CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Drug List (Pharmacy Benefit) — Formulary, Utilization Management, and Specialty Drug Guidance

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Provides Blue Cross Blue Shield of Oklahoma's 2025 pharmacy drug list, member cost-tiering, coverage considerations (including prior authorization, step therapy, quantity limits), specialty drug guidance, and processes for exceptions and appeals; intended for BCBSOK members, prescribing clinicians, pharmacists, and network providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Formulary & Utilization Controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting documentation when a drug is listed with 'PA' or 'PA, QL' to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+distinct drug line-items in this extract

multipleentries with PA or QL

MyPrime.comwebsites for current list

30/90day supply guidance

OKapplicability

Coverage and General Pharmacy Rules

General pharmacy coverage

Covered when ALL of the following are met:

General coverage conditions: Drug is listed on the BCBSOK Drug List (the member’s plan drug list) and the member’s specific benefit includes coverage for the drug category;

From statement that all available covered drugs are shown and drugs not shown are not covered.

Regulatory and guideline conformity: The drug is FDA‑approved for the requested indication or otherwise covered per the member’s plan (non‑FDA‑approved drugs are excluded); coverage follows FDA labeling and recognized evidence‑based or clinical practice guidelines where specified;

Reflects non‑FDA‑approved drugs exclusion and limitation to FDA‑approved labeling/guidelines.

Utilization management requirements: Any applicable prior authorization (PA), step therapy (ST), dispensing/quantity limits (QL), or specialty pharmacy (SP) requirements listed for the product are satisfied prior to benefit payment; if PA or ST commonly applies it will be noted with 'PA' or 'ST' in the Special Requirements column; QL indicates dispensing limits per period (e.g., 30 tablets/30 days);

Derived from PA/ST/QL descriptions and guidance to check Special Requirements column.

Site‑of‑care and dispensing channel: If the product is designated specialty (SP) or requires administration by a health care professional, coverage and routing must follow the payer’s specialty or medical‑benefit processes (e.g., specialty pharmacy, infusion/office billing) as indicated;

Based on statements that SP products are managed through specialty pharmacy and that medications administered by providers may be medical‑benefit rather than pharmacy.

Plan‑level exceptions and member responsibility: If a prescribed quantity exceeds a listed QL or the drug is not on the Drug List, the prescriber or member may request a Drug List exception or supply documentation for PA; decisions and timelines follow plan procedures (exception decisions: standard 15 calendar days; expedited 72 hours); members may be responsible for cost beyond allowed quantities if dispensing limits are exceeded or PA is not obtained;

From exception process timelines and consequences for exceeding QL or lacking PA.

Drugs that are not shown on the Drug List are not covered. The Drug List represents the medications the plan will consider for payment under the pharmacy benefit and coverage is subject to the member's specific plan rules and any utilization controls shown on the list (for example, PA, QL, or SP). Examples of exclusions called out in the plan materials include drugs indicated for cosmetic purposes (e.g., hair-growth agents), products with available over‑the‑counter equivalents, repackaged medications, and medications that are not FDA‑approved for the intended use or for self‑administration. Members and prescribers should check benefit-specific materials or contact the number on the member ID card for coverage determinations.

The policy explicitly states that non‑FDA‑approved drugs are not covered. Prior to coverage, drugs must be FDA‑approved for the indicated use unless an exception is granted per the member's benefit; prescribers should verify coverage and, when appropriate, submit an exception request following the payer's process.

Drug List and Coding References

Drug list (no CPT/ICD/NDC codes in these chunks)mixed

none	This extract contains drug names, tiers and requirement flags but no procedure or diagnosis codes.

inv-05: Example Quantity Limit — 60 tablets/30 days

Example QL60 tablets/30 days

ContextIllustrative example quantity limit from the drug list

Where notedShown as QL in the Requirements/Limits column

inv-06: Example Quantity Limit — 30 tablets/30 days

Example QL30 tablets/30 days

ContextIllustrative example quantity limit from the drug list

Where notedShown as QL in the Requirements/Limits column

inv-07: Enalapril oral solution quantity limit (1200 mls/30 days)

Enalapril oral solution (Epaned)QL 1200 mls/30 days

RequirementsListed with PA and QL in the drug list entry

Unitmilliliters per 30 days

inv-08: FUROSCIX quantity limit (8 kits/180 days)

FUROSCIX (furosemide subcutaneous cartridge kit)QL 8 kits/180 days

RequirementsEntry lists PA and QL for the kit

Interval180-day window

inv-09: REPATHA syringe/pen/cartridge quantity limits

REPATHA - prefilled syringeQL 6 syringes/28 days

REPATHA - cartridge (Pushtronex)QL 2 cartridges/30 days

REPATHA - SureClick/penQL 6 pens/28 days

inv-10: ADEMPAS quantity limit (90 tablets/30 days)

ADEMPAS (riociguat)QL 90 tablets/30 days

RequirementsListed with PA and QL in the cardiovascular agents section

Unittablets per 30 days

inv-11: UPTRAVI quantity limit (60 tablets/30 days)

UPTRAVI (selexipag)QL 60 tablets/30 days

RequirementsEntry lists PA and QL and SP designation

Unittablets per 30 days

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Prior Authorization

Obtain Prior Authorization when 'PA' is listed

Prescribers must obtain prior authorization (PA) when a drug’s Requirements/Limits column shows “PA”; PA will be noted next to medications for which approval is commonly required and must be approved before the medication is covered under the plan.

Prior Authorization

PA required for select inhaled/specialty agents

Prior authorization is required for selected inhaled antimicrobials and certain antifungal agents — examples include ARIKAYCE and KITABIS PAK; check the line-item Requirements/Limits for the PA designation before dispensing.

ARIKAYCE — Requirements/Limits = PA, QL (235.2 mls/28 days), SP
KITABIS PAK — Requirements/Limits = PA, QL (56 containers/56 days), SP

Prior Authorization

PA required for select antivirals / HCV regimens

Prior authorization is required for specified high‑cost antiviral and hepatitis C regimens; these products are listed with “PA” (and often QL and SP) and require prescriber PA prior to coverage.

EPCLUSA, HARVONI, MAVYRET, SOVALDI — listed with Requirements/Limits = PA, QL and SP

Prior Authorization

PA required for many specialty/oncology agents

Many oncology and specialty drugs in this section show “PA” in Requirements/Limits; prescribers must secure prior authorization before these specialty/oncology agents will be covered.

Examples: abiraterone (Zytiga) Requirements/Limits = PA, QL, SP; many antineoplastics list PA and SP

Prior Authorization

PA plus quantity limits required for specialty agents

Prescribers must obtain prior authorization and comply with quantity limits (QL) for many oncology and specialty drugs; individual entries list the exact QL and SP designations that must be honored.

