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CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2026 Drug List (Pharmacy Benefit) — Coverage Criteria

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This document is Blue Cross and Blue Shield of Oklahoma's 2026 Drug List describing covered pharmacy drugs, tier placement, special requirements (e.g., PA, ST, QL), and how members and providers can use the list. It applies to members and prescribing providers using BCBSOK pharmacy benefits.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List (Pharmacy Benefit) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and required documentation for drugs marked 'PA' before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026publication year

6member payment tiers described

manyentries with QL/PA/SP

~90+distinct drug entries (excerpt)

numerousoncology agents flagged PA/QL

Coverage criteria and formulary controls

Covered drugs are listed on the Drug List. Drugs not shown are not covered. In addition to product-level formulary flags, certain drugs have specific coverage requirements or utilization controls; when present these are shown in the Requirements/Limits column as PA (prior authorization), QL (quantity/dispensing limit), ST (step therapy), SP (specialty pharmacy), AC (age/clinical coverage), or other product-specific annotations.

Formulary coverage with requirements: Covered when listed on the Drug List and when any product-level requirements below are met; drugs not listed are not covered.

Drug list entries and coding/limits

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List (Pharmacy Benefit) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and required documentation for drugs marked 'PA' before dispensing.

SourceLink

On This Page

Prior authorization, step therapy, documentation, and denial risks

Prior Authorization

Obtain prior authorization when 'PA' is listed

Certain drugs listed with 'PA' in the Special Requirements column require prior authorization; the prescriber must submit a prior authorization request and obtain approval before the medication will be covered by the plan.

Prior Authorization

Submit PA for selected anti-infectives/antivirals

Selected products in the formulary such as ARIKAYCE, TOBI PODHALER, EPCLUSA, CRESEMBA and other listed anti-infectives/antivirals are marked with PA (and often QL/SP) and require prior authorization per the formulary before coverage.

ARIKAYCE — Requirements/Limits = PA, QL (28 vials/28 days), SP ([[chunk 28]])
TOBI PODHALER — QL (224 capsules/56 days), SP ([[chunk 29]])
EPCLUSA — Requirements/Limits = PA, QL (28 tablets/28 days), SP ([[chunk 37]])

Prior Authorization

PA required for select DAAs (hepatitis C agents)

Direct-acting antiviral agents for hepatitis C (e.g., EPCLUSA, MAVYRET, SOVALDI, VOSEVI) are designated PA and subject to quantity limits and specialty pharmacy routing; prior authorization must be obtained before coverage.

EPCLUSA — PA, QL (28 tablets/28 days), SP
MAVYRET — PA, QL (90 tablets/30 days), SP
SOVALDI — PA, QL (30 tablets/30 days), SP
VOSEVI — QL (30 tablets/30 days) (PA indicated in list)

Prior Authorization

Obtain PA for oncology and specialty drugs

Numerous oncology and specialty agents are marked 'PA' (often with QL and SP); prescribers must obtain prior authorization for these cancer and specialty drugs before dispensing.

Abiraterone — PA, QL (examples shown) ([[chunk 70]])
ALECENSA (alectinib) — PA, QL (240 capsules/30 days), SP ([[chunk 71]])
Various antineoplastics listed with PA and QL ([[chunk 72]])

Prior Authorization

PA plus quantity limits for specialty/oncology products

Many oncology and specialty products combine prior authorization with explicit quantity limits (e.g., PA, QL X units/Y days); providers must submit PA requests and ensure dispensing adheres to the stated QL.

PA and QL shown per product (e.g., BRAFTOVI — PA, QL (180 capsules/30 days))
Claims exceeding QL may require additional review or be denied

Prior Authorization

PA required for many specialty oncology agents

Many oral oncology/specialty agents are designated 'PA' (examples include pazopanib, pemigatinib, alpelisib packs); prior authorization is required before coverage.

Pazopanib — PA, QL (120 tablets/30 days) ([[chunk 92]])
PEMAZYRE (pemigatinib) — PA, QL (14 tablets/21 days) ([[chunk 92]])
PIQRAY (alpelisib) — PA, QL (various) ([[chunk 92]])

Prior Authorization

Submit PA for select specialty/high-use products

Several other non-oncology specialty products require prior authorization as listed (examples include testosterone enanthate formulations, MYFEMBREE, ORIAHNN); providers must submit PA per payer processes.

TESTOSTERONE ENANTHATE — Requirements/Limits = PA, QL (5 mls/28 days) ([[chunk 111]])
ELAGOLIX-ESTRAD-NORETH pack (MYFEMBREE/ORIAHNN packages) — PA, QL ([[chunk 116]])
Metformin ER osmotic forms — PA, QL (examples in list) ([[chunk 131]])

Prior Authorization

PA required for selected branded products

Certain branded products are noted with PA in the formulary and require prior authorization before coverage; follow the product line entry for PA designation and limits.

MOUNJARO — Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on presentation) ([[chunk 132]])
OZEMPIC — Requirements/Limits = PA, QL (1 pen/28 days) ([[chunk 132]])

Prior Authorization

PA required for endocrine and specialty metabolic drugs

Multiple endocrine and specialty endocrine agents (e.g., FARXIGA, GLP‑1 agents, various insulins) list PA and/or QL; prescribers must obtain prior authorization where 'PA' is indicated before dispensing.

FARXIGA — QL (30 tablets/30 days) (PA indicated on some entries) ([[chunk 127]])
MOUNJARO, OZEMPIC, TRULICITY — PA and QL examples provided ([[chunk 132]])
Insulin glargine products (reference and biosimilars) — QL (100 mLs/30 days) and tier P ([[chunk 143]])

Prior Authorization

PA required for listed specialty biologics

Multiple biologic and specialty agents (e.g., STRENSIQ, TRYNGOLZA, VOXZOGO, YORVIPATH, TYMLOS) are listed with 'PA' and require prior authorization prior to coverage; specialty pharmacy routing (SP) may also apply.

STRENSIQ — PA, SP ([[chunk 162]])
VOXZOGO — PA, QL (30 vials/30 days), SP ([[chunk 163]])
YORVIPATH — PA, QL (2 pens/28 days), SP ([[chunk 163]])

Prior Authorization

Check product entries and obtain PA when shown

The formulary denotes prior authorization where required; providers must check each product entry and obtain PA when 'PA' appears in the Requirements/Limits column before dispensing.

