2026 Drug List (Pharmacy formulary) — Coverage Criteria

Prior authorization may be required

Prior authorization may be required for certain drugs; such requirements are noted with 'PA' in the Special Requirements column and providers must submit a prior authorization request for coverage when PA is indicated.

• PA is shown in the Special Requirements column for drugs that require pre-approval.
• Submit prior authorization per payer process before dispensing to avoid denial.

PA required for selected products (e.g., ARIKAYCE, posaconazole, EPCLUSA)

Certain products are designated 'PA' in the drug list (examples shown include ARIKAYCE, posaconazole formulations, and EPCLUSA) — providers must obtain prior authorization for these items as indicated.

• ARIKAYCE — Requirements/Limits = PA, QL (28 vials/28 days), SP.
• NOXAFIL (posaconazole) delayed-release and suspension formulations — Requirements/Limits = PA.
• EPCLUSA (sofosbuvir-velpatasvir) — Requirements/Limits = PA, QL (28 tablets/28 days), SP.

PA required for select antivirals (HCV and other high-cost agents)

High-cost antivirals and hepatitis C agents are marked 'PA' and require prior authorization (examples: EPCLUSA, HARVONI, MAVYRET); submit PA documentation consistent with the antiviral regimen.

• EPCLUSA — PA, QL (28 tablets/28 days), SP.
• HARVONI — PA, QL (28 tablets/28 days), SP.
• MAVYRET — PA, QL (90 tablets/30 days), SP.

Prior authorization required for numerous listed drugs

Many drugs listed across the formulary carry a 'PA' designation; providers must obtain prior authorization for those products before coverage will be approved.

• Numerous oncology, specialty, and other high-cost agents show PA in Requirements/Limits.
• Claims may be denied if PA is not obtained when required.

PA generally required where indicated

Numerous agents throughout this segment require prior authorization as indicated next to each product entry; providers must submit PA per payer procedures to secure coverage.

• PA appears repeatedly for specialty oncology, pulmonary, and cardiovascular agents.
• Follow payer PA submission process to avoid coverage denial.

PA required for select testosterone, contraceptive and specialty oral agents

Certain testosterone products, some contraceptives, and specialty oral agents are marked 'PA' — prior authorization must be obtained for coverage of these formulations.

• Testosterone enanthate and topical gels — Requirements/Limits include PA and QL.
• Some contraceptives show 'AC' and PA flags; follow listed requirements.

PA required for specific agents (e.g., Riomet, ER metformin)

Specific agents such as Riomet oral solution and certain extended‑release metformin products are labeled with 'PA' and 'QL' — providers must submit prior authorization and adhere to the stated quantity limits.

• Riomet (metformin oral solution 500 mg/5 ml) — Requirements/Limits = PA, QL (780 mls/30 days).
• Metformin ER/modified‑release formulations — some entries require PA and list QL values.

PA plus quantity limits for specialty cardiovascular/pulmonary agents

Specialty or high-cost cardiovascular and pulmonary agents frequently carry both PA and QL flags; providers must obtain prior authorization and ensure quantities do not exceed the listed limits.

• Examples include REPATHA (PA, QL 6 syringes/28 days) and CAMZYOS (PA, QL 30 capsules/30 days).
• TYVASO and UPTRAVI are PA and have explicit QL values for dispensing.

PA required for TYVASO, UPTRAVI, NUCALA and similar agents

Several drugs (e.g., TYVASO, UPTRAVI, NUCALA and other specialty biologics) are marked 'PA' and require prior authorization before coverage; check the product line for QL and SP designations.

• TYVASO — Requirements/Limits = PA, QL (81.2 mls/28 days), SP.
• UPTRAVI — Requirements/Limits = PA, QL (60 tablets/30 days), SP.
• NUCALA — Requirements/Limits = PA, QL (1 syringe/28 days or 3 pens/28 days), SP.

PA required for listed specialty/high‑cost drugs

Many specialty biologics and high‑cost modulators are designated 'PA' — providers must submit prior authorization documentation for these agents before coverage is approved.

