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CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2026 Drug List — Pharmacy Coverage and Utilization Management

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This document is the 2026 pharmacy drug list for Blue Cross and Blue Shield of Oklahoma describing covered drugs, tier placement, special requirements (PA, ST, QL, ACA), and member/provider processes for coverage, prior authorization, and exceptions. It affects BCBSOK members and their prescribing providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List — Pharmacy Coverage and Utilization Management

Policy CodePolicy N/A

Change TypeAnnual drug list publication (no material changes)

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line item lists 'PA' before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120distinct product entries (excerpt)

multipleentries with Prior Authorization

severalentries with Quantity Limits

6member payment tiers referenced

MyPrime / bcbsokwebsites for current list

Coverage Criteria

General pharmacy coverage

Coverage is determined by drug list inclusion, tier, and applicable special requirements.

General coverage conditions: Drug must be listed on the BCBSOK Drug List or be subject to an approved Drug List exception; coverage may be limited to FDA‑approved labeling and recognized evidence‑based or clinical practice guidelines; some drugs or formulations (repackaged, non‑FDA, OTC equivalents, certain compounded medications) may be excluded by the plan or limited by member age or benefit design.

See Drug List and benefit plan materials for up‑to‑date coverage status and exception process (MyPrime.com / bcbsok.com).

Coverage controlled by per-drug PA/QL/SP requirements

Coverage and access are controlled by listed requirements/limits for each drug entry.

Per‑drug utilization controls: Each drug entry includes a Drug Tier and, where applicable, one or more Requirements/Limits flags such as PA (prior authorization), QL (quantity limits with exact quantities and timeframes), SP (specialty pharmacy), ST (step therapy) or AC (ACA/preventive). Coverage requires meeting the specific Requirements/Limits shown on the drug line item.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List — Pharmacy Coverage and Utilization Management

Policy CodePolicy N/A

Change TypeAnnual drug list publication (no material changes)

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line item lists 'PA' before dispensing.

SourceLink

On This Page

Refer to the listed Requirements/Limits for each product for exact QL values, PA/ST presence, and SP routing.

Per-drug coverage requirements (partial list)

Coverage and utilization management conditions are specified per drug entry.

Per‑drug requirements (partial list): When a drug line shows Requirements/Limits (for example: 'PA', 'QL (21 capsules/28 days)', 'SP'), coverage and dispensing are subject to those requirements. Quantity limits define the maximum amount allowed for the listed timeframe; prior authorization must be obtained where 'PA' is indicated; specialty products labeled 'SP' require specialty pharmacy handling.see drug line

This is a partial extract — see the full Drug List for complete per‑product clinical PA criteria and QL values.

Covered products with utilization controls

Coverage stance is mixed by product with utilization controls applied as listed.

Formulary coverage with utilization controls: Products on the Drug List are assigned a Drug Tier (e.g., P, NP) and may carry Administrative Controls (AC), Prior Authorization (PA), Quantity Limits (QL) and/or Specialty Pharmacy (SP) designations as shown. Coverage is subject to meeting these controls and any applicable benefit‑level limits (day supply, age restrictions).product‑specific

Administrative codes (AC) and ACA flags may affect member cost‑sharing; consult benefit materials for plan‑specific coverage and cost implications.

Formulary listing (tier and utilization controls)

Coverage and utilization management indicators shown per drug entry.

Formulary entries: Each listed product line displays Drug Tier and, when applicable, Requirements/Limits (examples: PA, QL with explicit amounts/timeframes, SP, ST, AC). The presence of these flags governs prior authorization needs, quantity enforcement, specialty routing, and step‑therapy requirements.see product line

This excerpt provides tier and utilization control indicators but does not include the detailed clinical PA criteria for each product.

General coverage conditions

Products listed are covered subject to the following conditions where specified:

PA and QL enforcement: If a product line shows 'PA' the provider must obtain prior authorization before coverage is approved; if a 'QL' is shown dispensing must not exceed the stated quantity within the listed timeframe; products marked 'SP' must be routed through specialty pharmacy channels as required by the plan.product‑line specific (see Requirements/Limits)

Failure to obtain required PA or to comply with QL/SP may result in denial or member full‑cost responsibility.

Sample product controls

Coverage and access are subject to the following per-product controls as listed (examples below).

TEZSPIRE: tezepelumab‑ekko subcutaneous solution auto‑injector 210 mg/1.91 ml: Drug Tier = P; Requirements/Limits = PA, QL (1 pen/28 days), SP.1 pen/28 days

Prior authorization and specialty pharmacy required per product line.

Coverage for outpatient pharmacy drugs is determined by inclusion on the BCBSOK Drug List and by any Drug Tier and Requirements/Limits noted for each product. Drugs that are not shown on the drug list are not covered. Coverage may also be limited to FDA‑approved labeling and recognized evidence‑based clinical guidelines. Refer to the payer portals (MyPrime.com or bcbsok.com) or the number on the member ID card for the up‑to‑date drug list and coverage details.

Some listed products appear with Drug Tier = NP or with the Drug Tier field left blank and no Requirements/Limits noted. When Requirements/Limits are blank, the entry does not specify a plan authorization or quantity rule in this segment; such products remain subject to standard plan terms and may require review of benefit materials or the provider portal to confirm coverage stance and any applicable administrative controls (e.g., AC) before dispensing.

Within the excerpted formulary lines there are no standalone exclusion conditions listed (for example, product‑specific 'not covered' rules tied to clinical criteria). Instead, entries show tiers and utilization controls (PA, QL, SP) that govern coverage; explicit per‑product exclusion language is not present in these chunks.

The reviewed segments list Drug Tier and Requirements/Limits for many products but do not set out explicit exclusion criteria in the text provided. Coverage decisions should follow the listed utilization controls and the member’s benefit terms; absent explicit exclusions in this excerpt, confirm any exclusionary rules via the full drug list or plan documents.

No explicit exclusions are shown for the products in this excerpt. Entries such as erectile dysfunction injectables and other specialty items list tiers and quantity limits but do not include standalone exclusion statements in these chunks; check the complete drug list for any plan‑level exclusions.