Prior Authorization

Submit PA documentation as indicated

When a product entry indicates 'PA' the prescriber must submit prior authorization documentation per BCBSOK processes before the plan will cover the medication.

Prior Authorization

PA required for select specialty/high-cost drugs

Select specialty and high-cost drugs such as NUCALA, TEZSPIRE, XOLAIR and CF modulators are designated 'PA' (and often QL/SP); prescribers must obtain prior authorization and adhere to QL/SP requirements.

NUCALA — PA, QL (3 pens/28 days or 1 syringe/28 days), SP ([[chunk 217]])
TEZSPIRE — PA, QL (1 pen/28 days), SP ([[chunk 220]])
XOLAIR — PA, SP ([[chunk 221]])

Prior Authorization

PA required for listed specialty and select drugs

Multiple specialty and select drugs (BYLVAY, CIMZIA, ENTYVIO PEN, SKYRIZI, TREMFYA, ZYMFENTRA, etc.) are subject to prior authorization; prescribers must submit documentation to support medical necessity and dosing with PA requests.

BYLVAY — Requirements/Limits = PA, SP ([[chunk 236]])
CIMZIA — PA, QL (2 kits/28 days or 4 syringes/28 days), SP ([[chunk 236]])
ENTYVIO PEN — PA indicated in list ([[chunk 235]])

Prior Authorization

PA and step therapy may both apply — confirm requirements

Certain drugs are marked with 'PA' or 'ST' indicating prior authorization or step therapy is required before coverage; providers should confirm whether step therapy applies in addition to PA.

AUVELITY — Requirements/Limits = ST ([[chunk 255]])
CLOZAPINE ODT entries — ST/QL noted for some formulations ([[chunk 263]])
NUPLAZID — PA, QL (30 capsules/30 days) and other entries with ST/PA flags ([[chunk 266]])

Step Therapy

Adhere to step therapy when 'ST' is shown

Some benefit plans include step therapy (ST); drugs noted with 'ST' require the member to try specified alternative medications first per plan rules before the listed product is covered.

ST flag indicates a required trial of an alternative agent before coverage (document notes ST appears in Special Requirements column).

Step Therapy

No explicit ST sequences in extract — confirm with payer

The document extract does not provide explicit step-by-step sequences for most ST entries; where 'ST' appears (product line), providers must follow payer step edit logic and confirm required prior steps with BCBSOK.

Step Therapy

Step therapy/SP indicated for select antivirals/biologics

Certain high-cost antiviral and biologic agents (e.g., EPCLUSA, HARVONI, MAVYRET, SOVALDI, PEGASYS) are indicated with step/special program flags (SP/ST) in addition to PA; prescribers should confirm if step therapy applies.

PEGASYS — Requirements/Limits = PA, SP ([[chunk 43]])
EPCLUSA — PA, QL, SP ([[chunk 37]])

Step Therapy

Step therapy sequences not specified — verify with payer

Where step therapy details are not specified in the document, prescribers must verify the required step sequence with the payer prior to submitting an authorization request.

Note

Follow specialty program (SP) requirements when flagged

The formulary includes entries with 'SP' (special program/specialty) indicating specialty plan or program requirements; providers should follow specialty program rules where 'SP' is noted.

SP indicates specialty pharmacy management or special program routing for the product.

Note

Observe administrative controls (AC) and possible step edits

Some contraceptives and related products are flagged with 'AC' (administrative control) which may represent administrative coverage controls or potential step edits; follow payer administrative procedures where AC is shown.

ANNOVERA, many oral contraceptives — Requirements/Limits include AC and QL (e.g., 1 ring/365 days or 28 tablets/21 days) ([[chunk 116]], [[chunk 117]])

Step Therapy

No explicit step order shown — confirm before submission

Where step therapy is not detailed for a product entry, the formulary still flags PA and QL but does not specify an ordered step sequence; confirm step requirements with the payer as needed.

Step Therapy

KERENDIA flagged for step therapy (ST)

KERENDIA (finerenone) is annotated with 'ST' indicating a step therapy requirement may apply; providers should confirm the required prior steps and include documentation when requesting coverage.

KERENDIA — Requirements/Limits = QL (30 tablets/30 days), ST ([[chunk 154]])

Step Therapy

Step therapy not specified in excerpt — contact payer

In many sections the extract does not specify step therapy sequences or failures required prior to coverage; providers must check plan-specific rules or contact the number on the member ID card for details.

Step Therapy

ST flagged medications — follow step requirements

Multiple branded agents are specifically marked 'ST' in the list (examples: AUVELITY, DESVENLAFAXINE ER, ESCITALOPRAM OXALATE, FETZIMA, FLUOXETINE DR, and certain clozapine forms); when ST is present providers must follow the plan's step requirements.

AUVELITY — Requirements/Limits = ST ([[chunk 255]])
DESVENLAFAXINE ER — Requirements/Limits = ST ([[chunk 256]])
ESCITALOPRAM OXALATE — Requirements/Limits = ST ([[chunk 257]])

Documentation Required

Request Drug List exceptions via ID-card number (timelines apply)

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

Documentation Required

Provide documentation supporting PA/QL requests

When a product is listed with 'PA' or 'QL', providers must supply required authorization documentation to support medical necessity, dosing, and requested quantity in the PA request.

Include diagnosis, dosing regimen, and quantity requested when submitting PA for PA/QL products.

Documentation Required

PA documentation required when SP is indicated

For products with both 'PA' and 'SP' designations, providers must submit prior authorization documentation per payer processes and may be required to have the medication dispensed through a specialty pharmacy.

Confirm specialty pharmacy routing (SP) and include any required specialty documentation with the PA.

Documentation Required

Follow AC (administrative) requirements for vaccines

Some vaccine products are annotated 'AC' in Requirements/Limits; administrative coverage conditions apply and providers should follow the AC guidance when seeking coverage or exception.

ABRYSVO, ACTHIB, AFLURIA and other vaccines show Requirements/Limits = AC in the list.

Documentation Required

Include diagnosis, dosing and QL adherence for specialty PA

Specialty medications frequently require specific authorization documentation; prescriptions for SP-designated agents must include documentation of diagnosis, dosing, and adherence to quantity limits when requesting PA.

Examples: specialty cardiovascular and pulmonary agents require PA and documentation consistent with formulary rules.

Documentation Required

Document adherence to PA and QL in authorization requests

When a drug entry shows 'PA, QL' the prescriber must document both the prior authorization rationale and that the requested quantity is appropriate per the listed quantity limit.

