Prior authorization requirement

Some medications listed on the Drug List require prior authorization (PA); when PA is commonly required the entry will show 'PA' in the Special Requirements column and the prescriber must submit a prior authorization request for approval before coverage is granted.

• PA flag next to product indicates authorization is required prior to coverage.
• Refer to benefit plan materials for plan‑specific PA requirements.

Prior authorization required

Certain high‑cost or specialty agents are subject to prior authorization as indicated by 'PA' in the Requirements/Limits column (examples include ARIKAYCE, EPCLUSA and other listed inhaled antibiotics/antivirals).

• Examples in the list: ARIKAYCE and selected inhaled antibiotics have PA noted.
• PA is shown in Requirements/Limits for several antiviral products (see antiviral sections).

PA required for selected antiviral agents

Prior authorization (PA) is required for specified antiviral agents when 'PA' is listed (examples in the Drug List include HARVONI, MAVYRET, SOVALDI and VOSEVI).

• HARVONI — Requirements/Limits = PA, QL (28 tablets/28 days), SP.
• MAVYRET — Requirements/Limits = PA, QL (90 tablets/30 days), SP.
• SOVALDI/VOSEVI entries are listed with PA where indicated.

Prior authorization requirement

When submitting PA requests, ensure the request reflects any listed Quantity Limits (QL) and Specialty Pharmacy (SP) routing indicated on the Drug List entry; PA requests should match the Requirements/Limits shown for that formulation.

• Include the exact quantity/timeframe per the QL (e.g., 28 packs/28 days) in the PA request.
• Route to specialty pharmacy when the entry includes 'SP' to avoid processing delays.

Prior authorization required

Many specialty and oncology products on the Drug List require prior authorization and are subject to specified quantity limits and specialty pharmacy routing when indicated.

• Oncology entries commonly show 'PA, QL, SP' and require PA prior to dispensing.
• Follow the Requirements/Limits field on each product line for required documentation and routing.

Selected products require PA

Selected branded and specialty products are listed with 'PA' and must have a prior authorization in place before coverage (examples include MYFEMBREE, ORIAHNN, MOUNJARO, OZEMPIC and RYBELSUS).

• MYFEMBREE — Requirements/Limits = PA, QL (30 tablets/30 days).
• ORIAHNN — Requirements/Limits = PA, QL (56 capsules/28 days).
• MOUNJARO / OZEMPIC / RYBELSUS entries show PA and QL per formulation.

Prior authorization requirement

Many products across the Drug List are designated with PA, QL and/or SP; providers must obtain PA where specified and adhere to any QL/SP routing shown on the product line.

• Examples show PA with QL and SP flags — follow each product’s Requirements/Limits.
• PA approval and adherence to QL/SP are prerequisites for coverage of many specialty agents.

PA and QL: enalapril oral solution

Enalapril maleate oral solution (Epaned) is listed with 'PA, QL' and a quantity limit of 1200 mL per 30 days; prescribers must submit PA and request quantities consistent with QL.

• Epaned — Requirements/Limits = PA, QL (1200 mls/30 days).
• PA request should document indication and the quantity requested matching the 1200 mL/30‑day limit.

PA and QL: FUROSCIX

FUROSCIX (furosemide subcutaneous cartridge kit 80 mg/10 mL) is listed with 'PA, QL' and a limit of 8 kits per 180 days; obtain PA and document the requested number of kits within the 8‑kit/180‑day limit.

• FUROSCIX — Requirements/Limits = PA, QL (8 kits/180 days).
• Prescribe and request only the QL amount unless PA justification for excess is provided.

PA and QL: bempedoic acid products

Bempedoic acid products NEXLETOL and NEXLIZET are listed with 'PA, QL' and a quantity limit of 30 tablets per 30 days; prior authorization must be obtained and quantities requested must not exceed 30 tablets/30 days.

• NEXLETOL — Requirements/Limits = PA, QL (30 tablets/30 days).
• NEXLIZET — Requirements/Limits = PA, QL (30 tablets/30 days).

