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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Cross Blue Shield OK Pharmacy Drug List Cover…
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    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

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

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    This document is Blue Cross and Blue Shield of Oklahoma's 2025 pharmacy drug list describing covered outpatient prescription drugs, tier placements, special requirements (PA, ST, QL), and instructions for members and providers about coverage and exceptions.

    Policy Summary
    PayerBlue Cross Blue Shield - Oklahoma
    Policy2025 Drug List (Pharmacy Benefit) — Formulary, Tiering, and Utilization Controls
    Policy CodePolicy N/A
    Change TypeAnnual drug list publication (no material changes)
    Effective DateOct 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when a product is marked 'PA' before submitting claims.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ~120+distinct drug entries (excerpt)
    PA presentPA indicated
    QL presentQuantity limits (common)
    6member payment tiers
    30/90day supply options

    Coverage criteria and formulary placement

    General coverage and formulary placement

    Coverage and tier placement rules described apply to drugs on the Drug List:

    Formulary placement and member payment: Each prescription drug product is assigned to one of up to six member payment tiers (Preferred Generic Tier 1, Non-Preferred Generic Tier 2, Preferred Brand Tier 3, Non-Preferred Brand Tier 4, Preferred Specialty Tier 5, Non-Preferred Specialty Tier 6).

    Tier and special requirements determine member cost-share and may vary by plan.

    Coverage limits and exclusions: Drugs not listed are not covered by the pharmacy benefit; non‑FDA‑approved drugs, repackaged medications, some compounded medications, and prescription products with OTC equivalents may be excluded. Drugs not FDA‑approved for self‑administration may be available under the medical benefit.

    Check plan materials or the member ID card for plan‑specific coverage and payment amounts.

    Supply and dispensing limits: Most plans cover up to a 30‑day supply; some plans permit up to a 90‑day supply for maintenance medications. Dispensing limits (QL/DL) shown on the Drug List apply and are enforced unless an exception or prior authorization is approved.
    Policy Summary
    PayerBlue Cross Blue Shield - Oklahoma
    Policy2025 Drug List (Pharmacy Benefit) — Formulary, Tiering, and Utilization Controls
    Policy CodePolicy N/A
    Change TypeAnnual drug list publication (no material changes)
    Effective DateOct 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when a product is marked 'PA' before submitting claims.
    SourceLink
    On This Page
    Coverage criteria and formulary placementDrug list entries and coding/tiersWhat providers must do — authorizations, documentation, denialsInitial therapy and authorization criteriaStep therapy requirementsQuantity limits by productSite-of-care and specialty routingTerminology and abbreviationsBackground and context
    30 days (typical) / 90 days (maintenance when allowed)

    State controlled‑substance laws may further restrict quantities beyond listed dispensing limits.

    Exception and expedited review

    Process and timeframes for Drug List exceptions:

    Standard exception request: Member or prescriber may request a Drug List exception by calling the number on the member ID card; BCBSOK will notify the prescriber/member of the coverage decision within 15 calendar days after receipt of the request.15 calendar days

    If denied, BCBSOK will provide the reason and offer a covered alternative when applicable.

    Expedited exception request: For situations where the member’s health condition may jeopardize life, health, or function (or when current therapy uses a non‑covered drug), an expedited review may be requested; BCBSOK will notify the prescriber/member of the decision within 72 calendar hours after receipt.72 hours

    Use expedited process when imminent harm is alleged or urgent clinical need exists.

    Formulary coverage stance

    Coverage and utilization controls for listed outpatient drugs are specified as follows when present:

    Formulary controls: Each drug entry on the Drug List includes a Drug Tier and may include one or more Requirements/Limits flags such as QL (quantity limit), PA (prior authorization), SP (specialty pharmacy) or AC (administrative coverage).

    Clinical PA criteria are not included in this excerpt; apply the presence of these controls per individual drug line.

    Coverage mapping (administrative)

    Coverage attributes for individual drugs in this excerpt are governed by their listed Drug Tier and Requirements/Limits.

    Formulary attribute rules: Coverage for a specific product is determined by its Drug Tier (e.g., P, NP) and the Requirements/Limits column on the Drug List; examples in the excerpt include vaccines with AC, antibiotics with QL, and many oncology/specialty agents with PA and QL values.