Billing Rule

Adhere to quantity limits or obtain authorization

Quantity limits shown in the formulary are enforceable — providers must ensure dispensing requests match the QL or obtain authorization to exceed the limit; claims exceeding QL may be denied or require documentation.

Example QLs: 30 tablets/30 days, 60 tablets/30 days, 1 pen/28 days, 100 mLs/30 days (varies by product).

Documentation Required

Support PA/QL with product-specific documentation

Provide supporting documentation with PA/QL requests for products that list specific limits or special handling (examples: metformin oral solution, MOUNJARO, OZEMPIC list PA/QL and require supporting evidence).

Metformin ER osmotic forms — PA, QL (150 tablets/30 days) ([[chunk 131]])
MOUNJARO — PA, QL (4 pens/180 days or 4 pens/28 days) ([[chunk 132]])

Documentation Required

Reference product-specific QL values in PA requests

When submitting PA requests include documentation of the specific quantity limit applicable to the product (e.g., X units per Y days) to demonstrate medical necessity within the QL.

Examples of QL values are provided in the formulary and should be referenced in requests.

Documentation Required

Include medical necessity, dosing and quantity in PA requests

Authorization requests for PA/QL/SP products must include documentation of medical necessity, dosing frequency, and the requested quantity to support coverage decisions.

Documentation Required

Supply disease-specific and dosing documentation with PA for specialty agents

Provide documentation supporting PA for specialty agents (e.g., BYLVAY, CIMZIA, ENTYVIO PEN) including diagnosis, prior treatments tried, dosing, and quantity limits when required by the formulary.

BYLVAY — PA, SP ([[chunk 236]])
CIMZIA — PA, QL, SP ([[chunk 236]])
ENTYVIO PEN — PA indicated in list ([[chunk 235]])

Documentation Required

Examples of documentation required with PA requests

Examples of documentation to include with PA requests: diagnosis, prior therapy history, dosing schedule, anticipated duration, and the specific quantity requested to match QL.

When PA/QL is specified, provide medical necessity rationale and that the requested quantity aligns with the stated QL.

Documentation Required

Document requests to exceed quantity limits

For products listed with QL, prescribers should document the clinical rationale when requesting quantities exceeding the stated limit; without appropriate documentation claims may be denied.

Documentation Required

Provide medical necessity and dosing documentation for BYLVAY/CIMZIA/ENTYVIO PEN

For BYLVAY, CIMZIA, and ENTYVIO PEN examples in the formulary, include documentation supporting medical necessity and dosing frequency when submitting prior authorization requests.

BYLVAY — PA, SP ([[chunk 236]])
CIMZIA — PA, QL (2 kits/28 days or 4 syringes/28 days), SP ([[chunk 236]])
ENTYVIO PEN — PA indicated ([[chunk 235]])

Documentation Required

State QL units and timeframe in PA requests

Follow quantity limit guidance when requesting PA for dispensing amounts; specify units and timeframe (e.g., tablets/30 days, pens/28 days, mLs/30 days) in the authorization.

Common formats: QL (30 tablets/30 days), QL (1 pen/28 days), QL (100 mLs/30 days).

Denial Risk

Risk of denial if PA not submitted for PA-designated drugs

Requests for medications not listed on the Drug List or for drugs that require prior authorization may be denied if a PA is not submitted and approved; providers should obtain PA where indicated to avoid denial.

Denial Risk

Denial triggers for anti-infective/selected agents if PA/QL/SP unmet

Select anti-infective agents with QL, PA, or SP designations (e.g., azithromycin, voriconazole, ARIKAYCE, TOBI PODHALER) may be subject to denial if those requirements or quantity limits are not met.

Azithromycin — QL (60 tablets/180 days) ([[chunk 23]])
Voriconazole — Requirements/Limits noted in antifungals section ([[chunk 31]])
TOBI PODHALER — QL (224 capsules/56 days), SP ([[chunk 29]])

Denial Risk

PA required for select antivirals — denial possible without PA

Use of select antivirals (EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI) is designated PA and may trigger denial if prior authorization and any QL/SP requirements are not met.

EPCLUSA — PA, QL (28 tablets/28 days), SP ([[chunk 37]])
VOSEVI — QL (30) in quantity limits section ([[chunk 164]])

Denial Risk

PA plus SP may cause specialty routing or denial without documentation

Some biologic and antiviral products list both PA and specialty (SP) designations; without required PA and specialty routing, claims may be denied or redirected to specialty pharmacy channels.

PEGASYS — PA, SP ([[chunk 43]])
SOVALDI — PA, QL, SP ([[chunk 37]])

Denial Risk

PA/QL/SP noncompliance may trigger claim denial

Drugs listed with 'PA' or 'QL' or 'SP' may be denied at point of claim if prior authorization is not obtained or quantity limits are exceeded; providers should confirm and comply with these requirements.

Denial Risk

PA absence can trigger denial at claim

If a formulary entry shows 'PA' the absence of required prior authorization may result in claim denial at the point of sale; obtain PA before dispensing to avoid denial.

Denial Risk

Exceeding QL may cause denial

Exceeding stated quantity limits (e.g., listed QL such as 30 tablets/30 days) may trigger claim denial or require prior authorization to cover the excess quantity.

Examples: RAYOS — QL (360 tablets/30 days) for some strengths; testosterone gels — various QLs ([[chunk 110]], [[chunk 111]])

Denial Risk

PA and QL enforcement may result in denial

The formulary enforces PA and QL for many products; claims for listed drugs may be denied if prior authorization or quantity limits indicated for the product are not met.

Denial Risk

Missing PA for hormone/testosterone products may trigger denial

Examples in the formulary (testosterone enanthate, XYOSTED, contraception products) show that missing required PA may lead to denial at point of claim; confirm PA prior to dispensing.

TESTOSTERONE ENANTHATE — PA, QL (5 mls/28 days) ([[chunk 111]])
XYOSTED — listed with Requirements/Limits and PA references ([[chunk 111]])

Denial Risk

PA/QL noncompliance risks denial (metformin example)

Noncompliance with PA/QL requirements (e.g., for metformin oral solution, extended-release metformin) may result in denial; ensure required authorizations and QL adherence are documented.

Metformin ER osmotic 500 mg — PA, QL (150 tablets/30 days) ([[chunk 131]])

Prior Authorization

Obtain PA for any product showing 'PA' to avoid denial

Drugs listed with 'PA' will require prior authorization; failure to obtain PA prior to dispensing may trigger claim denial.