Examples show PA plus QL (e.g., acalabrutinib PA, QL 60 tablets/30 days, SP)

Prior Authorization

Obtain PA before coverage is allowed

Providers must request prior authorization for drugs where the Requirements/Limits column indicates “PA”; coverage will not be allowed until the PA is approved per the plan’s process.

Prior Authorization

PA and QL required for select antidiabetic injectables

Certain GLP‑1 and related antidiabetic injectables require prior authorization and have specified quantity limits; submit PA and ensure requested quantities match the QL for the listed strength.

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 or 3 mL/28 days depending on presentation)
RYBELSUS, TRULICITY — listed with PA and QL

Prior Authorization

PA required for listed specialty products

Prescribers must obtain prior authorization for the listed specialty products; check each product line (e.g., MYALEPT, OMNITROPE) for the PA notation before dispensing.

MYALEPT — Requirements/Limits = PA, SP
OMNITROPE — Requirements/Limits = PA, SP

Prior Authorization

PA required for specialty pulmonary/cardiac agents

Prior authorization is required for multiple specialty agents including PAH and cardiology therapies; confirm PA (and any QL/SP) on products such as ADEMPAS, REPATHA and CAMZYOS before coverage.

ADEMPAS — Requirements/Limits = PA, QL (90 tablets/30 days), SP
REPATHA — Requirements/Limits = PA, QL (device-specific limits), SP

Prior Authorization

PA required for many specialty / high‑cost drugs

Many specialty and high‑cost drugs in this excerpt are listed with “PA”; prescribers must submit PA requests and follow specialty routing (SP) when indicated to avoid coverage delays or denials.

Specialty products frequently show Requirements/Limits = PA and SP (see individual entries for QL)

Prior Authorization

PA required for specified specialty agents

Prior authorization is required for several specified products listed with PA in the Requirements/Limits field (examples include KALYDECO, TRIKAFTA, OFEV); obtain PA prior to dispensing to prevent denial.

KALYDECO — Requirements/Limits = PA, QL (60 tablets/30 days), SP
TRIKAFTA — Requirements/Limits = PA, QL (56 packets/28 days or 90 tablets/30 days), SP

Prior Authorization

PA required for select listed drugs

Prescribers must obtain prior authorization for products explicitly designated “PA” in the Requirements/Limits field (examples in Part 15 include IMCIVREE, Hetlioz LQ, LOMAIRA); check each line for PA before coverage.

IMCIVREE — Requirements/Limits = PA, QL (10 vials/30 days), SP
WEGOVY — Requirements/Limits = PA, QL (8 pens/180 days or 4 pens/28 days), SP

Prior Authorization

PA required for other listed drugs

Prior authorization is required for additional listed drugs such as fingolimod and other Part 15 entries; coverage may be denied if PA is not obtained.

GILENYA (fingolimod) — fingolimod 0.25 mg requires PA and QL in some presentations

Denial Risk

Risk of denial if PA not obtained

Coverage may be denied if prior authorization is not obtained for drugs labeled “PA” in the Requirements/Limits column; providers must secure PA per the plan’s process to avoid claim denials.

Step Therapy

Follow Step Therapy when 'ST' is shown

Some benefit plans use step therapy; when a drug is marked “ST” in Requirements/Limits the member may need to try a preferred alternative first before the requested drug is covered.

If “ST” appears next to a drug, follow the plan’s step therapy sequence before requesting PA (if applicable).

Note

Follow payer operational procedures for PA and exceptions

Follow nearby operational instructions and payer contact procedures for PA submissions, exceptions, and utilization management as noted in the drug list and exception process.

Call the number on the member’s ID card for exception requests or questions.
Refer to the drug’s Requirements/Limits line for exact PA/ST/QL flags.

Note

No step therapy sequences shown here — check Requirements/Limits

Step therapy specifics are not shown in this excerpt; where step therapy applies it will be indicated in the Requirements/Limits field next to the drug (look for “ST”).

Note

Observe access (AC) / administrative codes where shown

Some entries include access (AC) or administrative designations; when present these codes and any accompanying “ST”/“PA” notes must be followed as indicated in the Requirements/Limits column.

Contraceptive examples show AC and QL — follow the access/administrative instructions listed.

Note

Step therapy details not present — verify per line-item

This extract does not include explicit step therapy sequences for most drugs; verify the Requirements/Limits column for any “ST” instructions when prescribing.

Step Therapy

Step therapy / step edits apply to many specialty agents

Many specialty agents are flagged with step edits (SP/ST) in Requirements/Limits; prescribers must follow the step therapy or specialty access rules listed for each product.

SP flags often accompany PA and QL for specialty drugs — follow specialty routing and step edits as indicated.

Step Therapy

Adhere to step therapy edits for 'ST'‑flagged products

Some specific products are marked with “ST” (step therapy) in Requirements/Limits (examples include risperidone ODT, Secuado, Versacloz); prescribers must meet the step requirements for these entries.

Risperidone ODT, Secuado patch, Versacloz suspension — listed with ST in Requirements/Limits

Step Therapy

Comply with step therapy for entries marked 'ST'

When a drug’s Requirements/Limits field lists “ST,” prescribers must follow the step therapy rules indicated for coverage of that product (examples include Gralise entries).

Gralise (gabapentin once-daily) entries include ST and QL — follow step requirements.

Documentation Required

Submit drug list exceptions by phone; note decision timelines

For Drug List exceptions, prescribers or members must call the number on the member’s ID card; BCBSOK will notify the decision within 15 calendar days (or 72 hours for expedited requests).

Expedited requests: decision within 72 calendar hours.
Standard requests: decision within 15 calendar days.

Documentation Required

Include supporting documentation with PA/QL requests

When requesting prior authorization or to meet quantity limits, submit supporting clinical documentation such as diagnosis, prior therapy history, and justification for the requested quantity or dispensing interval.

Include diagnosis and prior treatment tried when PA or SP is indicated.
Provide quantity/dispensing interval justification when QL is listed.

Documentation Required

Supply PA/SP supporting documentation (diagnosis, prior therapy, quantity)

When a product is listed with “PA” or “SP,” prescribers must supply documentation consistent with PA/specialty policies (diagnosis, prior therapy, and quantity rationale) to support coverage.

Documentation Required

PA entries require prior authorization documentation

Entries that list “PA” in Requirements/Limits imply the payer requires prior authorization documentation to obtain coverage; prescribers must submit the PA request with appropriate supporting information.

Documentation Required

Submit PA with quantity and dispensing justification

When a drug line shows both PA and a QL, prescribers must submit prior authorization including justification for the requested quantity and dispensing interval to meet the QL.

Example: submit quantity justification when QL = 60 tablets/30 days is listed.

Documentation Required

Provide clinical rationale when submitting PA

Prescribers must supply the information supporting PA requests for drugs labeled “PA” in the Requirements/Limits field; include clinical rationale and dosing details as needed.