    This section maps products to administrative controls; it does not provide the detailed clinical medical‑necessity language for PA determinations.

    Administrative coverage conditions

    Coverage subject to drug-specific utilization controls

    Formulary coverage conditions: Each drug line is conditional on meeting any listed utilization controls (e.g., PA, QL, SP). Coverage will be provided only when the listed administrative requirements for that product are satisfied or an approved exception is on file.

    Providers and pharmacies must follow per‑line Requirements/Limits when submitting claims or PA requests.

    Formulary utilization controls

    Coverage for the listed drugs is subject to the following product-level utilization controls as listed:

    Utilization controls present: Products may be annotated with: PA (prior authorization required before coverage), QL (numeric quantity limits with specified time windows), SP (specialty pharmacy routing), and AC (administrative coverage). These controls are applied per product as shown on the Drug List.

    Where QL is listed the exact numeric limit and time period (e.g., 30 tablets/30 days, 1 pen/28 days) must be observed; lack of PA when required may result in denial.

    Formulary coverage entries

    Formulary coverage and restriction indicators

    Per‑line coverage node: Each named product entry lists Drug Tier and may list Requirements/Limits (PA, QL, SP, AC). Coverage of a prescription is subject to those per‑product indicators and any supporting documentation requirements for PA or QL overrides.

    This excerpt contains many product lines showing tier and utilization flags; consult the full Drug List for the specific line item details.

    Formulary placement and utilization controls (partial list)

    Coverage, tiering, and utilization controls as listed for specific products in this segment.

    Example: Levothyroxine products: Levothyroxine formulations (capsules, tablets, oral solutions) are listed with Drug Tier assignments (P or NP) and are governed by the per‑line Requirements/Limits entry where present.

    See individual product lines for any PA/QL/SP indicators.

    Formulary drug coverage indicators

    Formulary coverage and utilization controls (per drug) as listed in this section

    Formulary entries: Each entry includes drug name, formulation/strength, Drug Tier and, where applicable, Requirements/Limits such as PA, QL and SP. Coverage is contingent on compliance with those listed controls.

    This excerpt provides administrative mapping only; clinical indications and full PA criteria are not reproduced here.

    Product-level coverage attributes

    Coverage and limits applied per product line as listed below.

    Product‑level coverage attributes: Products are shown with Drug Tier and may include Requirements/Limits such as PA (prior authorization), QL (with specified quantity/timeframe), and SP (specialty pharmacy). When PA and/or QL are present, authorization or adherence to the QL is required for coverage.

    Exact QL numeric values and SP routing vary by product and formulation; consult the specific line item for presentation‑specific limits.

    Product-level coverage with PA/QL

    Coverage is product-specific; where PA and QL are indicated, authorization is required per plan.

    NUCALA (mepolizumab): Mepolizumab presentations are listed with Prior Authorization and quantity limits that vary by presentation (examples include QL 1 syringe/28 days for some pref syringes or QL 3 mL/28 days for other presentations) and may be designated SP.PA and specified QL

    Follow the exact line‑item for presentation‑specific QL and SP flags.

    TEZSPIRE (tezepelumab): Tezepelumab is listed with Prior Authorization and a quantity limit of 1 pen/28 days and is managed through specialty pharmacy (SP).PA and QL 1 pen/28 days

    PA required prior to coverage.

    CF modulators and antifibrotics: Cystic fibrosis modulators (e.g., TRIKAFTA, ALYFTREK, KALYDECO, SYMDEKO) and antifibrotics (OFEV, PIRFENIDONE) are listed with Prior Authorization, specified QL values and SP designation for many formulations.PA and product‑specific QL

    See each product line for exact packet/tablet/pack QL and SP routing.

    Formulary coverage entries with utilization management

    Coverage for listed products is tied to drug tier and may be subject to utilization management; where present, QL, PA, and ST are applied as noted.

    Tier and utilization annotations: Each product entry includes a Drug Tier (P, NP, etc.) and may include Requirements/Limits such as QL (quantity limits), PA (prior authorization), and ST (step therapy). Providers must follow these annotations when prescribing and submitting claims.

    Some entries include ST (step therapy) for selected products; however, detailed step sequences are not provided in this excerpt.