Denial Risk

Denial triggers include missing PA, exceeding QL, failing SP routing

Formulary entries may trigger denial when required prior authorization, quantity limits, or specialty pharmacy requirements are not followed; confirm and comply with listed Requirements/Limits.

Denial Risk

QBRELIS example — PA and QL enforcement

Products with PA and QL designations (e.g., QBRELIS lisinopril oral solution) require prior authorization and adherence to the specified quantity limit; lack of compliance may result in denial.

QBRELIS — Requirements/Limits = PA, QL (2400 mls/30 days) ([[chunk 184]])

Denial Risk

Specialty PA required — risk of denial without documentation

Specialty agents (e.g., REPATHA, TRYVIO, ATTRUBY) list PA and QL; requests without required authorization documentation risk denial or referral to specialty pharmacy.

REPATHA — PA, QL (6 syringes/28 days) ([[chunk 195]])
TRYVIO — PA, QL (30 tablets/30 days) ([[chunk 195]])

Denial Risk

PA-designated biologics require authorization to avoid denial

Coverage may be denied or require prior authorization when a product is marked 'PA' in the formulary (examples include NUCALA, TEZSPIRE, XOLAIR); obtain PA to secure coverage.

NUCALA — PA, QL, SP ([[chunk 217]])
TEZSPIRE — PA, QL, SP ([[chunk 220]])
XOLAIR — PA, SP ([[chunk 221]])

Prior Authorization

PA is required for PA-designated drugs

Prior authorization is required for PA-designated drugs; providers must obtain and document PA to prevent coverage denial at claim adjudication.

Denial Risk

Missing PA/QL commonly triggers denials

Requests lacking required PA or exceeding QL are common denial triggers noted throughout the formulary; providers should confirm Requirements/Limits before dispensing.

Denial Risk

Comply with utilization management (PA/ST/QL) to avoid denial

Utilization management flags (PA, ST, QL) are applied widely; medications flagged with any of these require compliance with the respective program or prior authorization/step edits to avoid denial.

Specialty pharmacy and dispensing requirements

Note

Use specialty pharmacy when 'SP' is indicated

Many specialty drugs in the list must be dispensed through an approved specialty pharmacy (SP); prescribers should route prescriptions accordingly and include SP instructions with PA requests.

SP designation indicates specialty pharmacy distribution is required for the product.

Note

SP flag denotes specialty pharmacy requirement

The 'SP' flag identifies products that require specialty pharmacy handling or management; providers must ensure SP routing for those agents to comply with formulary distribution requirements.

Note

Specialty pharmacy designation applies to CF modulators and injectables

Some agents (for example CF modulators and certain injectables) are designated SP and must be managed through specialty pharmacy channels; include SP details on PA requests.

CF modulators (TRIKAFTA, KALYDECO, ORKAMBI, SYMDEKO) — PA, QL, SP ([[chunk 222]], [[chunk 225]])

Note

Specified quantity limits by product

inv-162: Examples of QL from list (azithromycin, ARIKAYCE, EPCLUSA, etc.)

Antibiotic QLs examplesazithromycin tab QL (60 tablets/180 days); tobramycin TOBI PODHALER QL (224 capsules/56 days); ARIKAYCE QL (28 vials/28 days)

Antiviral/DAA QLsEPCLUSA QL (28 tablets/28 days); VOSEVI QL (30 tablets/30 days)

Formulary enforcementThese examples illustrate how QLs are specified per product in the list

inv-163: efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg — QL

Productefavirenz-emtricitabine-tenofovir df tab 600-200-300 mg — QL (30 tablets/30 days)

ContextListed with QL alongside other HIV regimens in formulary extract

ImplicationDispensing limited to 30 tablets per 30-day period unless authorized

inv-164: EPCLUSA - sofosbuvir-velpatasvir — QL

ProductEPCLUSA (sofosbuvir-velpatasvir) — QL (28 tablets/28 days)

RequirementAlso designated PA and SP per formulary entry

Dispense notePack-based QL shown for pellet/pack presentations (28 packs/28 days)

inv-165: SUNLENCA — lenacapavir therapy pack — QL

ProductSUNLENCA (lenacapavir) therapy pack — QL (4 tablets/365 days)

FormatTherapy pack counts used (annual denominator) for long-acting regimens

Specialty noteListed with QL and specialty designation

inv-166: VOSEVI — QL

ProductVOSEVI (sofosbuvir-velpatasvir-voxilaprevir 400-100-100 mg) — QL (30 tablets/30 days)

RequirementAlso marked PA and SP in formulary entry

Pack/Tablet distinctionApplies to tablet presentation; pellet pack shown separately with pack-based QL

inv-167: vancomycin hcl caps (Vancocin) — QL

Productvancomycin hcl caps (Vancocin) — QL (120 capsules/30 days)

Formulation noteCapsule formulation has 120/30-day limit; oral solutions listed separately

Use caseApplied for C. difficile oral therapy formulations

inv-168: XIFAXAN — rifaximin 550 mg — QL

ProductXIFAXAN (rifaximin) 550 mg — QL (126 tablets/365 days)

Alternate strengthXIFAXAN 200 mg — QL (9 tablets/30 days)

Therapeutic contextDifferent strengths have distinct QLs reflecting indications (e.g., IBS vs. hepatic encephalopathy)

inv-169: tedizolid (SIVEXTRO) — QL

Producttedizolid (SIVEXTRO) 200 mg — QL (6 tablets/180 days)

DurationLonger interval (180 days) for limited short-course indications

ImplicationDispensing limited to small total count over extended period

inv-170: vancomycin hcl capsules — QL

Productvancomycin hcl capsules — QL (120 capsules/30 days)

Related formulationOral solution (Firvanq) listed separately without same capsule QL

Use noteCapsule QL supports oral CDI treatment supply limits

inv-171: XIFAXAN 200 mg — QL

ProductXIFAXAN 200 mg — QL (9 tablets/30 days)

Higher-strength comparison200 mg formulation limited per 30 days vs 550 mg annual total limit

Clinical implicationStrength-specific QLs reflect indication-specific dosing

inv-172: XIFAXAN 550 mg — QL

ProductXIFAXAN 550 mg — QL (126 tablets/365 days)