This segment of the drug list does not include any statements declaring products as Not Medically Necessary. The entries focus on utilization management flags—PA (prior authorization), QL (quantity limits), and SP (specialty pharmacy)—that define coverage controls rather than medical‑necessity determinations.

No explicit Not Medically Necessary determinations are present in these chunks. The content shows formulary tiers and controls (e.g., QL, PA) but does not include language that a listed drug is considered not medically necessary within the provided excerpt.

The examined excerpt does not contain product lines that are explicitly labeled 'not medically necessary.' Instead, product coverage is described by tier placement and utilization controls; where medical necessity is relevant, approval is managed through the payer’s prior authorization and exception processes referenced elsewhere in the document.

No entries in this portion of the formulary are stated as 'not medically necessary.' The document emphasizes administrative controls (e.g., AC), prior authorization, and quantity limits, and directs providers to the PA/exception process when coverage or medical necessity questions arise.

Coding / Drug Listings

Drug listings and tiers (sample)mixedCovered

AMOXICILLIN	amoxicillin (trihydrate) chew tab 125 mg, 250 mg — Drug Tier = NP
amoxicillin (trihydrate) cap 250 mg, 500 mg	Drug Tier = p
amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml	Drug Tier = p
amoxicillin (trihydrate) tab 500 mg, 875 mg	Drug Tier = p
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml	Drug Tier = p
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml, 400-57 mg/5ml	Drug Tier = np
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)	Drug Tier = np

No CPT/HCPCS/ICD-10 codes presentmixed

No codes listed

Sample drug entries (full list continues in other chunks)NDC|drug_name_text

entecavir tab 0.5 mg, 1 mg	entecavir (Baraclude) listed with Drug Tier = np
EPCLUSA - sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg	Drug Tier = P; Requirements/Limits = PA, QL (28 tablets/28 days), SP
EPCLUSA - pellet pack 150-37.5 mg, 200-50 mg	Drug Tier = P; Requirements/Limits = PA, QL (28 packs/28 days), SP
etravirine tab 100 mg, 200 mg (Intelence)	Drug Tier = np; Requirements/Limits = QL (60 tablets/30 days)

Additional antiviral/HIV drug entriesdrug_name_text

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg, 90-400 mg	Drug Tier = P; Requirements/Limits = PA, QL (28 tablets/28 days), SP
ISENTRESS - raltegravir chew tabs and other forms	Drug Tier = P; Requirements/Limits = various QL (e.g., 25 mg chew 180 tablets/30 days)
LIVTENCITY - maribavir tab 200 mg	Drug Tier = NP; Requirements/Limits = SP

Hepatitis C combination therapiesdrug_name_text

MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg	Drug Tier = P; Requirements/Limits = PA, QL (90 tablets/30 days), SP
SOVALDI - sofosbuvir tab 200 mg, 400 mg	Drug Tier = P; Requirements/Limits = PA, QL (30 tablets/30 days), SP
VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg	Drug Tier = P; Requirements/Limits = PA, QL (30 tablets/30 days), SP

Selected drug entriesNDC-like|internalCovered

PIQRAY 300MG

alpelisib tab pack 300 mg daily dose (2x150 mg tab)

Covered drug names (partial)mixedCovered

POMALYST	pomalidomide cap 1 mg, 2 mg, 3 mg, 4 mg
QINLOCK	ripretinib tab 50 mg
RETEVMO	selpercatinib tab 40 mg, 80 mg, 120 mg, 160 mg

Androgen-anabolic agentsmixedCovered

TESTOSTERONE CYPIONATE	testosterone cypionate IM inj in oil 100 mg/ml; 200 mg/ml
TESTOSTERONE ENANTHATE	testosterone enanthate IM inj in oil 200 mg/ml

Sample listed products (partial)mixed

ivabradine hcl tab 5 mg	ivabradine (Corlanor) listed with PA, QL (60 tablets/30 days)
ivabradine hcl tab 7.5 mg	ivabradine (Corlanor) listed with PA, QL (60 tablets/30 days)
macitentan tab 10 mg	OPSUMIT - PA, QL (30 tablets/30 days), SP
treprostinil diolamine tab er 0.125 mg, 0.25 mg, 1 mg, 2.5 mg	ORENITRAM - PA, QL (300 tablets/30 days), SP
sacubitril-valsartan tab 24-26 mg, 49-51 mg, 97-103 mg	Entresto - tier np

Pulmonary / PA productsmixed

sildenafil citrate solution 10 mg/ml	Revatio - PA, QL (2 bottles/30 days)
sildenafil citrate tab 20 mg	Revatio - QL (90 tablets/30 days)
tadalafil tab 20 mg (Adcirca)	PA, QL (60 tablets/30 days)
treprostinil inhalation solution 0.6 mg/ml	TYVASO - PA, QL (81.2 mls/28 days)
selexipag tabs (UPTRAVI) various strengths	PA, QL (60 tablets/30 days)

Cardio/PA/Specialtymixed

vericiguat tab 2.5 mg, 5 mg, 10 mg	VERQUVO - PA, QL (30 tablets/30 days)
tafamidis cap 61 mg	VYNDAMAX - PA, QL (30 capsules/30 days), SP
sotatercept kit	WINREVAIR - PA, QL (1 kit/21 days), SP
treprostinil inhalation capsules (YUTREPIA)	PA, QL (112 capsules/28 days), SP

Respiratory agents and biologicsmixed

albuterol sulfate inhaler 108 mcg/act	Proventil/Ventolin HFA - QL (2 inhalers/30 days)
ADVAIR HFA - fluticasone-salmeterol inhaler	QL (1 inhaler/30 days)
budesonide inhalation suspension (Pulmicort)	QL (120 mls/30 days or 240 mls/30 days depending on strength)
mepolizumab (NUCALA)	PA, QL (1-3 pens/syringes per 28 days), SP
benralizumab (FASENRA)	PA, QL (1 pen/28 days), SP

Biologics / CF modulatorsmixed

tezepelumab-ekko 210 mg/1.91 ml	TEZSPIRE - PA, QL (1 pen/28 days), SP
omalizumab (XOLAIR) various presentations	PA, SP
vanzacaftor-tezacaftor-deutivacaftor (ALYFTREK)	PA, QL (56-84 tablets/28 days), SP

