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CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2026 Drug List (Pharmacy Formulary) — Coverage Criteria

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Summarizes BCBSOK covered outpatient pharmacy drugs, drug tiers, and utilization controls (PA, QL, SP, ST, AC) and explains provider/member processes for prior authorization, exceptions, specialty routing, and quantity limits.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List — Coverage Criteria (Pharmacy)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApril 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting clinical documentation when a drug entry is marked 'PA' before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Member tiers described

30/90Typical supply limits

15/72Exception decision timeframes

multipleProducts with QL

severalProducts with PA or SP

statewideApplicability

Formulary Coverage and Requirements

Formulary coverage entries

Drug-tier assignments and utilization controls are listed for each formulary product.

Formulary entries: Each listed product includes a Drug Tier and, where applicable, Requirements/Limits flags such as PA (prior authorization), QL (quantity limit), SP (specialty pharmacy), ST (step therapy), or AC (administrative code).

See individual product lines for tier and requirement flags; absence of a flag indicates no special requirement listed for that formulation.

Per-product formulary coverage with utilization controls

Coverage and utilization controls are shown per product; many products are covered when the listed utilization controls are satisfied.

Example entry HARVONI: HARVONI - ledipasvir-sofosbuvir tab (45-200 mg, 90-400 mg): Drug Tier = P; Requirements/Limits = PA, QL (28 tablets/28 days), SP.QL 28 tablets/28 days

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List — Coverage Criteria (Pharmacy)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApril 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting clinical documentation when a drug entry is marked 'PA' before dispensing.

SourceLink

On This Page

PA and specialty pharmacy required for coverage of this product.

Example entry EPCLUSA: EPCLUSA - sofosbuvir-velpatasvir tab (200-50 mg, 400-100 mg): Drug Tier = P; Requirements/Limits = PA, QL (28 tablets/28 days), SP.QL 28 tablets/28 days

PA and specialty pharmacy required for coverage of this product.

Example entry PREVYMIS: PREVYMIS - letermovir tab (240 mg, 480 mg): Drug Tier = NP; Requirements/Limits = QL (200 tablets/365 days).QL 200 tablets/365 days

Quantity limit applies to dispensing.

Covered when utilization controls satisfied

Coverage of listed drugs requires meeting any utilization controls shown (PA, QL, SP, ST) on the product line.

General condition: Coverage of a listed drug follows the payer's requirements when the entry shows PA, QL, SP, or ST — the prescriber must obtain required prior authorization and adhere to quantity limits and specialty routing as indicated.

Specific clinical medical necessity text is not provided in these listed entries; adherence to the Requirements/Limits fields governs coverage.

Product listing and requirement flags

Product-level coverage flags are shown on each formulation line to indicate required administrative or utilization controls.

Product-level coverage flags: Each product line includes a Drug Tier and may include Requirements/Limits such as PA (prior authorization), QL (quantity limit with timeframe), SP (specialty pharmacy), ST (step therapy), AC (administrative code), or tier designations (P, NP, p, np+).

Examples: REPATHA (PA, QL 6 syringes/28 days); NEXLETOL/NEXLIZET (PA, QL 30 tablets/30 days); JUXTAPID (SP).

Product-level coverage controls

Coverage and utilization controls applied per product line are summarized below; follow the Requirements/Limits shown on the formulary entry.

Formulary entry rule: Each listed product line includes a Drug Tier and, when applicable, Requirements/Limits such as PA, QL (with numeric limit and timeframe), ST, or SP — coverage is contingent on meeting those requirements.

Extract individual quantity limits and flags from the product lines (examples include QL 120 tablets/30 days for certain agents, QL 8 pens/180 days for Wegovy depending on formulation).

The Drug List excludes certain categories and formulations from pharmacy coverage. Drugs not on the Drug List, repackaged medications, compounded medications, and non–FDA-approved drugs are not covered. Some benefit plans also exclude agents that have an over‑the‑counter equivalent or restrict coverage for products used for cosmetic indications or with age-based limits. Prior Authorization (PA) may be required for selected drugs and, when commonly required, is noted in the listing under Special Requirements.

