CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Drug List (Pharmacy Benefit) — Drug List / Coverage Criteria

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This document is Blue Cross and Blue Shield of Oklahoma's 2025 pharmacy drug list describing covered prescription drugs, tier placement, special requirements (e.g., PA, ST, QL), and instructions for members and providers about coverage and exceptions.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Drug List / Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual drug list publication — no material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a drug's Requirements/Limits field lists 'PA' and provide documentation to support medical necessity and requested quantity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+Drug entries

MyPrime.com / bcbsok.comReference sites

6Member tiers

multiplePA / QL present

SP / PA / ST / QL / ACRequirement codes

Coverage criteria and formulary rules

Coverage conditions

Covered when ALL of the following are met:

General coverage conditions: Coverage applies only to prescription drugs shown on the BCBSOK Drug List; drugs not shown are not covered unless a Drug List exception is approved.

See Exception Process for submission and review timelines (15 calendar days; 72 hours for expedited).

Plan and benefit limits: Coverage is subject to the member's benefit plan details including tier placement, plan exclusions (e.g., cosmetic indications, non-FDA-approved drugs, repackaged or certain compounded medications) and site-of-service rules.

Refer to member benefit materials or MyPrime.com for verification of specific plan coverage.

Prescriber responsibility: The prescriber must follow payer processes for exceptions and prior authorization when required; requests for exceptions or expedited review must be submitted by calling the number on the member ID card.

BCBSOK will notify prescriber of decision within 15 calendar days (standard) or 72 hours (expedited).

Formulary coverage with utilization controls

Covered when the listed utilization controls for the specific product are satisfied:

Utilization controls: Drugs listed with Requirements/Limits annotations (PA, QL, ST, SP, AC, DL) are subject to those controls; coverage is available only when the listed control(s) are met.

Per-product Requirements/Limits field indicates what must be satisfied for coverage.

Prior authorization (PA): If a product is annotated 'PA' in the Special Requirements column, the prescriber must obtain prior authorization before the medication will be covered.

Many specialty, hepatitis, HIV and oncology agents in the Drug List are marked PA; see individual entries for details.

Quantity/Dispensing limits (QL/DL): If a product is annotated with 'QL' or 'DL', coverage is limited to the numeric quantity/time period shown in the Requirements/Limits field and claims exceeding those limits may be denied or paid by the member.see product QL entry

Examples include 30 tablets/30 days, 720 mL/30 days, 4 tablets/365 days; check MyPrime.com for the full list.

Specialty pharmacy (SP) and site-of-service: Products marked 'SP' must be dispensed through specialty pharmacy or follow site-of-service requirements as indicated; coverage requires adherence to SP routing when shown.

Examples: many biologics and CF modulators are SP-designated.

Step therapy (ST): If a product is annotated 'ST', the plan's step therapy requirements (trial and failure or intolerance of preferred alternatives) must be satisfied prior to coverage.

Specific step sequences are managed by the plan; ST will be noted in the Special Requirements column when applicable.

Formulary coverage annotations

Coverage entries include product-level annotations that determine coverage behavior:

Entry annotations: Each formulary line includes the drug name, Drug Tier and Requirements/Limits annotations (examples: AC, PA, QL, ST, SP). Coverage availability and member cost-sharing are determined by these annotations and the member's benefit plan.

AC marks ACA preventive items which may have limited or $0 cost-sharing when conditions are met.

Interpretation of codes: PA = prior authorization required; QL = quantity/dispensing limit with a numeric threshold; ST = step therapy required; SP = specialty pharmacy/site restriction; AC = ACA preventive designation; DL = dispensing limits — coverage follows the annotation shown for the product.

See Special Requirements column next to each product for the exact annotation and any numeric QL.

General coverage rules

General rules that apply across listed outpatient drugs:

Formulary-conditional coverage: Coverage of outpatient prescription drugs shown is contingent on the drug's formulary status and any utilization controls listed on the Drug List; absence of a drug from the list indicates it is not covered unless an exception is approved.

Member cost-sharing depends on the Drug Tier for the product.

Enforcement of utilization controls: Prior authorization (PA) and quantity limits (QL) listed for specific products will be enforced; claims may be denied if PA is not obtained or QL is exceeded.

Specialty products (SP) will require specialty routing and may require PA and QL enforcement.

Supply limits: Standard coverage is generally up to a 30-day supply; some maintenance medications may be covered up to a 90-day supply as permitted by the member's plan.30 days; 90 days for maintenance when allowed

Refer to member plan materials for allowable day supply options.

Product-level PA + QL + SP coverage

Coverage for many specialty/high-cost products is product-specific and requires compliance with the listed Requirements/Limits:

PA + QL + SP enforcement: For cystic fibrosis modulators and similar specialty products (e.g., KALYDECO, ORKAMBI, SYMDEKO, TRIKAFTA, vanzacaftor‑tezacaftor‑deutivacaftor), coverage requires prior authorization, adherence to the stated quantity limits, and specialty pharmacy routing when 'SP' is indicated.See product QL (examples: 56 tablets/28 days; 60 tablets/30 days; 56 packets/28 days)

Provider must submit PA and comply with QL and SP handling per the Drug List entry.

Product-specific thresholds: Each product line provides the exact numeric QL (quantity per time period) when applicable; coverage is limited to those numeric thresholds unless an approved exception is documented.see individual Requirements/Limits entries

Examples across the Drug List include multiple QL patterns (per 28/30/60/180/365 days).

Coverage applies only to prescription drugs listed on the Blue Cross and Blue Shield of Oklahoma Drug List. Drugs not shown on the Drug List are not covered unless an exception is approved. The Drug List is updated regularly; providers and members should check MyPrime.com or bcbsok.com or call the number on the member ID card for the most current information. Non–FDA-approved drugs, repackaged medications, and some compounded products may not be covered; plan-specific exclusions and benefit details govern final coverage determinations.