Formulary product strengths and presentations (partial)mixed

210 mg/1.91ml	TEZSPIRE - tezepelumab-ekko subcutaneous soln auto-inj
108 mcg/act	VENTOLIN HFA - albuterol sulfate inhal aero
2.5 mg, 5 mg	terbutaline sulfate tab

Formulary product strengths and presentations (continued)mixed

75 mg/0.5ml; 150 mg/ml; 300 mg/2ml	XOLAIR - omalizumab subcutaneous soln
4-20-50 mg; 10-50-125 mg	ALYFTREK - vanzacaftor-tezacaftor-deutivacaftor tab

Quantity limits examples

Examples56 tablets/28 days; 90 tablets/30 days; 240 tablets/30 days

ContextThese are representative QL formats shown across oncology and specialty oral agents in the formulary

ApplicationUsed to enforce maximum dispensed tablets per 28/30-day period on selected products

Quantity limits

Examples28 tablets/21 days; 1 ring/365 days; 2 tablets/365 days; 4 pens/28 days; 30 tablets/30 days; 4 pens/180 days

ScopeExamples drawn from contraceptives, emergency contraception, and injectables listings

PurposeDemonstrates the variety of QL timeframes used in the formulary (per 21, 28, 30, 180, 365 days)

Insulin volume limit

Insulin volume limit100 mls/30 days

Applies toMost rapid-acting and many insulin pen/cartridge presentations listed (FIASP, HUMALOG, NOVOLOG, etc.)

EnforcementQuantity Limit (QL) as stated in product Requirements/Limits — documentation required for overrides

Oral tablet quantity limits

Common oral tablet QLs30–60 tablets/30 days (typical range for many oral therapies)

ExamplesTrijardy XR and similar oral antidiabetic combos shown with 30–60 tablets/30 days

Usage noteApplied across many chronic oral agents to control monthly supply

Enalapril oral solution quantity limit

Enalapril oral solution QL1200 mL/30 days

ProductEnalapril oral solution (Epaned) listed with this QL

ImplicationDispensing is limited to 1200 mL per 30-day period unless prior authorization supports larger quantity

Furoscix quantity limit

FUROSCIX QL8 kits/180 days

ProductFurosemide subcutaneous cartridge kit (FUROSCIX) — QL applies over 180-day period

EnforcementQuantity limit noted alongside PA/SP requirements; documentation needed for exceptions

Repatha limit

REPATHA QL (syringe)6 syringes/28 days

REPATHA QL (auto-injector)6 pens/28 days

NoteRepatha entries list PA and QL; specialty/high-cost agent controls apply

ATTRUBY (acoramidis) quantity limit

ATTRUBY (acoramidis) QL112 tablets/28 days

Product listingATTRUBY listed with PA and QL in formulary

Coverage implicationDispensing limited to 112 tablets per 28-day period unless PA allows override

TYVASO QL

TYVASO QL81.2 mls/28 days

ProductTreprostinil inhalation solution (TYVASO) — QL specified per 28-day period

Associated controlsListed with PA and SP in addition to the QL

Corlanor QL

Corlanor QL60 tablets/30 days

ProductIvabradine (Corlanor) listed with PA and QL in formulary

EnforcementDispensing restricted to 60 tablets per 30 days unless prior authorization justifies more

VERQUVO QL

VERQUVO QL30 tablets/30 days

ProductVericiguat (VERQUVO) listed with PA and QL

Operational noteQuantity limit enforces the monthly tablet supply for therapy

VENTOLIN HFA inhaler limit

VENTOLIN HFA QL2 inhalers/30 days

ProductAlbuterol sulfate inhaler (VENTOLIN HFA) — QL applies monthly

Provider noteQuantity limits documented in Requirements/Limits must be followed at dispensing

TEZSPIRE pen limit

TEZSPIRE pen QL1 pen/28 days

ProductTezepelumab-ekko (TEZSPIRE) — listed with PA, QL and SP

ImplicationSpecialty distribution and prior authorization required in addition to the 1-pen/28-day QL

Provider Actions & Authorization Requirements

Prior Authorization

Obtain prior authorization when 'PA' is listed

Prior authorization may be required for certain drugs; when commonly required the formulary will show 'PA' in the Special Requirements column. Providers must check the drug list entry for a PA flag and submit a prior authorization request when PA is indicated before dispensing.

If a medication line lists 'PA' under Requirements/Limits, obtain prior authorization prior to coverage.

Prior Authorization

Get PA for inhaled/specialty aminoglycosides

Certain inhaled and specialty aminoglycosides and other specialty agents are marked 'PA' (and often 'SP' and QL) and require prior authorization per the formulary entries; confirm PA for products such as ARIKAYCE, KITABIS PAK, TOBI PODHALER and tobramycin nebulized formulations before dispensing.

Examples: ARIKAYCE, KITABIS PAK, TOBI PODHALER — Requirements/Limits = PA, QL, SP

Prior Authorization

Submit PA for antifungals and antiviral/HCV therapies

Selected antifungal agents and hepatitis C/antiviral therapies are annotated with PA on the formulary; providers must submit prior authorization requests for products such as itraconazole formulations, posaconazole, CRESEMBA, EPCLUSA, HARVONI and SOVALDI when the entry shows 'PA'.

Itraconazole (Sporanox) — QL and examples shown; posaconazole (NOXAFIL) entries show PA.
EPCLUSA, HARVONI, SOVALDI entries include Requirements/Limits = PA and QL; submit PA accordingly.

Prior Authorization

PA required for listed hepatitis C therapies

Prior authorization is required for hepatitis C combination therapies explicitly labeled 'PA' in the drug list (examples include EPCLUSA, HARVONI, MAVYRET, and SOVALDI); obtain PA and follow listed quantity limits (e.g., EPCLUSA QL 28 tablets/28 days).

EPCLUSA and HARVONI — Requirements/Limits = PA, QL (28 tablets/28 days) and SP where noted.
SOVALDI — Requirements/Limits = PA, QL (30 tablets/30 days).

Documentation Required

Follow AC/authorization rules for vaccine entries marked AC

Many vaccine products are annotated with Requirements/Limits = AC, indicating administrative/coverage conditions; providers should follow the AC process (which may require authorization) before coverage is approved.

