPATHA, TRIKAFTAspecialty examples

part 8–11document part

Coverage Criteria and Product-Level Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Index — No coverage rules (fragment)

Index — no coverage rules fragment: the index lists product names and cross-references used elsewhere in this document. The index entries shown below are reproductions from the source index fragment; they are informational only and do not by themselves indicate coverage, limits, or requirements. For coverage and Requirements/Limits details, see the main formulary/product lists.

COMBIVENT RESPIMAT., 1 = 16. COMBIVENT RESPIMAT., 2 = . COMBIVENT RESPIMAT., 3 = COMBIVENT RESPIMAT.

donepezil hydrochloride orally disintegrating tab 5 mg,

donepezil hydrochloride tab 5 mg; 10 mg_ 10 mg:

DOPTELET

dorzolamide hcl ophth soln 2%.-

DOVATO

dorzolamide hcl-timolol maleate ophth soln 2-0.5%.

doxazosin mesylate tab mg; 2 mg;

doxepin hcl conc 10 mglml:

doxepin hcl cap 10 mg; 25 mg; 50 mg:- mg; 8 mg_

doxycycline hyclate cap 50 mg_

doxycycline hyclate tab 20 mg, 100 mg:

doxycycline hyclate cap 100 mg_

doxycycline monohydrate cap 50 mg- doxycycline monohydrate tab 50 mg; 100 mg:

doxycycline monohydrate cap 100 mg:

drospirenone-ethinyl estradiol tab 3-0.02 mg:

DUAVEE

drospirenone-ethinyl estradiol tab 3-0.03 mg:

DULERA

duloxetine hcl enteric coated pellets cap 20 mg (base eq)-

duloxetine hcl enteric coated pellets cap 30 mg (base eq):

duloxetine hcl enteric coated pellets cap 60 mg (base eq)-_

DUPIXENT _

dutasteride cap 0.5 mg_

EBGLYSS.

ELIQUIS.

ELIQUIS STARTER PACK

ELLA

ELOCTATE.

EMEND.

EMGALITY_

EMPAVELI:

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg:

enalapril maleate & hydrochlorothiazide tab 10-25 mg:.

ENBREL:

ENBREL MINI

ENBREL SURECLICK.

ENTRESTO.

ENTYVIO PEN:

EPCLUSA:

EPIDIOLEX

ERIVEDGE_

ergocalciferol cap 1.25 mg (50000 unit):

ERLEADA

erythromycin ophth oint 5 mglgm.

gentamicin sulfate ophth soln 0.3%. 29, 1 = 29. gentamicin sulfate ophth soln 0.3%. 29, 2 = hydrocortisone oint 1%, 2.5%.. gentamicin sulfate ophth soln 0.3%. 29, 3 = 30.

GENVOYA, 1 = . GENVOYA, 2 = hydromorphone hcl tab 2 mg, 4 mg-. GENVOYA, 3 = 22.

GLEOSTINE., 1 = . GLEOSTINE., 2 = hydroxychloroquine sulfate tab 100 mg; 300 mg_. GLEOSTINE., 3 = 3.

glimepiride tab, 1 = . glimepiride tab, 2 = hydroxyzine hcl tab 10 mg; 25 mg; 50 mg:. glimepiride tab, 3 = 19.

glipizide tab er 24hr 2.5 mg, 5 mg; 10 mg, 1 = . glipizide tab er 24hr 2.5 mg, 5 mg; 10 mg, 2 = hydroxyzine pamoate cap 25 mg, 50 mg-.. glipizide tab er 24hr 2.5 mg, 5 mg; 10 mg, 3 = 19.

glipizide tab 5 mg; 10 mg-, 1 = . glipizide tab 5 mg; 10 mg-, 2 = . glipizide tab 5 mg; 10 mg-, 3 = .

