2025 Drug List (Pharmacy Benefit) — Formulary, Tiering, and Utilization Controls

Obtain prior authorization for PA‑designated drugs

Providers must obtain prior authorization (PA) when a medication’s Requirements/Limits field lists “PA” — approval is required before the plan will cover the drug.

• PA is noted in the Special Requirements column for medications where it commonly applies.
• If PA is not obtained when required, the claim may be denied.

PA required for inhaled aminoglycoside agents (e.g., ARIKAYCE, tobramycin)

Medications shown with “PA” in the listing require prior authorization before coverage; examples in the formulary include ARIKAYCE (amikacin liposome inhalation) and tobramycin nebulizer products.

• ARIKAYCE — Requirements/Limits = PA, QL (235.2 mls/28 days), SP.
• KITABIS PAK / tobramycin nebu soln — Requirements/Limits include PA/QL/SP as shown on the line items.

Secure PA for listed antiviral/hepatitis agents (e.g., EPCLUSA)

Several antiviral and antiviral combination agents are listed with Prior Authorization (PA); providers must submit and secure PA before coverage for these agents.

• EPCLUSA (sofosbuvir‑velpatasvir) — Requirements/Limits = PA, QL (30 tablets/30 days), SP.
• Other hepatitis/antiviral agents (e.g., HARVONI, MAVYRET, SOVALDI) are similarly annotated with PA.

Obtain PA for oncology/specialty agents

Numerous oncology and other specialty oral targeted agents require prior authorization; providers must request PA and provide supporting documentation per the formulary line.

• Examples: ALUNBRIG, BOSULIF, CABOMETYX, many others show Requirements/Limits = PA and QL, often with SP.
• Therapy packs and initiation kits also require PA (e.g., ALUNBRIG initiation pack = PA, QL 1 pack/180 days).

Follow AC vs PA designations for vaccines

Vaccines listed with “AC” are administrative coverage items and do not use PA; when a vaccine line shows PA instead of AC, prior authorization must be obtained before coverage.

• Most vaccine entries in the excerpt show Requirements/Limits = AC (administrative coverage).
• If a vaccine/formulation lists PA, follow the PA process prior to dispensing.

PA required for oral oncology agents

Oral oncology and other specialty oral agents are frequently listed with PA; providers must obtain prior authorization before coverage for these oral specialty agents.

• Many oral oncology agents show Requirements/Limits = PA and QL (e.g., BOSULIF, OGSIVEO).
• Check each drug line for presentation‑specific QL and PA requirements.

Request PA and route through specialty pharmacy when SP indicated

Many high‑cost or specialty products in the formulary are designated as PA (prior authorization) and/or SP (specialty pharmacy); providers must initiate PA requests and, if SP is indicated, route dispensing through the specialty pharmacy channel.

• Examples include CIMZIA, ENTYVIO PEN, OCTREOTIDE ACETATE — Requirements/Limits include PA and SP.
• Specialty routing (SP) may require specific specialty pharmacy documentation.

Obtain PA and observe QL for testosterone products

Selected testosterone and androgen products list PA and numeric QL values; prescribers must obtain prior authorization when PA is shown and ensure dispensing does not exceed the listed QL.

• METHITEST (methyltestosterone) — Requirements/Limits = PA, QL (600 tablets/30 days).
• Testosterone gels, injectables and auto‑injectors show PA and specific QLs (see each line).

PA required for selected GLP‑1/GIP agents (e.g., MOUNJARO, OZEMPIC)

Certain GLP‑1/GIP agents require prior authorization as indicated in the formulary; providers must submit PA for coverage of these 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 or 3 mls/28 days depending on presentation).

Obtain PA for select injectables/biologics (e.g., ACTHAR, octreotide)

Prior authorization is required for certain specialty injectables and biologics (e.g., ACTHAR, octreotide acetate); providers must obtain PA and comply with any QL/SP designations on the product line.

• ACTHAR — Requirements/Limits include PA (see line for exact QL if present).
• OCTREOTIDE ACETATE — Requirements/Limits = SP; obtain prior authorization per formulary entry.

Obtain PA for listed cardiovascular/pulmonary products

Selected formulary drugs are annotated with PA; providers must secure prior authorization before coverage and follow any listed QL or SP requirements.