Examples: ENGERIX-B, FLUAD, FLUARIX — Requirements/Limits = AC.

Prior Authorization

Obtain PA and follow QL/SP for oncology/specialty oral agents

Prior authorization is required for most listed oncology and specialty oral agents; product lines include PA and specific quantity limits and many require specialty pharmacy (SP) routing — submit PA and supporting documentation as specified for each product.

Oncology examples: COPIKTRA, COTELLIC, dasatinib, IBRANCE — Requirements/Limits = PA, QL, SP
Provide documentation addressing diagnosis, dose, and requested quantity per the formulary QL.

Prior Authorization

PA required for specialty/oncology drugs labeled 'PA'

Many specialty and oncology agents are annotated with 'PA' in the Requirements/Limits field; obtain prior authorization and comply with any QL or SP requirements before dispensing these agents.

POMALYST, QINLOCK, RETEVMO and similar agents show Requirements/Limits = PA, QL, SP.

Prior Authorization

Check PA for MOUNJARO and GLP‑1 antidiabetics

Specific products (including MOUNJARO and certain GLP-1/combination antidiabetic agents) are identified as requiring prior authorization; check the drug line entry and obtain PA per the formulary before coverage.

MOUNJARO — Requirements/Limits include PA and QL (example: 4 pens).
Semaglutide products (OZEMPIC, RYBELSUS) are flagged with PA and QL where indicated.

Prior Authorization

Obtain PA for semaglutide and GLP‑1 agents as listed

Semaglutide products (e.g., OZEMPIC, RYBELSUS) and other GLP‑1/incretin agents have PA and QL annotations on the formulary; submit a prior authorization and documentation when the entry shows 'PA'.

RYBELSUS — Requirements/Limits = PA, QL (30 tablets/180 days or 30 tablets/30 days depending on strength).
OZEMPIC — QL shown (1 pen/28 days) and may require PA.

Prior Authorization

PA required for listed named specialty products

Select specialty products are labeled with 'PA' (and often QL and SP); obtain prior authorization for examples such as ACTHAR (PA, SP), CRENESSITY (PA, QL, SP) and GALAFOLD (PA, QL, SP) per the formulary entries.

ACTHAR — Requirements/Limits = PA, SP
GALAFOLD — Requirements/Limits = PA, QL (14 capsules/28 days), SP

Prior Authorization

Obtain PA and route via specialty pharmacy when 'SP' is shown

Products listed with 'Requirements/Limits = PA' — and many non‑preferred or specialty items — require prior authorization and may require specialty pharmacy routing where 'SP' is indicated; follow the formulary entry and obtain PA/specialty routing prior to dispensing.

When 'SP' appears, arrange specialty pharmacy distribution as required in addition to PA.

Prior Authorization

PA required for selected specialty/high‑cost agents

Prior authorization is required for many high‑cost specialty and certain oral agents (examples include REPATHA, NEXLETOL/NEXLIZET); obtain PA and ensure dispensed quantity adheres to the QL specified on the formulary.

REPATHA — Requirements/Limits = PA, QL (6 syringes/28 days or 6 pens/28 days)

Prior Authorization

PA required for PAH and specialty cardiology drugs

Pulmonary arterial hypertension and related specialty cardiology agents are frequently marked 'PA' and include quantity limits; obtain prior authorization for products such as CAMZYOS, ORENITRAM, OPSUMIT and TYVASO and follow stated QL.

TYVASO — Requirements/Limits = PA, QL (81.2 mL/28 days)
OPSUMIT — Requirements/Limits = PA, QL (30 tablets/30 days)

Prior Authorization

Confirm PA requirement for drugs labeled 'PA'

Multiple listed drugs across the formulary are marked 'PA' and require prior authorization before coverage; providers should review each product line for PA indications and submit PA requests when indicated.

The formulary uses 'PA' repeatedly across therapeutic classes — check each entry prior to prescribing/dispensing.

Prior Authorization

Obtain PA for listed specialty/high‑cost items

Many specialty or high‑cost agents list 'PA' in Requirements/Limits; obtain prior authorization before dispensing to avoid claim denials (examples include TEZSPIRE, XOLAIR, ALYFTREK).

TEZSPIRE — Requirements/Limits = PA, QL (1 pen/28 days), SP

Prior Authorization

Secure PA for specialty/biologic agents listed

Prior authorization is required for several specialty/high‑cost agents shown (e.g., SKYRIZI, TREMFYA, VOWST, ZYMFENTRA); ensure PA is in place and QL/SP rules are followed to secure coverage.

SKYRIZI — Requirements/Limits = PA, QL (1 cartridge/56 days), SP
TREMFYA — Requirements/Limits = PA, QL (1 syringe/28 days), SP

Prior Authorization

PA and QL for Hetlioz formulations

Hetlioz formulations (tasimelteon oral suspension and capsule) require prior authorization and have quantity limits and specialty designation; submit PA and adhere to the stated QL (e.g., suspension 158 mL/30 days; capsule 30 capsules/30 days).

HETLIOZ LQ (susp) — Requirements/Limits = PA, QL (158 mls/30 days), SP
HETLIOZ (capsule) — Requirements/Limits = PA, QL (30 capsules/30 days)

Prior Authorization

PA required for weight‑management and select wakefulness agents

Weight‑management injectables (Saxenda, Wegovy, Zepbound) and certain wakefulness/narcolepsy agents (Sunosi, Wakix) are subject to prior authorization and quantity limits; obtain PA and follow the QL specified for the product.

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

Prior Authorization

PA frequently required — verify before prescribing

Many products across the formulary list 'PA' next to the drug entry; check the drug list and obtain prior authorization where indicated to avoid coverage denial (examples include WEGOVY and other specialty therapies).

When PA is repeatedly indicated for a drug class or product, submit PA per payer process before dispensing.

Step Therapy

Follow step therapy (ST) requirements when 'ST' is indicated

Step therapy programs (noted with 'ST') may require trying a specified, cost‑effective alternative before the plan will cover the requested drug; providers must follow ST flags shown on the drug list and document prior trial of required therapies when submitting an authorization.