GLUCAGON EMERGENCY KIT FO., 1 = . GLUCAGON EMERGENCY KIT FO., 2 = . GLUCAGON EMERGENCY KIT FO., 3 = .

glyburide-metformin tab 1.25-250 mg; 2.5-500 mg; 5-500 mg:-, 1 = . glyburide-metformin tab 1.25-250 mg; 2.5-500 mg; 5-500 mg:-, 2 = ibandronate sodium tab 150 mg (base equivalent) IBRANCE..

glyburide-metformin tab 1.25-250 mg; 2.5-500 mg; 5-500 mg:-, 3 = 4. glyburide tab 1.25 mg, 2.5 5 mg 8 mg;, 1 = 8.

glyburide tab 1.25 mg, 2.5 5 mg 8 mg;, 2 = ibuprofen susp 100 mglsml:.

INDEX fragment entries continue:

COMBIVENT RESPIMAT.

indomethacin cap 25 mg, 50 mg,

ketorolac tromethamine tab 10 mg,

meloxicam tab 7.5 mg; 15 mg (Mobic),

nabumetone tab 500 mg; 750 mg,

naproxen tab 250 mg; 375 mg, 500 mg (Naprosyn),

OTEZLA apremilast tab 20 mg, 30 mg,

RINVOQ upadacitinib tab er 24hr 15 mg, 30 mg,

RINVOQ upadacitinib tab er 24hr 45 mg,

RINVOQ LQ upadacitinib oral soln mglml,

SIMLANDI 80 mg/o.8ml,

SIMLANDI 1-PEN KIT adalimumab-ryvk auto-injector kit 40 mg/O.4ml, 80 mg/o.8ml,

SIMLANDI 2-PEN KIT,

SIMPONI golimumab subcutaneous soln auto-injector 100 mg/ml,

SIMPONI golimumab subcutaneous soln prefilled syringe 100 mglml,

sulindac tab 150 mg; 200 mg,

TYENNE tocilizumab-aazg subcutaneous soln auto-inj 162 mg/O.9ml,

XELJANZ tofacitinib citrate oral soln mglml (base equivalent),

XELJANZ tofacitinib citrate tab 5 mg (base equivalent),

XELJANZ tofacitinib citrate tab 10 mg (base equivalent),

XELJANZ XR tofacitinib citrate tab er 24hr 11 mg (base equivalent),

XELJANZ XR tofacitinib citrate tab er 24hr 22 mg (base equivalent),

MIGRAINE PRODUCTS: AIMOVIG erenumab-aooe subcutaneous soln auto-injector 70 mglml; 140 mglml, AJOVY fremanezumab-vfrm subcutaneous soln auto-inj 225 mg/1.Sml,

AJOVY fremanezumab-vfrm subcutaneous soln pref syr 225 mg/1.Sml,

EMGALITY galcanezumab-gnlm subcutaneous soln auto-injector 120 mglml,

NURTEC rimegepant sulfate tab disint 75 mg,

QULIPTA atogepant tab 10 mg, 30 mg, 60 mg,

REYVOW lasmiditan succinate tab 50 mg, 100 mg,

rizatriptan benzoate oral disintegrating tab 5 mg (base eq), rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt), rizatriptan benzoate tab 5 mg (base equivalent); 10 mg (base equivalent),

OMNIPOD 5 DEXCOM G7G6 POD., OMNIPOD 5 LIBRE2 PLUS G6., OMNITROPE:, OMVOH:, ondansetron hcl tab 4 mg; 8 mg,

OPSUMIT., ondansetron orally disintegrating tab, OPTIUMEZ TEST STRIPS., OPVEE:, ORFADIN., ORIAHNN_, ORILISSA, OTEZLA, OVIDREL., oxcarbazepine tab 150 mg- oxybutynin chloride tab er 24hr 15 mg-

oxybutynin chloride solution 5 mgsml:, oxybutynin chloride tab er 24hr 5 mg; 10 mg:, oxycodone hcl cap 5 mg:, oxybutynin chloride tab 5 mg:, oxycodone hcl tab 5 mg oxycodone wl acetaminophen tab 5-325 mg:, oxycodone hcl tab 10 mg:

