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.

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

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.

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).

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.

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.

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.

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.

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.

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

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.

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)

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)

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.

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

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

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)

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)

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.

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.

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.

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.

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.

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.

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).

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.

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

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.

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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.

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

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).

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

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.

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.

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

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.

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.

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.

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

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.

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.

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)

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.

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.

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

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

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

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.