Within the extract provided there are no standalone medical-exclusion rules: entries are presented as formulary lines with drug-tier designations and any Requirements/Limits flags (for example, PA, QL, SP). Coverage determinations therefore depend on the per‑product flags shown rather than separate exclusion language in this segment.

Some product lines in the extract show blank or empty Requirements/Limits fields. Where no flags are listed the listing implies the drug follows the plan's standard coverage and dispensing rules (no special PA/QL/SP noted for that formulation in this excerpt).

The document portion supplied does not include explicit clinical exclusion criteria. Entries are formatted as product-level listings showing Drug Tier and any Requirements/Limits (for example, contraceptives and select antidiabetic agents list PA or QL), so clinical eligibility must be inferred from those per‑product flags or determined via the full prior authorization processes.

For formulations where no PA or QL is indicated in the extract, the listing suggests standard coverage rules apply for that formulation. Absence of a Requirements/Limits marker in this segment does not guarantee no utilization management applies under the member's full benefit — it only indicates none was listed here.

No detailed medical‑necessity criteria are provided in these chunks. The content is a formulary product listing showing tiers (e.g., P, NP) and any requirement flags (PA, QL, SP). Where authorization is required, clinicians must follow the plan's PA process and supply supporting clinical documentation as specified elsewhere.

In this excerpt there are no Not Medically Necessary (NMN) statements. The listing focuses on formulary entries and utilization markers rather than affirmative NMN determinations.

Review of the provided segments did not identify explicit 'not medically necessary' declarations. Coverage stance in these chunks is expressed through tiering and requirement flags rather than NMN language.

Identifiers, Codes, and Quantity Examples

Formulary drug entries (sample)NDC | plainCovered

amoxicillin	amoxicillin (trihydrate) chew tab 125 mg, 250 mg
amoxicillin	amoxicillin (trihydrate) cap 250 mg, 500 mg
amoxicillin	amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
amoxicillin	amoxicillin (trihydrate) tab 500 mg, 875 mg
amoxicillin & k clavulanate	amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate	amoxicillin & k clavulanate for susp 250-62.5 mg/5ml, 400-57 mg/5ml
amoxicillin & k clavulanate	amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)

Formulary entries (drug names and controls)mixed

NDC/HCPCS not listed

Document provides drug names, strengths, tiers and requirements/limits but does not list procedure or billing codes in this extract

Drugs and tiers as listedmixed

No codes listed

Listed drugs and requirement summariesmixed

REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml	Drug entry with Requirements/Limits = PA, QL (6 syringes/28 days)
REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml	Requirements/Limits = PA, QL (6 pens/28 days)
NEXLETOL - bempedoic acid tab 180 mg	Requirements/Limits = PA, QL (30 tablets/30 days)
NEXLIZET - bempedoic acid-ezetimibe tab 180-10 mg	Requirements/Limits = PA, QL (30 tablets/30 days)
ENTRESTO - sacubitril-valsartan sprinkle cap	Requirements/Limits = PA, QL (240 capsules/30 days)
REPATHA / others (examples)	Multiple entries across cardiovascular, pulmonary, allergy, and respiratory agents with tier designations and requirements

NDC / HCPCS not listedmixed

No codes listed

Quantity limits examples — mixed strengths and volumes

Azithromycin (tablets)QL 60 tablets per 180 days

Tobramycin nebulization solution (Tobi)QL 280 mls per 56 days

Itraconazole capsules (Sporanox)QL 120 capsules per 30 days

Example Quantity Limit — common pack/timeframe patterns

Common short-course tabletsQL 30 tablets per 30 days (typical ARV/antiviral tablets)

Extended supply tabletsQL 90 tablets per 30 days (example: MAVYRET)

Annual pack/tablet exampleQL 200 tablets per 365 days (example: PREVYMIS)