This section is reserved for additional coverage clarifications or examples that support the Drug List rules above. Specific per-product coverage controls (e.g., PA, QL, SP, ST, AC) are documented on each formulary line and must be met for coverage; see the Drug List entries or MyPrime.com for details.

The excerpt provided is a formulary listing and does not include standalone clinical exclusion criteria. Formulary lines show per-product utilization controls (for example, PA, QL, SP) rather than a separate set of clinical exclusion rules; any clinical coverage criteria or diagnosis-specific requirements would be detailed in product-specific PA policies or in other clinical policy documents.

No explicit exclusion rules are stated in these chunks for the products shown. Instead, the entries list administrative controls such as AC (administrative/access control), and per-product Requirements/Limits fields (e.g., PA, QL, SP) which determine coverage enforcement.

The Drug List notes that medications used for cosmetic purposes may not be covered; for example, finasteride for hair growth (Propecia) is cited as a cosmetic indication that may not be covered. Providers should confirm coverage under the member's specific benefit plan.

This placeholder is available for further explanatory details about coverage scope or examples of exclusions and utilization controls. Refer to per-drug Requirements/Limits fields on the Drug List for specific coverage conditions.

Within the provided excerpts there are no explicit statements labeling products as 'not medically necessary.' Coverage determinations are presented via formulary annotations and utilization controls (e.g., PA, QL, SP, AC); any 'not medically necessary' determinations would be handled through benefit rules, prior authorization review, or separate medical necessity policy language not contained in these chunks.

Formulary codes, annotations, and day-supply rules

Special Requirements codesmixed

PA	Prior Authorization (Special Requirements column)
ST	Step Therapy (Special Requirements column)
QL	Quantity Limit / Dispensing Limit (Special Requirements column)
DL	Dispensing Limits (document text)
AC	ACA preventive marking (document uses 'AC' in Special Requirements column)
SP	Specialty drug marker (Special Requirements column)

Sample listed drugsNDCCovered

AMOXICILLIN	amoxicillin (trihydrate) — multiple strengths and forms listed with tiers
AMOXICILLIN & K CLAVULANATE	amoxicillin & potassium clavulanate — multiple suspensions listed with tiers

Drug list (formulary entries)mixed

NDC	Various NDCs implied for listed drugs (not specified individually in these chunks)

Formulary codes and tier annotationsmixed

AC	Authorization Code / formulary requirement (document uses AC to mark requirements/limits)
QL	Quantity Limit (document provides numeric QL per product)
PA	Prior Authorization (document marks some specialty agents with PA)
NP	Non-preferred tier designation (document uses NP for drug tier)
P	Preferred tier designation

Formulary drug entries and utilization rulesmixed

CAMZYOS - mavacamten cap 5 mg	mavacamten capsule 5 mg; Requirements: PA, QL (30 capsule/30 days), SP; Tier NP
CORLANOR - ivabradine hcl oral soln 5 mg/5ml	ivabradine oral solution 5 mg/5 ml; Requirements: PA, QL (600 mls/30 days); Tier P
ENTRESTO - sacubitril-valsartan tab	sacubitril-valsartan tablets; Tier P; some formulations have PA/QL as specified
OPSUMIT - macitentan tab 10 mg	macitentan 10 mg tablet; Requirements: PA, QL (30 tablets/30 days), SP; Tier P
ORENITRAM - treprostinil diolamine tab er	treprostinil diolamine ER tablets; Requirements: PA, QL (300 tablets/30 days), SP; Tier NP
TYVASO - treprostinil inhalation solution 0.6 mg/ml	TYVASO inhalation solution; Requirements: PA, QL (7 packs/28 days), SP; Tier NP
UPTRAVI - selexipag tab	selexipag tablets multiple strengths; Requirements: PA, QL (60 tablets/30 days), SP; Tier P
VYNDAMAX - tafamidis cap 61 mg	tafamidis 61 mg capsule; Requirements: PA, QL (30 capsules/30 days); Tier P
VYNDAQEL - tafamidis meglumine cap 20 mg	tafamidis meglumine 20 mg capsule; Requirements: PA, QL (120 capsules/30 days), SP; Tier P
WINREVAIR - sotatercept kit	sotatercept subcutaneous kit; Requirements: PA, QL (1 kit/21 days), SP; Tier NP

1–10 of 17

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Quantity-limited products (examples)mixed

QL (900 mls/30 days)

Quantity limit applied to aripiprazole oral solution (900 mls/30 days)

Multiple QL entriesmixed

QL (60 tablets/30 days)	Quantity limit example (various formulations)
QL (30 tablets/30 days)	Quantity limit example (various formulations)
QL (150 tablets/30 days)	Quantity limit example (lorazepam tab)
QL (270 tablets/30 days)	Quantity limit example (clozapine 25 mg)

Utilization control codes usedmixed

ST	Step therapy requirement present
PA	Prior authorization required
SP	Specialty drug designation
AC	Age/Class or additional coverage condition

Day supply

Standard day supply30-day supply is standard for most prescriptions

Maintenance medicationsUp to 90-day supply may be allowed for maintenance medications (e.g., chronic conditions such as hypertension, diabetes, high cholesterol)

ExceptionsSome plans may impose different limits or exclude certain categories (e.g., erectile dysfunction, weight loss); refer to member benefit materials

Quantity limits examples

30 tablets / 30 daysExplicit QL example shown for multiple antiviral/antiretroviral products (e.g., Truvada, EPCLUSA, HARVONI)

60 tablets / 30 daysShown as a QL for several agents (e.g., certain strengths of atazanavir, other antivirals)

720 mLs / 30 daysExample QL for liquid antiretroviral formulation (emtricitabine solution listed at 720 mls/30 days)

4 tablets / 365 daysExample QL for long-interval therapy packs (e.g., SUNLENCA therapy packs 4 tablets/365 days)

Quantity limits examples

1 ring / 365 daysANNOVERA listed with QL 1 ring/365 days

28 tablets / 21 daysMultiple contraceptive entries show QL 28 tablets/21 days (e.g., many oral contraceptives)