OZEMPIC .

pantoprazole sodium ec tab 20 mg (base equiv), 40 mg

PAXLOVID.

paroxetine hcl tab 10 mg; 20 mg, 30 mg; 40 mg

PEGASYS., peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm:

phendimetrazine tartrate tab 35 mg:_, penicillin potassium tab 250 mg; 500 mg,

phenobarbital tab 15 mg; 16.2 mg; 30 mg:, phentermine hcl cap 15 mg, 30 mg phentermine hcl cap 37.5 mg_, phentermine hcl tab 37.5,

pioglitazone hcl tab 15 mg (base equiv), 30 mg (base

PIQRAY 200MG DAILY DOSE:, PIQRAY 250MG DAILY DOSE, PIQRAY 3O0MG DAILY DOSE:, PLEGRIDY, PLEGRIDY STARTER PACK, polymyxin b-trimethoprim ophth soln 10000 unitl ml-0.1%._

POMALYST_, potassium chloride microencapsulated crys er tab 10

potassium chloride tab er 10 meq; 20 meq (1500)

Formulary Listings and Coding / Quantity Examples

Formulary drug listings (by class)NDC

	PENICILLINS: amoxicillin (trihydrate) cap 250 mg; 500 mg; amoxicillin (trihydrate) tab 500 mg; amoxicillin & k clavulanate for susp 200-28.5 mg/sml; ampicillin cap 500 mg; penicillin v potassium tab 250 mg; 500 mg
	CEPHALOSPORINS: cefadroxil cap 500 mg; cefdinir cap 300 mg; cefuroxime axetil tab 250 mg; cephalexin cap 250 mg, 500 mg (Keflex)
	MACROLIDES: azithromycin for susp 200 mg/5ml (Zithromax); azithromycin tab 250 mg, 500 mg; QL (60 tablets/180 days); DIFICID fidaxomicin for susp 40 mg/ml
	TETRACYCLINES: doxycycline hyclate cap 50 mg; doxycycline hyclate cap 100 mg (Vibramycin); doxycycline hyclate tab 20 mg; 100 mg; doxycycline monohydrate cap 50 mg; doxycycline monohydrate cap 100 mg (Monodox); doxycycline monohydrate tab 50 mg; 100 mg; minocycline hcl cap 50 mg (Minocin)

Requirement/Limits codes observedmixed

QL (30 tablets/30 days)	Quantity limit example applied to several oral antiviral products (e.g., BIKTARVY, CIMDUO, DELSTRIGO, DESCOVY, DOVATO)
PA	Prior authorization required (abbreviated) as shown for products such as EPCLUSA
SP	Specialty designation (SP) noted for select high-cost agents such as EPCLUSA, MAVYRET

insulin products (various concentrations and delivery forms)mixedCovered

Rapid-Acting Insulins: FIASP insulin aspart inj 100 unit/ml; FIASP FLEXTOUCH pen; FIASP PENFILL cartridge; HUMALOG insulin lispro cartridges and pens; HUMALOG JUNIOR KWIKPEN; HUMALOG KWIKPEN (100 unit/ml, also 200 unit/ml); HUMALOG TEMPO PEN; LYUMJEV insulin lispro-aabc inj 100 unit/ml; LYUMJEV KWIKPEN; LYUMJEV TEMPO PEN. Requirements/Limits = QL (100 mls/30 days) for listed formulations.

thyroid agents (levothyroxine, liothyronine)mixedCovered

	levothyroxine sodium tab 25 mcg; 50 mcg; 75 mcg; 88 mcg; 100 mcg; 112 mcg; 125 mcg; 137 mcg; 150 mcg; 175 mcg; 200 mcg; 300 mcg (Synthroid) — Requirements/Limits = .
	liothyronine sodium tab 5 mcg (Cytomel) — Requirements/Limits = .

example specialty biologicNDCCovered

REPATHA evolocumab subcutaneous soln prefilled syringe 140 mg/mL — Requirements/Limits = PA, QL (6 syringes/28 days).

respiratory maintenance agentsNDCCovered

SPIRIVA RESPIMAT tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act; 2.5 mcg/act — Requirements/Limits = QL (1 cartridge/30 days).