• Examples include CORLANOR, ENTRESTO sprinkle, ORENITRAM, OPSUMIT — check each product line for PA and QL.
• Failure to obtain PA when required may result in claim denial.

Secure PA for specialty biologics (e.g., REPATHA, TRYVIO)

Prior authorization is required for many specialty biologics and injectables (e.g., TRYVIO, REPATHA, ATTRUBY); providers must submit PA requests and adhere to any specified quantity limits and specialty dispensing rules.

• REPATHA — Requirements/Limits = PA, QL (6 syringes/28 days or 2 cartridges/30 days depending on presentation).
• TRYVIO — Requirements/Limits = PA, QL (30 tablets/30 days), SP.

Obtain PA for cardiovascular/pulmonary agents

PA is required for multiple cardiovascular and pulmonary agents listed with Requirements/Limits = PA; obtain prior authorization and observe QL per product line.

• CORLANOR — Requirements/Limits = PA, QL (600 mls/30 days for oral solution; 60 tablets/30 days for tablets).
• TYVASO, UPTRAVI, ORENITRAM, TRACLEER and others are PA‑designated with QLs and often SP.

NUCALA — obtain PA and follow QL

NUCALA (mepolizumab) formulations are listed with Prior Authorization and quantity limits that vary by presentation; providers must obtain PA and adhere to the specified QL (e.g., 1 syringe/28 days or 3 ml/28 days depending on presentation).

• NUCALA pref syringe 40 mg/0.4 ml — Requirements/Limits = PA, QL (1 syringe/28 days), SP.
• NUCALA 100 mg/ml presentations — Requirements/Limits = PA, QL (3 ml/28 days), SP.

TEZSPIRE — PA required and QL 1 pen/28 days

TEZSPIRE (tezepelumab) is listed with Prior Authorization and a quantity limit of 1 pen/28 days; providers must obtain PA and comply with the QL.

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

XOLAIR — PA required and specialty pharmacy handling

XOLAIR (omalizumab) requires prior authorization and is designated SP; providers must obtain PA and route dispensing per specialty pharmacy/site‑of‑care requirements.

• XOLAIR — Requirements/Limits = PA, SP (various presentations).
• Specialty pharmacy handling and PA documentation are required for coverage.

Submit PA for many specialty agents and include supporting documentation

Many specialty biologics and select oral agents across the formulary require prior authorization; providers must submit PA requests and include supporting clinical documentation for approval.

• Examples: CIMZIA, ENTYVIO PEN, various oncology and rare‑disease agents show Requirements/Limits = PA, QL, SP.
• PA requests for specialty oncology agents should include supporting clinical information per the formulary line items.

PA required for selected CNS/psychiatric products (e.g., NUPLAZID)

Certain products such as NUPLAZID (pimavanserin) and selected hypnotics/phenobarbital formulations are noted with “PA”; providers must request prior authorization before coverage.

• NUPLAZID — Requirements/Limits = PA and QL as listed on the formulary.
• Phenobarbital elixir and some hypnotic agents may require PA and have QL (e.g., phenobarbital elixir PA, QL 158 ml/30 days).

Follow step therapy (ST) when listed

Some drugs and drug classes may be subject to step therapy (ST); when step therapy applies the formulary will show “ST” in the Special Requirements column and the provider must follow any required step sequence before the drug will be covered.

• Step Therapy (ST) is noted where applicable (e.g., AUVELITY, FETZIMA, KERENDIA shows ST on its line).
• Refer to benefit plan materials for plan‑specific step therapy details.

Adhere to utilization management flags (PA, QL, SP, AC)

The formulary shows utilization management indicators (PA, QL, SP, AC, ST) on product lines; providers should interpret SP/AC flags as additional controls and follow plan processes for PA or specialty routing when present.

• Some entries include 'SP' or 'AC' in addition to PA/QL — these denote specialty pharmacy routing or administrative coverage requirements.
• If an item is SP, route dispensing via specialty pharmacy and include required documentation with PA requests.

No explicit step therapy sequences provided in this excerpt

This excerpt does not provide explicit step‑therapy sequencing or detailed step algorithms for most products; when “ST” is not shown, PA and QL are the primary utilization controls to follow.