4 pens / 28 daysExample QL for some GLP-1/antidiabetic pens (e.g., TRULICITY listed as 4 pens)

3 mLs / 28 daysExample QL for certain biologic pen/auto-injector volumes (e.g., some NUCALA presentations 3 mL/28 days)

30 tablets / 30 daysCommon QL example for numerous tablet products (contraceptives and others)

Selected quantity limits

30 capsules / 30 daysExample QL for specialty cardiology agent CAMZYOS (mavacamten) and similar listings

600 mL / 30 daysCORLANOR oral solution listed with QL 600 mls/30 days

240 capsules / 30 daysExample QL used for some formulations (e.g., ENTRESTO sprinkle caps QL 240 capsules/30 days)

7 packs / 28 daysTYVASO inhalation solution listed with QL 7 packs/28 days

60 tablets / 30 daysUPTRAVI (selexipag) listed with QL 60 tablets/30 days

1 kit / 21 daysWINREVAIR (sotatercept) listed with QL 1 kit/21 days

84–120 tablets / 28–30 daysALYFTREK and other CF/oncology modulators show ranges (e.g., 56–84 or 84–120 tablets per period) — examples vary by product

Prior authorization, step therapy, documentation, and denial risks

Prior Authorization

Prior authorization required when 'PA' is shown

Certain medications listed on the Drug List that show 'PA' in the Special Requirements/Requirements‑Limits column require prior authorization; the prescriber must submit and obtain PA approval before pharmacy coverage will be available.

PA is indicated next to drugs in the Special Requirements column; PA must be obtained prior to coverage.
Coverage depends on meeting all listed Requirements/Limits for the product line item.

Prior Authorization

Examples of products that require PA

Select high‑cost and specialty products are annotated with 'PA' (examples in the list include ARIKAYCE, CRESEMBA, EPCLUSA); these specific products will require the prescriber to obtain prior authorization per the Drug List entry before coverage.

ARIKAYCE (amikacin liposome inhalation) — Requirements/Limits = PA, QL, SP.
CRESEMBA (isavuconazonium) and similar antifungals appear with PA/QL designations.
EPCLUSA (sofosbuvir‑velpatasvir) — Requirements/Limits = PA, QL, SP.

Prior Authorization

PA applies to products marked 'PA' and 'SP'

Drugs marked 'PA' in the Requirements/Limits must have prior authorization obtained; products also marked 'SP' indicate specialty designation and may require specialty pharmacy handling in addition to PA.

When a line item lists 'PA' the prescriber must follow the payer PA process prior to dispensing.
'SP' on a product line indicates specialty pharmacy routing that must be honored along with any PA requirement.

Prior Authorization

PA required for entries with 'PA' in Requirements/Limits

Prior authorization is required for drugs where 'PA' appears in the Requirements/Limits column (for example, many oncology agents and therapy packs listed); prescribers must submit PA before coverage is approved.

COMETRIQ, COPIKTRA, dasatinib and other oncology agents list 'PA' and specified QL; PA must be obtained.
If PA is not obtained where indicated, coverage may be denied.

Prior Authorization

Prior authorization required for PA‑designated drugs

Drugs annotated with 'Requirements/Limits = PA' (numerous specialty and oncology agents such as revumenib, rucaparib, venetoclax entries) require prior authorization; prescribers must submit PA requests consistent with the product listing.

REVUFORJ (revumenib) and RUBRACA (rucaparib) examples show 'PA' with QL and SP.
VENCLEXTA (venetoclax) and many others list PA and QL — obtain PA before dispensing.

Prior Authorization

PA required for select antidiabetic specialty agents

Certain antidiabetic specialty agents (for example MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) are subject to prior authorization and specific quantity limits; prescribers must obtain PA and adhere to the listed QL.

MOUNJARO — listed with QL (4 pens) and may require PA depending on formulation.
OZEMPIC — Requirements/Limits = PA, QL (1 pen/28 days or 3 mL/28 days).
RYBELSUS and TRULICITY entries show PA/QL annotations; follow PA process for these GLP‑1/GIP‑GLP agents.

Prior Authorization

PA required for select specialty/high‑cost drugs

Certain specialty and high‑cost drugs require prior authorization and have specified quantity limits (examples in the Drug List show PA and QL; prescribers must obtain PA and comply with QL and any specialty routing).

GENOTROPIN — Requirements/Limits = PA, SP (specialty); PA required.
GALAFOLD — Requirements/Limits = PA, QL (14 capsules/28 days), SP; PA must be obtained to meet coverage.

Prior Authorization

Obtain PA for listed PA drugs

Many listed drugs indicate 'PA' in their Requirements/Limits; prior authorization must be obtained per the product line before coverage will be provided.

Examples include GALAFOLD, JYNARQUE, OMNITROPE and other specialty items marked PA.
Follow the PA process for each drug annotated with PA in the Drug List.

Prior Authorization

PA and QL apply to certain oral/solution products

Limitations on oral solution formulations are noted with PA and QL (for example enalapril oral solution Epaned is listed as PA, QL 1200 mL/30 days); prescribers must obtain PA and adhere to the stated quantity limit for these liquid formulations.

Enalapril maleate oral solution (Epaned) — Requirements/Limits = PA, QL (1200 mls/30 days).
When PA and QL are present for a liquid formulation, both controls apply to coverage.

Prior Authorization

PA required for specialty cardiovascular/PAH agents

Multiple pulmonary hypertension and specialty cardiovascular agents (e.g., ADEMPAS, OPSUMIT, ORENITRAM, CAMZYOS, CORLANOR) are subject to prior authorization and quantity limits; prescribers must obtain PA and follow the listed QL.

ADEMPAS (riociguat) — Requirements/Limits = PA, QL (90 tablets/30 days), SP.
OPSUMIT (macitentan) and ORENITRAM (treprostinil) list PA, QL and SP and require PA prior to coverage.