NDC/CPT/HCPCS not providedmixed

Document excerpt lists drug names, strengths, and Requirements/Limits but does not provide standard billing codes (NDC/CPT/HCPCS) in this section.

Formulation-level listing without codesNDC

NDC not listed

Document lists drugs and formulations (index entries) but does not provide NDC codes in this excerpt.

Common quantity limits for glucose monitoring suppliesmixedCovered

204 strips/30 days	Quantity limit frequently applied to many glucose blood test strips (e.g., FREESTYLE, PRECISION series) — Requirements/Limits = QL (204 strips/30 days).
1 receiver/365 days	Dexcom G6/G7 receiver quantity limit — Requirements/Limits = PA, QL (1 receiver/365 days).
3 sensors/30 days	Dexcom G6/G7 sensor quantity limit — Requirements/Limits = PA, QL (3 sensors/30 days).

NDC/Coding not presentNDC

No codes listed

index_text_onlymixed

Index fragment contains drug names, strengths, and formulations without explicit procedure or product billing codes (NDC/CPT/HCPCS).

Codes not providedmixed

This segment is an alphabetic index of drug names and cross-references; no billing codes (NDC/CPT/HCPCS) are provided in the excerpt.

Index (no codes)mixed

Alphabetical drug index entries only; no billing or clinical codes present in this section of the document excerpt.

inv-25: Quantity limit example

Example productazithromycin — QL (60 tablets/180 days)

Therapeutic classMacrolides (example shown)

Source noteListed as QL in formulary macrolides section

inv-26: Common QL thresholds

Common 30-day tablet limits30 tablets/30 days

90-day maintenance example90 tablets/30 days (MAVYRET example)

Packet/short-course limit28 packets/28 days

Alternate 60-day format60 tablets/30 days

inv-27: contraceptive quantity limit example

Contraceptive QL exampleMost combined oral contraceptives — AC, QL (28 tablets/21 days)

Emergency contraception exampleELLA — AC, QL (2 tablets/365 days)

91-day formulation noteSome 91-day levonorgestrel/ethinyl estradiol entries referenced with QL (28 tablets/21 days)

inv-28: common QL for antidiabetics

Typical antidiabetic QL30 tablets/30 days — common for agents like JANUVIA, JARDIANCE

Higher short-term QL60 tablets/30 days — e.g., JANUMET XR listed as 60 tablets/30 days

GLP-1 pen limitsGLP-1 injectables (e.g., MOUNJARO, OZEMPIC) listed with pen/28 days QL (e.g., 4 pens/28 days)

inv-29: REPATHA quantity limit

REPATHA QL6 syringes (or pens) per 28 days

AuthorizationREPATHA requires Prior Authorization (PA)

FormulationEvolocumab subcutaneous solution prefilled syringe 140 mg/mL

inv-30: ALYFTREK quantity limit

ALYFTREK QL56 tablets/28 days

Authorization and designationALYFTREK requires PA and is designated SP (specialty)

Product compositionvanzacaftor-tezacaftor-deutivacaftor tab 10-50-125 mg

inv-31: Quantity limit examples

Example — 28- or 365-day QLsZURZUVAE (zuranolone) — QL 14 capsules/365 days (30 mg) or QL 28 capsules/365 days (other strengths)

Example — long supply QLCRINONE progesterone vaginal gel — QL 60 applicators/30 days

Psychotropic QL examplearipiprazole — QL 60 tablets/30 days for select strengths

inv-32: Common quantity limit examples

Migraine/acute therapy QLsumatriptan — QL 18 tablets/30 days

Anticonvulsant/neuropathic pain QLpregabalin — multiple QLs (e.g., 360 caps/30 days for 25 mg; 60 caps/30 days for higher strengths)