Quantity limits examples — cartridges, capsules, vials

FOLLISTIM AQ cartridgesQL 15 cartridges per 30 days (300 unit)

GALAFOLD capsulesQL 14 capsules per 28 days

IMCIVREE vialsQL 10 vials per 30 days

Quantity limits examples — syringes, tablets, pens

REPATHA prefilled syringesQL 6 syringes per 28 days

TRULANCE tabletsQL 30 tablets per 30 days

FASENRA PEN auto-injectorQL 1 pen per 28 days

Quantity limits examples — mid-document examples

CREON pancrelipase strengthsRequirements/Limits listed per strength (no single QL value shown in this segment)

TREMFYA injectionQL 1 syringe or 1 pen per 28 days (depending on formulation)

Lorazepam tabletsQL 150 tablets per 30 days

Wegovy pens limit — specific examples

WEGOVY pens (standard listing)QL 8 pens per 180 days

WEGOVY alternate strength listingQL 4 pens per 28 days

WEGOVY oral tablet formsQL 60 tablets per 180 days (tab formulations noted)

Wegovy pens (alternate strengths) — alternate QL

Wegovy alternate-strength pensQL 4 pens per 28 days (for 1.7 mg/2.4 mg pen formulations)

Wegovy longer-interval packQL 8 pens per 180 days (alternate listing for other strengths)

Wegovy tabletsQL 60 tablets per 180 days (oral formulations noted separately)

Zepbound pens — quantity limit examples

Zepbound pens (general)QL 4 pens per 28 days (listed for some formulations)

Zepbound longer-interval listingQL 4 pens per 180 days (alternate listing depending on pack)

Zepbound designationRequirements/Limits = PA, QL — specialty weight-management listing

Cladribine (MAVENCLAD) QL — pack-dependent examples

MAVENCLAD therapy pack (4-tab)QL 8 tablets per 301 days (example pack-dependent QL)

MAVENCLAD therapy pack (10-tab)QL 20 tablets per 301 days (alternate pack size)

MAVENCLAD general noteRequirements/Limits = PA, QL; QL varies by therapy pack size