Annual denominatorUses 365-day denominator for certain long-term indications

Formulary statusListed as Drug Tier = P for the 550 mg strength

inv-173: ALECENSA — QL

ProductALECENSA (alectinib) — QL (240 capsules/30 days)

Specialty pairingShown with PA and SP for oncology management

High-monthly countReflects dosing and capsule strength pack sizes

inv-174: avapritinib — QL

Productavapritinib — QL (30 tablets/30 days)

RequirementEntry includes PA and SP annotations

ContextStandard 30/30 QL for many oral oncology agents

inv-175: encorafenib — QL

Productencorafenib — QL (180 capsules/30 days)

High-count exampleReflects capsule-based dosing and pack sizes for oncology therapy

PA/SPListed alongside PA and SP in formulary

inv-176: lenvatinib — QL

Productlenvatinib 10 mg therapy pack — QL (30 capsules/30 days)

Therapy pack formatPack-based therapy dosing expressed as monthly capsule count

Oncology enforcementPaired with PA and SP flags

inv-177: darolutamide — QL

Productdarolutamide — QL (120 tablets/30 days)

NUBEQA specificNUBEQA (darolutamide 300 mg) QL (120 tablets/30 days)

Oncology pairingListed with PA and SP designations

inv-178: NUBEQA — darolutamide — QL detailed

ProductNUBEQA (darolutamide 300 mg) — QL (120 tablets/30 days)

Formulary notePA and SP accompany the QL for specialty oncology management

Dispense implicationMonthly supply limited to 120 tablets without authorization

inv-179: TAGRISSO — QL

ProductTAGRISSO (osimertinib) — QL (30 tablets/30 days)

Oncology standardTypical 30/30 QL for targeted oral oncology agents

PA/SPEntry includes PA and SP annotations

inv-180: VITRAKVI — QL (mls)

ProductVITRAKVI (larotrectinib) oral soln 20 mg/ml — QL (300 mls/30 days)

Liquid formulationmL-based QL used for oral solution presentations

Specialty annotationPA and SP accompany the QL for specialty management

inv-181: RAYOS — QL variations by strength

RAYOS strengths variationRAYOS QLs vary by strength: examples include QL (90 tablets/30 days), QL (60 tablets/30 days), and QL (360 tablets/30 days)

Formulation noteDifferent tablet strengths have separate QLs

Prescriber implicationEnsure strength-specific QL is observed when requesting prior authorization

inv-182: testosterone products — QL examples

Testosterone examplesExamples include QL (1 vial/28 days), QL (10 mls/28 days), QL (4 pens/28 days), QL (2 bottles/30 days)

Formulation diversityInjectables, gels, pens and topical forms each have distinct QLs

PA/QL pairingSome testosterone formulations also require PA in addition to QL

inv-183: contraceptives — QL examples

Contraceptive QLsExamples include QL (1 ring/365 days), QL (28 tablets/21 days), QL (3 patches/21 days), QL (30 patches/30 days)

AC flagMany contraceptives carry AC administrative coverage flags in addition to QLs

Cycle-based limitsQLs often align with dosing cycles (21- or 28-day) or annual ring limits

inv-184: FARXIGA — QL

ProductFARXIGA (dapagliflozin) — QL (30 tablets/30 days)

Standard diabetic agent QL30/30 is common for oral antidiabetics

Formulary contextListed with AC in some strengths and QL applied in formulary extract

inv-185: assorted antidiabetic/insulin examples — QL

Antidiabetic/insulin examplese.g., 30 tablets/30 days; 1 pen/28 days; 4 pens/28 days; 100 mLs/30 days for insulin liquids

Pen and mL unitsGLP-1/insulin products use pen counts or mL volume limits rather than tablet counts

PA associationMany branded antidiabetic products list PA with QL for supply control

inv-186: TRESIBA QL example

TRESIBA QLTRESIBA — QL (100 mLs/30 days)

Insulin volume standard100 mLs/30 days commonly applied to multiple insulin brands

Continuation noteUsed for refill/maintenance supply control

inv-187: GALAFOLD/VOXZOGO/TYMLOS examples — QL

Specialty biologic examplesGALAFOLD QL (14 capsules/28 days); VOXZOGO QL (30 vials/30 days); TYMLOS QL (1.56 mls/30 days)

Unit diversityShows capsules, vials and mL units across specialty agents

PA/SPThese entries carry PA and SP flags in formulary

inv-188: TYMLOS — QL (1.56 mls)

TYMLOS QLTYMLOS — QL (1.56 mls/30 days)

Product formSpecified for abaloparatide pen-injector liquid volume

PA and SPListed with PA and SP in formulary

inv-189: VOXZOGO — QL (30 vials)

VOXZOGO QLVOXZOGO — QL (30 vials/30 days)

Pediatric/rare-disease formatVials per month used for weight- or dose-based biologic therapy

PA/SPListed with PA and SP alongside QL

inv-190: YORVIPATH — QL (2 pens)

YORVIPATH QLYORVIPATH — QL (2 pens/28 days)

Pen-based dosingPen count per 28 days used for refill control

Specialty handlingListed with PA and SP in formulary

inv-191: TRYNGOLZA — QL (1 device)

TRYNGOLZA QLTRYNGOLZA — QL (1 injection device/28 days)

Device-based QLSingle device per period limitation for injectable therapy

PA/SPEntry includes PA and SP annotations

inv-192: QBRELIS lisinopril oral solution — QL

QBRELIS QLQBRELIS (lisinopril oral solution 1 mg/ml) — QL (2400 mls/30 days)

Large-volume oral solutionHigh mL total used for liquid formulations with chronic dosing

PA pairingListed with PA and QL in formulary extract

inv-193: REPATHA — QL

REPATHA QLREPATHA (evolocumab) — QL (6 syringes/28 days)

Prefilled syringe limitSyringe/pen counts per period used for PCSK9 biologics

PA/SPListed with PA and SP in formulary

inv-194: TRYVIO — QL

TRYVIO QLTRYVIO (aprocitentan) — QL (30 tablets/30 days)

Cardiovascular agent QLMonthly tablet QL for specialty cardiovascular therapy

PA pairingListed with PA in formulary

inv-195: ATTRUBY — QL

ATTRUBY QLATTRUBY (acoramidis) — QL (112 tablets/28 days)

High-count 28-day packPack-based tablet QL used for chronic cardiac therapy

PA/SPListed with PA and SP in formulary

inv-196: ENTRESTO — QL (sprinkle)