Prior Authorization

MOUNJARO — PA required and observe specified QL

MOUNJARO requires prior authorization and has strength-dependent quantity limits; submit PA and request quantities aligned with the listed QL (4 pens/180 days or 4 pens/28 days as applicable).

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

Note

Adhere to listed utilization controls (PA / QL / SP)

Providers and pharmacies must follow the PA, QL, and SP requirements listed next to each drug; check each product line for the exact utilization controls before dispensing.

Documentation Required

Provide documentation for oral solutions and specialty delivery systems

Documentation to support PA and quantity‑limit requests is expected for oral solutions and specialty items (examples include enalapril oral solution and FUROSCIX); include dosing and volume justification.

Enalapril oral solution (Epaned) — Requirements/Limits = PA, QL (1200 mls/30 days)
FUROSCIX — Requirements/Limits = PA, QL (8 kits/180 days)

Documentation Required

Submit documentation to meet PA and QL requirements

When PA and QL are listed, providers should submit prior authorization documentation that satisfies the PA criteria and supports the requested quantity within the QL limits.

Documentation Required

Ensure PA/QL documentation satisfies payer requirements

Prescribers must provide required documentation to satisfy PA and QL rules where indicated for individual drugs; failure to provide sufficient evidence may result in denial.

Billing Rule

Observe and document quantity limits (QL)

Observe quantity limits shown in the Requirements/Limits field; QL statements specify maximum supply (e.g., 30 tablets/30 days, 4 pens/28 days) and requests exceeding QL may be denied or require PA justification.

Examples: QL (30 tablets/30 days); WEGOVY QL (8 pens/180 days or 4 pens/28 days)

Documentation Required

Submit evidence of necessity and dosing with PA requests

When prior authorization is required, prescribers must supply evidence supporting medical necessity and dosing to meet the listed QL and any SP designation for specialty drugs.

Include clinical necessity, prior treatment failures (if applicable), and dose/quantity calculations.

Denial Risk

Non‑listed or excluded drugs are not covered — denial risk

Drugs not included on the BCBSOK Drug List are not covered under the pharmacy benefit; coverage may be denied if the member’s benefit excludes the drug category or the drug is not FDA‑approved.

Denial Risk

PA required for select inhaled/antifungal agents — denial risk if not obtained

Prior authorization is specifically listed for select specialty/inhaled antimicrobials and antifungals (e.g., ARIKAYCE, KITABIS PAK, posaconazole, voriconazole); failure to obtain PA may trigger claim denial.

Posaconazole and voriconazole formulations show PA and QL in Requirements/Limits.

Denial Risk

PA required for specific HCV agents — risk of denial

PA is required for certain hepatitis C agents (EPCLUSA, HARVONI, SOVALDI, MAVYRET, VOSEVI); claims submitted without PA may be denied or require retrospective review.

Documentation Required

Ensure specialty authorization/handling for SP‑flagged products

Specialty products flagged “SP” require appropriate specialty authorization and handling; missing specialty authorization or incorrect routing (not using specialty pharmacy) can result in denial.

SP flags often accompany PA and QL for biologics and specialty therapies.

Denial Risk

PA plus QL entries risk denial if requirements not met

Drugs listed with both PA and QL indicate coverage may be denied without PA approval or if the requested quantity exceeds the stated QL; obtain PA and request quantities within limits.

Denial Risk

Claims may be denied without approved PA

Claims for drugs labeled “PA” will be subject to prior authorization; lack of an approved PA at time of claim submission may result in claim denial or member financial responsibility.

Billing Rule

Route SP drugs through specialty pharmacy and secure PA

Specialty drugs designated SP typically require specialty pharmacy routing plus PA; failure to follow specialty channel requirements or obtain PA may lead to denial.

Examples: XOLAIR, KESIMPTA, AVONEX — Requirements/Limits show PA and SP.

Denial Risk

Verify PA and SP for listed products to avoid denial

When PA or SP is listed for a product (e.g., KALYDECO), coverage may be denied if PA or specialty requirements are not met; verify both PA and SP flags on the product line before prescribing or dispensing.

KALYDECO — Requirements/Limits = PA, QL, SP

Note

Step Edits and Sequences

Coverage feature	Description / When shown	Coverage label
Step therapy (ST)
May require trying a proven, cost‑effective medication before coverage of the requested drug. When commonly required it is noted with 'ST' in the Special Requirements column.
ST indicated where present

Formulary preference	Examples from list	Coverage label
Tier preference for strengths/formulations
Non‑preferred or preferred placement appears by strength/formulation (examples: azithromycin tabs with QL and varying tiers; multiple contraceptive formulations marked AC and tiered).

Observation	Policy examples	Coverage label
No explicit step sequences listed
Many high‑cost antiviral/HCV agents (e.g., EPCLUSA, HARVONI, MAVYRET) are shown with Prior Authorization (PA) and Quantity Limits (QL) and Specialty (SP) where applicable, but explicit ST sequences are not provided in these excerpts.

Product type	Management approach	Coverage label
Specialty oncology drugs
Managed via Specialty Pharmacy (SP) designation and Prior Authorization (PA); many oncology agents also have Quantity Limits (QL) as listed per product.
PA / SP where listed

Category	Notes / access codes	Coverage label
Contraceptives / access designations
Some contraceptive entries carry 'AC' (administrative control) and QL (e.g., 28 tablets/21 days); certain formulations may also show PA where required.
AC or PA as shown

Drug group	Requirements / limits	Coverage label
Specialty antidiabetic injectables (GLP‑1/GIP and GLP‑1 agents)
MOUNJARO, OZEMPIC, TRULICITY and similar agents require Prior Authorization (PA) and have specified Quantity Limits (examples: MOUNJARO QL = 4 pens/28 days or 4 pens/180 days; OZEMPIC QL = 1 pen/28 days or specified ml limits).
PA required

Finding	Source / implication	Coverage label
Step therapy not shown in excerpt
Where step therapy would apply it is indicated in the Requirements/Limits field; this excerpt does not present explicit step sequences for most products.

Scope	Requirement	Coverage label
Several specialty agents
Many specialty agents (cardiology/PAH, pulmonary, cystic fibrosis and other specialties) require Prior Authorization (PA); step therapy details are not specified in these entries.
PA required where listed

Indicator	Examples / location in list	Coverage label
Step therapy (SP) flagged for specialty agents
Numerous specialty products are shown with 'SP' and may also have 'ST' noted in Requirements/Limits for step edits; examples and SP flags appear throughout the Requirements/Limits columns for specialty drugs.
SP / ST where listed

Example item	Requirements/Limits shown	Coverage label
Risperidone orally disintegrating tablets (ODT)
Requirements/Limits = QL (60 tablets/30 days), ST for some ODT strengths.
ST

Policy note	Operational effect	Coverage label
Entries marked 'ST' require step therapy
Prescribers must follow the specified step edits (try required alternative therapies first) where 'ST' appears in the Requirements/Limits column; coverage is contingent on meeting the step requirement or obtaining an approved exception/override.
ST required

Quantity Limits (QL) by Product

inv-111: Quantity limits overview — limits may apply and are noted with 'QL' in Requirements/Limits.