Authorization, Documentation, and Dispensing Rules

Prior Authorization

Prior authorization requirement

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

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

Prior Authorization

Prior authorization required

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

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

Prior Authorization

PA required for selected antiviral agents

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

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

Prior Authorization

Prior authorization requirement

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

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

Prior Authorization

Prior authorization required

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

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

Prior Authorization

Selected products require PA

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

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

Prior Authorization

Prior authorization requirement

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

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

Prior Authorization

PA and QL: enalapril oral solution

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

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

Prior Authorization

PA and QL: FUROSCIX

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

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

Prior Authorization

PA and QL: bempedoic acid products

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

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

Prior Authorization

PA and QL: evolocumab products

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

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

Prior Authorization

Prior authorization required for selected specialty drugs

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

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

Prior Authorization

Prior authorization required

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

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

Prior Authorization

PA + QL on injectables

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

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

Prior Authorization

Prior authorization / specialty channel required

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

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

Prior Authorization

Prior authorization: select agents

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

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

Step Therapy

Step therapy usage note

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

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

Step Therapy

Step or utilization signals

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

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

Note

PROVIDER ACTIONS

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

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

Prior Authorization

Prior authorization requirement

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

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

Documentation Required

Access classification noted

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

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

Step Therapy

Step therapy presence

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

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

Prior Authorization

Specialty program/step indicator for lomitapide

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

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

Step Therapy

Step therapy example

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

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

Step Therapy

Step therapy applies to selected branded agents

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

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

Step Therapy

Step therapy present

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

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

Note

Providers or members may request a Drug List exception

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

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

Documentation Required

Documentation for PA/SP

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

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

Prior Authorization

Prior authorization required for select agents

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

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

Documentation Required

Documentation for PA/QL products

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

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

Documentation Required

PA plus QL examples

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

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

Documentation Required

PA documentation

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

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

Documentation Required

Support for step therapy / prior authorization

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

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

Billing Rule

Quantity limit adherence

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

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

Denial Risk

Coverage may be denied if drugs are not

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

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

Prior Authorization

Prior authorization triggers

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

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

Billing Rule

Specialty pharmacy routing

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

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

Billing Rule

Quantity limits enforcement

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

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

Denial Risk

PA and QL enforcement

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

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

Prior Authorization

Prior authorization required for listed drugs

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

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

Prior Authorization

Prior authorization required

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

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

Prior Authorization

Specialty diabetes agents PA

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

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

Denial Risk

PA/Denial risk

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

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

Prior Authorization

Prior authorization required for certain oral solutions

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

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

Prior Authorization

PA and quantity limit for FUROSCIX

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

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

Prior Authorization

PA and QL for bempedoic acid products

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

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

Prior Authorization

PA and QL for PCSK9 inhibitors

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

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

Denial Risk

Prior authorization and quantity limits enforceability

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

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

Prior Authorization

PA required drugs

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

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

Billing Rule

Specialty pharmacy routing

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

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

Prior Authorization

Tasimelteon prior auth / specialty

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

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

Denial Risk

Quantity limit exceedance

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

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

Prior Authorization

Prior authorization required

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

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

Note

Terms and Abbreviations

Specialty drugs — definition and examples

Specialty drugs definitionMedications used to treat complex conditions (e.g., hepatitis, hemophilia, multiple sclerosis, rheumatoid arthritis); may be oral, topical or injectable and often require specialty handling

Specialty pharmacy routingSpecialty-designated products (marked 'SP') are dispensed via specialty pharmacy channels

Coverage/resource locationCurrent specialty medication lists available at MyPrime.com or bcbsok.com

Generic equivalent vs generic alternative — definition

Generic equivalent vs alternativeGeneric equivalent: same active ingredient(s) and dosage as the reference brand; generic alternative: treats same condition but different active ingredient(s)

FDA standardFDA-approved generics meet same safety and efficacy standards as brand products

Member cost implicationMember may pay difference if reference brand is requested instead of generic equivalent

QL — Quantity Limit definition and example

Quantity Limit (QL) definitionMaximum quantity allowed within a specified timeframe (e.g., 60 tablets/180 days); QL appears as 'QL (amount/time period)' in listings

Examples of QL formatShown as number + unit + timeframe (e.g., QL 28 tablets/28 days; QL 224 mls/56 days)

Enforcement noteClaims exceeding QL may be denied or require prior authorization or override

PA — Prior Authorization definition

Prior Authorization (PA) definitionPrior Authorization: approval required before coverage is granted for the medication; indicated by 'PA' in Requirements/Limits

Provider actionProviders must submit PA requests with supporting documentation when 'PA' is listed

Denial riskCoverage may be denied if PA is required but not obtained

SP — Specialty Pharmacy definition

Specialty Pharmacy (SP) definitionSpecialty Pharmacy: products designated 'SP' require dispensing via a specialty pharmacy channel and often include PA/QL controls

Site-of-care implicationSP-designated products may require specialized distribution or administration planning

Where to confirmSpecialty routing noted on the drug list entries for affected products

QL abbreviation reiterated

QL abbreviationQL = Quantity Limit (maximum permitted quantity over a timeframe)

UsageUsed throughout the drug list to limit units dispensed per period

Example formattingDisplayed as 'QL (amount/unit/timeframe)' next to a formulation

PA abbreviation reiterated

PA abbreviationPA = Prior Authorization (approval required before coverage)

IndicatorAppears in the Requirements/Limits column when required

Provider requirementPA requests typically need diagnosis and prior therapy documentation

SP abbreviation reiterated

SP abbreviationSP = Specialty Pharmacy handling requirement

ImplicationSP entries often coincide with PA and QL controls

Routing riskFailing to route SP drugs through specialty pharmacy may result in claim denial