    The Drug List excludes certain categories from pharmacy benefit coverage. Specifically, non–FDA-approved drugs, repackaged medications, some compounded medications, and prescription products that have over‑the‑counter equivalents may not be covered under the pharmacy benefit. Providers and members should verify plan-specific coverage in benefit materials or by calling the number on the member ID card.

    Within the provided excerpt there are no discrete clinical exclusion rules or diagnostic‑specific denial statements. The listing is primarily a formulary mapping (tier and Requirements/Limits) rather than a narrative of clinical exclusions; where clinical limits exist they would be captured in product‑specific PA criteria not included in these chunks.

    Coverage in this document is presented as a formulary listing: each product is assigned a Drug Tier (e.g., P, NP) and may include administrative annotations in the Requirements/Limits column such as PA, QL, SP, or AC. These attributes determine member cost‑share and the utilization controls that apply for that product.

    Provider actions are driven by the product-level Requirement/Limits flags. Entries marked PA indicate that a prior authorization must be obtained before the drug will be covered; entries with QL indicate numeric quantity limits that must be observed; SP flags denote specialty pharmacy routing; and AC indicates administrative coverage rules for certain vaccines or biologics.

    The excerpt does not list any stand‑alone clinical exclusions (for example, indications specifically denied regardless of PA/QL). Instead, coverage is conditioned on meeting the per‑line utilization controls (PA, QL, SP, AC) shown for each drug entry.

    No detailed medical necessity clinical criteria are provided in these chunks. The document segment is administrative in nature: presence of PA or other flags indicates an authorization requirement but the clinical PA criteria themselves are not included here.

    There are no explicit excluded clinical indications or denial lists presented in the excerpt. Lines without Requirements/Limits appear as standard formulary entries subject to the tier in which they are placed.

    Many product lines show a combination of tier assignment and utilization controls. For example, oncology and specialty agents commonly display PA and QL (quantity limits) and are frequently routed via SP (specialty pharmacy).

    Several high‑cost metabolic and GLP‑1/GIP agents are listed with explicit utilization annotations. Products such as MOUNJARO and OZEMPIC are shown with PA and numeric QL values (e.g., pen limits), indicating authorization and dispensing limits apply.

    Across the excerpt there are no explicit clinical exclusion criteria tied to individual drugs. The document focuses on administrative controls—tier and Requirements/Limits—rather than on listing clinical scenarios that would exclude coverage.

    The excerpt does not identify any listed indications as explicitly excluded. Items are presented with tiers and any applicable Requirements/Limits; absence of an exclusion statement in these chunks means any coverage limitations would be operationalized through PA/QL/SP requirements or in separate policy sections.

    Where present, the Requirements/Limits column signals utilization management: many biologics and specialty products (for example NUCALA, TEZSPIRE, CF modulators) list PA and specific QL values and often the SP designation, indicating authorization, dispensing limits, and specialty routing apply.

    This excerpt functions primarily as a formulary listing rather than a detailed clinical inclusion/exclusion policy. Coverage determination is driven by product tier and the listed Requirements/Limits; clinical PA criteria, if applicable, are maintained separately and are not included in these chunks.

    The Drug List notes that agents indicated for cosmetic use (for example hair‑growth agents) may be excluded and some products may be limited by age or other plan‑specific safety criteria. These limitations are administratively applied per plan.

    The excerpt does not identify any drugs as explicitly labeled Not Medically Necessary. No NMN determinations are present in these chunks; coverage stance is expressed via tiering and utilization controls.

    There are no statements within these chunks that declare products to be Not Medically Necessary. The document segment is a formulary with PA/QL/SP indicators rather than NMN rulings.

    This section is a product‑level formulary list that assigns tiers and administrative controls to each entry. It should be used to determine whether a prior authorization, quantity limit, or specialty pharmacy routing applies for a given formulation.

    No statements defining items as Not Medically Necessary appear in the excerpt. Coverage limitations are operationalized by PA, QL, and other Requirements/Limits rather than by NMN declarations in these chunks.

    The excerpt contains no NMN language; instead, coverage posture for each listed product is provided as a combination of Drug Tier and any associated utilization controls (PA, QL, SP, AC).

    No items in these chunks are explicitly labeled Not Medically Necessary. Providers should follow the per‑line Requirements/Limits and consult plan materials for any NMN determinations that may exist elsewhere in policy.