Kerendia (finerenone) is specifically noted with 'ST' indicating step therapy applies.
If 'ST' appears on a product line, document trials of the required alternative(s) in the PA submission.

Prior Authorization

PA/QL apply for antiviral combos; step therapy not specified

Some antiviral combination agents have quantity limits and prior authorization requirements but do not show explicit step‑therapy algorithms in this excerpt; obtain PA and confirm QL when applicable.

PAXLOVID — Requirements/Limits = QL (11/20/30 tablets/90 days) and other antiviral combos show PA/QL as applicable.

Note

Step therapy not specified — rely on PA/QL where shown

No explicit step therapy (fail‑first) sequences are detailed in this document excerpt for most products; when step therapy is not displayed, follow the PA and QL controls listed for the specific drug entry.

When 'ST' is absent, PA and QL remain the primary utilization controls.

Prior Authorization

Follow PA, QL and SP for specialty oncology agents

Certain specialty oncology and other agents list Requirements/Limits including PA, QL and SP; providers must obtain prior authorization and comply with quantity and specialty pharmacy requirements when submitting requests.

Examples: many antineoplastic agents require PA, QL and SP as noted in product lines.

Note

No explicit step sequences — comply with PA/QL/SP controls

Where step therapy is not specified for a product line, the formulary entries focus on prior authorization, quantity limits, and specialty routing; follow these controls and provide required documentation with PA submissions.

Most oncology entries show PA, QL and SP rather than explicit step sequences.

Note

Check PA/QL for hormone/testosterone products; ST not specified

Some hormone/testosterone and related products have utilization controls listed but explicit step therapy requirements are not provided in this excerpt; check the individual product line for PA, QL or SP flags and follow those requirements.

Testosterone formulations: check Requirements/Limits on each product line (PA/QL/SP as shown).

Documentation Required

PA and QL present for some specialty agents; step therapy not detailed

Some specialty agents show PA and QL in the formulary but do not include explicit step‑therapy sequences in this excerpt; obtain PA and provide documentation for any QL override requests per the payer process.

When QL is present, include clinical justification for exceeding the limit in the PA submission.

Step Therapy

Kerendia requires step therapy

Kerendia (finerenone) is noted with 'ST' in the formulary, indicating step therapy applies; document prior trials of required alternatives when requesting coverage.

KERENDIA — Requirements/Limits = QL (30 tablets/30 days), ST

Step Therapy

Document prior therapy for products flagged 'ST'

Some products include an 'ST' flag indicating step therapy applies (for example, KERENDIA); when 'ST' appears on a drug line, include documentation of prior appropriate therapy in the PA/authorization request.

Document the alternative(s) tried and dates/duration of therapy in the submission.

Note

Step therapy noted only where 'ST' is shown

Step therapy is not broadly specified in this excerpt for most drug classes; where step therapy applies it will be noted with 'ST' in the Special Requirements column and must be followed per plan rules.

If 'ST' is not shown, do not assume a step requirement — follow PA and QL instead.

Step Therapy

Adhere to step therapy for antipsychotics and specified agents

Step therapy is required for select agents listed with 'ST' (examples include FANAPT and certain antipsychotic titration packs); follow the plan's step requirements and document prior failed/attempted therapies when requesting authorization.

FANAPT and FANAPT titration packs — Requirements/Limits = QL and ST
Risperidone ODT and Versacloz liquid are examples where ST applies

Step Therapy

Follow ST for select antipsychotics

Certain antipsychotic products are marked with step therapy (ST) flags — for these products providers must follow the plan's step rules and include evidence of required prior therapies in the authorization request.

Risperidone ODT — Requirements/Limits = QL (60–120 tablets/30 days) and ST

Documentation Required

Use the ID‑card number for Drug List exceptions; note decision timelines

For a Drug List exception, the prescriber or member must call the number on the ID card; BCBSOK will notify the decision within 15 calendar days for standard requests or within 72 hours for expedited requests.

Call the phone number on the member's ID card to initiate an exception request.
Decision timelines: 15 calendar days standard; 72 hours expedited.

Documentation Required

Provide clinical documentation with PA requests

When submitting a PA request, prescribers should supply documentation supporting medical necessity as indicated by the formulary entry (diagnosis, dosing, prior therapies, and requested quantity/days' supply).

Include clinical rationale and prior therapy history when PA is required.

Documentation Required

Document QL justifications when requesting overrides

Quantity limits (QL) are specified for many products (e.g., EPCLUSA QL 28 tablets/28 days); if requesting quantities beyond the QL include supporting documentation justifying medical necessity.

Example: EPCLUSA — QL 28 tablets/28 days; provide justification for higher quantities in PA request.

Documentation Required

Verify requirements when Requirements/Limits is blank

Some vaccine and biologic entries have blank Requirements/Limits (no AC); where no AC/PA/QL is shown, no special authorization is indicated in this segment — nevertheless verify benefits per the member's plan.

If Requirements/Limits is blank, confirm coverage via benefit materials or by contacting the payer.

Documentation Required

Follow per‑product Requirements/Limits (PA, QL, SP)

Each drug entry annotates Drug Tier and, where applicable, Requirements/Limits (PA, QL amounts/timeframes, SP); providers must follow the PA and QL rules shown for each specific product when submitting authorizations.

Review the Special Requirements column on the drug list for PA, QL and SP flags before prescribing.

Documentation Required

Supply required clinical documentation with PA/QL requests

When a drug line lists 'Requirements/Limits = PA', prescribers must submit documentation supporting the prior authorization and any clinical justification for quantity overrides as part of the PA request.

Include diagnosis, requested days' supply/quantity, and prior treatment history in the PA submission.

Documentation Required

Include medical‑necessity details in PA submissions

Documentation supporting medical necessity (diagnosis, dosing, requested quantity/days' supply, and prior therapies) is implied for products marked PA, AC, or QL; include these data in PA submissions to facilitate review.

The PA submission should clearly state the indication and why alternatives are not appropriate when required.

Documentation Required

Follow payer PA process and submit supporting records

No detailed clinical documentation templates are provided in this excerpt; the document indicates PA or SP requirements — providers must follow the payer's PA process and supply requested clinical information per the PA form.

Use the insurer's PA form/process and attach supporting clinical notes when required.