AC — Administrative Code for vaccines

AC code (vaccines)AC = Administrative Code or coverage administrative condition; appears next to many vaccines in the listing

Operational noteAC is shown on vaccine entries in the Requirements/Limits column

Confirm specificsRefer to plan materials for AC operational interpretation

QL — contraceptive examples

Contraceptive QL examplesQL examples include 28 tablets per 21 days and 1 ring per 365 days for certain products

AC alongside QLContraceptive entries often show 'AC' plus a QL (e.g., ANNOVERA QL 1 ring/365 days)

Prescriber/member actionFollow listed QL/AC when dispensing contraceptives

PA — prior authorization definition for listed drugs

PA for listed drugs'PA' indicates prior authorization is required for coverage of the listed drug (providers must obtain approval before dispensing)

ExamplesMany specialty and high-cost agents (e.g., MYFEMBREE, ORIAHNN) are marked PA

DocumentationPA requests should include clinical justification and prior therapy where applicable

AC — access classification code presence near contraceptives

AC presence near contraceptivesAccess classification code 'AC' appears adjacent to many contraceptive entries (operational meaning in plan materials)

Example entriesANNOVERA and many oral contraceptives show AC in Requirements/Limits

Provider noteConfirm AC handling per plan documentation when submitting claims

SP — specialty pharmacy routing present next to many agents

SP designation next to agents'SP' appears next to many specialty or high-cost agents indicating specialty pharmacy routing

ImplicationSP entries frequently require PA and QL in addition to specialty dispensing

ExamplesFOLLISTIM AQ, IMCIVREE, many biologics listed with SP

QL — quantity limit with amount/timeframe example

QL amount/timeframe formattingQuantity limits specified as amount/unit and timeframe (e.g., 6 syringes/28 days; 30 tablets/30 days)

ExamplesREPATHA 6 syringes/28 days; ATTRUBY 112 tablets/28 days

EnforcementClaims exceeding the listed QL may be denied or require PA override

PA — prior authorization reiterated

PA reiteratedPA = Prior Authorization — approval required before coverage

Where shownDisplayed in Requirements/Limits column next to applicable products

Provider taskSubmit PA with supporting clinical information

Drug Tier — p/P preferred and np/NP non-preferred designations

Drug tier designationsDrug tiers shown as p/P (preferred) or np/NP (non-preferred) beside each formulation

Specialty tieringPreferred specialty drugs may be shown as lower-case bold or CAPITAL with 'SP' flag

Plan-specific modifiers'+' indicates group-specific coverage variations; consult benefit plan materials

PA, QL, SP — short definitions together

PA / QL / SP — key abbreviationsPA = Prior Authorization; QL = Quantity Limit; SP = Specialty Pharmacy — these appear together in Requirements/Limits

Operational meaningTheir presence indicates provider obligations (PA submission), dispensing limits (QL), and routing (SP)

ExamplesHARVONI = PA, QL (28/28 days), SP; REPATHA = PA, QL (6/28 days)

PA — prior authorization definition (additional segment)

PA definition (additional)PA indicates prior approval is required before the plan will cover the medication

TriggerProducts listed with 'PA' will trigger a prior authorization requirement at point of dispensing

ExamplesARIKAYCE, HARVONI, MAVYRET commonly shown with PA

QL — quantity limit definition (additional segment)

QL definition (additional)QL limits the maximum quantity over a specified timeframe (e.g., 60 tablets/180 days)

DisplayShown as 'QL (amount/unit/timeframe)' in the Requirements/Limits column

PurposeUsed to manage utilization and control dispensing frequency

SP — specialty pharmacy definition (additional segment)

SP definition (additional)SP indicates specialty pharmacy dispensing and often accompanies PA and QL

Implication for claimsSP routing may be enforced at claim adjudication and failure to route may delay or deny coverage

ExamplesMany biologics and specialty injectables are marked SP

ST — Step Therapy definition

ST — Step Therapy definitionST = Step Therapy — prior trial of preferred agents required before coverage of the listed drug