Quantity limits overviewQuantity limits (QL) may apply to listed drugs and are shown as 'QL' in the Requirements/Limits column

EffectLimits specify maximum quantity in a defined time window (e.g., tablets/30 days, mls/30 days)

Provider actionWhen QL is present, prescribers must supply documentation to justify quantities exceeding the limit (PA may also be required)

inv-112: Azithromycin tab 250/500/600 mg — QL 60

Azithromycin tabsQL 60 (250 mg, 500 mg, 600 mg formulations)

Where listedShown as QL (60 tablets/180 days) in the macrolides section

NotesDispensing window may be shown as 180 days for some formulations

inv-113: ARIKAYCE — amikacin liposome inhal suspension 590 mg/8.4 ml — QL 235.2.

ARIKAYCE (amikacin liposome inhal suspension 590 mg/8.4 ml)QL 235.2 mls/28 days

RequirementsEntry notes PA and SP in addition to QL

Unitmilliliters per 28 days

inv-114: KITABIS PAK — tobramycin nebu solution 300 mg/5 ml — QL 56.

KITABIS PAK (tobramycin nebu solution 300 mg/5 ml)QL 56 containers/56 days

RequirementsListed with PA and SP in the aminoglycosides section

Interval56-day dispensing window

inv-115: Itraconazole cap 100 mg — QL 120

Itraconazole cap 100 mgQL 120 tablets/30 days

SectionListed under antifungals with QL indicated

Unittablets per 30 days

inv-116: Posaconazole / voriconazole formulations — QL 1200.

Posaconazole / Voriconazole formulationsQL 1200 (ml-equivalent or stated formulation windows)

RequirementsSome formulations list PA in addition to the QL

Unitmls/30 days or equivalent per entry

inv-117: Multiple antiretrovirals (Biktarvy, Truvada, Descovy) — QL 30.

Multiple antiretrovirals (examples)QL 30 tablets/30 days (Biktarvy, Truvada, Descovy and similar agents)

ContextCommonly shown with QL 30 in the antivirals/HIV entries

Provider noteSome entries also include AC/PA flags where applicable

inv-118: EDURANT PED oral suspension — 1200 mls/30 days

EDURANT PED (rilpivirine) oral suspension 2.5 mg)QL 1200 mls/30 days

Where listedShown with QL in the antiviral section

Unitmilliliters per 30 days

inv-119: Representative antiviral/antiretroviral examples commonly QL 30 tablets/30 days or other windows (60,90,120,180 days).

Representative antiviral/antiretroviral examplesCommonly QL 30 tablets/30 days; other windows shown include 60, 90, 120, 180 days depending on product

ScopeExamples include Truvada, Complera, ISENTRESS, GENVOYA, HARVONI, MAVYRET, SOVALDI, VOSEVI, PAXLOVID

Where to confirmSee individual drug entries for exact QL and any PA/SP flags

inv-120: rifaximin (XIFAXAN) 550 mg — QL 60 tablets/30 days

rifaximin (XIFAXAN) 550 mgQL 60 tablets/30 days

NotesListed under anti-infectives with QL specified

Unittablets per 30 days

inv-121: Multiple specialty/oncology drugs — various QL values as listed (e.g., 120, 240, 90, 60, 30 tablets/30 days).

Multiple specialty/oncology drugsVarious QL values as listed (examples include 120, 240, 90, 60, 30 tablets/30 days depending on product)

RequirementMany entries also require PA and are designated SP

ActionRefer to each product line for the exact QL, PA and SP flags

inv-122: acalabrutinib 100 mg — QL 60 tablets.

acalabrutinib 100 mg (CALQUENCE)QL 60 tablets/30 days

ContextListed with PA and SP in the antineoplastics section

Unittablets per 30 days

inv-123: vandetanib 100 mg — QL 60 tablets.

vandetanib 100 mg (CAPRELSA)QL 60 tablets/30 days

ContextEntry includes PA and SP

Unittablets per 30 days

inv-124: vandetanib 300 mg — QL 30 tablets.

vandetanib 300 mg (CAPRELSA)QL 30 tablets/30 days

ContextListed with PA and SP as in the oncology section

Unittablets per 30 days

inv-125: cabozantinib kit (COMETRIQ) — QL 1 carton.

cabozantinib kit (COMETRIQ)QL 1 carton/28 days

RequirementsEntry lists PA, QL and SP for kit formulations

IntervalCarton per 28 days

inv-126: ibrutinib oral suspension 70 mg/ml — QL 216 mls.

ibrutinib oral suspension 70 mg/mlQL 216 mls/30 days

ContextListed with PA and SP in oncology agents

Unitmilliliters per 30 days

inv-127: imatinib 100 mg — QL 90 tablets.

imatinib 100 mg (Gleevec)QL 90 tablets/30 days

RequirementEntry shows PA and SP designation

Unittablets per 30 days

inv-128: olaparib 100/150 mg — QL 120 tablets.

olaparib (LYNPARZA) 100/150 mgQL 120 tablets/30 days

ContextListed with PA and SP in the antineoplastics section

Unittablets per 30 days

inv-129: RETEVMO 40 mg — QL 90 tablets; 80/120/160 mg — QL 60 tablets.

RETEVMO 40 mgQL 90 tablets/30 days

RETEVMO 80/120/160 mgQL 60 tablets/30 days

ContextEntries list PA and SP designations

inv-131: RUBRACA 200/250/300 mg — QL 120 tablets.

RUBRACA (rucaparib) 200/250/300 mgQL 120 tablets/30 days

ContextListed with PA and SP in oncology section

Unittablets per 30 days

inv-132: TUKYSA 50 mg — QL 300 tablets.

TUKYSA (tucatinib) 50 mgQL 300 tablets/30 days

ContextListed with PA and SP in targeted therapy section

Unittablets per 30 days

inv-133: TAGRISSO 40/80 mg — QL 30 tablets.

TAGRISSO (osimertinib) 40/80 mgQL 30 tablets/30 days

ContextListed with PA and SP in oncology entries

Unittablets per 30 days

inv-134: Testosterone cypionate IM — QL 10 ml.

Testosterone cypionate IM injQL 10 ml/28 days

ContextListed under androgen-anabolic products with QL specified

Unitmilliliters per 28 days

inv-135: ANNOVERA (vaginal ring) — QL 1 ring.

