CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Drug List (Formulary) — Pharmacy Coverage Criteria

This document is the 2025 drug list (formulary) describing covered pharmacy products, tier placement, specialty drug handling, prior authorization/step therapy/quantity limit conventions, and processes for members and providers for Blue Cross and Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Formulary) — Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual formulary publication

Effective DateOctober 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests and supporting documentation for drugs listed with 'PA' before dispensing and ensure prescribed quantities adhere to listed quantity limits (QL).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025publication year

~120+drug lines listed

PA/QL/SPutilization flags present

MyPrime.comwebsites

15 daysexception decision (standard)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

72 hoursexception decision (expedited)

Formulary Coverage and Requirements

Formulary coverage lines

Coverage positions and conditions are presented per drug line as tiers and flags; where PA/QL/SP/AC are present those denote additional coverage controls.

Formulary entries: Drugs listed with Drug Tier and Requirements/Limits; some include PA, QL, SP, AC; absence of these flags in this excerpt does not imply unconditional coverage.

No patient-level clinical criteria provided in this excerpt

Listed drugs with per-item requirement flags

Coverage/listing with associated per-line Requirements/Limits

Per-line coverage rules: Each drug line includes a Drug Tier and may include Requirements/Limits (e.g., AC, PA, QL, SP, NP). Coverage and authorization actions depend on the listed Requirement/Limits for that specific drug.

Document segment lists items and flags; no unified clinical criteria provided in these chunks.

Formulary coverage flags

Coverage and utilization management attributes are indicated per product; coverage is conditional on PA and adherence to QL where specified.

Formulary entries: Each listed drug line includes drug tier and may include one or more of: PA (prior authorization), QL (quantity limit with numeric limit and time frame), SP (specialty pharmacy).

No further clinical criteria in these chunks

Covered with management

Coverage entries shown with management flags — interpret as 'covered with management' when PA and QL satisfied

Formulary managed coverage: Drug is listed on formulary with Drug Tier and requires Prior Authorization (PA) and adheres to Quantity Limits (QL) and Site of Service (SP) as listed.

No detailed medical necessity criteria included in these chunks; refer to full policy sections for indication-specific rules.

Coverage conditioned on administrative requirements

Coverage is subject to the listed administrative controls when present (AC/PA and QL).

General formulary condition: Coverage for each listed product is available only under the Requirements/Limits indicated next to that product (e.g., AC, PA, QL).

Specific clinical PA criteria are not included in these chunks.

Formulary listing with PA/QL/SP

Coverage entries indicating formulary tier and requirements

Formulary entry pattern: Each listed drug entry includes: drug name and formulation, Drug Tier, Requirements/Limits possibly including PA (prior authorization), QL (quantity limits), and SP (specialty pharmacy)

Pattern observed across chunks

Formulary coverage annotations

Coverage and utilization management designations shown per product

Formulary entries: Each product line shows Drug Tier, and where applicable Requirements/Limits such as QL (quantity limits), PA (prior authorization), ST (step therapy), and SP (specialty).

Extract lists individual products; no patient-level medical necessity criteria provided in these chunks.

Formulary coverage with requirements

Coverage and utilization management for listed drugs as specified by drug-level entries

Formulary entry rule: Drugs listed include a drug tier and may list Requirements/Limits (PA, QL, ST, SP, AC). Coverage is subject to those requirements.

Applies to each individual drug line where requirements are shown

Coverage is determined at the drug-line level on the 2025 Drug List. Drugs shown on the list are eligible for coverage according to their listed Drug Tier and any adjacent Requirements/Limits (for example: PA = prior authorization, QL = quantity limit, SP = specialty pharmacy, AC = administrative condition). Drugs not shown on the list are not covered. Non–FDA‑approved drugs, repackaged medications, and some compounded products are not covered, and prescriptions with an over‑the‑counter equivalent may be excluded per the member’s benefit plan.

This excerpt does not present a separate, explicit list of categorical exclusions beyond the general statements included on the Drug List; instead the document shows per‑product entries and their Requirements/Limits. Refer to plan benefit materials for any additional exclusion lists not contained in this extract.

Where a formulary line shows a blank or a period ('.') in the Requirements/Limits column, no specific prior authorization, quantity limit, specialty or administrative requirement is specified in this segment for that item. Such blank entries should be interpreted as the absence of an explicit per‑line restriction within this excerpt, not necessarily as a guarantee of unconditional coverage.