Where usedDisplayed as 'ST' in Requirements/Limits for selected branded agents (e.g., AUVELITY)

Provider actionPrescribers must document prior steps or failure when submitting PA for ST drugs

AC — age/coverage condition code presence

AC — age/coverage code presenceAC appears as an administrative/coverage code on some entries (often contraceptives); plan materials clarify meaning

InterpretationAC likely relates to access classification or administrative handling

ActionConfirm AC handling per plan documentation when processing claims

PA — prior authorization (further segment)

PA (further segment)PA indicates prior authorization required and is commonly paired with QL and/or SP on the drug list

EffectFailure to obtain PA when indicated may lead to claim denial

ExamplesMYFEMBREE, MOUNJARO, OZEMPIC listed with PA in the drug list

QL — quantity limit (additional segment)

QL (additional)QL limits specified as amount per timeframe (e.g., 28 tablets/21 days; 1 ring/365 days)

Contraceptive examplesMany oral contraceptives listed with QL 28 tablets/21 days

EnforcementClaims must adhere to the listed QL when adjudicated

SP — specialty pharmacy designation (additional segment)

SP designation (additional)SP = Specialty Pharmacy routing required for many high-cost or biologic agents

Operational noteSP entries often require coordination with specialty pharmacy providers

ExamplesFOLLISTIM AQ, GENOTROPIN, many oncology/rare-disease therapies marked SP

ST — step therapy abbreviation (additional segment)

ST abbreviation (additional)ST = Step Therapy — prior trial requirements before coverage (appears for select branded drugs)

ExampleAUVELITY is marked ST in the drug list

Provider implicationDocument prior therapy trials when submitting requests for ST drugs

Step and Initial Therapy Rules

Step therapy

Step therapy entries present in this segment require prior trial(s) as shown on specific product lines.

AUVELITY step therapy: AUVELITY (dextromethorphan HBr–bupropion) is designated 'ST' — step therapy must be met prior to coverage.

From formulary entry: AUVELITY Requirements/Limits = ST (chunk 234).

FETZIMA step therapy: FETZIMA (levomilnacipran ER) is designated 'ST' — step therapy must be met prior to coverage.

FETZIMA and other branded antidepressants are marked ST in the listing (chunks 236 and related).

TRINTELLIX step therapy: TRINTELLIX (vortioxetine) is designated 'ST' — step therapy must be met prior to coverage.

TRINTELLIX is marked ST on the formulary (chunk 236).

RISPERIDONE/SECUADO step therapy: Selected risperidone formulations (including ODT) and SECUADO patch are listed with 'ST' — step therapy applies for these formulations.

Formulary entries indicate ST for these products (chunks 247–248).

Gralise/HORIZANT step therapy: Some gabapentin formulations (Gralise) and HORIZANT are marked 'ST' — step therapy must be followed prior to coverage.

Step therapy flags appear on these neurology agents (chunk 264).

Product / formulation	Drug Tier	Requirements / Limits
BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 30-120-15 mg, 50-200-25 mg	P	QL (30 tablets/30 days)
EPCLUSA - sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg	P	PA, QL (28 tablets/28 days), SP
HARVONI - ledipasvir-sofosbuvir tab 45-200 mg, 90-400 mg	P	PA, QL (28 tablets/28 days), SP
MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg	P	PA, QL (90 tablets/30 days), SP
GENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg	P	QL (30 tablets/30 days)
PAXLOVID - nirmatrelvir/ritonavir pack (various)	P	QL (11–30 tablets/90 days depending on pack)

Product / formulation	Drug Tier	Requirements / Limits
EPCLUSA - sofosbuvir-velpatasvir tab (hepatitis C)	P	PA, QL (28 tablets/28 days), SP
PEGASYS - peginterferon alfa-2a prefilled syr/ inj	P	PA, SP
LIVTENCITY - maribavir tab 200 mg	NP	SP