    When coverage is described, it is provided as a tier assignment plus any utilization controls. The effective coverage stance for a product in this excerpt is therefore articulated as its Drug Tier and the presence of PA, QL, or SP flags.

    There are no NMN statements in these chunks. The document segment is focused on formulary placement and utilization management markers rather than on explicit not‑medically‑necessary rulings.

    Fallback: This document is an administrative Drug List excerpt that maps products to member payment tiers and shows per‑line Requirements/Limits. For full clinical coverage rules, PA criteria, and any exclusion or NMN policies, refer to the complete policy or contact the plan using the number on the member ID card.

    The provided chunks do not include explicit conditions or situations labeled as Not Medically Necessary. Coverage controls in the excerpts are administrative (tier, PA, QL, SP) and any NMN determinations would be documented elsewhere.

    No statements in these chunks declare products as Not Medically Necessary. The Drug List uses tiering and utilization designations to describe coverage and restrictions in this excerpt.

    Drug list entries and coding/tiers

    Listed drugs (sample lines from PENICILLINS section)NDC/mixedCovered
    amoxicillinamoxicillin (trihydrate) chew tab 125 mg, 250 mg
    amoxicillin_cap_250_500amoxicillin (trihydrate) cap 250 mg, 500 mg
    amoxicillin_suspensionsamoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
    amoxicillin_tab_500_875amoxicillin (trihydrate) tab 500 mg, 875 mg
    amoxicillin_clavulanate_susp_200_400amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 400-57 mg/5ml
    amoxicillin_clavulanate_susp_250_600amoxicillin & k clavulanate for susp 250-62.5 mg/5ml; 600-42.9 mg/5ml (Augmentin es-600)
    Formulary drug listing (names & strengths)mixed
    drug names and strengthsMultiple NDCs/Codes not listed; document provides drug names and strengths (e.g., rilpivirine hcl tab for oral susp 2.5 mg; efavirenz tab 600 mg; EPCLUSA sofosbuvir-velpatasvir 200-50 mg; etc.).
    Drug list (no billing codes)mixed
    No CPT/HCPCS/ICD codes in excerptThis excerpt contains drug names, tiers, and requirements but no specific procedure, diagnosis, or billing codes.
    Listed oral oncology products (sample)mixed
    bosutinib 100 mg capBOSULIF - bosutinib cap 100 mg
    bosutinib 100 mg tabBOSULIF - bosutinib tab 100 mg
    bosutinib 400 mg, 500 mg tabBOSULIF - bosutinib tab 400 mg, 500 mg
    IMBRUVICA formulationsmixed
    ibrutinib tab 140/280/420 mgIMBRUVICA - ibrutinib tab 140 mg, 280 mg, 420 mg
    ibrutinib oral susp 70 mg/mlIMBRUVICA - ibrutinib oral susp 70 mg/ml
    ibrutinib cap 70 mg, 140 mgIMBRUVICA - ibrutinib cap 70 mg; IMBRUVICA - ibrutinib cap 140 mg
    Drug listing (no procedure/diagnosis codes)mixed
    none listedThis section lists drug names, strengths, tiers, and requirements; no CPT/HCPCS/ICD-10 codes are provided in chunks 90-109.
    Formulary entries (no billing codes in excerpt)mixed
    N/AThis excerpt does not contain CPT/HCPCS/ICD-10/NDC codes; it lists medication names, strengths, tiers, and requirements.
    Sample listed endocrine agentsmixed
    levothyroxine sodium cap 13 mcglevothyroxine sodium capsule 13 mcg (TIROSINT entry)
    levothyroxine sodium tab 25 mcglevothyroxine sodium tablet 25 mcg (Synthroid/SYNTHROID entry)
    liothyronine sodium tab 5 mcgliothyronine sodium tablet 5 mcg (Cytomel)
    Sample specialty injectablesmixed
    ACTHAR - corticotropin inj gel 80 unit/mlACTHAR corticotropin injection gel 80 unit/ml
    OCTREOTIDE ACETATE - octreotide acetate subcutaneous soln pref syr 50 mcg/mlOctreotide acetate subcutaneous solution, prefilled syringe 50 mcg/ml
    SOMAVERT - pegvisomant for inj 10 mgPegvisomant injection 10 mg (Somavert)
    Formulary items (no explicit billing codes in excerpt)mixed
    Drug list entriesMultiple NDCs/CPT/HCPCS not listed in this excerpt; only product names, strengths, tiers and requirements are provided.