Acute oral QL exampleUBRELVY ubrogepant — PA, QL 16 tablets/30 days

inv-33: Specialty biologic QL examples

Specialty biologic QL examplesRanges vary by product — e.g., 1 syringe/28 days; 2 pens/28 days; 1 syringe/84 days; 1 syringe/56 days

Authorization and specialtyMany biologics require PA and SP designation (examples: COSENTYX, DUPIXENT, ADBRY)

Dose examplesCOSENTYX 300 mg dose may be QL 2 syringes/28 days; DUPIXENT 300 mg may be QL 4 pens/28 days

inv-34: Not applicable

ApplicabilityNot applicable — these chunks contain no utilization thresholds or quantity limits

Index statusIndex text only; coverage criteria located in other sections

Document noteNo QL entries present in these specific index fragments

inv-35: Index completeness in this part

Index completenessPartial — contains repeated entries and truncated lines in this part of the index

Coverage contentThis segment is an index; explicit coverage rules appear in other sections

RecommendationRefer to product sections for PA/QL/SP details

Provider Requirements, Prior Authorization, and Dispensing Rules

Prior Authorization

Prior authorization (PA) may be required for certain medications listed in this formulary. When PA is commonly required, the medication entry will display "PA" in the Special Requirements / Requirements/Limits column. Providers should submit a prior authorization request and obtain approval before dispensing to ensure coverage. Some plans may require PA for additional medications not explicitly marked here; verify member benefit details as needed.

PA indicator: medications in the formulary that require prior approval are marked with "PA" in the Requirements/Limits column
Some specialty products and biologics may have PA plus specialty pharmacy (SP) requirements

Step Therapy

Step therapy (ST) may apply to selected medications. If a step-therapy requirement is commonly applied, the medication entry will display "ST" in the Requirements/Limits column. Providers should verify step requirements and document trials of required first-line agents when submitting PA or appeals.

ST indicator: medications that require trying another medication first are marked with "ST"

Billing Rule

Dispensing / Quantity Limits

Quantity limits (QL) and dispensing limits (DL) are applied to many products to align use with FDA labeling and plan rules. If a quantity limit applies, the medication entry will display "QL" with the limit detail in the Requirements/Limits column. Exceeding the QL may result in member financial responsibility unless an override/PA is approved.

QL indicator: shown as "QL (quantity / time period)" next to affected medications (examples in the formulary list include QL (30 tablets/30 days), QL (6 pens/28 days), QL (56 capsules/28 days))
Some controlled substances are subject to state-mandated dispensing limits; dispensed quantities beyond limits may be non-covered

Prior Authorization

Bempedoic acid products

Bempedoic acid products are subject to prior authorization and a monthly quantity limit. Providers should submit PA requests when prescribing these agents and ensure the request documents medical necessity per plan criteria.

NEXLETOL (bempedoic acid) 180 mg — Requirements/Limits = PA, QL (30 tablets/30 days)
NEXLIZET (bempedoic acid 180 mg - ezetimibe 10 mg) — Requirements/Limits = PA, QL (30 tablets/30 days)

Note

Formulary index — informational / no auth rules in this section

Some sections of the index and formulary are informational only and do not include authorization rules in that specific area. Providers should reference the main Requirements/Limits column in the formulary for PA, ST, QL, SP, and AC indicators rather than relying on index entries alone.

Formulary index entries may list drug names and page references but not authorization details
Always confirm the Requirements/Limits column on the drug listing for coverage constraints

Note

Formulary index — partial authorization details

Some parts of the formulary index include partial authorization details (e.g., QL or PA flags) alongside page references. These partial entries should be validated against the detailed drug listing to determine the full set of requirements.