• Examples: NUCALA, TEZSPIRE, XOLAIR, ALYFTREK, KALYDECO, ORKAMBI, TRIKAFTA are listed with PA (and often QL/SP).
• Specialty agents may also require specialty pharmacy dispensing (SP).

PA required for select specialty drugs (e.g., BYLVAY, GATTEX, ENTYVIO PEN, TREMFYA, FILSPARI, PROCYSBI)

Selected specialty therapies such as BYLVAY, GATTEX, ENTYVIO PEN, TREMFYA, FILSPARI and PROCYSBI are marked 'PA' indicating prior authorization is required for coverage of these products.

• ENTYVIO PEN — Requirements/Limits = PA, QL (2 pens/28 days), SP.
• GATTEX — Requirements/Limits = PA, SP.
• PROCYSBI — Requirements/Limits = PA, SP.

PA required for NUPLAZID and tasimelteon examples

Certain products such as NUPLAZID and tasimelteon (Hetlioz) are listed with 'PA' and require prior authorization; follow the listed Requirements/Limits for coverage.

• NUPLAZID — Requirements/Limits = PA, QL (30 capsules/30 days).
• tasimelteon (Hetlioz) — Requirements/Limits = PA, QL (30 capsules/30 days), SP.

Step therapy (ST) may be required when noted

Step therapy may be required for some products and is denoted with 'ST' in the Special Requirements column; members may need to try designated preferred alternatives prior to coverage of the listed product.

• If 'ST' is shown next to a product (e.g., AUVELITY, certain antidepressants/antipsychotics), document prior trials and failures per plan rules.
• ST notation indicates a fail‑first requirement before the targeted drug is covered.

Utilization controls present; step sequencing not detailed here

The document lists utilization controls (PA, QL, SP) but does not specify full step therapy sequencing for many agents in this excerpt; verify step‑sequence requirements with the payer when 'ST' is not shown but PA/QL/SP apply.

• Where 'ST' is not present, primary controls shown are PA, QL and SP.
• Contact the payer or refer to plan materials for any detailed step therapy algorithms.

Step therapy not specified in this segment; PA/QL/SP flags prevail

In this section PA, QL and SP flags are the primary utilization controls shown; explicit step therapy sequences are not provided for the majority of listed drugs in these chunks.

• When step therapy is not specified, follow PA and QL requirements and confirm ST rules with the plan if needed.
• PA and QL entries should be followed as listed to obtain coverage.

Administrative condition (AC) shown for some contraceptives

Some contraceptive entries are labeled 'AC' (administrative condition) and also include quantity limits; these administrative flags may indicate coverage constraints such as formulary substitutions or other administrative requirements.

• ANNOVERA and many combined oral contraceptives show 'AC' with QL values (e.g., 1 ring/365 days; 28 tablets/21 days).
• Verify administrative coverage conditions and any required documentation when 'AC' is present.

Step therapy algorithms not included in this section

No explicit fail‑first (step therapy) algorithms are provided in these chunks; where 'ST' is absent, access is controlled primarily by PA, QL, and SP notations.

• Confirm step therapy requirements with the plan for products where benefit rules are unclear.
• If 'ST' appears for a product, document prior therapy failures per plan requirements.

Step therapy absent for many specialty entries; rely on PA/QL/SP

Products in this portion are largely managed by PA, SP and QL flags; explicit step therapy sequences are absent for these entries and should be confirmed with the payer if required.

• Specialty products often require PA and have QL; step sequencing is not defined here.
• Follow PA/QL/SP controls and request clarification on ST from the plan when needed.

Step therapy not specified for listed drugs in this part

This portion of the drug list does not include explicit step therapy sequences for the majority of listed drugs; providers should adhere to PA and QL notations and check plan guidance for ST rules.

• UPTRAVI and similar products show PA/QL/SP but no ST sequence in this excerpt.
• If ST is required for a product, it will be marked 'ST' in the Special Requirements column.

No step therapy algorithm provided in this excerpt

No explicit step therapy algorithm text is present in these chunks; providers must follow the product flags (PA, QL, SP) and consult payer materials for any step‑based requirements.