    Formulary entries shown (selected examples)NDC|Brand
    NUCALA - mepolizumab subcutaneous solution auto-injector 100 mg/mlDrug Tier = P; Requirements/Limits = PA, QL (3 ml/28 days), SP (for some presentations)
    NUCALA - mepolizumab pref syringe 40 mg/0.4mlDrug Tier = P; Requirements/Limits = PA, QL (1 syringe/28 days), SP
    TEZSPIRE - tezepelumab-ekko 210 mg/1.91mlDrug Tier = P; Requirements/Limits = PA, QL (1 pen/28 days), SP
    XOLAIR - omalizumab subcutaneous solution (various strengths)Drug Tier = P; Requirements/Limits = PA, SP
    ALYFTREK - vanzacaftor-tezacaftor-deutivacaftor 4-20-50 mgDrug Tier = P; Requirements/Limits = PA, QL (84 tablets/28 days), SP
    KALYDECO - ivacaftor 150 mg tabDrug Tier = P; Requirements/Limits = PA, QL (60 tablets/30 days), SP
    TRIKAFTA - elexacaftor-tezacaftor-ivacaftor (various strengths)Drug Tier = P; Requirements/Limits = PA, QL (56 packets/28 days or 90 tablets/30 days depending on formulation), SP
    OFEV - nintedanib esylate cap 100 mg, 150 mgDrug Tier = NP; Requirements/Limits = PA, QL (60 capsules/30 days), SP
    PIRFENIDONE - pirfenidone tab 534 mgDrug Tier = NP; Requirements/Limits = PA, QL (21 tablets/180 days), SP
    CREON - pancrelipase DR caps (multiple strengths)Drug Tier = P; Requirements/Limits = none listed in these chunks
    1–10 of 12
    1/2
    Gastrointestinal agents (selected)Brand
    PEG-PREP kitDrug Tier = NP
    PRILOSEC - omeprazole magnesium for delayed release susp packetDrug Tier = NP+; Requirements/Limits = QL (30 packets/30 days)
    pantoprazole sodium EC tab 20 mg, 40 mg (Protonix)Drug Tier = p; Requirements/Limits = QL (60 tablets/30 days)
    lansoprazole cap 15 mg, 30 mg (Prevacid)Drug Tier = np+; Requirements/Limits = QL (60 capsules/30 days)
    Formulary drug list (psychiatric medications) — product-levelmixed
    hydroxyzine hcl syrup 10 mg/5mllisted formulation
    hydroxyzine hcl tab 10 mg, 25 mg, 50 mglisted formulation
    hydroxyzine pamoate cap 25 mg, 50 mg, 100 mglisted formulation (Vistaril)
    lorazepam conc 2 mg/mllisted formulation
    lorazepam tab 0.5 mg, 1 mg, 2 mgAtivan
    LOREEV XR lorazepam cap er 24hr 1 mg–3 mglisted ER sprinkle formulation
    amitriptyline hcl tab 10–150 mglisted formulations
    AUVELITY dextromethorphan hbr-bupropion hcl tab er 45-105 mglisted product
    bupropion hcl tabs (various IR/ER/XR strengths)Wellbutrin formulations listed
    citalopram hydrobromide cap 30 mg; tabs 10, 20, 40 mg; soln 10 mg/5mlCelexa formulations
    1–10 of 29
    1/3
    inv-51: Common quantity limits (examples)
    Common QL formatsExamples include 30 tablets/30 days; 60 tablets/30 days; 90 tablets/30 days; 180 tablets/30 days; larger-volume limits (e.g., 720–2400 mls/30 days) for oral solutions.
    Vaccine/biologic administrative designationSome vaccines and biologics are listed with Requirements/Limits = AC (administrative coverage) rather than PA (prior authorization).
    PA and SP flagsMany specialty and oncology agents include Requirements/Limits = PA and/or SP indicating prior authorization and specialty pharmacy handling are required.
    No procedure/diagnosis codes in excerptThe document lists drug names, strengths, tiers, and utilization controls but does not include CPT/HCPCS/ICD codes in these chunks.
    inv-52: Quantity limits examples
    Typical tablet/capsule QLsExamples shown include QL (30 tablets/30 days), QL (60 tablets/30 days), and QL (120 tablets/30 days) depending on product.
    Carton/pack limitsSome oncology kits/packs are limited by carton or pack (e.g., QL 1 carton/28 days; QL 1 pack/180 days).
    Pen/kit limitsInjectable pens and starter kits use pen/kit limits (e.g., 4 pens/28–180 days; 1 pack/180 days).
    Specialty pharmacy (SP) pairingHigh-cost oral oncology entries pair QL with PA and SP designations (e.g., bosutinib entries list PA + QL + SP).
    inv-53: Example quantity limits