Formulary index — partial: may show a PA or QL flag next to an index term but not the full limit (e.g., "NEXLETOL" referenced in index with a PA/QL flag; see drug listing for details)

Documentation Required

Device / Formulary index repetition

Device listings (for example, insulin pumps, starter kits, and pods) appear multiple times across the formulary and index. Providers should use the explicit Requirements/Limits values on the device listing itself for PA and QL information; repeated index references do not alter coverage rules.

Device/formulary index repetition: items such as OMNIPOD kits and pods are referenced repeatedly in the index — check the device entry for Requirements/Limits (e.g., OMNIPOD DASH INTRO KIT = PA, QL (1 kit/720 days); OMNIPOD DASH PODS = PA, QL (30 pods/30 days))

Note

Drug index — informational

The drug index is provided for quick lookup and is informational; it may include page references and occasional flags but is not a substitute for the detailed drug listing that contains the Requirements/Limits column. Always confirm coverage details on the main formulary rows.

Drug index — informational: use to locate drug entries, then review the full listing for PA, ST, QL, SP, and AC indicators

Definitions and Index Notes

inv-63: Generic and Brand naming/format

Generic naming conventionGeneric drugs are shown in lower-case boldface with reference brand in parentheses (example: atorvastatin (Lipitor))

Brand naming conventionBrand drugs are shown in ALL CAPITALS followed by the generic name (example: NOVOLOG Insulin aspart inj 100 unit/mL)

PurposeFormatting helps distinguish generic vs brand in the formulary listing

inv-64: Generic types

Generic equivalentSame active ingredient(s) and dosage as reference brand — chemically the same, FDA-approved

Generic alternativeDifferent active ingredient(s) but used to treat same condition

Member cost implicationMembers may pay lower cost for generics; requesting reference brand may incur additional member cost-share

inv-65: Specialty drugs

DefinitionSpecialty drugs treat complex conditions and may be oral, topical, or injectable; may require special handling or specialty pharmacy

Benefit distinctionMedications administered by a health care professional may be covered under medical benefit rather than pharmacy

ReferenceCurrent specialty medication lists are available at MyPrime.com

inv-66: Prior Authorization

PA meaningPrior Authorization (PA) may be required for certain drugs and will be noted with a PA in the Special Requirements column

Plan variabilityPlans may require additional PAs not listed in the formulary

ActionPrescribers or members should submit PA requests when noted

inv-67: Quantity Limit

Quantity Limit definitionQuantity Limit (QL/DL) — maximum units allowed within a specified time frame; exceeding limits may result in member responsibility for full cost

NotationQL or DL appears in the Special Requirements column next to product entries

PurposeApplied to encourage FDA-intended use and control dispensing

inv-68: Specialty

Specialty designation (SP)SP indicates specialty pharmacy designation; many high-cost biologics and hematologic agents are designated SP

ImplicationMay require filling at designated specialty pharmacy or different coverage rules

ExamplesADBRY, COSENTYX, NEULASTA cited with SP in product listings

inv-69: Access Control / additional control

Access Control (AC)AC denotes administrative coverage or access control applied to certain products (example: APRETUDE listed with AC)

UseUsed for select products to denote special administrative coverage requirements

ExampleDESCOVY listed with AC and QL (30 tablets/30 days)

inv-70: quantity limit

Quantity Limit (QL) abbreviationQL indicates a specified maximum units/time (e.g., QL 56 capsules/28 days for ORIAHNN)

EffectExceeding QL may result in claim denial or member financial responsibility

PlacementAppears in the Requirements/Limits column next to product entries

inv-71: prior authorization

Prior Authorization (PA)Indicated when additional clinical review is required before coverage (PA flag appears in Requirements/Limits)

Provider actionSubmit required supporting documentation with PA requests

Plan noteFormulary notes that plans may have additional PA requirements beyond the list

inv-72: authorization category (e.g., administrative coverage requirement)

Authorization category (AC)AC used to denote administrative coverage requirement or access control for specific drugs (e.g., some contraceptives)

ExamplesDesogestrel & ethinyl estradiol listed with AC, QL (28 tablets/21 days)