Products that are listed without an adjacent PA, QL, SP or other flag in the Requirements/Limits column are presented under the formulary’s standard coverage rules in this excerpt. Providers should still verify benefits and any plan‑level rules that may apply, since absence of a flag here does not rule out other benefit‑specific controls.

Some entries are marked with NP (non‑preferred) or displayed as non‑preferred tiering; this notation in the extract indicates formulary status but the excerpt does not state explicit clinical exclusions tied to NP designation. Members/providers should expect different cost‑sharing for non‑preferred items and verify whether utilization controls (PA/QL) apply.

Across the provided chunks there are no standalone statements listing additional explicit exclusion conditions; the text is primarily product‑level formulary lines with Drug Tier and Requirements/Limits. Any exclusionary rules beyond these per‑line entries would be found in plan documents or other sections not included here.

This document segment focuses on formulary placement and administrative controls for listed products. It does not include indication‑specific clinical medical‑necessity decision criteria; instead coverage is conditioned on the per‑drug Requirements/Limits (e.g., PA, QL, SP, AC) shown next to each product.

No discrete medical necessity criteria or clinical decision trees are provided in the excerpted portions; the listing indicates when administrative controls apply but does not define the clinical eligibility criteria required to satisfy a prior authorization in this extract.

Lines with blank Requirements/Limits appear throughout the extract; where an entry’s Requirements/Limits field is empty in these chunks, no specific utilization control is documented for that presentation within this excerpt.

The formulary presents products and their tiering, but the excerpt does not include explicit statements that particular listed products are categorically 'not covered.' Coverage should be interpreted per the listed Drug Tier and any Requirements/Limits shown for each product.

No overarching categorical exclusions are provided in this section of the Drug List; the extract lists per‑drug Requirements/Limits (for example, PA and QL). Remember that drugs not shown on the drug list are not covered and non‑FDA‑approved agents are excluded.

The Drug List states that non–FDA‑approved drugs are not covered. It also notes that prescription items that have over‑the‑counter equivalents may not be covered under a member’s benefit — refer to the specific benefit plan for any OTC‑equivalent exclusions.

Within this excerpt there are no explicit statements formatted as 'Not Medically Necessary.' The presented material is primarily a product listing with tiering and Requirements/Limits; determination of medical necessity would follow plan processes outside the per‑line entries shown here.

This portion of the Drug List does not include discrete 'Not Medically Necessary' declarations. Coverage limitations in the extract are expressed through per‑product administrative controls (e.g., PA, QL, SP), not NMN statements.

No explicit 'Not Medically Necessary' language appears in the antidiabetic and related product entries included here; products are shown with formulary tiering and utilization flags that govern coverage and authorization.

The psychiatric/neurologic sections in this excerpt show Drug Tier and Requirements/Limits (including ST for some agents) but do not include explicit 'Not Medically Necessary' statements within these chunks.

Formulary lines in this part of the Drug List include utilization controls (for example, PA, QL, SP). The excerpt does not present NMN language; coverage is governed by each product’s listed Requirements/Limits and the member’s benefit plan.

Drug Listings and Coding / Quantity Examples

Provider Requirements, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization (PA) is required for many drugs listed in this document. When a medication requires PA, it will be annotated with "PA" in the Special Requirements or Requirements/Limits column. Providers must submit a prior authorization request and receive approval before the medication will be covered.

PA flagged drugs include selected inhaled/nebulized antibiotics (e.g., ARIKAYCE, KITABIS PAK), antifungals (e.g., posaconazole, voriconazole), antivirals and hepatitis C agents (e.g., EPCLUSA, HARVONI, MAVYRET), and many specialty biologics and oncology agents.

Prior Authorization

Prior Authorization for Selected Agents

Selected high-cost, specialty, or complex agents specifically require prior authorization and often specialty pharmacy (SP) dispensing; these include but are not limited to ARIKAYCE, CRESEMBA/posaconazole, EPCLUSA, HARVONI, MAVYRET, and similar antiviral regimens. Look for PA, SP and QL annotations next to product lines.

Antibiotics: ARIKAYCE — PA, QL, SP.
Antifungals: NOXAFIL/posaconazole — PA.