Documentation Required

Provide documentation to justify exceeding QL values

When a product shows 'QL' in Requirements/Limits (e.g., 2 syringes/30 days, 8 capsules/28 days), quantity‑limit documentation is required to request overrides; include clinical rationale in the PA submission.

Provide dosing regimen and reason for quantity above the stated QL when requesting an override.

Documentation Required

Document requests to exceed explicit QLs (e.g., enalapril, FUROSCIX)

Products with explicit QL entries (e.g., enalapril oral solution QL 1200 mL/30 days; FUROSCIX QL 8 kits/180 days) require documentation to support requests for quantities beyond the listed limit; include prior dosing records and clinical justification.

Enalapril oral solution — QL 1200 mL/30 days; FUROSCIX — QL 8 kits/180 days.

Documentation Required

Provide PA documentation for SP‑designated specialty products

Specialty products (marked 'SP') and products with PA require documentation per the payer's prior authorization process (including dose, frequency, diagnosis and prior therapies) to support approval; coordinate specialty pharmacy routing when 'SP' is indicated.

When 'SP' is shown, arrange for specialty pharmacy distribution and include required documentation in PA.

Billing Rule

Adhere to product‑specific PA and QL rules when dispensing

Prescribers and pharmacies must follow prior authorization and quantity‑limit rules specified for each product line (for example TEZSPIRE QL = 1 pen/28 days; VENTOLIN HFA QL = 2 inhalers/30 days); ensure PA is in place and dispense within QL to avoid claim issues.

TEZSPIRE — QL 1 pen/28 days
VENTOLIN HFA — QL 2 inhalers/30 days

Documentation Required

Provide justification to meet PA and specialty pharmacy requirements

When a drug is marked with PA and SP, prescribers must supply justification to meet both prior authorization and specialty pharmacy requirements (e.g., indication, dosing, prior therapy history) to facilitate approval and specialty distribution.

Examples: TREMFYA, SKYRIZI, ZYMFENTRA — Requirements/Limits = PA, QL, SP

Documentation Required

Include indication, quantity and prior‑therapy details in PA requests

Prescribers must provide documentation supporting prior authorization requests for listed PA drugs (including indication, requested quantity and days' supply); include prior therapy trials and clinical rationale as applicable.

For weight‑management or specialty therapies, include BMI, prior interventions, and contraindications to alternatives where applicable.

Documentation Required

Provide PA/QL documentation for specialty agents (examples listed)

Providers must supply documentation to meet prior authorization and quantity‑limit rules for specific drugs as indicated (examples include WEGOVY, ZEPBOUND, MAVENCLAD, GILENYA); submit PA with clinical justification and prior treatment history.

MAVENCLAD — Requirements/Limits = PA, QL (varies by pack), SP

Denial Risk

Non‑listed drugs and missing PA trigger denials

Drugs not shown on the drug list are not covered; if prior authorization is required and not obtained, the request will be denied — verify formulary inclusion and obtain PA when indicated to prevent denials.

If a drug is not on the drug list, submit an exception request per the exception process (call the number on the ID card).

Denial Risk

Missing PA for aminoglycoside/specialty inhaled agents risks denial

Prior authorization is required for certain inhaled/specialty aminoglycosides and listed specialty medications (e.g., ARIKAYCE, KITABIS PAK, TOBI PODHALER); failure to obtain PA may result in denial of coverage.

ARIKAYCE, KITABIS PAK, TOBI PODHALER — Requirements/Limits = PA, QL, SP

Denial Risk

Missing PA for antifungals and HCV agents risks denial

PA is indicated for specified antifungals and hepatitis/antiviral agents (for example CRESEMBA/Isavuconazonium, NOXAFIL/posaconazole, EPCLUSA, HARVONI); claims may be denied if PA is not obtained prior to dispensing.

NOXAFIL (posaconazole) entries show Requirements/Limits = PA.
EPCLUSA and HARVONI — Requirements/Limits = PA, QL, SP.

Denial Risk

Claims may be denied if PA is not obtained

Claims for drugs listed with 'PA' may be denied if authorization is not obtained prior to dispensing; ensure PA is approved before submitting claims for PA‑flagged products.

Lack of PA will trigger denial or medical necessity review per the formulary.

Denial Risk

AC requirements for vaccines can trigger denial if unmet

Vaccine entries with Requirements/Limits = AC indicate administrative coverage conditions that, if not met, could trigger denial; confirm AC requirements and obtain necessary authorizations or documentation prior to administration.

Examples: ENGERIX‑B, FLUAD, SHINGRIX — Requirements/Limits = AC

Denial Risk

Non‑compliance with PA/QL/SP risks denial

Claims for listed products may be denied if PA, QL, or SP requirements are not met; verify the product entry for these controls and ensure authorization, specialty routing and quantity compliance before dispensing.

Noncompliance with PA/QL/SP (e.g., exceeding QL, missing PA, or not using SP) may lead to denial.

Denial Risk

Missing PA will trigger denial or review

Lack of prior authorization for drugs that list 'Requirements/Limits = PA' will trigger denial or medical necessity review; obtain PA before dispensing PA‑flagged products.

Providers should confirm PA approval is active before pharmacy dispenses medication.

Denial Risk

PA/AC and QL flags trigger administrative review and potential denial

Products labeled with 'PA' or 'AC' and with quantity limits are subject to administrative review; failure to obtain PA or meet AC/QL conditions may trigger denial of coverage.

When AC appears, follow administrative control steps as noted in the formulary entry.

Denial Risk

Ensure PA and specialty routing for PA+SP products

Products listed with both 'PA' and 'SP' require prior authorization and specialty distribution; failing to obtain PA or to route through specialty pharmacy when 'SP' is indicated may result in denial or a returned claim.

Examples: ACTHAR, GALAFOLD, IMCIVREE — Requirements/Limits include PA and SP

Denial Risk

Obtain PA for items marked 'PA' to avoid denial

Claims for listed products may be denied if prior authorization is not obtained where Requirements/Limits includes PA; verify PA approvals for each PA‑flagged item prior to dispensing.

Check the Special Requirements column for 'PA' before claim submission.