Prior Authorization

PA required for many PA‑designated products

Many brand and specialty drugs in the formulary require prior authorization as indicated in the Requirements/Limits field; prior authorization must be obtained before dispensing when 'PA' is specified on the product line.

Cystic fibrosis modulators (KALYDECO, ORKAMBI, TRIKAFTA, ALYFTREK) and other specialty agents list PA, QL and SP — obtain PA for coverage.
When 'PA' is present coverage is contingent on approval and adherence to listed limits.

Prior Authorization

PA required for listed specialty modulators

Several cystic fibrosis modulators and other specialty drugs require prior authorization; providers must submit PA requests for coverage per the Drug List (examples include KALYDECO, ORKAMBI, TRIKAFTA entries).

KALYDECO — Requirements/Limits = PA, QL (60 tablets/30 days), SP.
TRIKAFTA — Requirements/Limits = PA, QL (56 packets/28 days and 90 tablets/30 days for certain strengths), SP.

Prior Authorization

PA required for select specialty oral agents

Several specialty oral agents (for example FILSPARI, PROCYSBI, VANRAFIA) are listed with PA (and often SP) designations; prescribers must obtain prior authorization and meet specialty distribution requirements where indicated.

FILSPARI (sparsentan) — Requirements/Limits = PA, QL (30 tablets/30 days), SP.
PROCYSBI — Requirements/Limits = PA, SP; obtain PA and dispense via specialty channel as required.

Prior Authorization

PA required for various listed PA‑designated drugs

Certain listed products (examples include tasimelteon/Hetlioz, IMCIVREE, SUNOSI, WEGOVY, ZEPBOUND) are marked 'PA' and require prior authorization before coverage; prescribers must submit PA requests for these items.

Hetlioz (tasimelteon) — Requirements/Limits = PA, QL (30 capsules/30 days), SP.
WEGOVY, ZEPBOUND, SUNOSI and other weight‑management or narcolepsy agents are noted with PA and QL — obtain PA per listing.

Step Therapy

Step therapy required when 'ST' is shown

Some benefit plans include step therapy; drugs that commonly require a trial of preferred alternatives are marked 'ST' in the Special Requirements column — prescribers must ensure step‑therapy requirements are met where 'ST' is shown.

FETZIMA and several psychiatric agents are labeled 'ST' — trial of preferred therapies is required prior to coverage for the ST‑marked product.
The Drug List indicates ST when step therapy is commonly required; verify specific step requirements with the plan.

Step Therapy

Step therapy: no explicit algorithm provided in this excerpt

No explicit step‑therapy algorithm or step sequence (i.e., required trial drugs and failure criteria) is detailed in this Drug List excerpt; where 'ST' is present the plan requires step therapy but specific algorithmic steps are not listed here.

The document notes 'ST' flags but does not provide the step‑by‑step algorithm in this excerpt.
Providers should consult the benefit plan or prior authorization instructions for specific step requirements.

Note

Access controls and administrative requirements (AC)

Some products are marked with access controls (AC) or other administrative controls rather than step therapy; prescribers should follow the listed Requirements/Limits (AC, PA, QL) for those items and confirm any additional plan rules.

Contraceptives and bowel prep agents may show AC or QL (e.g., ANNOVERA, NUVARING with AC and QL).
When AC appears, administrative coverage conditions (age/program) apply; follow plan procedures.

Documentation Required

Exception and expedited review request process and timing

To request a Drug List exception or an expedited review, the prescriber (or authorized representative) must call the number on the member's ID card; BCBSOK will notify the prescriber of the coverage decision within 15 calendar days (72 hours for expedited requests).

Call the number on the member's ID card to submit an exception request.
Standard decision timeline: 15 calendar days; expedited review: 72 calendar hours.

Documentation Required

Documentation required to support PA and QL (including specialty drugs)

When a product line shows 'PA' or 'PA, QL, SP' the prescriber must submit documentation to support medical necessity and the requested quantity; specialty drugs often require supporting clinical documentation and specialty distribution details.

Prescribers must supply clinical documentation consistent with the indication and the Drug List's QL to support PA.
Specialty products (SP) such as REPATHA, TEZSPIRE, PROCYSBI require PA and documentation and may need to be dispensed via specialty pharmacy.

Documentation Required

PA and documentation expectations for antiretroviral/hepatitis products

For drugs marked with PA and QL (for example EPCLUSA, HARVONI and other antiretroviral/hepatitis agents), prescribers must follow the payer prior authorization process and provide documentation supporting the indication and quantity justification.

EPCLUSA, HARVONI — Requirements/Limits = PA, QL, SP; submit PA with indication and quantity rationale.
Antiretroviral and hepatitis agents commonly have QL (30 tablets/30 days) and may require clinical documentation during PA review.

Billing Rule

Adhere to listed quantity limits (QL) and authorization codes

Quantity limits (QL) and explicit authorization controls are listed per product (examples: NUVARING QL 1 ring/21 days; many specialty injectables list QL in their Requirements/Limits); prescribers must request authorization consistent with the product's QL.

NUVARING — Requirements/Limits = AC, QL (1 ring/21 days).
REPATHA and other specialty injectables include PA and numeric QL (e.g., REPATHA prefilled syringe = 6 syringes).

Denial Risk

Noncompliance with listed controls may result in denial

Coverage may be denied if utilization controls listed on the Drug List (PA, QL, ST, SP, AC) are not met; prescribers should obtain PA, respect QL, and follow ST and SP requirements to avoid claim denials.

Requests for drugs not on the Drug List may be denied unless a Drug List exception is approved.
Failure to obtain PA where 'PA' is indicated or to comply with QL/SP/ST may result in coverage denial.

Prior Authorization

PA applies to select inhaled aminoglycosides and inhaled antibiotics

Prior authorization applies to select inhaled aminoglycosides and inhaled antibiotic products (examples: ARIKAYCE, KITABIS PAK, TOBI PODHALER, tobramycin nebu solutions) which are marked PA, QL and SP; prescribers must obtain PA for these inhaled agents and adhere to QL.