• Where ST is absent, obtain PA if PA is listed and observe QL.
• If ST is shown, follow the formulary note and plan materials for required prior steps.

Step therapy algorithms not specified here — follow plan materials

No additional explicit step therapy rules for individual products are specified in these chunks; providers must rely on the Special Requirements flags (PA, QL, SP, ST) and plan materials for detailed step requirements.

• Contraceptive products list AC and PA together but do not include a step algorithm in this excerpt.
• For products showing ST (e.g., KERENDIA, AUVELITY), follow the ST flag and plan procedures.

When ST flag present (e.g., KERENDIA) provide required prior therapy evidence

Step therapy is not specified for most agents in this section; providers should check the Special Requirements column for an “ST” flag and follow the payer’s step therapy process when present.

• KERENDIA — Requirements/Limits = QL (30 tablets/30 days), ST (step therapy applies).
• If ST applies, documentation of prior therapy trials may be required with PA.

Limited ST flags — follow plan guidance when ST is shown

Step therapy is not described for the majority of products in this excerpt; only a limited set of agents are annotated with ST and those require following the step therapy flag and plan guidance.

• Examples of agents with ST include AUVELITY, desvenlafaxine ER, FETZIMA and select antipsychotic titration packs.
• Absent explicit ST language, follow PA and QL controls listed on the product line.

Follow AC/SP/PA indicators shown on formulary lines

Utilization management markers (AC, SP, PA) are present on many lines; providers must follow the process tied to each marker — e.g., AC indicates administrative coverage rules for vaccines, SP indicates specialty pharmacy routing, and PA indicates prior authorization is required.

• Vaccines commonly show AC (administrative coverage) rather than PA.
• SP lines (e.g., many biologics) require specialty pharmacy dispensing and appropriate documentation.

Route SP‑designated drugs through specialty pharmacy

Specialty (SP) designation implies specialty pharmacy handling and may affect routing, dispensing, and documentation; providers should arrange specialty pharmacy dispensing when SP is indicated on the product line.

• Products with SP (e.g., many biologics, CF modulators) must be dispensed through specialty pharmacy channels as required.
• Specialty pharmacy routing may necessitate additional documentation for PA submissions.

PA and SP required for CF modulators and antifibrotics

CF modulators and other cystic fibrosis/pulmonary antifibrotic agents are designated SP and PA; providers must obtain prior authorization and route through specialty pharmacy per the formulary lines.

• Examples: TRIKAFTA, ALYFTREK, KALYDECO, ORKAMBI, SYMDEKO — Requirements/Limits = PA, QL, SP.
• Ensure PA documentation supports medical necessity for these high‑cost specialty products.

Document prior therapy when ST flag is present

Step therapy applies to some agents annotated with “ST” in the Special Requirements column; providers must follow the step requirement and document prior therapy failures where applicable.

• Examples with ST: AUVELITY, FETZIMA, carious antipsychotic titration packs show ST on their lines.
• Aripiprazole, quetiapine and other psychiatric agents may list ST and QL — provide evidence of step completion as required.

Follow exception request process and timing

For Drug List exceptions, the prescriber or member must call the number on the member’s ID card to request a review; BCBSOK will notify the decision within 15 calendar days for standard requests and within 72 hours for expedited requests when life/health/function is jeopardized.

• Standard exception decision timeframe = 15 calendar days.
• Expedited (urgent) timeframe = 72 calendar hours.

Adhere to quantity limits (QL) on formulary lines

Quantity limits (QL) listed on product lines must be observed when submitting claims; exceeding a QL may lead to claim denial or require an exception — providers should verify the QL for each product prior to dispensing.

• Examples: azithromycin tab QL (60 tablets/180 days); many products use common QL formats (e.g., 30 tablets/30 days).
• If prescribing beyond the QL, submit an exception request per plan procedures.

Submit required documentation with PA/QL/SP requests

Providers must supply documentation to support prior authorization and quantity‑limit requests for PA/QL/SP items; for specialty oncology and biologic agents include clinical rationale and dosing details with the PA submission.