ANNOVERA (segesterone acetate-ethinyl estradiol vaginal ring)QL 1 ring (365 days)

RequirementsListed with AC and QL in contraceptive section

IntervalOne ring per 365 days

inv-136: ANNOVERA — QL 1 ring/365 days

ANNOVERA (yearly)QL 1 ring/365 days

NotesAppears as AC, QL in the contraceptives section

Provider noteAdministrative control (AC) may apply as listed

inv-137: Oral contraceptives (many formulations) — QL 28 tablets/21 days

Oral contraceptives (many formulations)QL commonly 28 tablets/21 days

ContextListed with AC and QL flags in the contraceptive section

IntervalTypically per 21- or 28-day cycle depending on product

inv-138: ELLA (ulipristal) — QL 2 tablets/365 days

ELLA (ulipristal acetate)QL 2 tablets/365 days

RequirementListed with AC and annual QL in contraceptive/EC section

Unittablets per 365 days

inv-139: MOUNJARO — QL 4 pens/180 days or 4 pens/28 days (strength-dependent)

MOUNJARO (tirzepatide)QL 4 pens/180 days or 4 pens/28 days (strength-dependent)

RequirementEntry indicates PA and QL; strength affects dispensing window

ActionRefer to specific strength line for exact QL interval

inv-140: OZEMPIC — QL 1 pen/28 days for lower-dose pens; larger pens QL 3 ml/28 days

OZEMPIC (semaglutide pen)QL 1 pen/28 days for lower-dose pens; larger-volume pens QL 3 ml/28 days

RequirementsListed with PA and QL in GLP-1 category

Unitpen or milliliters per 28 days depending on presentation

inv-141: RYBELSUS — QL varies by strength (30 tablets/180 days for 3 mg; 30 tablets/30 days for 7 mg and 14 mg)

RYBELSUS (semaglutide tablets)QL 30 tablets/180 days for 3 mg; 30 tablets/30 days for 7 mg and 14 mg

RequirementListed with PA and QL in antidiabetic section

IntervalDifferent QL windows by strength

inv-142: FIASP, HUMALOG — QL 100 mls/30 days for insulin formulations

FIASP / HUMALOG (insulin formulations)QL 100 mls/30 days (typical for rapid-acting insulin presentations)

ContextListed under Rapid-Acting Insulins with QL specified

Unitmilliliters per 30 days

inv-143: JANUMET — QL 60 tablets/30 days for some formulations

JANUMET (some formulations)QL 60 tablets/30 days

ContextListed with QL in the antidiabetic section

Unittablets per 30 days

inv-144: MENOPUR — QL 60 vials

MENOPUR (menotropins) for injectionQL 60 vials/30 days

RequirementsListed with QL and SP in fertility medications section

Unitvials per 30 days

inv-145: MYCAPSSA — QL 120 capsules

MYCAPSSA (octreotide delayed-release) 20 mgQL 120 capsules/30 days

RequirementsEntry notes PA, QL and SP for this specialty product

Unitcapsules per 30 days

inv-146: OVIDREL — QL 2 syringes

OVIDREL (choriogonadotropin alfa) prefilled syringe 250 mcg/0.5 mlQL 2 syringes/30 days

ContextListed with QL and SP in fertility agents

Unitsyringes per 30 days

inv-147: Multiple specialty injectables — QL values as listed (e.g., SOMAVERT 30 vials; VOXZOGO 30 vials; YORVIPATH 2 pens).

SOMAVERT (pegvisomant)QL 30 vials/30 days

VOXZOGO (vosoritide)QL 30 vials/30 days

YORVIPATH (palopegteriparatide)QL 2 pens/28 days

inv-150: enalapril oral solution (Epaned) — QL 1200 mls

enalapril oral solution (Epaned)QL 1200 mls/30 days

RequirementsEntry lists PA and QL in the cardiovascular agents section

Unitmilliliters per 30 days

inv-151: FUROSCIX — QL 8 kits

FUROSCIX - furosemide subcutaneous cartridge kit 80 mg/10 mlQL 8 kits/180 days

RequirementsEntry requires PA and QL; listed under diuretics/specialty delivery systems

Interval180-day window

inv-152: ADEMPAS — QL 90 tablets

ADEMPAS (riociguat)QL 90 tablets/30 days

RequirementListed with PA, QL and SP in cardiovascular agents

Unittablets per 30 days

inv-153: REPATHA prefilled syringe/pen/cartridge — QL as listed

REPATHA formulationsQL 6 syringes/28 days; 2 cartridges/30 days; 6 pens/28 days

RequirementsEntries include PA and SP as applicable

Unitdevices per specified interval

inv-154: UPTRAVI — QL 60 tablets

UPTRAVI (selexipag)QL 60 tablets/30 days

RequirementsListed with PA and SP in PAH agents

Unittablets per 30 days

inv-155: ORENITRAM — QL values as listed

ORENITRAM (treprostinil diolamine)QL 300 tablets/30 days

ORENITRAM TITRATION KIT MQL 1 pack/180 days

RequirementsPA and SP designations noted

inv-157/158: Pulmonary agent QLs (sildenafil suspension 224 ml; TYVASO refill/starter kit)

sildenafil citrate for suspension 10 mg/mlQL 224 ml/30 days

TYVASO refill kitQL 1 pack/28 days (refill); starter kit 1 kit/180 days

RequirementsPA and SP flags listed for these pulmonary agents

inv-161: TYVASO/related starter & refill kit QLs

TYVASO STARTER KITQL 1 kit (starter)

TYVASO refillQL 1 pack/28 days

WINREVAIRQL 1 kit/21 days

inv-167/168/169: Inhaler QL examples

ASMANEX HFAQL 1 inhaler/30 days or 13 grams/30 days depending on strength

BREO ELLIPTAQL 1 inhaler/30 days (some strengths 60 blisters/30 days)

COMBIVENT RESPIMATQL 2 inhalers/30 days

inv-170/171/173: Examples of inhaled biologic & inhaler QLs

NUCALA presentationsQL 3 ml/28 days or 1 syringe/28 days depending on presentation

SPIRIVA HANDIHALER/RESPIMATQL examples: 30 capsules/30 days or 1 cartridge/30 days

TRELEGY ELLIPTAQL 60 blisters/30 days or 1 inhaler/30 days depending on strength

inv-175: ALYFTREK, KALYDECO, OFEV, ORKAMBI, PIRFENIDONE, PULMOZYME, SYMDEKO, TRIKAFTA — various QLs

Cystic fibrosis and related specialty productsVarious QL values listed (examples: KALYDECO 60; ORKAMBI/TRIKAFTA packets 56; PIRFENIDONE 21/180 days)

RequirementMost such entries include PA and SP as noted

ActionRefer to each product line for the precise QL interval and units

inv-176/177/178: Selected CF agent QLs

KALYDECO (ivacaftor) 150 mgQL 60 tablets/30 days

PIRFENIDONE (Esbriet) 534 mgQL 21 tablets/180 days (or alternate capsule/tablet windows listed)