ARIKAYCE — Requirements/Limits = PA, QL (235.2 mls/28 days), SP.
KITABIS PAK and TOBI entries show PA, QL and SP — obtain PA before dispensing.

Prior Authorization

PA and specialty handling required for certain hepatitis/antiviral agents

Agents listed with 'PA' and/or 'SP' (for example EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI) are subject to prior authorization and specialty handling; prescribers must submit PA and meet SP routing where indicated to obtain coverage.

EPCLUSA, HARVONI, SOVALDI — Requirements/Limits = PA, QL, SP; PA and specialty dispensing apply.
Coverage is contingent on approval of PA and adherence to any QL/SP noted.

Denial Risk

Denial risk if PA not obtained where indicated

Requests for listed drugs may be denied if prior authorization is not obtained where 'PA' is indicated in the Requirements/Limits field; prescribers should confirm PA requirements prior to dispensing.

Many oncology and specialty agents list 'PA' — if PA is not obtained coverage may be denied.
Follow the PA submission process to prevent claim denial.

Denial Risk

PA and QL enforcement can trigger denial for specialty agents

Coverage may be denied for listed products when the Requirements/Limits (PA, QL, SP) are not met; several specialty drugs (e.g., GALAFOLD, GENOTROPIN, JYNARQUE) specifically note PA and QL enforcement — obtain PA and document requested quantity.

GALAFOLD — Requirements/Limits = PA, QL (14 capsules/28 days), SP; lack of PA or exceeding QL may trigger denial.
GENOTROPIN — Requirements/Limits = PA, SP; PA and specialty distribution required for coverage.

Prior Authorization

PA and QL flagged products require PA and adherence to QL

Products flagged 'PA, QL' (for example enalapril oral soln Epaned, FUROSCIX) indicate prior authorization and quantity limits that must be met; claims that exceed QL or lack PA may be denied.

Epaned (enalapril oral solution) — Requirements/Limits = PA, QL (1200 mls/30 days).
FUROSCIX — Requirements/Limits = PA, QL (8 kits/180 days); obtain PA and adhere to QL.

Prior Authorization

Specialty injectable biologics require PA and specialty dispensing

Specialty injectables and biologics (examples: NUCALA, TEZSPIRE, XOLAIR) require prior authorization and are managed through specialty pharmacy (SP); prescribers must obtain PA and ensure specialty dispensing as listed.

NUCALA — Requirements/Limits = PA, QL (1 syringe/28 days or 3 mL/28 days), SP.
TEZSPIRE — Requirements/Limits = PA, QL (1 pen/28 days), SP.
XOLAIR — Requirements/Limits = PA, SP (multiple presentations); obtain PA and route via specialty pharmacy.

Denial Risk

PA/QL enforcement may result in denial if controls not met

Requests without prior authorization (PA) or requests that exceed specified quantity limits (QL) — for example QL 56 tablets/28 days for certain CFTR modulators — may be subject to coverage denial; prescribers must secure PA and comply with QL.

ALYFTREK and other CFTR modulators list QL ranges (56–84 tablets/28 days) and PA; exceeding these limits without PA can trigger denial.
The Drug List enforces PA and numeric QL per product — follow those limits when requesting coverage.

Denial Risk

Utilization controls (PA/QL/ST/SP/AC) can trigger denials

Drugs listed with Requirements/Limits of PA, QL, ST, SP, or AC may trigger denial if utilization controls are not satisfied; prescribers should verify each product's listed controls and obtain any required PA or meet ST and QL conditions.

Verify the Special Requirements column for PA, QL, ST, SP, or AC on each Drug List line item.
If the controls are not met, a Drug List exception or PA may be required to avoid denial.

Documentation Required

PA, QL and SP expectations for approval

When a drug entry lists Requirements/Limits = PA, QL, SP the prescriber must obtain prior authorization and adhere to the stated quantity limits and specialty pharmacy routing for coverage to be approved.

Examples: ALYFTREK, TRIKAFTA, and other CFTR modulators — Requirements/Limits = PA, QL, SP.
Follow the listed QL and specialty dispensing instructions when submitting PA.

Documentation Required

PA documentation required for weight‑management and narcolepsy agents

Prior authorization documentation will be required for weight‑management and narcolepsy agents marked PA and QL (examples: SUNOSI, SAXENDA, WEGOVY, ZEPBOUND); prescribers must submit PA with supporting documentation per the Drug List.

WEGOVY — Requirements/Limits = PA, QL (8 pens/180 days or 4 pens/28 days depending on presentation).
ZEPBOUND — Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on presentation).

Billing Rule

Claims are subject to enforcement of AC/PA/QL controls

Claims may be subject to formulary requirement and limit enforcement such as AC (administrative control), PA (prior authorization), and QL (quantity limits) — prescribers must follow the Drug List annotations to avoid claim denials.

Contraceptives often display AC and QL (e.g., ANNOVERA, NUVARING) which must be followed.
Payer enforces listed Requirements/Limits for each product line — confirm controls before prescribing/dispensing.

Prior Authorization

PA plus specialty pharmacy (SP) routing required when shown

Some products require both PA and specialty pharmacy handling (SP); when SP is indicated the drug must be dispensed via specialty pharmacy and PA approval obtained prior to coverage.

When 'SP' appears on the product line the drug is routed via specialty pharmacy (examples: REPATHA, TRIKAFTA entries).
Obtain PA and arrange specialty dispensing per the Drug List entry.

Step Therapy

Step therapy noted for select psychiatric and other agents

The Drug List shows step‑therapy designations for selected psychiatric and other agents (e.g., FETZIMA, risperidone ODT, VERSACLOZ) — prescribers must ensure step‑therapy requirements are met for ST‑flagged products prior to coverage.