• PA and QL documentation should demonstrate medical necessity, diagnosis, dosing and prior therapies where applicable.
• Specialty oncology PA requests should include supporting clinical information (e.g., for selpercatinib, revumenib examples).

Coordinate specialty pharmacy handling for SP items

Products designated SP require specialty pharmacy dispensing and associated documentation; providers should coordinate with the specialty pharmacy and include necessary clinical and administrative information in PA requests.

• Examples: OCTREOTIDE ACETATE, FASENRA PEN, many biologics list SP and PA.
• Specialty pharmacy routing affects site‑of‑care and claim submission processes.

Follow administrative coverage (AC) for AC‑designated vaccines

Vaccines and biologicals with Requirements/Limits = AC are handled under administrative coverage rules; when AC is present follow administrative coding/coverage procedures rather than PA.

• Many vaccine lines (e.g., ABRYSVO, AFLURIA, COMIRNATY) show Requirements/Limits = AC.
• If a vaccine line shows PA instead of AC, obtain PA per the formulary line.

Provide evidence that utilization controls are met on claims

Pharmacy claims must include evidence that utilization controls (PA, QL, SP) have been met for the product; when QL values are specified ensure the dispensed quantity falls within the listed limit or an exception/PA is obtained.

• Quantity limits are expressed as amounts per time period (e.g., 30 tablets/30 days, 1 pen/28 days, 1920 ml/30 days).
• Claims exceeding listed QL require prior authorization or an exception to avoid denial.

Include clinical support when requesting PA for oncology agents

When requesting PA for specialty oncology agents, prescribers must submit supporting clinical information (e.g., diagnosis, prior therapies, dosing) to justify the authorization per the formulary line‑item.

• RETEVMO, SCEMBLIX, and other oncology agents show Requirements/Limits = PA and QL — include clinical justification with PA.
• Supporting documentation expedites review and aligns with the formulary’s PA expectation.

Follow AC/PA and QL for contraceptives

Some contraceptive products list AC and QL (and occasionally PA); when these administrative controls are present, providers should follow the AC/PA process and supply documentation to justify dispensing within the QL.

• Combined oral contraceptives show AC and QL (e.g., 28 tablets/21 days).
• If PA is also listed for a contraceptive line, obtain PA per formulary instructions.

Document medical necessity for PA and adhere to QL

For items with PA or QL designations, prescribers must provide documentation supporting the prior authorization and ensure dispensing adheres to the listed quantity limits (e.g., per‑30‑day QLs shown on product lines).

• PA and QL documentation should include diagnosis, dosing, and prior therapy history where applicable.
• Examples of QL formats: 30 tablets/30 days, 1 syringe/28 days, 4 pens/180 days.

Ensure PA documentation for specialty injectables/infusions

Specialty injectable and infusion products listed with SP or PA require specialty pharmacy handling and authorization documentation; providers should route these through the specialty channel and include necessary PA paperwork.

• Examples: OCTREOTIDE ACETATE, FASENRA PEN, many biologics list PA and SP.
• Specialty products often have presentation‑specific QLs (e.g., 1 pen/28 days, 1 syringe/28 days).

Observe QL volumes for oral solutions/liquids

For oral solutions and liquid formulations that include explicit QL volumes, providers must document and bill only within the stated volume limits or obtain prior authorization/exception if more is needed.

• Epaned (enalapril oral solution) — QL 1200 mls/30 days; QBRELIS lisinopril oral soln — QL 2400 ml/30 days.
• KATERZIA/NORLIQVA and other oral solution QLs are specified and must be observed.

Submit exception if dispensing exceeds listed QLs (e.g., Epaned, QBRELIS)

Examples of products with explicit QLs (e.g., Epaned, QBRELIS) must be dispensed within those limits; if the prescription exceeds the numeric QL, submit an exception or PA per plan process.

• Epaned — QL 1200 mls/30 days.
• QBRELIS — QL 2400 mls/30 days.

Provide PA documentation for biologic agents (e.g., FASENRA, NUCALA)

Authorization documentation is required for biologic agents that list PA and QL (e.g., FASENRA PEN, NUCALA); providers must include clinical justification and dosing details with PA submissions.