Denial Risk

PA and QL enforcement can cause denials (e.g., enalapril solution)

Some products (for example enalapril oral solution) have both PA and QL controls; exceeding the listed QL or failing to obtain PA may result in claim denial — ensure PA is secured and dispensing adheres to the QL.

Enalapril oral solution (Epaned) — QL 1200 mL/30 days and PA where indicated.

Denial Risk

Specialty agents require PA/QL — missing PA/Q L risks denial

High‑cost specialty agents (e.g., REPATHA, NEXLETOL/NEXLIZET) list PA and QL; absence of required authorization or exceeding QL may result in denial — secure PA and dispense within QL.

REPATHA — PA, QL (6 syringes/28 days)

Denial Risk

Verify PA status and QL compliance to prevent denials

Requests for products without required prior authorization or that exceed stated quantity limits may be denied or returned for review; verify PA status and quantity compliance against the formulary before submission.

Follow the product‑specific QL (e.g., TEZSPIRE 1 pen/28 days) when dispensing.

Denial Risk

PA and specialty routing missing may cause denial

Requests for drugs listed with both 'PA' and 'SP' may be denied if PA or specialty routing is not obtained as required; coordinate PA approval and specialty pharmacy distribution for these products.

Examples include TEZSPIRE and XOLAIR which require PA and SP.

Denial Risk

Missing PA/QL for specialty biologics risks denial

If prior authorization or quantity‑limit requirements for listed drugs (e.g., SKYRIZI, TREMFYA, VOWST) are not met, requests may be denied; ensure PA approvals and QL adherence before dispensing these specialty agents.

VOWST — Requirements/Limits = PA, QL (12 capsules/12 months), SP

Denial Risk

PA required for Hetlioz suspension and capsules

Coverage for Hetlioz formulations requires prior authorization and quantity limits; obtain PA for tasimelteon oral suspension or capsule to avoid denial (e.g., suspension QL 158 mL/30 days; capsule QL 30 capsules/30 days).

HETLIOZ LQ (suspension) — PA, QL (158 mls/30 days), SP

Denial Risk

PA and QL apply to weight‑management and select wakefulness agents

Weight‑management agents (liraglutide/Saxenda, semaglutide/Wegovy, tirzepatide/Zepbound) and certain narcolepsy/wakefulness agents require prior authorization and have QL controls; lack of PA or exceeding QL may lead to denial.

WEGOVY — PA, QL (4 pens/28 days or 8 pens/180 days depending on strength)
SAXENDA — QL (15 mL/30 days) and PA where indicated

Denial Risk

Expect frequent PA requirements across the drug list

Many drugs across the formulary are repeatedly marked 'PA'; providers should assume prior authorization may be required for numerous specialty/high‑cost products and verify for each drug to avoid denials.

Frequent PA flags across classes — always check the Special Requirements column.

Quantity Limits (per-product examples)

azithromycin tabs QL

Azithromycin tablets QL60 tablets/180 days

Strengths covered250 mg, 500 mg, and 600 mg tablet presentations listed with this QL

ApplicationMacrolide listings indicate this QL across listed oral tablet strengths

clarithromycin ER 500 mg QL

Clarithromycin ER 500 mg QL28 tablets/180 days

ProductClarithromycin ER 24hr 500 mg listed with this QL

NotesListed under macrolides with NP tier and QL in formulary

ARIKAYCE QL

ARIKAYCE QL28 vials/28 days

ProductAmikacin liposome inhalation suspension (ARIKAYCE) — PA and SP also indicated

ImplicationMonthly vial limit enforced per formulary Requirements/Limits

KITABIS PAK / TOBRAMYCIN nebu soln QL

KITABIS PAK / TOBRAMYCIN QL280 mls/56 days or 224 mls/56 days depending on formulation

ProductsTobramycin nebulized solutions (KITABIS PAK, TOBI) — QL varies by formulation

Associated requirementsEntries include PA and SP in addition to the stated QL

NUZYRA (omadacycline) 150 mg QL

NUZYRA (omadacycline) 150 mg QL30 tablets/180 days

ProductOral omadacycline 150 mg listed with this QL in tetracycline/anti-infectives section

ImplicationQuantity limited over 180-day window per formulary entry

Itraconazole (Sporanox) formulations QL

Itraconazole formulations QL120 capsules/30 days or 1200 mls/30 days for oral solution

ProductSporanox capsules and oral solution each show distinct QLs in the formulary

NoteOral solution QL is expressed in mL while capsule QL is in capsule count

EPCLUSA and HARVONI QL

EPCLUSA / HARVONI QL28 tablets/28 days or 28 packs/28 days for pellet packs

ProductsSofosbuvir-containing hepatitis C regimens (EPCLUSA, HARVONI) — PA, QL and SP indicated

ApplicationQL aligns with monthly dosing/packs used for HCV therapy courses

EPCLUSA specifics

EPCLUSA specifics28 (tablets/packs per 28 days)

ContextEPCLUSA entries explicitly list QL = 28 per 28-day period in the formulary

Associated controlsPA and SP are also noted for EPCLUSA

MAVYRET

MAVYRET QL90 tablets (typical monthly pack)

ProductGlecaprevir-pibrentasvir (MAVYRET) listed with QL = 90 tablets/30 days

NoteUsed for HCV regimens with PA and SP designations

PAXLOVID pack quantities

PAXLOVID pack QLsPack quantities vary (examples: 11, 20, 30 tablets/90 days depending on pack)

ProductNirmatrelvir/ritonavir (PAXLOVID) pack sizes listed with QL per 90-day period

ImplicationFormulary lists specific pack-based QLs rather than single-tablet monthly limits

BESREMI

BESREMI QL2 syringes/28 days

ProductRopeginterferon alfa-2b (BESREMI) listed with PA and QL

DistributionTypically specialty pharmacy (SP) designated

ALUNBRIG

ALUNBRIG QL30 tablets

ContextBrigatinib (ALUNBRIG) initiation pack and maintenance listings include QL values across periods; 30-tablet QL shown for certain packs