ENTRESTO sprinkle QLENTRESTO (sacubitril-valsartan sprinkle) — QL (240 capsules/30 days)

Capsule-count QLHigh capsule monthly limit for cardiac agents

PA requirementListed with PA in formulary extract

inv-197: ORENITRAM — QL

ORENITRAM QLORENITRAM (treprostinil diolamine) — QL (300 tablets/30 days)

High monthly tablet countLarge QL consistent with titration and maintenance kits

PA/SPListed with PA and SP in formulary

inv-198: acoramidis pack — QL

Acoramidis pack QLAcoramidis tablet pack (356 mg) — QL (112 tablets/28 days)

Pack dosingPack-based tablet QLs used for specific dosing regimens

Specialty handlingPA and SP annotations present

inv-199: bosentan suspension — QL

Bosentan suspension QLbosentan (Tracleer) oral suspension — QL (120 tablets/30 days)

PA/SPListed with PA and SP for pulmonary hypertension agents

Formulation noteSuspension and tablet presentations have distinct QLs

inv-200: sacubitril-valsartan sprinkle — QL

Entresto sprinkle cap QLsacubitril-valsartan sprinkle cap (Entresto) — QL (240 capsules/30 days)

High monthly capsule countUsed for chronic heart failure regimen control

PA indicationListed with PA in formulary entry

inv-201: ivabradine solution — QL

Ivabradine solution QLivabradine (Corlanor) oral solution — QL (600 mls/30 days)

Large liquid volumemL-based QL reflecting chronic dosing needs

PA/SPListed with PA in formulary extract

inv-202: tadalafil suspension — QL

Tadalafil (Adcirca) QLtadalafil 20 mg — QL (60 tablets/30 days)

PA noteListed with PA in some entries for PAH indications

Monthly tablet limitUsed for pulmonary arterial hypertension dosing regimens

inv-203: uptravi — QL

UPTRAVI QLUPTRAVI (selexipag) — QL (60 tablets/30 days)

PA/SPListed with PA and SP for specialty pulmonary agents

Monthly tablet limitUsed for chronic pulmonary arterial hypertension therapy

inv-204: vyndaqel — QL

VYND A QLVYNDAQEL (tafamidis meglumine cardiac 20 mg) — QL (120 capsules/30 days)

High-count capsule QLUsed for chronic transthyretin therapy management

PA/SPListed with PA and SP in formulary

inv-205: sildenafil suspension — QL

Sildenafil suspension QLsildenafil (Revatio) suspension 10 mg/ml — QL (224 ml/30 days)

mL-based limitLiquid formulation uses mL total per month

PA/SPListed with PA and SP in some entries

inv-206: Advair HFA — QL

Advair HFA QLAdvair HFA — QL (1 inhaler/30 days)

Inhaler-based limitsCommon QL format for inhaled maintenance therapies

Package-size variationSome inhaled products list blister or inhaler counts depending on device

inv-207: assorted examples across list

Representative examplesDocument contains numerous QL examples across respiratory, biologic, and CF modulators — see individual entries for exact unit/time limits

QL pairing with PA/SPMany inhaled and biologic agents show QL together with PA and SP flags

Unit diversityExamples include inhalers, pens, syringes, vials, tablets and mLs

inv-208: NUCALA — QL

NUCALA QLsNUCALA — QL (3 pens/28 days for 100 mg auto-injector) or QL (1 syringe/28 days for 40 mg syringe)

Multiple presentationsDifferent presentations have different QLs (pens vs syringes)

PA/SPListed with PA and SP in formulary entry

inv-209: TEZSPIRE — QL

TEZSPIRE QLTEZSPIRE — QL (1 pen/28 days)

Pen-based dosingSingle pen per 28 days for maintenance dosing

PA/SPListed with PA and SP in formulary extract

inv-210: QVAR REDIHALER — QL

QVAR REDIHALER QLQVAR REDIHALER — QL (1 inhaler/30 days for 40 mcg; 2 inhalers/30 days for 80 mcg)

Strength-dependent QLHigher microgram strength allows larger monthly inhaler allotment

Formulary noteListed with Drug Tier = P and QL in entry

inv-211: VENTOLIN HFA — QL

VENTOLIN HFA QLVENTOLIN HFA — QL (2 inhalers/30 days)

Short-term rescue inhaler QLCommonly limited to 1–2 inhalers per month to manage supply

TieringListed with Drug Tier = P in formulary extract

inv-212: CF modulators — QL examples

CF modulators QLsCF modulators vary by product: TRIKAFTA QL (56 packets/28 days or 84 tablets/28 days depending on formulation); KALYDECO QL (60 tablets/30 days)

Product-specificQL differs by formulation (packets vs tablets) for same therapy

PA/SPThese entries commonly include PA and SP

inv-213: SUCRAID — QL

SUCRAID QLSUCRAID (sacrosidase solution 8500 unit/ml) — QL (300 mls/30 days)

Liquid enzyme QLmL-based monthly limit for digestive enzyme therapy

PA/SPListed with PA in formulary extract

inv-214: CIMZIA — QL

CIMZIA QLsCIMZIA (certolizumab) — QL (2 kits/28 days) or QL (4 syringes/28 days) depending on entry

Kit vs syringeDifferent supply presentations have different QLs

PA/SPListed with PA and SP in formulary extract

inv-215: ZYMFENTRA — QL

ZYMFENTRA QLZYMFENTRA (infliximab-dyyb) — QL (2 pens/28 days) or QL (2 syringes/28 days)

Biologic presentation QLPen and syringe presentations specified with per-28-day limits

PA/SPListed with PA and SP in formulary extract

inv-216: clozapine ODT — QL

Clozapine ODT QLClozapine ODT 12.5 mg — QL (90 tablets/30 days)

Clozapine tabs QLClozapine tabs 25/50/100 mg — QL (90 tablets/30 days); 200 mg — QL (120 tablets/30 days)

Monitoring implicationQLs reflect need for controlled dispensing and monitoring requirements

inv-217: clozapine tabs — QL

Clozapine tab QLClozapine 25/50/100 mg — QL (90 tablets/30 days)

Higher-dose QL200 mg formulation — QL (120 tablets/30 days)

PA/ST noteSome clozapine entries include ST or other requirements

inv-218: clozapine 200 mg — QL

Clozapine 200 mg QLClozapine 200 mg — QL (120 tablets/30 days)

Liquid/suspension counterpartsVERSACLOZ suspension has separate mL QL (540 mls/30 days)