TRIKAFTA granulesQL 56 packets/28 days

inv-179/180/181: GI and biologic QL examples

pantoprazole (Protonix) tabletsQL 60 tablets/30 days

SEVELAMER carbonate packet (Renvela)QL 1530 packets/365 days

ENTYVIO PEN (vedolizumab)QL 2 pens/28 days

inv-189: Representative QL examples across the formulary

Representative QL rangesMany products across therapeutic classes have QLs (examples span 28–365 day windows with counts like 30, 60, 90, 120, 180 days)

ImplicationProviders must check the specific drug line for exact QL, PA and SP flags before prescribing

Where to confirmSee the drug list entries and Requirements/Limits column (MyPrime.com / bcbsok.com may provide searchable details)

Site of Care and Specialty Pharmacy Routing

Note

Abbreviations and Key Definitions

inv-71: Specialty drugs definition — medications used to treat complex conditions and may require specialty handling.

Specialty drugs definitionMedications used to treat complex conditions that may be oral, topical, or injectable; can be self-administered or administered by a health care professional

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

ReferenceVisit MyPrime.com or bcbsok.com for current specialty drug list

inv-72: Tier definitions — Preferred Generic, Non-Preferred Generic, Preferred Brand, Non-Preferred Brand.

Tier definitionsPreferred Generic (p), Non-Preferred Generic (np), Preferred Brand (P), Non-Preferred Brand (NP), Preferred Specialty (p/np/P), Non-Preferred Specialty (NP)

UsageTier letters shown with each product indicate member payment tier and group-specific coverage where '+'' is present

Where listedTier markers appear next to drug names in the formulary extract

inv-73: QL / PA / SP definitions — QL = Quantity Limit; PA = Prior Authorization; SP = Specialty.

QL / PA / SP abbreviationsQL = Quantity Limit; PA = Prior Authorization; SP = Specialty Pharmacy designation

How shownThese flags appear in the Requirements/Limits column next to each product

Provider implicationPA typically requires prescriber submission of supporting documentation; SP indicates specialty channel management

inv-74: PA definition — Prior Authorization explanation.

PA (Prior Authorization)Prescriber must obtain approval before coverage is provided for drugs listed with 'PA'

Where appliedPA appears for many high-cost antivirals, specialty and oncology agents in the formulary extract

Provider actionSubmit clinical documentation consistent with PA requirements when requesting coverage

inv-75: QL definition — Quantity Limit explanation.

QL (Quantity Limit)Specifies maximum quantity allowed in a time period (e.g., '60 tablets/30 days', '1200 mls/30 days')

How enforcedDisplayed as 'QL' in Requirements/Limits; exceeding QL may result in member responsibility or need for PA/exception

Provider actionIf a greater quantity is needed, prescriber may request PA or an exception per plan process

inv-76: SP definition — Specialty designation explanation.

SP (Specialty)Designation indicating product is managed via specialty pharmacy processes and may require specialty handling or distribution

ImplicationSP items often also have PA and explicit QL; they may require routing to a specialty pharmacy

Where listedSP flag appears in the Requirements/Limits column for many specialty pulmonary, oncology and biologic agents

inv-78: Abbreviations used in Requirements/Limits — PA, QL, SP (and AC where shown).

Abbreviations used in Requirements/LimitsPA = Prior Authorization; QL = Quantity Limit; SP = Specialty Pharmacy; AC = Administrative Control

Where usedThese abbreviations appear in the Requirements/Limits column and next to contraceptive and specialty entries

Provider noteRefer to the individual drug entry for the specific combination of flags (e.g., PA, QL, SP, AC)

Background and Scope

Specialty drugs are therapies used to manage complex, often chronic or rare conditions (examples cited by the plan include hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis). These products may be oral, topical, or injectable and can require special handling, distribution, or clinical oversight. The Drug List is developed by a committee of physicians and pharmacists who consider FDA regulation, safety, efficacy, and cost when selecting products. Many specialty agents are designated SP (managed through specialty pharmacy channels) and may also require prior authorization (PA) and/or specific quantity limits (QL); some medications administered by a health care professional may instead be processed under the medical benefit rather than the pharmacy benefit.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Formulary & Utilization Controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting documentation when a drug is listed with 'PA' or 'PA, QL' to avoid claim denial.

SourceLink

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2025 Drug List (Pharmacy Benefit) — Formulary, Utilization Management, and Specialty Drug Guidance

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Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Formulary & Utilization Controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting documentation when a drug is listed with 'PA' or 'PA, QL' to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+distinct drug line-items in this extract

multipleentries with PA or QL

MyPrime.comwebsites for current list

30/90day supply guidance

OKapplicability

Coverage and General Pharmacy Rules

General pharmacy coverage

Covered when ALL of the following are met:

General coverage conditions: Drug is listed on the BCBSOK Drug List (the member’s plan drug list) and the member’s specific benefit includes coverage for the drug category;

From statement that all available covered drugs are shown and drugs not shown are not covered.

Reflects non‑FDA‑approved drugs exclusion and limitation to FDA‑approved labeling/guidelines.

Derived from PA/ST/QL descriptions and guidance to check Special Requirements column.

Based on statements that SP products are managed through specialty pharmacy and that medications administered by providers may be medical‑benefit rather than pharmacy.

From exception process timelines and consequences for exceeding QL or lacking PA.

Drug List and Coding References

Drug list (no CPT/ICD/NDC codes in these chunks)mixed

none	This extract contains drug names, tiers and requirement flags but no procedure or diagnosis codes.

inv-05: Example Quantity Limit — 60 tablets/30 days

Example QL60 tablets/30 days

ContextIllustrative example quantity limit from the drug list

Where notedShown as QL in the Requirements/Limits column

inv-06: Example Quantity Limit — 30 tablets/30 days

Example QL30 tablets/30 days

ContextIllustrative example quantity limit from the drug list

Where notedShown as QL in the Requirements/Limits column

inv-07: Enalapril oral solution quantity limit (1200 mls/30 days)

Enalapril oral solution (Epaned)QL 1200 mls/30 days

RequirementsListed with PA and QL in the drug list entry

Unitmilliliters per 30 days

inv-08: FUROSCIX quantity limit (8 kits/180 days)

FUROSCIX (furosemide subcutaneous cartridge kit)QL 8 kits/180 days

RequirementsEntry lists PA and QL for the kit

Interval180-day window

inv-09: REPATHA syringe/pen/cartridge quantity limits

REPATHA - prefilled syringeQL 6 syringes/28 days

REPATHA - cartridge (Pushtronex)QL 2 cartridges/30 days

REPATHA - SureClick/penQL 6 pens/28 days

inv-10: ADEMPAS quantity limit (90 tablets/30 days)