FETZIMA — Requirements/Limits = ST; step therapy must be satisfied prior to coverage.
RISPERIDONE ODT and VERSACLOZ entries include ST alongside QL — check plan for precise step requirements.

Step Therapy

ST flag present but algorithm not specified in this excerpt

No explicit multi‑step algorithms (specific preferred drugs to try and failure definitions) are provided in this Drug List excerpt; where 'ST' appears, consult the benefit plan or prior authorization instructions for exact step therapy criteria.

The Drug List flags ST but does not list the required preferred agents or failure criteria in this excerpt.
Contact the plan or use the PA/step‑therapy guidance provided by the payer for specifics.

Note

Definitions of utilization control abbreviations

Specialty drugs

Specialty drugs — definitionSpecialty drugs are oral, topical, or injectable medications for complex conditions; some require administration by a health care professional and may be covered under the medical benefit (MyPrime.com / bcbsok.com).

May require specialty pharmacyCertain higher-cost or complex agents are designated 'SP' and are managed/dispensed through specialty pharmacy channels

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

Prior Authorization (PA)Prior authorization is required when a product's Requirements/Limits field shows 'PA'; prescriber must submit and obtain approval before coverage

How notedPA requirement for listed medications is generally indicated with 'PA' in the Special Requirements column

ScopeMany specialty and high-cost agents (e.g., hepatitis C and oncology drugs) are commonly marked PA

Quantity Limit (QL)Quantity Limit is the maximum allowed amount per specified time period (examples in the list: '30 tablets/30 days', '60 tablets/30 days', '720 mls/30 days')

How presentedQLs are shown in the Requirements/Limits column next to the product and specify quantity and period

EnforcementClaims exceeding QL may be denied or require prior authorization per the policy

Specialty pharmacy (SP)'SP' indicates a specialty designation for certain high-cost or complex drugs that require specialty pharmacy handling and distribution

Site-of-care implicationWhen 'SP' is indicated the drug is typically dispensed via specialty pharmacy; some agents administered by provider may be billed to medical benefit

Common examplesMany biologics and oncology/specialty agents (e.g., NUCALA, TEZSPIRE, XOLAIR) are flagged SP in the list

Administrative control (AC)'AC' denotes administrative controls often applied to vaccines or age/program-based coverage as listed in the Requirements/Limits column

ExamplesMultiple vaccine entries (e.g., ABRYSVO, AFLURIA, COMIRNATY) show 'AC' in Requirements/Limits

Effect on coverageAC entries specify administrative routing or eligibility conditions that affect coverage rather than clinical PA/QL rules

Prior Authorization (abbrev)

Abbreviation: PAPrior Authorization

Abbreviation: QLQuantity Limit

Abbreviation: SPSpecialty

Quantity Limit (abbrev)

Quantity Limit examples (abbrev)Examples shown: '1 carton/28 days', '120 tablets/30 days', '56 capsules/28 days' listed in Requirements/Limits

How usedAbbreviated QL values accompany product lines to indicate numeric limits per time period

EnforcementClaims exceeding these QL abbreviations may be denied or require PA per policy

Site-of-service restriction

Site-of-service (SP) meaning'SP' indicates specialty distribution or site-of-service restriction (e.g., infusion/ specialty pharmacy), commonly applied to biologics and specialty injectables

ExamplesMany PA/QL-listed agents for PAH, CF, and biologics are marked 'SP' indicating specialty routing

Coverage implicationWhen 'SP' appears the drug must typically be dispensed through specialty pharmacy; billing/benefit may vary

Quantity Limit

Quantity Limit definitionMaximum supply permitted per specified period (examples in document: '30 tablets/30 days', '100 mls/30 days')

NotationDisplayed in Requirements/Limits as 'QL (quantity/period)' next to each product when applied

EffectPrescribers must adhere to QL or request PA/exception if more quantity is needed

Specialty designation

Specialty designation (definition)A product designated 'SP' is considered a specialty product requiring specialty pharmacy management and often PA/QL controls

Typical productsIncludes biologics, injectables, and select oral specialty agents (examples: GENOTROPIN, GALAFOLD, REPATHA)

Dispensing pathwaySP designation generally routes fulfillment through specialty pharmacy; member should consult benefit materials

PA — definitionPrior Authorization: a payer requirement for approval before coverage; shown when plan requires approval (noted as 'PA' in Requirements/Limits)

When listedPA is listed next to products that commonly require administrative review prior to dispensing

Prescriber actionPrescriber must submit PA documentation per payer process to obtain coverage

QL — definitionQuantity Limit: numeric maximum on amount dispensed per time period (e.g., '30 tablets/30 days')

NotationDisplayed as QL (quantity/period) in the Requirements/Limits column for each product it applies to

ExamplesCommon numeric examples include 30 tablets/30 days, 60 tablets/30 days, 720 mls/30 days

SP — definitionSpecialty Pharmacy designation: identifies high-cost or complex drugs requiring specialty handling/dispensing

ImplicationMay require specialty pharmacy routing and additional authorization/documentation

ExamplesBiologic asthma/allergy agents and many oncology agents are marked 'PA, SP' in the list

ST — definitionStep Therapy: requires trial and failure or intolerance of preferred alternatives before this drug is covered (marked 'ST')

ExampleKERENDIA (finerenone) is explicitly marked with ST plus QL

DocumentationPrescriber must document prior trials or reasons for bypassing step therapy when requesting PA/exception

PA + QL definition (shorthand)

PA + QL shorthandEntries commonly list combined controls as 'PA, QL' indicating prior authorization plus a numeric quantity limit apply

Typical useUsed for many specialty agents where both approval and quantity enforcement are required

Provider expectationSubmit PA with documentation and adhere to QL when approved

SP (shorthand)

SP — shorthand'SP' indicates specialty product designation requiring specialty pharmacy handling

ImplicationOften paired with PA and QL in Requirements/Limits for high-cost drugs

ExamplesGENOTROPIN, GALAFOLD and other specialty injectables are marked PA, SP or PA, QL, SP