    Therapy pack and tab examplesExamples include QL (4 tablets/28 days) to QL (32 tablets/28 days) for selinexor therapy packs and QL (120 tablets/30 days) for some oral oncology agents.
    Large QL values for chronic oral agentsSome chronic oral agents are assigned higher QLs (e.g., 120 tablets/30 days; 240 capsules/30 days for sprinkle formulations).
    SP and PA often co-listedTherapy packs and many oral oncology products show Requirements/Limits = PA and SP in addition to numeric QLs.
    inv-54: Quantity limits examples
    Multiple presentation QLsProducts may have different QLs by presentation — e.g., CRENESSITY: 60 capsules/30 days (capsule) or 120 mls/30 days (oral solution).
    Cartridge/carrier limitsFollistim and similar injectables list QL as cartridges per 30 days (e.g., 5 cartridges/30 days).
    PA and SP designationsThese specialty products routinely carry PA and SP requirements along with the QL numeric limits.
    inv-55: Quantity limits for oral/solution products
    Oral solution volume QLsExamples include large-volume limits such as 1920 ml/30 days for multiple calcium-channel blocker oral solutions and 300 ml/30 days for certain oral suspensions.
    Use for liquid formulationsOral liquids and suspensions are expressed in mL per 30 days (e.g., Riomet metformin oral soln QL 780 mls/30 days elsewhere in the document).
    Claims must adhere to volume QLsClaims exceeding the stated mL QLs for oral solutions/suspensions may be denied without prior authorization or exception.
    inv-56: Examples of Quantity Limits
    Specific product QL examplesEpaned (enalapril oral soln) QL = 1200 mls/30 days; QBRELIS (lisinopril oral soln) QL = 2400 mls/30 days; REPATHA QL = 6 syringes/28 days.
    Varied QL unitsQuantity limits use different units (mls, syringes/pens, tablets) and time windows (28 or 30 days) per product.
    High-cost biologic limitsBiologic injectables often have per-device limits (e.g., REPATHA 6 pens/28 days) paired with PA and SP designations.
    inv-57: Example quantity limits observed
    Common numeric QL patternsFrequently observed examples include QL (30 capsules/30 days), QL (60 tablets/30 days), and QL (1 pack/180 days) across product lines.
    Cardiopulmonary agents QLsPAH and pulmonary agents show large tablet or pack limits (e.g., ORENITRAM QL 300 tablets/30 days; TYVASO QL 7 ampules/28 days).
    Enforcement riskClaims exceeding these QLs may be denied or require exception/prior authorization per formulary rules.
    inv-58: Example quantity limits
    Per-device and per-pen QLs for biologicsExamples include 1 syringe/28 days or 1 pen/28 days for some injectables and larger tablet counts like 84 tablets/28 days for certain oral regimens.
    NUCALA and TEZSPIRE QLsNUCALA pref syringe: QL 1 syringe/28 days (40 mg/0.4 ml); NUCALA 100 mg/ml presentation: QL 3 ml/28 days. TEZSPIRE: QL 1 pen/28 days.
    CF modulator tablet QLsCF modulators (e.g., ALYFTREK) use multi-tablet QLs (e.g., 84 tablets/28 days for some strengths).
    inv-59: Example quantity limits
    Common denominator QLsExamples commonly include QL (30 tablets/30 days) and QL (60 tablets/30 days); liquid limits like 900 mls/30 days or 540 mls/30 days also appear.
    Psychotropic drug QLsMany psychotropic agents are subject to tablet-count QLs (e.g., aripiprazole QL 60 tablets/30 days; clozapine QL values vary by strength).
    Step Therapy (ST) may also appearSome psychiatric agents list ST alongside QL (e.g., aripiprazole entries include ST).
    inv-60: Common quantity limits
    Representative QL rosterThe formulary shows repeated QL formats: 30/30, 60/30, 90/30, 1 pack/180 days, per-device limits (1 syringe/28 days), and large-volume oral solution limits.
    Administrative flags presentEntries pair QL with utilization flags such as PA (prior authorization), SP (specialty pharmacy), or AC (administrative coverage) which govern coverage enforcement.
    No billing codes in excerptThe excerpt contains drug-level entries and utilization controls but does not include CPT/HCPCS/ICD procedure or diagnosis codes for these products.