Key Term Definitions

inv-118: Specialty drugs — definition and context

Specialty drugsMedications used to treat complex conditions; may be oral, topical or injectable and may require specialty pharmacy or medical benefit handling

Formulary tiersPreferred Generic, Non-Preferred Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty, Non-Preferred Specialty (tier affects member cost-sharing)

PA (Prior Authorization)Requirement for payer approval before coverage is allowed

QL (Quantity Limit)Maximum units permitted in a specified time frame (e.g., 30 tablets/30 days)

SP (Specialty Pharmacy)Designation indicating dispensing via specialty pharmacy channel is required for certain products

AC (Administrative Condition)Administrative coverage restriction notation shown on some vaccine and drug lines

Step Therapy Indicators and Notes

Product / note	Special Requirements
Step therapy overview (program applies where noted)
If step therapy applies, it is indicated by 'ST' in the Special Requirements column; member may be required to try a proven, cost‑effective alternative first

Observation	Implication
Formulary lines in this excerpt show Prior Authorization (PA), Quantity Limit (QL) and Specialty Pharmacy (SP) flags
No discrete step therapy algorithm or step sequence is presented in the provided document chunks; the listing uses flags rather than flow rules

Product / pack	Notes
PALFORZIA LEVEL 1 / LEVEL 2 / LEVEL 3 / LEVEL 4 / LEVEL 10 / LEVEL 11 (various pack levels)
Requirements/Limits = SP; pack/level entries represent product pack strengths/levels (not step-therapy steps) as listed

Finding	Formulary flag
Multiple oncology product lines (e.g., dasatinib, glasdegib, leuprolide depot) listed with management annotations
Requirements/ Limits show PA, QL, SP; explicit step therapy steps are not specified in this section

Product group	Program indicator
Contraceptives and progestins (multiple brand lines listed, e.g., DEPO-SUBQ PROVERA 104, various oral combined contraceptives)
Many entries show 'AC' (administrative condition) and QL — may indicate alternative coverage program or administrative review related to utilization management

Product / annotation	Step-related note
GLP-1/GIP and antidiabetic products (examples: MOUNJARO, OZEMPIC, TRULICITY)
Some strengths/packs annotated with SP or pack-specific QL; step therapy details or order of steps are not provided in these chunks

Product	Special Requirements
KERENDIA (finerenone) 10 mg, 20 mg
Requirements/Limits = QL (30 tablets/30 days); ST

Product	ST designation
KERENDIA (finerenone)
Listed with 'ST' indicating step therapy applies where noted

Class / examples	Management flags
PCSK9 inhibitors (e.g., REPATHA variants) and PAH agents (e.g., ORENITRAM, TYVASO, UPTRAVI)
Managed with Prior Authorization (PA) and Quantity Limits (QL); explicit step therapy details not specified in this excerpt

Observation	Document note
Numerous specialty and pulmonary hypertension agents listed with PA/QL
No explicit step therapy algorithm or step sequence described for these entries in the provided chunks; PA/QL/SP are the listed controls

Product category	Management implication
Biologic and specialty agents (examples: ENTYVIO PEN vedolizumab, GATTEX, CTEXLI)
Designated SP and PA in lines — implies specialty pharmacy and prior authorization steps will be required before coverage

Finding	Step therapy flag
Several antipsychotic and psychotropic presentations (e.g., aripiprazole oral solution, aripiprazole ODT, clozapine ODT, FANAPT) are listed
Multiple entries show 'ST' in Requirements/Limits indicating step therapy may be required for those specific products

Product examples	ST annotation
Aripiprazole (ODT and tablets), Clozapine ODT, FANAPT (iloperidone), Risperidone formulations, SECUADO patch
These products are labeled 'ST' indicating step therapy applies to selected formulations as shown in the listing

Product group	ST / note
Gabapentin formulations (e.g., GRALISE, once-daily gabapentin lines, HORIZANT), various strengths
Multiple gabapentin entries list QL and 'ST' indicating step therapy may be required prior to coverage for these formulations

Specified Quantity Limits (Examples by Product)

Dispensing Channel and Site of Care Notes

Denial Risk

Confirm coverage for non‑listed, repackaged or non‑FDA products

Drugs not included on the drug list, non‑FDA‑approved products, repackaged or compounded medications are potential exclusions and can trigger denial — check coverage before prescribing.

Non‑FDA‑approved drugs and repackaged medications are not covered per the coverage considerations.
Refer to member benefit materials or call the number on the ID card for verification.

Billing Rule

Dispense SP‑designated oral oncology and specialty drugs via specialty pharmacy

Many oral oncology drugs and numerous specialty agents are designated 'SP' (specialty pharmacy) on the formulary; when SP is shown the drug must be dispensed via specialty pharmacy channels.