PA (alternate)

PA (alternate) — definitionPrior authorization: administrative approval required before coverage; indicated in Requirements/Limits as 'PA'

When to checkRefer to Special Requirements column and benefit materials for PA applicability

ConsequenceCoverage may be denied without PA when 'PA' is listed

QL (alternate)

QL (alternate) — definitionQuantity Limit: maximum permitted quantity per specified period, displayed as QL (e.g., 30 tablets/30 days)

Where shownNoted in Requirements/Limits next to product entries when applied

ActionIf needed quantity exceeds QL, prescriber must request PA or exception per payer process

SP (alternate)

SP (alternate) — definitionSpecialty: product managed via specialty pharmacy; often paired with PA and QL

ExamplesMany high-cost injectables and biologics in the list carry SP designation

Coverage routingDispensing and benefit routing follow specialty pharmacy procedures when SP is indicated

PA (abbrev)

PA (abbrev) — note'PA' used to signal prior authorization requirement in the Special Requirements column

Provider stepSubmit PA per payer instructions; see member ID card for contact info

Review timelinesPA and exception decisions follow the plan's review timelines (refer to benefit materials)

QL (abbrev)

QL (abbrev) — examplesDocument shows QL examples such as '30 tablets/30 days' and '1200 mls/30 days' in the Requirements/Limits column

UsageAbbreviated QL values accompany specific product lines to enforce dispensing limits

EnforcementExceeding these QLs without PA/exception may result in denial

SP (abbrev)

SP (abbrev) — usageThe 'SP' abbreviation flags specialty pharmacy route or site-of-service restriction for listed products

ImpactProducts with SP are typically dispensed via specialty pharmacy and may require additional handling/documentation

Common pairingsSP often appears with PA and QL (e.g., PA, QL, SP) for specialty agents

Initial authorization controls for specialty and modulator agents

Initial authorization for specialty modulators

Initial authorization requirements for specialty modulators:

Initial PA requirement: Initial coverage for cystic fibrosis modulators and similar specialty modulators is provided only after prior authorization is approved when the product's Requirements/Limits field lists 'PA'.

Examples include ALYFTREK, KALYDECO, ORKAMBI, SYMDEKO, TRIKAFTA entries showing 'PA' in Requirements/Limits.

Quantity limits at initiation: Initial dispensing and refills must comply with the numeric quantity limits shown for the product (e.g., 56 tablets/28 days; 60 tablets/30 days; 56 packets/28 days), and requests exceeding those limits require justification through the PA process.see per-product QL entries

Specialty pharmacy routing (SP) applies when indicated.

Specialty routing: When 'SP' is indicated for the product, initial therapy must be dispensed via the specialty pharmacy channel as required by the Drug List entry.

Provider should include specialty dispensing intent in PA documentation.

Step therapy indicators and affected products

Drug / Product	Special Requirements
FETZIMA (levomilnacipran) — cap ER (various strengths)
ST (Step therapy required)
Risperidone ODT (orally disintegrating tab) — various strengths
ST (Step therapy required) + QL (60–120 tablets/30 days as listed)
VERSACLOZ (clozapine suspension 50 mg/ml)
ST (Step therapy required) + QL (540 mL/30 days)
KERENDIA (finerenone) — tab 10 mg, 20 mg
ST (Step therapy indicated) + QL (30 tablets/30 days)

Drug / Product	Example Annotation
APRETUDE (cabotegravir IM extended-release 600 mg/3 mL)
AC (Administrative/clinical control noted)
DESCOVY (emtricitabine-tenofovir AF) — various strengths
AC indicated on some formulations in Special Requirements column
RYBELSUS (semaglutide tablets)
Listed with QL (30 tablets/30 days) and may have PA per product line

Drug / Product	Requirements / Notes
COMETRIQ (cabozantinib kit) — oncology kit formulations
PA, QL (1 carton/28 days), SP
COPIKTRA (duvelisib) — caps 15 mg, 25 mg
PA, QL (56 capsules/28 days), SP
OZEMPIC (semaglutide pen) — various pen sizes
PA, QL (1 pen/28 days or 3 mL/28 days depending on formulation)

Drug / Product	Coverage Controls
OZEMPIC (semaglutide soln pen-inj) — 0.25/0.5/1/2 mg presentations
PA required; QL applies (1 pen/28 days or 3 mL/28 days depending on formulation)
MOUNJARO (tirzepatide) — pens
Listed with QL (4 pens) and PA may apply depending on formulation/plan
RYBELSUS (semaglutide tablets)
QL (30 tablets/30 days); prior authorization may be required per product line

Placeholder	Note
Step therapy (ST) — general guidance
Per Coverage Considerations: drugs marked 'ST' require trial of another proven, cost-effective medication before coverage may be available; specific step sequences are not specified in this excerpt.

Drug / Product	Special Requirements
KERENDIA (finerenone) — tab 10 mg, 20 mg
QL (30 tablets/30 days) + ST (Step therapy indicated)

Drug / Product	Special Requirements / Channel
COMETRIQ (cabozantinib) — oncology kits
PA, QL, SP (specialty pharmacy indicated)
REPATHA (evolocumab) — prefilled syringe/cartridge/sureclick
PA, QL, SP — specialty distribution noted
CAMZYOS (mavacamten) — capsules
PA, QL, SP — specialty channel management indicated

Drug / Product	Step Therapy Specified?
Many oncology and specialty agents listed across excerpts (examples: COMETRIQ, COPIKTRA, dasatinib)
No explicit multi-step therapy sequences (specific required trials) are specified in these chunks; ST appears as a flag for some products but algorithms are not detailed.
General policy note
Coverage considerations state that ST indicates a required trial of another proven, cost-effective medication prior to coverage; refer to benefit materials for plan-specific step therapy details.