• Formulary entries note PA/QL/SP but do not supply step sequences here.
• Request plan guidance when prior trials are required for coverage.

ST noted for some products (e.g., AUVELITY) — document prior failures

Some agents are shown with 'ST' notation (for example AUVELITY) — providers must document failure or intolerance to required prior agents per the plan's step therapy rules when submitting requests.

• AUVELITY — Requirements/Limits = ST.
• When ST applies, include documentation of prior therapy trials and reasons for discontinuation or intolerance.

Step therapy products (ST) require documented prior therapy failure/intolerance

Products marked 'ST' require demonstration of failure or intolerance to the designated prior agent(s) before coverage; include supporting documentation with the request.

• Document dates, medications tried, doses, durations, and reason for discontinuation.
• Submit ST exception documentation if the member cannot try required agents due to contraindication.

Exception request process and decision timelines

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

• Standard exception decision timeline: 15 calendar days.
• Expedited (urgent) review timeline: 72 calendar hours.

Adhere to stated quantity limits (QL); document accordingly

Some products list explicit quantity limits (QL) — dispense within the stated limits and ensure documentation supports the requested quantity when submitting prior authorization.

• EPCLUSA — QL (28 tablets/28 days).
• Examples of QL across the list (e.g., ARIKAYCE QL 28 vials/28 days).

Documentation expectations for PA drugs (indication and quantity)

When PA is indicated, prescribers must document the clinical indication and the quantity consistent with the regimen requested; antiviral/HCV regimens require documentation supporting the specific regimen and pack sizes.

• For HCV agents (EPCLUSA, HARVONI, MAVYRET), include diagnosis and regimen details and match quantity to QL (e.g., 28‑day packs).
• Attach relevant lab results or specialist notes when applicable.

Provide documentation for PA and QL when both apply

When products carry both 'PA' and 'QL' flags, submit prior authorization documentation or adhere to the specified quantity limits; documentation should justify the requested quantity relative to the QL.

• If requesting above the QL, include clinical rationale and supporting records.
• Follow payer guidance for PA submission to avoid claim denial.

Document quantity and specialty pharmacy requirements with PA

For products flagged 'QL' or 'SP', prescribers should supply documentation supporting the prescribed quantity and the intended dispensing site (specialty pharmacy) when submitting a PA.

• SP designation often indicates specialty pharmacy dispensing or limited distribution.
• Include site‑of‑care or dispensing channel details when required.

Submit PA per payer process and follow QL rules

Submit prior authorization per the payer's process for products labeled 'PA'; where quantity limits (QL) are listed, adhere to those limits when submitting claims or provide supporting documentation if requesting above the limit.

• Follow payer PA submission procedures to obtain coverage approval.
• Claims exceeding QL may be denied unless supported by approved PA or exception.

When 'PA' or 'QL' is shown, submit PA or adhere to QL

Providers must submit prior authorization documentation or otherwise follow quantity limits for products labeled with 'PA' or 'QL' in the Requirements/Limits field; failure to do so may result in claim denial.

• Examples: Riomet requires PA and QL (780 mls/30 days); MOUNJARO and OZEMPIC have PA and pen/period QLs.
• Include clinical justification, prior therapy history, and requested quantity details in PA submissions.

QBRELIS requires PA and QL (2400 mL/30 days)

QBRELIS (lisinopril oral solution) is listed with Requirements/Limits = PA and a quantity limit of 2400 mL per 30 days; prior authorization and adherence to this QL are required for coverage.

• QBRELIS — PA, QL (2400 mls/30 days).
• Ensure PA documentation specifies the formulation and required volume.

UPTRAVI requires PA and QL; titration pack limited

UPTRAVI (selexipag) requires prior authorization and has a quantity limit of 60 tablets per 30 days; the UPTRAVI titration pack is limited to 1 pack per 180 days — include these limits when requesting authorization.

• UPTRAVI — PA, QL (60 tablets/30 days); titration pack QL (1 pack/180 days).
• Include titration plan and justification in PA documentation.