Background and Scope

Specialty drugs treat complex conditions and may be oral, topical, or injectable. Some specialty medications are administered by a health‑care professional and may be covered under the medical benefit rather than the pharmacy benefit. The Drug List is maintained and updated by a committee of clinicians and pharmacists; for the most current drug and specialty lists see MyPrime.com or bcbsok.com.

Scope: this document is the 2025 Drug List for Blue Cross and Blue Shield of Oklahoma and summarizes covered pharmacy products and their tier placement. It indicates common utilization management conventions used across the list: Prior Authorization (PA) is noted where required, Quantity Limits (QL) specify permitted amounts and timeframes (examples include 30 tablets/30 days or other product‑specific limits), Specialty Pharmacy (SP) denotes specialty dispensing requirements, and Step Therapy (ST) is shown where an alternate agent must be tried first. Providers and members should refer to the plan benefit materials and the payer’s websites for up‑to‑date listings and for instructions on prior authorization and exception request processes.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Formulary) — Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual formulary publication

Effective DateOctober 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests and supporting documentation for drugs listed with 'PA' before dispensing and ensure prescribed quantities adhere to listed quantity limits (QL).

SourceLink

On This Page

Hepatitis C/specialty antivirals: EPCLUSA, HARVONI, MAVYRET — PA, QL, SP.

Prior Authorization

Prior Authorization for Specialty / Antineoplastic Agents

Many specialty and antineoplastic (oncology) oral and injectable agents require prior authorization and are subject to quantity limits and specialty distribution. These therapies frequently carry PA, QL and SP designations and will require documentation to support medical necessity.

Examples include: abiraterone (Zytiga), alectinib (ALECENSA), brigatinib (ALUNBRIG), many TKIs and PARP inhibitors (PA + QL + SP).
Oral oncology agents often have specific starter packs or titration pack QLs noted (e.g., VENCLEXTA starting pack, TAFINLAR starter).

Prior Authorization

Prior Authorization for Listed Specialty Drugs

Numerous specialty and high-tier products (biologics, injectables, gene/rare disease therapies) are subject to prior authorization, quantity limits and specialty pharmacy handling. Providers must route requests through the PA process and, when indicated, arrange dispensing through the plan-designated specialty pharmacy.

Examples: TREMFYA, SKYRIZI, SKYRIZI induction packs, TREMFYA induction packs — PA, QL, SP.
Many biologics (e.g., mirikizumab, risankizumab, guselkumab, infliximab biosimilars) are PA + QL + SP.

Documentation Required

Prior Authorization and Quantity Limits

Prior authorization and quantity limits are commonly paired: when a product is marked with PA and QL the provider must both obtain authorization and comply with the listed dispensing/quantity limit. Requests that exceed QL require justification and explicit authorization to avoid denial.

Quantity Limits (QL) examples: many antivirals/ARVs (30 tablets/30 days), diabetes/GLP agents (pen/pen limits), oncology agents (capsules/tablets per 30 days).
If greater than the QL is prescribed, the provider must document clinical rationale in the PA request.

Prior Authorization

Prior Authorization Required for Listed Products

Many specific products across therapeutic classes require PA. Examples from the list include TRIJARDY XR, ACTHAR, GALAFOLD, JYNARQUE, ISTURISA, MYALEPT, PALYNZIA and others — see the Requirements/Limits column for PA, QL, SP flags.

Endocrine/metabolic and rare disease agents frequently require PA and SP (e.g., GALAFOLD, JYNARQUE).
Weight-management and antidiabetic specialty agents (e.g., MOUNJARO, OZEMPIC, TRULICITY, WEGOVY, SAXENDA, ZEPBOUND) are PA-flagged and often have pen/pack QLs.

Prior Authorization

Prior Authorization and Specialty Dispensing

Numerous specialty drugs require prior authorization and specialty pharmacy dispensing; when PA is indicated, claims submitted without approval are at risk of denial. Providers should confirm specialty routing and plan-specific specialty pharmacy requirements before prescribing.

Specialty drugs with SP annotation must be dispensed via the specialty channel (SP).
Examples: cystic fibrosis modulators (TRIKAFTA, ORKAMBI), enzyme replacement and rare disease therapies — PA + QL + SP.

Prior Authorization

PA for Select Formulations & Specialty Agents

Certain formulations and select specialty agents (e.g., oral solutions, titration packs, inhalation/nebulized antibiotics, inhalation solutions) require prior authorization and may have unique quantity or pack limits. Confirm formulation-level requirements when submitting PA.