ADEMPAS (riociguat)QL 90 tablets/30 days

RequirementsListed with PA and QL in the cardiovascular agents section

Unittablets per 30 days

inv-11: UPTRAVI quantity limit (60 tablets/30 days)

UPTRAVI (selexipag)QL 60 tablets/30 days

RequirementsEntry lists PA and QL and SP designation

Unittablets per 30 days

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Prior Authorization

Obtain Prior Authorization when 'PA' is listed

Prior Authorization

PA required for select inhaled/specialty agents

ARIKAYCE — Requirements/Limits = PA, QL (235.2 mls/28 days), SP
KITABIS PAK — Requirements/Limits = PA, QL (56 containers/56 days), SP

Prior Authorization

PA required for select antivirals / HCV regimens

EPCLUSA, HARVONI, MAVYRET, SOVALDI — listed with Requirements/Limits = PA, QL and SP

Prior Authorization

PA required for many specialty/oncology agents

Many oncology and specialty drugs in this section show “PA” in Requirements/Limits; prescribers must secure prior authorization before these specialty/oncology agents will be covered.

Examples: abiraterone (Zytiga) Requirements/Limits = PA, QL, SP; many antineoplastics list PA and SP

Prior Authorization

PA plus quantity limits required for specialty agents

Prescribers must obtain prior authorization and comply with quantity limits (QL) for many oncology and specialty drugs; individual entries list the exact QL and SP designations that must be honored.

Examples show PA plus QL (e.g., acalabrutinib PA, QL 60 tablets/30 days, SP)

Prior Authorization

Obtain PA before coverage is allowed

Providers must request prior authorization for drugs where the Requirements/Limits column indicates “PA”; coverage will not be allowed until the PA is approved per the plan’s process.

Prior Authorization

PA and QL required for select antidiabetic injectables

Certain GLP‑1 and related antidiabetic injectables require prior authorization and have specified quantity limits; submit PA and ensure requested quantities match the QL for the listed strength.

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 or 3 mL/28 days depending on presentation)
RYBELSUS, TRULICITY — listed with PA and QL

Prior Authorization

PA required for listed specialty products

Prescribers must obtain prior authorization for the listed specialty products; check each product line (e.g., MYALEPT, OMNITROPE) for the PA notation before dispensing.

MYALEPT — Requirements/Limits = PA, SP
OMNITROPE — Requirements/Limits = PA, SP

Prior Authorization

PA required for specialty pulmonary/cardiac agents

Prior authorization is required for multiple specialty agents including PAH and cardiology therapies; confirm PA (and any QL/SP) on products such as ADEMPAS, REPATHA and CAMZYOS before coverage.

ADEMPAS — Requirements/Limits = PA, QL (90 tablets/30 days), SP
REPATHA — Requirements/Limits = PA, QL (device-specific limits), SP

Prior Authorization

PA required for many specialty / high‑cost drugs

Specialty products frequently show Requirements/Limits = PA and SP (see individual entries for QL)

Prior Authorization

PA required for specified specialty agents

KALYDECO — Requirements/Limits = PA, QL (60 tablets/30 days), SP
TRIKAFTA — Requirements/Limits = PA, QL (56 packets/28 days or 90 tablets/30 days), SP

Prior Authorization

PA required for select listed drugs

IMCIVREE — Requirements/Limits = PA, QL (10 vials/30 days), SP
WEGOVY — Requirements/Limits = PA, QL (8 pens/180 days or 4 pens/28 days), SP

Prior Authorization

PA required for other listed drugs

Prior authorization is required for additional listed drugs such as fingolimod and other Part 15 entries; coverage may be denied if PA is not obtained.

GILENYA (fingolimod) — fingolimod 0.25 mg requires PA and QL in some presentations

Denial Risk

Risk of denial if PA not obtained

Coverage may be denied if prior authorization is not obtained for drugs labeled “PA” in the Requirements/Limits column; providers must secure PA per the plan’s process to avoid claim denials.

Step Therapy

Follow Step Therapy when 'ST' is shown

Some benefit plans use step therapy; when a drug is marked “ST” in Requirements/Limits the member may need to try a preferred alternative first before the requested drug is covered.

If “ST” appears next to a drug, follow the plan’s step therapy sequence before requesting PA (if applicable).

Note

Follow payer operational procedures for PA and exceptions

Follow nearby operational instructions and payer contact procedures for PA submissions, exceptions, and utilization management as noted in the drug list and exception process.

Call the number on the member’s ID card for exception requests or questions.
Refer to the drug’s Requirements/Limits line for exact PA/ST/QL flags.

Note

No step therapy sequences shown here — check Requirements/Limits

Step therapy specifics are not shown in this excerpt; where step therapy applies it will be indicated in the Requirements/Limits field next to the drug (look for “ST”).

Note

Observe access (AC) / administrative codes where shown

Some entries include access (AC) or administrative designations; when present these codes and any accompanying “ST”/“PA” notes must be followed as indicated in the Requirements/Limits column.

Contraceptive examples show AC and QL — follow the access/administrative instructions listed.

Note

Step therapy details not present — verify per line-item

This extract does not include explicit step therapy sequences for most drugs; verify the Requirements/Limits column for any “ST” instructions when prescribing.

Step Therapy

Step therapy / step edits apply to many specialty agents

Many specialty agents are flagged with step edits (SP/ST) in Requirements/Limits; prescribers must follow the step therapy or specialty access rules listed for each product.

SP flags often accompany PA and QL for specialty drugs — follow specialty routing and step edits as indicated.

Step Therapy

Adhere to step therapy edits for 'ST'‑flagged products

Risperidone ODT, Secuado patch, Versacloz suspension — listed with ST in Requirements/Limits

Step Therapy

Comply with step therapy for entries marked 'ST'

When a drug’s Requirements/Limits field lists “ST,” prescribers must follow the step therapy rules indicated for coverage of that product (examples include Gralise entries).

Gralise (gabapentin once-daily) entries include ST and QL — follow step requirements.

Documentation Required

Submit drug list exceptions by phone; note decision timelines

For Drug List exceptions, prescribers or members must call the number on the member’s ID card; BCBSOK will notify the decision within 15 calendar days (or 72 hours for expedited requests).

Expedited requests: decision within 72 calendar hours.
Standard requests: decision within 15 calendar days.

Documentation Required

Include supporting documentation with PA/QL requests

Include diagnosis and prior treatment tried when PA or SP is indicated.
Provide quantity/dispensing interval justification when QL is listed.

Documentation Required

Supply PA/SP supporting documentation (diagnosis, prior therapy, quantity)

When a product is listed with “PA” or “SP,” prescribers must supply documentation consistent with PA/specialty policies (diagnosis, prior therapy, and quantity rationale) to support coverage.