Dispensing controlHigher tablet-strength QL increased to support dosing patterns

inv-219: NUPLAZID — QL

NUPLAZID QLNUPLAZID (pimavanserin) — QL (30 capsules/30 days)

PA appliedEntry listed with PA and QL in formulary extract

Monthly tablet limitStandard 30/30 format for psychiatric agents

inv-220: olanzapine ODT — QL

Olanzapine ODT QLOlanzapine ODT — QL (30 tablets/30 days)

Olanzapine tablet QLOlanzapine 2.5–10 mg — QL (60 tablets/30 days)

Formulary noteDifferent formulations have distinct QLs

inv-221: olanzapine tabs — QL

Olanzapine tabs QLOlanzapine 2.5–10 mg — QL (60 tablets/30 days)

Dose-specific limitsHigher single-dose strengths may have lower or similar monthly limits

Prescriber implicationObserve tablet-specific QLs when authorizing refills

inv-222: quetiapine fumarate 150 mg — QL

Quetiapine 150 mg QLQuetiapine fumarate 150 mg — QL (30 tablets/30 days)

Range noteQuetiapine formulations show QLs ranging from 30 to 180 depending on strength/formulation

Step therapySome strengths marked with ST as well as QL

inv-223: quetiapine fumarate range — QL

Quetiapine QL rangeQuetiapine ER/IR strengths — QLs reported from 30 up to 180 tablets/30 days depending on strength

Formulation impactER vs IR formulations have differing QLs in the list

PA/STSome entries include ST flags in addition to QL

inv-224: REXULTI — QL

REXULTI QLREXULTI (brexpiprazole) — QL (30 tablets/30 days)

Standard antipsychotic QL30/30 commonly applied to many newer antipsychotics

Formulary noteListed with Drug Tier = P in extract

inv-225: risperidone oral solution — QL

Risperidone solution QLRisperidone oral solution — QL (480 mls/30 days)

Liquid formulation limitLarge mL-based monthly limit for oral solution presentations

Alternate formsODT and tablet presentations have distinct QLs

inv-226: VERSACLOZ — QL

VERSACLOZ QLVERSACLOZ (clozapine suspension 50 mg/ml) — QL (540 mls/30 days)

Large-volume suspensionmL-based QL for suspension formulation

ST flagEntry lists ST along with QL for monitoring/dispensing controls

inv-227: eszopiclone — QL

Eszopiclone QLEszopiclone (Lunesta) — QL (30 tablets/30 days)

Hypnotic standard30/30 commonly used for hypnotic agents

STSome hypnotics marked with ST as well as QL

Terminology and flags used in the formulary

inv-116: Specialty drugs definition

Specialty drugs definitionMedications for complex conditions that may be oral, topical or injectable; may require administration by a health care professional; provider-administered drugs are not covered under the pharmacy benefit

Where to find listFor a current list of specialty medications, visit MyPrime.com or bcbsok.com

Coverage nuanceSome drug classes may be excluded by some plans; check benefit materials or call the number on your ID card

inv-117: Tier designators explanation

Tier designators'p' = Preferred Generic; 'np' = Non-Preferred Generic; 'P' = Preferred Brand; 'NP' = Non-Preferred Brand; 'SP' marks specialty drugs in the Special Requirements column

Presentation conventionsGeneric drugs shown lower-case bold; brand drugs in ALL CAPS followed by generic name

Group-specific mark'+' indicates group-specific coverage — see benefit plan materials

inv-118: QL definition

QL definitionQuantity Limit — a restriction on the amount of medication dispensed within a defined period (e.g., 'QL (30 tablets/30 days)')

FormatExpressed as number of units per days (e.g., tablets/30 days, pens/28 days, mLs/30 days)

EnforcementClaims exceeding the QL may require documentation or be denied

inv-119: PA definition

PA definitionPrior Authorization — requirement to obtain approval before the payer will cover the medication

When indicatedPA is shown in the Special Requirements column next to applicable drugs

ConsequenceCoverage may be denied if PA is not submitted and approved

inv-120: SP definition

SP definitionSpecialty (SP) — designation indicating specialty pharmacy handling or management; products flagged 'SP' require dispensing via specialty pharmacy where indicated

Common useApplied to many high-cost injectables, biologics and complex therapies

PA pairingSP entries are frequently paired with PA and QL in the formulary

inv-121: QL (Quantity Limit) label

QL label usageQL indicates a quantity limit for the product (e.g., 'QL (30 tablets/30 days)')

PlacementShown in the Requirements/Limits column next to product entries

Unit typesCan reference tablets, capsules, pens, syringes, vials or mLs depending on formulation

inv-122: PA (Prior Authorization) label

PA label usagePA indicates prior authorization is required before coverage is approved

How displayedShown in the Requirements/Limits column adjacent to applicable drugs

Provider actionPrescribers must submit required authorization documentation per payer processes

inv-123: SP (Specialty Pharmacy/Step Therapy) label

SP label usageSP indicates Specialty Pharmacy — product is managed through specialty pharmacy channels and may require specialty dispensing

Common pairingSP commonly appears alongside PA and QL for biologics, oncology and rare-disease therapies

Where to verifySpecialty routing and dispensing instructions available via MyPrime.com or payer guidance

inv-124: Drug Tier label

Drug Tier labelDrug Tier values include p (Preferred Generic), np (Non-Preferred Generic), P (Preferred Brand), NP (Non-Preferred Brand)

Specialty tierPreferred Specialty drugs may be marked with p, np, or P and also marked 'SP' in Special Requirements column

Coverage detailTier determines member cost-share; see benefit plan materials for specifics

inv-125: PA (redundant label)

PA label (duplicate)PA: Prior Authorization — coverage requires approval before dispensing

Shown whereDisplayed in the Requirements/Limits column next to affected products

Denial riskAbsence of required PA may trigger claim denial

inv-126: QL (format examples)

QL format examplesFormats shown include 'QL (## tablets/# days)', 'QL (## pens/# days)', 'QL (### mls/# days)'

Examples in docE.g., QL (30 tablets/30 days); QL (1 pen/28 days); QL (100 mLs/30 days)

InterpretationNumber before slash = allowed units; denominator = time period in days

inv-127: SP (definition)

SP definition (duplicate)SP: Specialty Pharmacy — product managed through specialty pharmacy channels

UseApplied to biologics, complex injectables and high-cost therapies

PA associationOften paired with PA and QL flags

inv-128: PA (definition duplicate)