• FASENRA PEN — Requirements/Limits = PA, QL (1 pen/28 days), SP.
• NUCALA presentations show PA and QL that differ by presentation; include presentation‑specific details in PA requests.

Submit complete clinical documentation with PA for specialty biologics

Prescribers must submit documentation to support PA for specialty injectables and biologics where PA is listed; include diagnosis, prior treatments, and proposed dosing to support medical necessity.

• Examples: NUCALA, TEZSPIRE, XOLAIR require PA and often SP handling — include clinical notes with PA.
• Timely and complete documentation helps avoid denials and expedites review.

Bill within specified QLs for cartridge/kit products (e.g., SKYRIZI, ZYMFENTRA)

Quantity limits are specified for many products (e.g., SKYRIZI QL 1 cartridge/56 days; ZYMFENTRA QL 2 kits/28 days); providers must bill within these limits or obtain prior authorization/exception.

• SKYRIZI — QL 1 cartridge/56 days.
• ZYMFENTRA 2‑syringe kit — QL 2 syringes/28 days.

Include clinical supporting documentation for PA/QL requests

Provide supporting documentation (diagnosis, dosing, prior therapies) with PA and QL requests; the formulary indicates that products with PA/QL entries require supporting evidence to justify approval.

• General supporting documentation is expected for PA/QL items to demonstrate medical necessity.
• Failure to provide required documentation may result in denial or delay.

Risk of denial for non‑formulary, non‑FDA, or PA/QL noncompliance

Coverage can be denied for drugs not on the Drug List, for non‑FDA‑approved products, for repackaged/compounded items excluded by the plan, or when dispensing exceeds listed QLs — providers should confirm formulary placement and limits before prescribing.

• Non‑FDA‑approved drugs and repackaged medications are not covered under the pharmacy benefit.
• Claims for quantities beyond QL or without required PA may be denied.

Denial risk if PA not obtained for PA‑designated drugs

Failure to obtain prior authorization for products marked “PA” (e.g., ARIKAYCE, posaconazole formulations, EPCLUSA) may trigger claim denials; providers must secure PA before dispensing these medications.

• ARIKAYCE and posaconazole lines show Requirements/Limits = PA and QL.
• If PA is required but not obtained, the claim may be denied.

PA/SP designation creates denial risk if controls not met

Drugs labeled with PA or SP indicate that prior authorization or specialty pharmacy routing is required; absence of required authorization or improper routing may lead to denial.

• Many entries use PA and SP together (e.g., oncology and biologic agents) — follow both authorization and specialty routing requirements.
• Claims lacking PA or routed outside specialty pharmacy when SP is required may be denied.

Claims without PA for PA‑listed products risk denial

Products with Requirements/Limits = PA may be denied without prior authorization per the formulary; providers must request and obtain PA before coverage is approved.

• Many antineoplastic and specialty drugs list PA and will be denied if PA is not on file.
• Check the product line for PA and QL before dispensing.

Exceeding QL may trigger denial or need for exception

Quantity limits (QL) listed on the formulary are enforced; claims exceeding the stated QL may be denied or require an exception/PA to cover the excess quantity.

• Examples: REPATHA QL 6 syringes/28 days; many agents use QL 30 tablets/30 days.
• If dispensing exceeds the QL, submit an exception/PA to avoid denial.

Denial risk for specialty drugs without PA

Prior authorization (PA) is required for many specialty drugs in the listing; failure to obtain PA when indicated will likely result in denial of coverage for those drugs.

• Most specialty oral and injectable oncology and endocrine agents are PA‑designated.
• Obtain PA before dispensing to prevent coverage denial.

High denial risk for specialty biologics without PA/QL/SP compliance

Many specialty agents and biologics are PA‑designated; providers must obtain PA to prevent coverage denial and follow any SP and QL constraints listed on the product line.

• CIMZIA, ENTYVIO PEN, GATTEX and similar agents require PA and QL; SP routing often applies.
• Noncompliance with PA/QL/SP increases risk of denial.

PA required for many testosterone formulations — denial risk if missing

Testosterone products and related androgen agents list PA on multiple formulations; failing to obtain PA for these products may result in claim denial.

• METHITEST and many testosterone gels/injectables show PA in Requirements/Limits.
• Confirm PA prior to dispensing to avoid denial.