Drug / Product	Special Requirements
Various bowel prep products (Golytely, Moviprep, Suprep, SUTAB)
AC (Access control) indicated for several bowel prep formulations; PA may be required for select GI products—no explicit step edits detailed in these chunks.
APRETUDE (cabotegravir IM) — listed earlier
AC noted for APRETUDE (administrative/clinical control)

Drug / Product	Special Requirements
FETZIMA (levomilnacipran) — cap ER (various strengths)
ST (Step therapy required) — listed as Requirements/Limits = ST

Drug / Product	Step Therapy / Notes
Multiple antipsychotics and psychiatric products (examples: aripiprazole formulations, risperidone ODT, clozapine formulations, quetiapine, brexpiprazole)
Selected entries are marked ST (step therapy) — e.g., aripiprazole oral solution and ODT forms, risperidone ODT; many psychiatric agents also include QL; where ST is indicated the member must trial preferred alternatives first.
Risperidone ODT — QL (60 tablets/30 days) + ST
Aripiprazole oral solution — QL (900 mL/30 days) + ST

Drug / Product	Special Requirements / QL
Risperidone ODT (orally disintegrating tab) — 0.25 mg, 0.5 mg, etc.
ST indicated; QL noted (60 tablets/30 days for some strengths; 60–120 listed across entries)
VERSACLOZ (clozapine suspension 50 mg/mL)
ST indicated alongside QL (540 mL/30 days)

Drug / Product	Notes
General ST guidance
Per Coverage Considerations: drugs marked 'ST' require trial of another proven, cost-effective medication before coverage; QL/DL are noted with 'QL' where applicable. Specific numeric QLs and examples are provided elsewhere in the drug list.
Example: aripiprazole oral solution
Marked QL (900 mL/30 days) and ST for step therapy enforcement as listed in the formulary excerpt.

Quantity limit specifics by product and common examples

Azithromycin / Clarithromycin / BAXDELA

Azithromycin (Zithromax) QLAzithromycin tablets 250 mg and 500 mg: QL = 60 tablets/180 days

Clarithromycin ER 500 mg QLClarithromycin extended‑release 500 mg tablets: QL = 28 tablets/30 days

BAXDELA (delafloxacin) QLDelafloxacin meglumine 450 mg tablets: QL = 28 tablets/180 days

Aminoglycoside inhalation products

ARIKAYCE QLARIKAYCE (amikacin liposome inhalation) Requirements/Limits = PA, QL (235.2 mls/28 days)

Tobramycin nebulization QLTobramycin nebulization solutions (various brands): QL = 56 containers/56 days (also shown for Bethkis)

Itraconazole (Sporanox) QLs

Itraconazole capsule QLItraconazole capsules 100 mg (Sporanox): QL = 120 capsules/30 days

Itraconazole oral solution QLItraconazole oral solution 10 mg/mL (Sporanox): QL = 1200 mLs/30 days

Antiretroviral and antiviral QLs

Antiretroviral / antiviral tablets QLMultiple antiretroviral and antiviral tablet products commonly show QL = 30 tablets/30 days (specific entries vary)

Liquid antiretroviral QLSome liquid formulations show larger mL QLs (e.g., emtricitabine soln QL 720 mLs/30 days)

Multiple QL examples

Common QL examplesDocument includes examples such as 30 tablets/30 days; 60 tablets/30 days; 720 mLs/30 days; 4 tablets/365 days; 90 tablets/30 days

Where appliedThese QLs appear across antivirals, antiretrovirals, oral solutions and other classes in the drug list

Provider actionIf requested quantity exceeds the listed QL, prescriber must request PA or an exception per plan rules

SUNLENCA

SUNLENCA QLSUNLENCA (lenacapavir) tablet: QL = 4 tablets/365 days for single packs or 5 tablets/365 days for therapy packs

Therapy pack variantsTherapy pack presentations carry the stated annual QL consistent with pack size

Selected oncology QLs

COMETRIQ (kit) QLCOMETRIQ (cabozantinib) 100‑dose kit: QL = 1 carton/28 days

COPIKTRA QLCOPIKTRA (duvelisib) capsules: QL = 56 capsules/28 days

ERIVEDGE QLERIVEDGE (vismodegib) 150 mg capsules: QL = 30 capsules/30 days

SELINEXOR therapy packsSelinexor therapy packs list specific tablet counts per 28 days (e.g., 16 tablets, 24 tablets, 4–8 tablets variants)

Selected oncology QLs (examples)

Revumenib QLsRevumenib (REVUFORJ) tabs: QL = 240 tablets/30 days (25 mg), 120 tablets/30 days (110 mg), 60 tablets/30 days (160 mg)

Olutasidenib QLOlutasidenib (REZLIDHIA) 150 mg capsules: QL = 60 capsules/30 days

Tazemetostat QLTazemetostat (TAZVERIK) 200 mg tabs: QL = 240 tablets/30 days

Additional product-specific quantity limits

Larotrectinib and selinexor QLs

Larotrectinib QLsLarotrectinib oral solution: QL = 300 mL/30 days; Larotrectinib capsules 25 mg: QL = 180 capsules/30 days; 100 mg: QL = 60 capsules/30 days

Selinexor therapy pack examplesSelinexor therapy packs include pack‑level QLs (e.g., 16 tablets, 24 tablets, 4–8 tablets variants per 28 days)

Contraceptives and select antidiabetic QLs

Contraceptive ring QLsANNOVERA listed QL = 1 ring/365 days; NUVARING listed QL = 1 ring/21 days

Oral contraceptives QLMany oral contraceptive entries show QL = 28 tablets (typically per 21‑day pack conventions)

GLP‑1 / antidiabetic pensExamples: MOUNJARO QL = 4 pens; OZEMPIC QL = 1 pen/28 days or 3 mLs/28 days depending on formulation; TRULICITY QL = 4 pens

Site-of-service and specialty pharmacy routing

Note

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Drug List / Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual drug list publication — no material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a drug's Requirements/Limits field lists 'PA' and provide documentation to support medical necessity and requested quantity.

SourceLink

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