    What providers must do — authorizations, documentation, denials

    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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).
    Note

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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).
    Prior Authorization

    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).
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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).
    Step Therapy

    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.
    Note

    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.
    Note

    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.
    Note

    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.
    Step Therapy

    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.
    Note

    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.
    Note
    Note
    Note

    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.
    Billing Rule

    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.
    Prior Authorization

    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.
    Step Therapy

    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.
    Documentation 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.
    Billing Rule

    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.
    Documentation Required

    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).
    Billing Rule

    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.
    Note

    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.
    Documentation Required

    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.
    Documentation Required

    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.
    Billing Rule

    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.
    Documentation Required

    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.
    Documentation Required

    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).
    Billing Rule

    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.
    Billing Rule

    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.
    Documentation Required

    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.
    Documentation Required

    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.
    Billing Rule

    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.
    Documentation Required

    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.
    Denial Risk

    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

    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.
    Denial Risk

    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.
    Denial Risk

    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.
    Denial Risk

    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

    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.
    Denial Risk

    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.
    Denial Risk

    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.
    Denial Risk

    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.
    Denial Risk

    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.
    Denial Risk

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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.
    Prior Authorization

    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).
    Denial Risk

    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.

    Initial therapy and authorization criteria

    PA for selected GLP-1/GIP/other agents

    Prior authorization indicators for certain agents

    PA requirement examples for GLP‑1/GIP and related agents: Several GLP‑1/GIP agents and related antidiabetic products (examples in the Drug List: MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY and selected metformin formulations) are annotated with 'PA' in the Requirements/Limits column indicating that prior authorization is required for coverage initiation or continuation.

    This excerpt does not include the specific clinical criteria used to adjudicate PA requests for these agents; refer to the payer’s PA documentation for required clinical information.

    Step therapy requirements

    Coverage controlNotes
    No explicit step therapy algorithm provided in this excerptEntries show Requirements/Limits flags (e.g., PA, QL, SP, AC) but do not define step sequences for individual drugs; some lines include 'SP' or 'AC' which may imply specialty routing or administrative handling.
    Coverage controlNotes
    Step therapy not specified for listed agentsFormulary lines for oncology and other agents list PA, QL, SP but do not specify a required prior agent or step sequence for coverage.
    Coverage controlNotes
    No explicit step-therapy steps listedProduct entries include PA and numeric QL values and SP designation; step-therapy is not enumerated as part of these Requirements/Limits fields.
    Coverage controlNotes
    No explicit step therapy sequences listedSpecialty oncology products are listed with PA/QL/SP; the excerpt does not present a multi-step sequence or required prior therapies.
    Coverage controlNotes
    AC and PA co-listed for some contraceptivesCertain contraceptive products show Requirements/Limits = AC and in some cases PA plus QL (e.g., 28 tablets/21 days); this suggests administrative and authorization controls but no step-therapy algorithm is given.
    Coverage controlNotes
    Step therapy not specified in excerptListings emphasize PA, QL, and SP as utilization controls; step therapy requirements are not described for most lines in this segment.
    Coverage controlNotes
    KERENDIA — ST indicatedKERENDIA (finerenone) is listed with Requirements/Limits = QL (30 tablets/30 days) and ST, indicating a step therapy requirement applies to this product in the formulary excerpt.
    Coverage controlNotes
    High-cost/specialty agents subject to PA/SPMany specialty or high-cost products list Requirements/Limits = PA and SP (e.g., REPATHA entries), which are primary utilization controls; the excerpt does not show multi-step sequences for these agents.
    Coverage controlNotes
    AC/PA/SP markings present without step detailsSome lines combine AC, PA, and SP designations implying administrative edits, prior authorization, or specialty pharmacy routing, but explicit step therapy requirements or sequences are not provided in this excerpt.
    Coverage controlNotes
    Products marked SP and PA (example: Uptravi)UPTRAVI entries include Requirements/Limits = PA, QL (60 tablets/30 days) and SP; the titration pack is listed with PA, QL (1 pack/180 days) and SP — indicating specialty routing and PA are primary controls rather than a step-therapy sequence in the excerpt.
    Coverage controlNotes
    Step therapy not explicitly specified; PA/SP are primary controlsAcross oncology and specialty listings, Requirements/Limits fields predominantly show PA, QL, and SP as the mechanisms for utilization management; explicit ST sequences are generally absent in these chunks.
    Coverage controlNotes
    PA and SP designated products may imply specialty handlingEntries with PA and SP suggest specialty pharmacy dispensing and prior authorization requirements (e.g., REPATHA, UPTRAVI), but the document does not provide explicit step therapy sequences or failure criteria for coverage.
    Coverage controlNotes
    Certain products flagged with ST (examples)Some medications are explicitly annotated with 'ST' in the Requirements/Limits (examples in the excerpt include AUVELITY, desvenlafaxine ER entries, FETZIMA and certain antipsychotic/titration packs), indicating step therapy requirements apply to those specific products.