Documentation expectations for specialty biologic PA requests

Prescribers must supply documentation supporting PA requests for specialty biologics and other specialty agents marked with PA and SP (examples include NUCALA, TEZSPIRE, XOLAIR); include diagnosis and prior therapies as applicable.

• NUCALA — PA, QL (1 syringe/28 days or 3 pens/28 days depending on presentation).
• TEZSPIRE — PA, QL (1 pen/28 days), SP.
• Include relevant specialty documentation (e.g., specialist notes, prior biologic trials).

Follow quantity limits (QL) when submitting requests/claims

Adhere to the specified quantity limits when submitting prior authorization or claims; many products have explicit QL values (for example CF modulators and other specialty agents) that must be followed.

• ALYFTREK — QL 84 tablets/28 days or 56 tablets/28 days depending on strength.
• KALYDECO — QL 60 tablets/30 days; TRIKAFTA/SYMDEKO have packet/tablet QLs as listed.

Supply diagnosis and prior therapy documentation to support PA

When submitting prior authorization requests, prescribers should include diagnosis, prior therapies, and other supporting records to substantiate the need for the requested drug when 'PA' is indicated.

• Provide relevant diagnostic information and documentation of prior medication trials and outcomes.
• Specialty agents frequently require more detailed clinical documentation.

Provide supporting documentation for ST or QL exceptions

If requesting an exception to a step therapy or quantity limit, expect to provide supporting documentation (e.g., contraindication, intolerance, prior treatment history) when the product is flagged 'ST' or 'QL'.

• ST exceptions require documentation of failure or intolerance to designated prior agents.
• QL exceptions should provide clinical rationale for exceeding the listed limit.

Triggers for denial: non‑formulary, non‑FDA, repackaged, missing PA/ST

Coverage may be denied if the drug is not on the drug list, is non‑FDA‑approved, is repackaged, or if prior authorization or step therapy requirements are not met; providers should verify coverage and submit required authorizations.

• Non‑FDA‑approved drugs and repackaged medications are not covered.
• Failure to obtain required PA or to meet ST requirements can result in denial.

Denial risk when PA/QL/SP controls not met

Pharmacy claims for products listed with 'PA', 'SP' or 'QL' may be denied if prior authorization is not obtained, if specialty distribution requirements are not met, or if quantity limits are exceeded.

• Examples include ARIKAYCE, KITABIS PAK, TOBRAMYCIN, EPCLUSA where PA/SP/QL are present.
• Ensure specialty dispensing (SP) requirements are followed to avoid denial.

PA triggers for select antiviral agents

Drugs listed with 'PA' (examples: EPCLUSA, HARVONI, MAVYRET, SOVALDI) require prior authorization prior to coverage; submit PA to avoid claim denials.

• EPCLUSA, HARVONI, MAVYRET, SOVALDI — all marked PA for hepatitis C treatment regimens.
• Provide relevant clinical documentation with PA submission.

Specialty (SP) designation may require specialty dispensing

Products labeled 'SP' indicate specialty pharmacy handling or limited distribution; claims may be denied if the medication is not processed through the appropriate specialty channel.

• Many HCV and specialty biologic products include 'SP' designation.
• Use the specialty pharmacy channel when required by the product line.

Denial risk if PA is not obtained when required

Coverage may be denied if prior authorization is not obtained when listed as a requirement for a medication; providers must obtain required PA to secure coverage.

• PA absence may result in claim denial or additional review.
• Check the Special Requirements column for PA flags prior to dispensing.

PA required for many listed drugs — risk of denial without PA

Many listed drugs require prior authorization; requests submitted without the required PA for 'PA'‑flagged products may be denied or delayed.

• Providers should confirm PA requirements before prescribing high‑cost or specialty agents.
• Use payer resources or call the number on the member ID card for PA submission guidance.

PA/AC/QL flagged products carry higher administrative review and denial risk

Products flagged with 'PA' or 'AC' and those exceeding QL may trigger denial if appropriate authorization or administrative conditions are not satisfied; adhere to listed controls and provide required documentation.

• AC flags on contraceptives indicate administrative constraints; follow plan rules.
• Exceeding QL without approved PA or exception may cause denial.