Associated requirementsPA and SP indicated in formulary entries

COPIKTRA

COPIKTRA QL56 capsules/28 days

ProductDuvelisib (COPIKTRA) listed with PA, QL and SP

NoteApplied to oncology oral agents to manage monthly supply

COTELLIC

COTELLIC QL63 tablets/28 days

ProductCobimetinib (COTELLIC) entry lists PA, QL and SP

PurposeMonthly tablet cap used for dosing and supply control

dasatinib 20 mg

dasatinib 20 mg QL90 tablets

ContextLower-strength dasatinib (20 mg) has larger QL compared with higher strengths

Associated controlsPA and SP noted in formulary for oncology dosing

dasatinib 50–140 mg

dasatinib 50–140 mg QL30 tablets

ContextHigher-strength dasatinib tablets listed with a 30-tablet QL per 30 days

NoteReflects strength-specific monthly dispensing limits

ENSACOVE QLs

ENSACOVE 25 mg QL30 capsules

ENSACOVE 100 mg QL60 capsules

NoteStrength-dependent QLs are specified in the formulary entries

erlotinib quantity limits

erlotinib 25 mg QL60 tablets

erlotinib 100–150 mg QL30 tablets

Associated controlsPA and SP accompany the QL entries for Tarceva formulations

everolimus various

everolimus QL range30–90 tablets (strength-dependent)/30 days

ProductAfinitor formulations list QLs of 30, 60 or 90 tablets per 30 days depending on strength

NoteUsed for oncology dosing control with PA and SP

FRUZAQLA / GAVRETO QLs

FRUZAQLA 1 mg QL84 capsules/28 days

FRUZAQLA 5 mg QL21 capsules/28 days

GAVRETO QL120 capsules/30 days

Selected oncology QLs

HERNEXEOS QL180 tablets

IBRANCE QL21 capsules/tablets per 28 days

ICLUSIG QL30 tablets/30 days

Site of Care / Specialty Routing

Note

Definitions and Key Terms

Initial Therapy Criteria

Initial therapy requirements (general)

Initial authorization: When prior authorization is required for initial therapy, the prescriber must submit a PA request with supporting clinical documentation (diagnosis, prior therapies if applicable, and requested quantity/days supply). Quantity must not exceed the listed QL and specialty products must follow SP routing. Initial approvals follow payer PA processes and are subject to plan benefit terms.product‑specific

See Drug List line items for exact QL values and flags; exception requests follow the Drug List exception timelines (decision within 15 calendar days, 72 hours for expedited requests).

Step Therapy

Summary	Evidence in source
No explicit step-therapy sequences specified for the listed products; many entries show PA and/or QL but do not state fail-first steps.	Source lines list EPCLUSA, HARVONI and other agents with Requirements/Limits = PA, QL and SP but no ST sequences are provided in these chunks.

Summary	Evidence in source
Some oncology and specialty agents are subject to utilization controls (PA, QL) and specialty routing (SP); step therapy sequences are not explicitly defined in the excerpt.	Example oncology entries (abiraterone, ALECENSA, AKEEGA) show Requirements/Limits = PA, QL and SP; the brief notes PA/QL/SP presence but no step algorithms.

Summary	Evidence in source
Some products are annotated with AC or other administrative controls (e.g., contraceptives marked AC) or have QL, but explicit step therapy sequences are not provided here.	Chunks reference AC and QL for various products (e.g., contraceptives and endocrine agents) while the step-therapy module indicates no detailed sequences in this segment.

Summary	Evidence in source
Prior authorization may be required before coverage for certain specialty antidiabetic agents (GLP‑1 products and tirzepatide); the document does not provide explicit step sequences.	Entries for semaglutide products (RYBELSUS) and weight‑management injectables show Requirements/Limits = PA and QL; the step therapy notes state PA may apply but no ST algorithms are given.

Summary	Evidence in source
Kerendia (finerenone) is marked with 'ST', indicating that step therapy applies to this product.	Source lists KERENDIA with Requirements/Limits = QL (30 tablets/30 days), ST confirming the presence of step therapy for this agent.

Summary	Evidence in source
KERENDIA is annotated with 'ST' in the Requirements/Limits, indicating plan step therapy applies.	Chunk shows: 'KERENDIA ... Requirements/Limits = QL (30 tablets/30 days), ST.'

Summary	Evidence in source
Several agents (e.g., NEXLETOL/NEXLIZET, REPATHA) are marked with PA and QL; the excerpt does not present explicit multi‑step therapy sequences for these products.	Source lists NEXLETOL/NEXLIZET with Requirements/Limits = PA, QL (30 tablets/30 days) and REPATHA with Requirements/Limits = PA, QL (6 syringes/28 days) but no ST details are provided.

Summary	Evidence in source
No explicit step therapy sequences are listed in the excerpt; many products instead require prior authorization (PA) as the primary control.	Chunk content emphasizes PA and QL annotations for numerous drugs and the step therapy module states 'No explicit step therapy sequences are listed in this excerpt.'

Summary	Evidence in source
Step therapy is required for certain agents listed with 'ST' flags (examples include FANAPT, FETZIMA, fluoxetine DR, TRINTELLIX) where indicated.	Source shows FANAPT entries and titration packs with Requirements/Limits including QL and 'ST'; the brief also enumerates other agents with 'ST' annotations in this section.

Summary	Evidence in source
Step therapy applies to certain antipsychotic products and titration packs (e.g., FANAPT packs, Risperidone ODT) indicated by 'ST' flags in the formulary entries.	Chunks list Risperidone ODT and multiple FANAPT titration packs with Requirements/Limits showing QL and ST; the brief explicitly notes ST flags for these antipsychotics.

Summary	Evidence in source
Several specialty agents are marked 'SP' indicating specialty pharmacy management; the excerpt does not provide explicit step therapy sequencing for these products.	Examples include MAVENCLAD and multiple weight‑management and specialty products listed with PA, QL and SP; the step therapy inventory notes SP flags but no ST algorithms are shown.

Background

Specialty drugs are high‑cost or complex therapies used to treat conditions such as hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis. They may be self‑administered (oral or injectable) or clinician‑administered; clinician‑administered therapies are often managed under the medical benefit rather than the pharmacy benefit. The drug selection committee evaluates FDA‑regulated drugs for safety, efficacy, and comparative value, and listed specialty products may carry PA, QL, and SP designations that drive coverage and distribution requirements.