PA and QL: evolocumab products

REPATHA (evolocumab) products require prior authorization and are limited to 6 syringes/28 days for prefilled syringes or 6 pens/28 days for auto‑injectors; obtain PA and request quantities consistent with these QLs.

• REPATHA prefilled syringe — Requirements/Limits = PA, QL (6 syringes/28 days).
• REPATHA SURECLICK auto‑injector — Requirements/Limits = PA, QL (6 pens/28 days).

Prior authorization required for selected specialty drugs

Many specialty agents (for example REPATHA, ENTRESTO, TYVASO, FASENRA PEN) are shown with 'PA' and may also carry QL/SP requirements; providers must secure PA before dispensing and adhere to listed quantity limits and specialty routing.

• ENTRESTO — Requirements/Limits = PA, QL (240 capsules/30 days).
• TYVASO — Requirements/Limits = PA, QL and SP as listed for cartridge kits and refill kits.
• FASENRA PEN — Requirements/Limits = PA, QL (1 pen/28 days).

Prior authorization required

Provider must obtain prior authorization before dispensing for drug entries marked 'PA' — claims submitted without required PA may be denied.

• Verify 'PA' indicator in the Requirements/Limits field before dispensing.
• If PA is required and not obtained, coverage may be denied at claim adjudication.

PA + QL on injectables

Some injectable autoinjector/pen formulations require prior authorization and have quantity limits tied to specific timeframes; include that QL information when submitting the PA to ensure requests match the listed limits.

• OMVOH — Requirements/Limits = PA, QL (1–2 pens or syringes/28 days depending on formulation).
• ZYMFENTRA — Requirements/Limits = PA, QL (2 pens/28 days) and SP.

Prior authorization / specialty channel required

Certain products are identified with PA and/or SP flags requiring prior authorization and/or specialty pharmacy channel dispensing (examples include tasimelteon and versacloz entries); route and authorize per the entry to avoid denial.

• HETLIOZ LQ (tasimelteon oral susp) — Requirements/Limits = PA, QL (158 mls/30 days), SP.
• VERSACLOZ (clozapine suspension) — Requirements/Limits = QL (540 mls/30 days), ST and SP noted where applicable.

Prior authorization: select agents

Weight‑management and other specialty agents are marked 'PA' indicating prior authorization is required before coverage (examples: Saxenda, Wegovy, Zepbound).

• Saxenda — Requirements/Limits = PA, QL (15 mls/30 days).
• Wegovy — Requirements/Limits = PA, QL (8 pens/180 days or 4 pens/28 days depending on formulation).
• Zepbound — Requirements/Limits = PA, QL (4 pens/180 days).

Step therapy usage note

Some plans use step therapy (ST); when present the Drug List will show 'ST' in Special Requirements and members may need to try specified prior therapies before coverage for the listed product is available.

• ST flag indicates step therapy requirement; check the plan’s step protocol.
• AUVELITY and other branded agents in the list show 'ST' where step therapy applies.

Step or utilization signals

Quantity limits (QL) and tiering (P/NP) on product entries can signal possible step therapy or other utilization management; providers should review the Requirements/Limits field and follow any ST, PA or QL instructions when prescribing.

• Entries with QL and/or higher tier may be subject to utilization management or step edits.
• If 'ST' appears next to the product, prior trials are required before coverage.

PROVIDER ACTIONS

Some product lines and entries include 'PA' and may be used to enforce step edits; providers must follow the Requirements/Limits shown on each product line when requesting coverage.

• PA entries often accompany ST or other utilization controls.
• Specific step sequences are detailed in plan materials when applicable.

Prior authorization requirement

Prior authorization is required for many oncology and specialty medications; ensure PA requests include the specified QL and SP routing where indicated to meet dispensing requirements.

• Oncology products frequently require PA, have QLs (e.g., 1 kit/28 days) and require SP routing.
• Include pack/kit details in PA requests to match the product listing.