Product / formulation	Drug Tier	Requirements / Limits
Various oncology/specialty entries (examples shown) - CAPRELSA, COMETRIQ, COPIKTRA	P / NP (varies)	PA, QL, SP (used to enforce specialty/step edits)
NEXLETOL / NEXLIZET - bempedoic acid +/- ezetimibe	P	PA, QL (30 tablets/30 days)
REPATHA - evolocumab (prefilled syringe / auto-injector)	P	PA, QL (6 syringes or 6 pens/28 days)

Product / formulation	Drug Tier	Requirements / Limits
ANNOVERA - segesterone acetate-ethinyl estradiol vaginal ring	NP	AC, QL (1 ring/365 days)
Multiple oral contraceptives (examples: ARANELLE, AVERI, desogestrel-ethinyl estradiol formulations)	P / NP (varies)	AC, QL (28 tablets/21 days) commonly listed
Transdermal patches (selected brands)	P	AC, QL (3 patches/21 days) in some entries

Product / formulation	Drug Tier	Requirements / Limits
KERENDIA - finerenone tab 10 mg, 20 mg, 40 mg	P	QL (30 tablets/30 days), ST

Product / formulation	Drug Tier	Requirements / Limits
JUXTAPID - lomitapide mesylate cap (5, 10, 20, 30 mg)	NP	SP

Product / formulation	Drug Tier	Requirements / Limits
ADEMPAS - riociguat tablets (various strengths)	NP	PA, QL (90 tablets/30 days), SP
Ambrisentan (Letairis) - tablet 5 mg, 10 mg	NP	PA, QL (30 tablets/30 days), SP
REPATHA (evolocumab) - prefilled syringe / SURECLICK auto-injector	P	PA, QL (6 syringes/28 days or 6 pens/28 days)

Product / formulation	Drug Tier	Requirements / Limits
NEXLETOL - bempedoic acid tab 180 mg	P	PA, QL (30 tablets/30 days)
NEXLIZET - bempedoic acid-ezetimibe tab 180-10 mg	P	PA, QL (30 tablets/30 days)
ATTRUBY - acoramidis tab pack	P	PA, QL (112 tablets/28 days)

Product / formulation	Drug Tier	Requirements / Limits
AUVELITY - dextromethorphan hbr-bupropion tab ER 45-105 mg	NP	ST

Product / formulation	Drug Tier	Requirements / Limits
FETZIMA - levomilnacipran HCl ER cap (20, 40, 80, 120 mg)	NP	ST

Product / formulation	Drug Tier	Requirements / Limits
TRINTELLIX - vortioxetine HBr tab 5, 10, 20 mg	NP	ST

Product / formulation	Drug Tier	Requirements / Limits
FANAPT - iloperidone tab (various strengths)	NP	QL (60 tablets/30 days), ST
FANAPT TITRATION PACK (various)	NP	QL (1 pack/180 days), ST

Product / formulation	Drug Tier	Requirements / Limits
RISPERIDONE ODT - risperidone orally disintegrating tab (various strengths)	NP	QL (60 tablets/30 days), ST
SECUADO - asenapine transdermal patch (3.8, 5.7, 7.6 mg/24hr)	NP	QL (30 patches/30 days), ST

Product / formulation	Drug Tier	Requirements / Limits
Gralise - gabapentin once-daily tab (300, 450, 750 mg)	NP	QL (30 tablets/30 days), ST
HORIZANT - gabapentin enacarbil formulations	NP	ST

Quantity Limits (QL) by Product

Specialty Pharmacy and Administration Settings

Note

Formulary Background and Scope

The formulary classifies drugs by therapeutic class and the product's first FDA‑approved use, and uses tier designations to indicate preferred status. Specialty drugs and products requiring administration by a health care professional may be routed through a specialty pharmacy (SP) or require additional handling; selection of covered products is guided by FDA approval, clinical evidence, and a multi‑disciplinary review committee.