InterpretationAC may signal additional administrative steps for coverage

inv-73: PA

PA abbreviationPA = Prior Authorization

UsageShown in Requirements/Limits column when required

Provider notePlans may require PA submission for certain products

inv-74: QL

QL abbreviationQL = Quantity Limit (maximum units allowed within specified time frame)

ExampleMany test strips: QL 204 strips/30 days; insulin needles: QL 300 needles/30 days

EffectExceeding QL may result in member paying full cost

inv-75: SP

SP abbreviationSP = Specialty Pharmacy designation

ImplicationIndicates specialty handling or distribution and may affect where the drug is dispensed

ExamplesNEULASTA, COSENTYX, TREMFYA shown with SP in listings

inv-76: Abbreviations used in Requirements/Limits

Abbreviation key — PAPA = Prior Authorization

Abbreviation key — QLQL = Quantity Limit

Abbreviation key — SP/ACSP = Specialty Pharmacy; AC = Administrative Coverage/Access Control

inv-77: Prior Authorization

Prior Authorization guidancePA may be required and is noted in Special Requirements; plans may have additional PAs

Where shownAppears next to product entries in Requirements/Limits column

ActionProviders should follow PA submission processes when indicated

inv-78: Quantity Limit

Quantity Limit guidanceQL/DL denote dispensing or quantity limits and are shown in Requirements/Limits; exceeding limits may shift cost to member

Typical formatsExamples: QL (30 tablets/30 days), QL (6 syringes/28 days)

Provider implicationPrescribers should consider QL when writing quantities or durations

inv-79: Specialty Pharmacy

Specialty Pharmacy guidanceSP indicates specialty pharmacy designation for certain agents and is shown in Requirements/Limits

Coverage implicationMay require use of designated specialty pharmacy or different fulfillment rules

ExamplesMany biologics and hematologic agents listed with SP in product controls

inv-80: Prior Authorization

PA — provider actionSubmit clinical documentation for review when PA is indicated

Where notedPA flag appears in Requirements/Limits column next to drug entries

Plan notePlans may have additional PA requirements beyond this list

inv-81: Quantity Limit (maximum units allowed within specified time frame)

QL meaningMaximum units allowed within specified time frame — e.g., 204 strips/30 days, 3 sensors/30 days

Device examplesDexcom receivers: QL 1 receiver/365 days; sensors: QL 3 sensors/30 days

EffectExceeding QL may require prior authorization or result in member cost liability

inv-82: Specialty Pharmacy

Specialty Pharmacy (SP)SP denotes specialty designation and appears for many high-cost injectables and biologics

ExamplesFULPHILA, NEULASTA, certain hemophilia agents listed with SP

ImplicationMay affect dispensing channel and coverage rules

inv-83: Alphabetical drug index entries showing product name, strength, and formulation

Index entry formatAlphabetical drug index entries show product name, strength, and formulation with cross-reference numbers

ScopeIndex fragments contain many drug names but not detailed PA/QL information

UseRefer to product sections for coverage and Requirements/Limits

inv-84: Formulary index fragment

Formulary index fragmentAlphabetical index entries listing drug products, strengths, and formulations (partial text shown)

LimitationThis fragment does not include PA/QL details — see other sections

Example entriesEntries include lithium carbonate, mirtazapine, montelukast, OMNIPOD, DEXCOM references

inv-85: INDEX — alphabetical or catalog listing of covered drugs and associated page or internal references

INDEX purposeAlphabetical/catalog listing of covered drugs with placement references; not a coverage criteria section

Reference instructionUse index cross-references to locate product-specific Requirements/Limits elsewhere in the drug list

Fragment statusPartial — contains drug names and references for navigation

inv-86: Index entry

Index entry examplerizatriptan oral disintegrating tabs and rosuvastatin listed with cross-reference numbers in index fragments

NavigationIndex entries provide pointers (numbers) to product locations in the formulary document

NoteIndex text does not include PA/QL/SP details in these chunks