Access classification noted

Some contraceptive entries include an Access Classification (AC) code alongside QL; providers should follow the AC/QL guidance on the product line and consult plan materials for operational interpretation.

• ANNOVERA — Requirements/Limits = AC, QL (1 ring/365 days).
• Many oral contraceptives show AC with QL (28 tablets/21 days).

Step therapy presence

Some listed products indicate step therapy ('ST') as a requirement (example: KERENDIA shows 'ST'); prescribers must follow step therapy protocols where noted.

• KERENDIA — Requirements/Limits include QL (30 tablets/30 days) and ST.
• Confirm required prior treatments per the plan’s step therapy policy before prescribing.

Specialty program/step indicator for lomitapide

JUXTAPID (lomitapide) is designated 'SP' which suggests specialty program or step restrictions may apply; obtain PA and follow specialty program routing if required.

• JUXTAPID — Requirements/Limits = SP; check plan for specialty program requirements.
• Specialty routing may be required for dispensing and PA.

Step therapy example

AUVELITY is listed with 'ST' (step therapy) — prescribers must meet the formulary step requirements before coverage will be approved.

• AUVELITY — Requirements/Limits = ST.
• Document prior therapy trials or exceptions when submitting PA or exceptions.

Step therapy applies to selected branded agents

Step therapy applies to several branded agents marked 'ST' (examples include FETZIMA, TRINTELLIX, FANAPT, RISPERIDONE ODT, SECUADO, VERSACLOZ); providers must document prior required therapies or provide justification when requesting coverage.

• FETZIMA and TRINTELLIX entries include 'ST' requiring prior steps.
• FANAPT titration packs and RISPERIDONE ODT include 'ST' where applicable.

Step therapy present

Some products are marked 'ST' indicating step therapy applies (for example Gralise and HORIZANT); follow the step therapy sequence before requesting coverage for the listed product.

• Gralise and HORIZANT entries show QL and ST flags.
• Provide documentation of prior trials when requesting PA or exception.

Providers or members may request a Drug List exception

Providers or members may request a Drug List exception by calling the phone number on the member ID card; BCBSOK will notify the decision within 15 calendar days (72 hours expedited if life/health jeopardy is claimed).

• Standard exception decision timeframe = 15 calendar days.
• Expedited review timeframe = 72 calendar hours when applicable.

Documentation for PA/SP

When PA or SP is indicated, supporting documentation is typically required with the prior authorization request — commonly needed items include diagnosis, prior therapies tried, and prescriber specialty.

• Include clinical rationale and prior treatment history when submitting PA.
• Prescriber specialty may be required for certain specialty agents.

Prior authorization required for select agents

Prior authorization is required for select high‑cost agents (notably hepatitis C medications such as HARVONI, MAVYRET, SOVALDI, VOSEVI); submit PA with clinical documentation per the Requirements/Limits field.

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

Documentation for PA/QL products

When a product is listed with 'PA, QL' the provider must submit a prior authorization request and documentation supporting the requested quantity (examples include enalapril oral solution, FUROSCIX, NEXLETOL/NEXLIZET, and REPATHA).

• Include indication and quantity justification matching the QL when requesting PA.
• PA requests that do not align with QL or lack supporting clinical evidence may be denied.

PA plus QL examples

Products listed with both PA and QL require adherence to both controls; for example REPATHA requires PA and is limited to 6 syringes/28 days (or 6 pens/28 days for the auto‑injector).

• REPATHA prefilled syringe — PA, QL (6 syringes/28 days).
• Ensure the PA request specifies the intended formulation and requested quantity consistent with the QL.

PA documentation

Providers should supply clinical information to support PA requests per the drug‑specific requirements shown on drug list entries; include diagnosis, prior therapy trials, and relevant clinical notes.

• Follow the Requirements/Limits field on the product line for specific documentation needs.
• Incomplete PA documentation may delay or result in denial of coverage.