PA label (duplicate)Prior Authorization — approval required prior to payer coverage

Provider actionSubmit PA documentation per payer instructions

EnforcementClaims may be denied without approval

inv-129: QL (definition duplicate)

QL definition (duplicate)Quantity Limit — maximum quantity allowed in specified time frame (e.g., QL (30 tablets/30 days))

DisplayedAppears in the Requirements/Limits column next to products requiring limits

Claims handlingClaims exceeding QL may be denied or require additional documentation

inv-130: AC administrative coverage flag

AC definitionAC — Administrative Coverage flag; indicates administrative control or access condition (used for many vaccines and some contraceptives)

Typical useApplied to preventive vaccines and certain contraceptives in the list

DocumentationMay require administrative documentation or benefit-specific handling

Initial authorization and therapy entry conditions

Initial therapy PA/QL

Initial authorization requirements where indicated

PA/QL for initial therapy: Certain GLP‑1, GIP/GLP‑1 and related agents include prior authorization and defined quantity limits for initiation (examples in the list: MOUNJARO — PA, QL; OZEMPIC — PA, QL 1 pen/28 days; RYBELSUS — PA, QL), noting that specific clinical criteria for PA are not detailed in this extract.

See product entry and PA policy for required documentation.

Continuation and maintenance criteria

Insulin continuation limits

Continuation/maintenance limits for insulin products

Insulin refill/continuation limits: Many insulin products are listed with a quantity limit of QL (100 mLs/30 days) for continuation or ongoing supply. Prescribers and pharmacies should adhere to the 100 mLs/30 days dispensing limit unless prior authorization specifies otherwise.100 mLs/30 days

Applies across multiple rapid‑acting and basal insulin brands in the Drug List.

Step therapy flags and tables

Drug/Agent	Step Therapy / Special Requirement
EPCLUSA (sofosbuvir-velpatasvir)	Requirements/Limits = PA, QL (28 tablets/28 days), SP — step/specialty indication present (SP) per formulary
PEGASYS (peginterferon alfa-2a)	Requirements/Limits = PA, SP — specialty/step indication present
MAVYRET (glecaprevir-pibrentasvir)	Requirements/Limits = PA, QL (90 tablets/30 days), SP — specialty designation noted

Drug/Agent	PA / SP / Step Therapy Notes
Abiraterone acetate (Zytiga)	Requirements/Limits = PA, QL (120 or 60 tablets/30 days), SP — prior authorization and specialty routing shown
AYVAKIT (avapritinib)	Requirements/Limits = PA, QL (30 tablets/30 days), SP — PA and specialty designation present
BOSULIF (bosutinib)	Requirements/Limits = PA, QL (30–150 capsules/30 days), SP — PA and SP indicated

Observation	Details
Explicit step sequences	No explicit step-therapy sequences or required prior step failures are provided in the excerpt; entries show PA, QL, SP flags only
Implication for providers	Step therapy may be indicated by ST or SP markers, but specific required prior agents and failure criteria are not listed in the document excerpts

Entry type	Formulary flags present
Selected specialty/oncology entries	Many entries include 'SP' (specialty) and frequently require 'PA' prior to coverage; explicit step order not described
General observation	PA is frequently required before coverage; SP indicates specialty channel — step edits implied but not detailed

Product / Class	Administrative or Step Flags
ANNOVERA (contraceptive ring)	Requirements/Limits = AC, QL (1 ring/365 days) — AC indicates administrative control that may reflect administrative/step edits
Various oral contraceptives (e.g., desogestrel-ethinyl estradiol)	Requirements/Limits = AC, QL (28 tablets/21 days) — administrative coverage flags present; some entries include PA

Observation	Details
Step therapy specification	Step therapy is not specified for most products in the provided excerpt; only requirement flags (PA, QL, SP, AC) are shown

Product	Step Therapy Annotation
KERENDIA (finerenone) 10 mg, 20 mg	Requirements/Limits = QL (30 tablets/30 days), ST — 'ST' annotation indicates step therapy requirement

Observation	Source note
Step therapy detail	Step therapy protocols are not detailed in the excerpt; entries show PA and QL but do not enumerate required prior steps

Drug/Agent	Authorization prior to coverage
Ivabradine (Corlanor)	Requirements/Limits = PA, QL (60 tablets/30 days) — prior authorization required before coverage
OPSUMIT (macitentan)	Requirements/Limits = PA, QL (30 tablets/30 days), SP — PA required prior to coverage; specialty routing noted
ORENITRAM (treprostinil diolamine)	Requirements/Limits = PA, QL (300 tablets/30 days), SP — PA required prior to coverage

Observation	Notes
Step therapy protocols	Step therapy protocols and explicit sequences are not detailed in these excerpts; the formulary flags utilization controls but does not list step order

Observation	Support from source
Explicit sequences absent	No explicit step therapy sequences are listed; product lines show tier and requirements (PA, QL, SP) but not ordered steps

Observation	Implication
Specialty channel management	Some specialty agents are designated 'SP' and require specialty pharmacy dispensing; step edits are not described in the section

Product / Example	Step Therapy (ST) Flag
AUVELITY (dextromethorphan HBr–bupropion HCl)	Requirements/Limits = ST — product marked 'ST' in formulary indicating step therapy applies
DESVENLAFAXINE ER (extended-release)	Requirements/Limits = ST — step therapy flag specified for some antidepressant formulations
CITALOPRAM, ESCITALOPRAM, QUETIAPINE (selected strengths)	Some entries include 'ST' indicating step therapy applies to specific products/strengths as listed (e.g., escitalopram, quetiapine, citalopram)

Biosimilar references and insulin glargine notes

Billing Rule

Insulin glargine reference and biosimilars — QL 100 mLs/30 days

Reference and biosimilar insulin glargine presentations (including SEMGLEE) are listed with a QL of 100 mLs/30 days and tier P; providers must adhere to the QL when dispensing these formulations.

INSULIN GLARGINE-YFGN and SEMGLEE — Requirements/Limits = QL (100 mLs/30 days), Drug Tier = P ([[chunk 143]])

Background and scope

Specialty drugs are medications used to treat complex conditions (for example, hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis) and may be self‑administered or require administration by a health care professional. The Drug List distinguishes specialty products and, where applicable, indicates specialty pharmacy (SP) routing, prior authorization (PA), and quantity limits (QL) that must be followed for coverage.