Documentation Required

PA entries require prior authorization documentation

Documentation Required

Submit PA with quantity and dispensing justification

When a drug line shows both PA and a QL, prescribers must submit prior authorization including justification for the requested quantity and dispensing interval to meet the QL.

Example: submit quantity justification when QL = 60 tablets/30 days is listed.

Documentation Required

Provide clinical rationale when submitting PA

Prescribers must supply the information supporting PA requests for drugs labeled “PA” in the Requirements/Limits field; include clinical rationale and dosing details as needed.

Prior Authorization

MOUNJARO — PA required and observe specified QL

MOUNJARO requires prior authorization and has strength-dependent quantity limits; submit PA and request quantities aligned with the listed QL (4 pens/180 days or 4 pens/28 days as applicable).

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

Note

Adhere to listed utilization controls (PA / QL / SP)

Providers and pharmacies must follow the PA, QL, and SP requirements listed next to each drug; check each product line for the exact utilization controls before dispensing.

Documentation Required

Provide documentation for oral solutions and specialty delivery systems

Enalapril oral solution (Epaned) — Requirements/Limits = PA, QL (1200 mls/30 days)
FUROSCIX — Requirements/Limits = PA, QL (8 kits/180 days)

Documentation Required

Submit documentation to meet PA and QL requirements

When PA and QL are listed, providers should submit prior authorization documentation that satisfies the PA criteria and supports the requested quantity within the QL limits.

Documentation Required

Ensure PA/QL documentation satisfies payer requirements

Prescribers must provide required documentation to satisfy PA and QL rules where indicated for individual drugs; failure to provide sufficient evidence may result in denial.

Billing Rule

Observe and document quantity limits (QL)

Examples: QL (30 tablets/30 days); WEGOVY QL (8 pens/180 days or 4 pens/28 days)

Documentation Required

Submit evidence of necessity and dosing with PA requests

When prior authorization is required, prescribers must supply evidence supporting medical necessity and dosing to meet the listed QL and any SP designation for specialty drugs.

Include clinical necessity, prior treatment failures (if applicable), and dose/quantity calculations.

Denial Risk

Non‑listed or excluded drugs are not covered — denial risk

Drugs not included on the BCBSOK Drug List are not covered under the pharmacy benefit; coverage may be denied if the member’s benefit excludes the drug category or the drug is not FDA‑approved.

Denial Risk

PA required for select inhaled/antifungal agents — denial risk if not obtained

Posaconazole and voriconazole formulations show PA and QL in Requirements/Limits.

Denial Risk

PA required for specific HCV agents — risk of denial

PA is required for certain hepatitis C agents (EPCLUSA, HARVONI, SOVALDI, MAVYRET, VOSEVI); claims submitted without PA may be denied or require retrospective review.

Documentation Required

Ensure specialty authorization/handling for SP‑flagged products

Specialty products flagged “SP” require appropriate specialty authorization and handling; missing specialty authorization or incorrect routing (not using specialty pharmacy) can result in denial.

SP flags often accompany PA and QL for biologics and specialty therapies.

Denial Risk

PA plus QL entries risk denial if requirements not met

Drugs listed with both PA and QL indicate coverage may be denied without PA approval or if the requested quantity exceeds the stated QL; obtain PA and request quantities within limits.

Denial Risk

Claims may be denied without approved PA

Claims for drugs labeled “PA” will be subject to prior authorization; lack of an approved PA at time of claim submission may result in claim denial or member financial responsibility.

Billing Rule

Route SP drugs through specialty pharmacy and secure PA

Specialty drugs designated SP typically require specialty pharmacy routing plus PA; failure to follow specialty channel requirements or obtain PA may lead to denial.

Examples: XOLAIR, KESIMPTA, AVONEX — Requirements/Limits show PA and SP.

Denial Risk

Verify PA and SP for listed products to avoid denial

KALYDECO — Requirements/Limits = PA, QL, SP

Note

Step Edits and Sequences

Coverage feature	Description / When shown	Coverage label
Step therapy (ST)
May require trying a proven, cost‑effective medication before coverage of the requested drug. When commonly required it is noted with 'ST' in the Special Requirements column.
ST indicated where present

Formulary preference	Examples from list	Coverage label
Tier preference for strengths/formulations
Non‑preferred or preferred placement appears by strength/formulation (examples: azithromycin tabs with QL and varying tiers; multiple contraceptive formulations marked AC and tiered).

Observation	Policy examples	Coverage label
No explicit step sequences listed
Many high‑cost antiviral/HCV agents (e.g., EPCLUSA, HARVONI, MAVYRET) are shown with Prior Authorization (PA) and Quantity Limits (QL) and Specialty (SP) where applicable, but explicit ST sequences are not provided in these excerpts.

Product type	Management approach	Coverage label
Specialty oncology drugs
Managed via Specialty Pharmacy (SP) designation and Prior Authorization (PA); many oncology agents also have Quantity Limits (QL) as listed per product.
PA / SP where listed

Category	Notes / access codes	Coverage label
Contraceptives / access designations
Some contraceptive entries carry 'AC' (administrative control) and QL (e.g., 28 tablets/21 days); certain formulations may also show PA where required.
AC or PA as shown

Drug group	Requirements / limits	Coverage label
Specialty antidiabetic injectables (GLP‑1/GIP and GLP‑1 agents)
MOUNJARO, OZEMPIC, TRULICITY and similar agents require Prior Authorization (PA) and have specified Quantity Limits (examples: MOUNJARO QL = 4 pens/28 days or 4 pens/180 days; OZEMPIC QL = 1 pen/28 days or specified ml limits).
PA required

Finding	Source / implication	Coverage label
Step therapy not shown in excerpt
Where step therapy would apply it is indicated in the Requirements/Limits field; this excerpt does not present explicit step sequences for most products.

Scope	Requirement	Coverage label
Several specialty agents
Many specialty agents (cardiology/PAH, pulmonary, cystic fibrosis and other specialties) require Prior Authorization (PA); step therapy details are not specified in these entries.
PA required where listed

Indicator	Examples / location in list	Coverage label
Step therapy (SP) flagged for specialty agents
Numerous specialty products are shown with 'SP' and may also have 'ST' noted in Requirements/Limits for step edits; examples and SP flags appear throughout the Requirements/Limits columns for specialty drugs.
SP / ST where listed

Example item	Requirements/Limits shown	Coverage label
Risperidone orally disintegrating tablets (ODT)
Requirements/Limits = QL (60 tablets/30 days), ST for some ODT strengths.
ST

Policy note	Operational effect	Coverage label
Entries marked 'ST' require step therapy
Prescribers must follow the specified step edits (try required alternative therapies first) where 'ST' appears in the Requirements/Limits column; coverage is contingent on meeting the step requirement or obtaining an approved exception/override.
ST required