Support for step therapy / prior authorization

When products are marked 'ST' (step therapy) or 'PA', documentation of prior steps or clinical justification is expected when submitting a PA or exception; provide evidence of treatment failure or intolerance to required prior agents.

• For ST entries, document trials of required prior agents and reasons for failure/intolerance.
• Provide clear clinical rationale if requesting an exception to step therapy.

Quantity limit adherence

Quantity limits (QL) listed for many products (e.g., Wegovy, Saxenda, Zepbound) must be adhered to when submitting claims; claims exceeding QL may be denied or require PA justification.

• Wegovy — Requirements/Limits = PA, QL (8 pens/180 days or 4 pens/28 days depending on formulation).
• Saxenda — Requirements/Limits = PA, QL (15 mls/30 days).

Coverage may be denied if drugs are not

Coverage may be denied if a drug is not on the Drug List, is not FDA‑approved, is repackaged, or otherwise excluded by the member’s plan; verify the product appears on the Drug List and meets plan rules prior to dispensing.

• Repackaged and non‑FDA approved drugs are not covered per the Coverage considerations section.
• Confirm eligibility and formulary status before prescribing or dispensing.

Prior authorization triggers

Products listed with 'PA' will trigger a prior authorization requirement at point of dispensing; examples in the Drug List include ARIKAYCE, KITABIS PAK, tobramycin nebulizer solutions, and multiple antiviral agents.

• Check each product line for 'PA' to avoid dispensing without required authorization.
• Examples: ARIKAYCE and several antiviral/inhaled antibiotic entries show PA in Requirements/Limits.

Specialty pharmacy routing

Products marked 'SP' indicate specialty pharmacy distribution; failing to route a specialty product through the specialty channel may result in claim denial or processing delays.

• When 'SP' appears in Requirements/Limits, dispense via the specialty pharmacy channel.
• Examples: tobramycin nebulizer solutions and many biologics have SP flags.

Quantity limits enforcement

Claims may be denied or limited if dispensing exceeds listed Quantity Limits (QL); providers must request quantities that conform to the QL or support overrides with PA documentation.

• Example QL enforcement: aripiprazole oral solution QL 900 mL/30 days; many tablet QLs (30/30, 60/30) are enforced.
• Requests for quantities above QL require PA with clinical justification.

PA and QL enforcement

Claims for listed drugs that do not meet PA requirements or exceed specified quantity limits may be denied; confirm PA and QL compliance prior to claim submission to avoid denial risk.

• Ensure PA approval is active and the dispensed quantity is within the QL before submitting a claim.
• If specialty pharmacy routing (SP) is required, ensure dispensing is through the specialty channel.

Prior authorization required for listed drugs

Coverage entries list 'PA' as a requirement for many drugs; failure to obtain required prior authorization may result in denial of coverage at claim adjudication.

• Review the Requirements/Limits field for 'PA' before dispensing.
• Obtain PA prior to dispensing to avoid potential denials.

Prior authorization required

Products shown with 'PA' require prior authorization before coverage (examples include MYFEMBREE and ORIAHNN); submit PA with supporting clinical documentation per the listing.

• MYFEMBREE — PA, QL (30 tablets/30 days).
• ORIAHNN — PA, QL (56 capsules/28 days).

Specialty diabetes agents PA

GLP‑1/GLP/GIP agents including MOUNJARO, OZEMPIC and RYBELSUS carry PA requirements and quantity limits; absence of PA may result in denial for these specialty diabetes agents.

• MOUNJARO — Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on strength).
• OZEMPIC — Requirements/Limits = PA, QL (1 pen/28 days).
• RYBELSUS — Requirements/Limits = PA, QL (30 tablets/30 or 180 days depending on strength).

PA/Denial risk

Requests for specialty drugs shown with 'PA' where PA is specified may be denied if PA is not obtained; verify PA is approved before dispensing to mitigate denial risk.

• Many specialty drug entries show PA and SP together; lack of PA may lead to coverage denial.
• Confirm approval and specialty routing as required by the product line.