Examples: enalapril oral solution (Epaned) — PA + QL; ORENITRAM titration kits and TYVASO inhalation solution — PA + QL + SP.
Titration kits, starter packs and pellet/granule/packet formulations often have specific QLs (pack/kit per days).

Prior Authorization

PA Required for Many Specialty Agents

Many pulmonary hypertension, transplant, and complex chronic disease biologics require prior authorization. Examples include ORENITRAM, TYVASO, UPTRAVI and other agents listed with PA, QL and SP — ensure PA is in place before dispensing.

Pulmonary hypertension agents: ORENITRAM, TYVASO, UPTRAVI — PA + QL + SP.
Cardiac and rare disease biologics (tafamidis products, sotatercept) also carry PA and QL.

Denial Risk

Authorization / Denial Triggers

For any drug marked with PA, failure to obtain prior authorization or to adhere to the plan’s QL/SP requirements may result in claim denial or full member financial responsibility. Providers should verify PA status and QLs prior to dispensing.

Claims submitted without required PA are subject to denial.
Exceeding a QL without prior approval may result in the member being responsible for the cost beyond coverage.

Denial Risk

Coverage Exclusions That May Trigger Denial

Coverage exclusions may trigger denials — examples include non-FDA-approved drugs, repackaged or compounded products when the plan excludes them, over-the-counter substitutes, or drugs not on the Drug List. Confirm benefit specifics for the member.

Non-FDA-approved drugs and repackaged medications are commonly not covered.
Over-the-counter equivalents may be excluded; check member’s benefit materials.

Denial Risk

Denial Risk from Unmet PA/QL/SP Requirements

Denials may occur if PA is not obtained, QL is exceeded, SP routing is not followed, or required documentation is not provided. Providers should include clinical rationale and supporting documentation with PA requests to reduce denial risk.

Missing PA or insufficient documentation are common denial reasons.
Specialty and oncology PAs typically require detailed clinical information (diagnosis, prior therapies, labs, staging/genomic information where applicable).

Prior Authorization

Specialty Drug PA / SP Requirements

Specialty drugs often require both PA and dispensing through an approved specialty pharmacy (SP). When SP is required, the plan’s specialty channel must be used; failure to do so can cause claim denial or processing delays.

SP flag indicates specialty pharmacy distribution and management.
Examples: infusion and self-injectable biologics (many entries in the specialty sections) — verify SP routing prior to fill.

Documentation Required

Required Documentation for Prior Authorization

Providers must submit prior authorization requests with supporting documentation. For PA items, include diagnosis, prior treatment history, relevant labs or test results, and rationale for the requested therapy to support medical necessity.

Documentation expectations: prior trials/step-therapy outcomes, clinical markers, weight/BMI when applicable (weight-management agents), and dosing/packaging needs for starter/titration packs.
Antidiabetics and GLP-1/GIP agents (e.g., MOUNJARO, OZEMPIC, TRULICITY, RYBELSUS) are PA-flagged and commonly require documentation of previous therapies and indication.

Note

Exception Request Process & Timeframes

Exception (appeal/coverage) requests are available when a drug is not on the Drug List or when an expedited review is clinically warranted. Standard exception decisions are issued within 15 calendar days; expedited reviews are decided within 72 calendar hours for urgent clinical situations.

To request an exception, call the number on the member’s ID card. If denied, BCBSOK will provide the reason and, if applicable, a covered alternative.
Expedited review is available when the member’s condition could jeopardize life, health, or function; requested by prescriber for urgent cases.

Step Therapy

Step Therapy / Utilization Controls

Step therapy (ST) and other utilization controls may apply where indicated. The presence of ‘ST’ in the Special Requirements column signals that a patient may need to try specified first-line or lower-cost alternatives before the requested agent will be approved.

ST examples: some antipsychotics, gabapentin formulations, and selected cardiometabolic agents are annotated with ST.
If ST is marked, include documentation of trials and failures of required step medications when submitting a PA.

inv-119: Formulary tiers — Preferred/Non-preferred/Generic/Brand tier definitions

Preferred/Non-preferred/Generic/Brand tiersDrugs placed into tiers: Preferred Generic (p), Non-Preferred Generic (np), Preferred Brand (P), Non-Preferred Brand (NP); specialty variants also flagged

Tier affects cost-sharingTier designation (P/NP/p/np) influences member payment and coverage rules

Specialty tier indicatorsPreferred Specialty and Non-Preferred Specialty also marked and shown in Special Requirements column as 'SP'

inv-121: PA — Prior Authorization definition

Prior Authorization (PA)Requires approval before coverage; noted as 'PA' on formulary lines