PA/QL noncompliance may cause denials

Noncompliance with PA or QL (“PA/QL noncompliance”) for products that list these controls may lead to coverage denial or limitation; providers must ensure PA approvals are in place and dispensing adheres to QL.

• Claims lacking PA or exceeding QL are at risk for denial.
• Submit necessary documentation or request an exception when needed.

Address all UM triggers (PA, QL, SP, ST) to avoid denial

Products listed with PA, QL, SP or ST represent utilization management triggers; providers should obtain PA, adhere to QL, and follow SP routing when indicated to avoid denials.

• Examples: ACTHAR (PA), CRENESSITY (QL), GALAFOLD (PA, QL, SP).
• When multiple controls apply, address each requirement in the authorization and claim process.

Verify PA and QL to prevent denials

Claims for listed products may be denied or limited if PA is not obtained or QLs are exceeded; providers should verify authorization status and quantity allowances prior to dispensing.

• PA absence or QL exceedance are common reasons for denial across product groups.
• Confirm PA and QL compliance at the point of prescribing/dispensing.

Follow PA procedures per formulary to ensure coverage

Formulary enforcement requires prior authorization for PA‑designated drugs; providers must follow the PA process detailed in member plan materials to secure coverage.

• PA will be indicated in the Special Requirements column for affected products.
• If PA is required and not obtained, the claim is subject to denial.

Obtain PA for select cardio/pulmonary agents and observe QL

Cardiovascular and pulmonary agents listed with PA and/or QL (e.g., CORLANOR, ORENITRAM, TYVASO) require prior authorization and adherence to quantity limits; providers should confirm PA before dispensing.

• CORLANOR — PA, QL (600 mls/30 days for solution; 60 tablets/30 days for tablets).
• ORENITRAM and TYVASO lines include PA, QL and SP designations.

PA required for NUCALA, TEZSPIRE, XOLAIR — follow QL/SP

Several products specifically call out PA, QL, or SP (e.g., NUCALA, TEZSPIRE, XOLAIR) and failure to meet those requirements may result in denial; providers must obtain PA and adhere to QL/SP as applicable.

• NUCALA, TEZSPIRE, XOLAIR — all list PA and have presentation‑specific QLs and/or SP flags.
• Obtain PA and coordinate specialty pharmacy dispensing when SP is indicated.

PA required for CF modulators and pulmonary antifibrotics

PA is required for cystic fibrosis modulators and pulmonary antifibrotics (e.g., ALYFTREK, KALYDECO, ORKAMBI, PIRFENIDONE, OFEV, TRIKAFTA); providers must obtain PA and observe QL/SP noted on each line.

• ALYFTREK, TRIKAFTA, KALYDECO, ORKAMBI — Requirements/Limits = PA, QL, SP in many presentations.
• High‑cost CF agents require PA and specialty routing; include clinical rationale with PA requests.

PA/QL/SP requirements are enforceable — secure authorizations and document compliance

The formulary includes PA, QL and SP requirements for many products; providers must secure prior authorization where indicated and ensure claims document compliance with quantity and specialty requirements to avoid denial.

• Examples across sections include CIMZIA, ENTYVIO PEN, FERRIC CITRATE, and numerous biologics with PA/QL/SP.
• Failure to meet these requirements can result in claims being denied or limited.

PA indicated for select psychotropic/hypnotic products (e.g., NUPLAZID)

Certain products such as NUPLAZID and select hypnotics/phenobarbital formulations are noted with “PA”; providers must obtain prior authorization and adhere to listed QL to secure coverage.

• NUPLAZID (pimavanserin) — Requirements/Limits = PA and QL as shown on the product line.
• Phenobarbital elixir and related formulations list PA and QL (158 ml/30 days).

Quantity‑limit exceedance may trigger denial — request exception if needed

Exceeding quantity limits specified on the formulary (e.g., 30 tablets/30 days or 60 tablets/30 days) can trigger denials or require an exception; providers should confirm QL and submit exceptions when clinically necessary.

• Common QLs include 30 tablets/30 days and similar month‑based limits.
• If greater quantity is clinically needed, submit an exception request per the exception process.