Prior authorization required for certain oral solutions

Some oral solutions are listed with 'PA, QL' (for example enalapril oral solution requires PA and has a QL of 1200 mL/30 days); submit PA and document the requested quantity consistent with the QL to avoid denial.

• Epaned (enalapril oral solution) — PA, QL (1200 mls/30 days).
• Document indication and quantity to match the QL in the PA submission.

PA and quantity limit for FUROSCIX

FUROSCIX is listed with 'PA, QL (8 kits/180 days)'; lack of PA or dispensing beyond the 8‑kit/180‑day limit may result in denial.

• FUROSCIX — Requirements/Limits = PA, QL (8 kits/180 days).
• Obtain PA and order only within the specified QL unless a documented medical justification is provided.

PA and QL for bempedoic acid products

NEXLETOL and NEXLIZET are listed with 'PA, QL (30 tablets/30 days)'; absence of prior authorization or requests exceeding 30 tablets/30 days may lead to denial.

• NEXLETOL / NEXLIZET — Requirements/Limits = PA, QL (30 tablets/30 days).
• PA requests should specify and justify the quantity in line with the QL.

PA and QL for PCSK9 inhibitors

REPATHA products are listed with 'PA, QL (6 syringes/28 days or 6 pens/28 days)'; lack of PA may cause claim denial and quantities exceeding the QL may be denied.

• REPATHA prefilled syringe — PA, QL (6 syringes/28 days).
• REPATHA SURECLICK auto‑injector — PA, QL (6 pens/28 days).

Prior authorization and quantity limits enforceability

Requests for products listed with 'PA' or requests exceeding specified QLs may be denied without authorization or if the requested quantity exceeds the stated limit; confirm PA and QL compliance before dispensing.

• Absent PA or quantities outside the QL are grounds for denial.
• Follow the Requirements/Limits field for each product to ensure compliance.

PA required drugs

Coverage may be denied if prior authorization is required but not obtained for drugs designated 'PA' (examples listed include BYLVAY, ENTYVIO PEN, GATTEX); obtain PA prior to dispensing for PA‑flagged drugs.

• Confirm PA status for BYLVAY, ENTYVIO PEN, GATTEX and similar PA‑flagged products before dispensing.
• Claims submitted without required PA may be denied.

Specialty pharmacy routing

Specialty pharmacy (SP) assigned drugs (for example CREON, CIMZIA, TREMFYA) may require dispensing through a specialty pharmacy; failure to route claims through the specialty channel may result in denial or processing issues.

• CIMZIA — Requirements/Limits = PA, QL (4 syringes/28 days); SP.
• TREMFYA — Requirements/Limits = PA, QL (1 syringe/28 days); SP.

Tasimelteon prior auth / specialty

Tasimelteon (Hetlioz) entries show both 'PA' and 'SP' (and an oral suspension line with PA, QL and SP); prior authorization and specialty pharmacy routing are required and lack of either may trigger coverage denial.

• HETLIOZ LQ (tasimelteon oral susp) — PA, QL (158 mls/30 days), SP.
• tasimelteon capsule (Hetlioz) — PA, QL (30 capsules/30 days), SP.

Quantity limit exceedance

Multiple antipsychotic and other agents have specified QLs (for example aripiprazole oral solution QL 900 mL/30 days; clozapine tablet QLs vary by strength); dispensing beyond these limits may result in denial or require override documentation.

• Aripiprazole oral solution — QL (900 mls/30 days).
• Clozapine ODT and tablet strengths — QLs range from 90–270 tablets/30 days depending on form/strength.
• Quetiapine formulations have QLs tied to strength and formulation.

Prior authorization required

Drugs listed with 'PA' require prior authorization; claims submitted without a required PA may be denied — confirm PA is in place prior to dispensing to avoid claim denials.

• Verify PA indicator on the Drug List before dispensing specialty or high‑cost agents.
• Obtain and document PA approvals to support claim payment.