PA triggersPresence of 'PA' next to product indicates prior authorization must be obtained before coverage

Documentation requiredProviders must submit PA requests and supporting clinical information where 'PA' is listed

inv-122: QL — Quantity Limit definition

Quantity Limit (QL)Maximum quantity allowed in a specified time period (e.g., '30 tablets/30 days')

PurposePromotes use consistent with FDA-intended dosing and limits excess dispensing

NotationShown as 'QL' adjacent to product with numeric limit and timeframe

inv-124: SP — Specialty Pharmacy definition

Specialty Pharmacy (SP)Drug designated to be dispensed via specialty pharmacy channel (noted as 'SP')

Applies to high-cost/complex agentsCommon for biologics, oncology, and complex injectables requiring special handling

May require PA and SP routingLines often show PA and QL along with SP designation

inv-123: AC — Administrative Condition / Coverage restriction code

AC (Administrative Condition)Administrative coverage restriction notation used on some vaccine and drug lines; document lists AC but does not define it further in-line

Applied to vaccines and contraceptivesMultiple vaccine and contraceptive lines show 'AC' in Requirements/Limits

May indicate plan-specific programAC may denote alternative coverage programs or administrative review

inv-124: AC notation presence — AC shown on vaccine and drug lines but not defined in chunk

AC notation presenceAC is shown on many vaccine and drug lines in the listing though not explicitly defined in the chunk text

ExamplesMultiple vaccine entries (e.g., ABRYSVO, AFLURIA) list Requirements/Limits = AC

ActionWhen AC is shown providers should follow plan administrative guidance for those items

inv-125: PA notation presence — PA shown on specialty/antineoplastic agents

PA notation presencePA is shown adjacent to many specialty and antineoplastic product lines (e.g., oncology agents)

Examplesabiraterone, alectinib, brigatinib and many others are marked PA in the oncology listings

Provider actionObtain prior authorization as indicated to avoid denial

inv-126: QL notation presence — QL shown with examples in chunks

QL notation presenceQuantity limits (QL) are shown across many product lines with numeric limits and timeframes (e.g., 120 tablets/30 days)

ExamplesQL examples include 30 tablets/30 days, 100 mls/30 days, 56 capsules/28 days

EnforcementClaims may be denied if QL is exceeded or PA not obtained when listed

inv-127: SP notation presence — specialty designation on high-cost items

SP designation presenceSpecialty (SP) designation appears on many high-cost biologic and specialty items

ExamplesMany oncology, biologic, and infusion products show SP alongside PA and QL

ImplicationSP items often require specialty pharmacy dispensing and specific handling

inv-128: NP — Non-preferred notation presence

NP (Non-Preferred)Indicates non-preferred tier placement on listed items

EffectNP items may have higher member cost-sharing and utilization controls

ExamplesMany branded products and specialty items are listed as NP in the formulary

Examples: multiple oral oncology agents, cystic fibrosis modulators and biologics are marked SP.
Coordinate PA plus specialty pharmacy routing when both PA and SP are listed.

Billing Rule

Confirm site‑of‑care and SP dispensing for specialty agents

Products marked 'SP' indicate specialty pharmacy distribution/site‑of‑care flags in the formulary lines; providers should confirm site‑of‑care (infusion vs. pharmacy) and dispense through the appropriate channel.

Many specialty injectables and infusion products include 'SP' and may require infusion center or specialty handling.
Verify medical benefit vs pharmacy benefit for drugs administered by a health care professional.

Billing Rule

Arrange specialty pharmacy dispensing when 'SP' is listed

When a product line includes 'SP', the formulary requires dispensing through the specialty pharmacy channel; providers must arrange specialty pharmacy fulfillment for SP‑flagged products.

SP appears on biologics, growth hormones, and many high‑cost therapies — coordinate with the specialty pharmacy vendor for fulfillment.
Specialty pharmacy routing is part of the requirements shown on the drug line.

Billing Rule

Specialty pharmacy required for multiple injectable biologics and specialty agents

Several injectable and high‑cost specialty agents are designated 'SP' on the formulary (e.g., many biologics and enzyme replacement therapies); providers must ensure these are dispensed via specialty pharmacy when required.

Examples include ORENITRAM packs, NUCALA, REPATHA, and cystic fibrosis modulators listed with SP.
Failure to route SP items through specialty pharmacy may result in non‑coverage or claim denial.