PA/QL triggers for specific formulations (Riomet, ER metformin, tirzepatide, semaglutide)

Requests for certain formulations (for example Riomet solution, ER metformin formulations, tirzepatide, semaglutide, dulaglutide) may be subject to PA or QL per the drug list; ensure PA and QL compliance to avoid denials.

• Riomet — PA, QL (780 mls/30 days).
• MOUNJARO, OZEMPIC, RYBELSUS — PA and specified pen/tablet QLs.

Prior authorization risk for specialty/SP agents

Specialty agents that are designated 'SP' and 'PA' are subject to coverage limits and may be denied without prior authorization and appropriate specialty handling; providers should submit required documentation and use specialty pharmacies when indicated.

• Examples: TYVASO, UPTRAVI, NUCALA — PA and SP designations with QL values.
• Failure to meet SP/PA/QL requirements can result in claim denial.

Noncompliance with PA/QL may result in denial (TYVASO, UPTRAVI examples)

Requests that do not meet PA or QL requirements for listed drugs (e.g., TYVASO, UPTRAVI) may be denied; providers should ensure PA approvals and adherence to QL prior to dispensing.

• TYVASO — PA, QL (81.2 mls/28 days), SP; UPTRAVI — PA, QL (60 tablets/30 days), SP.
• Obtain PA and follow QL to prevent denials.

PA required where indicated — obtain approval to avoid denial

Prior authorization is required for the drugs listed with 'PA' — absence of required PA risks coverage denial; confirm PA status on the product line before dispensing.

• PA is required for many specialty biologics and modulators in this segment.
• Submit PA per payer instructions to secure coverage.

PA required when shown — verify before dispensing

Prior authorization is required where indicated in the drug list; failure to obtain PA when shown may result in claim denial.

• Always check the Special Requirements column for PA before dispensing.
• Claims submitted without PA for PA‑flagged drugs risk denial.

Quantity limit exceedance may trigger denial (VOWST example)

Quantity limits are enforced per product; exceeding the listed QL (for example VOWST limited to 12 capsules/12 months) may trigger claim denial unless an approved exception or PA is in place.

• VOWST — QL 12 capsules/12 months; exceeding this may lead to denial.
• Request exception or PA with supporting documentation to exceed QL.

PA may be required for NUPLAZID and Hetlioz

Prior authorization may be required for products such as NUPLAZID and tasimelteon (Hetlioz) as noted on the formulary; providers should obtain PA and adhere to any QL to prevent denial.

• NUPLAZID — PA, QL (30 capsules/30 days).
• tasimelteon (Hetlioz) — PA, QL (30 capsules/30 days), SP.

QL examples for CNS agents; adhere to QL or provide documentation

Quantity limits for CNS and related agents are specified (examples include zuranolone and aripiprazole oral solution) — ensure dispensed quantities do not exceed the listed QL or provide supporting documentation with PA/exception requests.

• zuranolone — QL 28 or 14 capsules per 365 days depending on strength.
• aripiprazole oral solution — QL 900 mL/30 days.

Site‑of‑care: provider‑administered drugs may be medical benefit

Medications administered by a health care professional may be covered under the medical benefit rather than the pharmacy benefit; check site‑of‑care guidance for applicable agents.

• Drugs administered in outpatient infusion centers, offices, or hospitals may be billed to the medical benefit.
• Refer to plan/site‑of‑care rules to determine appropriate billing pathway.

Specialty pharmacy required for 'SP'‑flagged products

Products flagged 'SP' require specialty pharmacy dispensing; providers should arrange specialty fulfillment through the appropriate channel to ensure coverage.

• Many specialty biologics and high‑cost agents carry the 'SP' designation.
• Claims may be denied if SP requirements are not met.

Specialty distribution: use specialty pharmacy channels for SP items

Specialty agents designated 'SP' are expected to be dispensed through specialty pharmacy channels and may have limited/distribution requirements; ensure use of the correct specialty vendor when filling these products.

• ENTYVIO PEN, TRIKAFTA, many biologics and modulators include SP designation and QL values.
• Confirm specialty distribution requirements and route orders accordingly.