    Quantity limits by product

    azithromycin (Zithromax) — quantity limit
    Productazithromycin tab 250 mg, 500 mg (Zithromax)
    Quantity limit60 tablets
    Time window180 days
    ARIKAYCE — quantity limit
    ProductARIKAYCE (amikacin liposome inhalation suspension)
    Quantity limit235.2 mls/28 days
    RequirementsPA, SP
    TOBI PODHALER — quantity limit
    ProductTOBI PODHALER (tobramycin inhalation capsules 28 mg)
    Quantity limit224 capsules/56 days
    RequirementsQL, SP
    tobramycin nebulization solution — quantity limit
    Producttobramycin nebu soln 300 mg/5 ml (various brands)
    Quantity limit56 containers/56 days
    RequirementsPA (some entries), SP
    EPCLUSA — quantity limit
    ProductEPCLUSA (sofosbuvir-velpatasvir)
    Quantity limit30 tablets/30 days (or 28 tablets/28 days for pellet pack)
    RequirementsPA, SP
    Many agents — QL patterns
    RangeQLs vary by agent; common patterns include 30/30, 60/30, 90/30, 180/30 and specialized pack counts
    ExamplesOncology, antivirals, and specialty injectables show product‑specific QLs — see individual entries for exact values
    ImplicationClaims exceeding listed QLs may be denied or require exception/PA
    Examples from excerpt — QL varies by product
    Varied product QLsExamples across the excerpt show QLs by product and formulation (tablets, capsules, mls, kits, pens) rather than a single uniform limit
    Therapy and starter packsSeveral therapy/start packs are limited (e.g., VENCLEXTA 1 pack/180 days; UPTRAVI titration pack 1 pack/180 days)
    Device countsBiologics and injectables limited by devices (pens/syringes) per 28–56 day windows
    ALUNBRIG initiation pack — quantity limit
    ProductALUNBRIG initiation pack (brigatinib)
    Quantity limit1 pack/180 days
    RequirementsPA, SP
    BOSULIF — quantity limit
    ProductBOSULIF - bosutinib capsule 100 mg
    Quantity limit150 capsules/30 days
    RequirementsPA, SP
    IMBRUVICA — quantity limits
    ProductIMBRUVICA - ibrutinib tablet/capsule formulations
    Quantity limit30 tablets/30 days (common entry for some strengths); other entries show 90 capsules/30 days or 216 mls for suspension
    RequirementsPA, SP
    LYNPARZA — quantity limit
    ProductLYNPARZA - olaparib tablets (100 mg, 150 mg)
    Quantity limit120 tablets/30 days
    RequirementsPA, SP
    OGSIVEO — quantity limit
    ProductOGSIVEO - nirogacestat tablets (100 mg, 150 mg)
    Quantity limit56 tablets/28 days
    RequirementsPA, SP
    PIQRAY therapy pack — quantity limit
    ProductPIQRAY 200 mg daily dose (alpelisib) therapy pack
    Quantity limit28 tablets/28 days
    RequirementsPA, SP
    VENCLEXTA starter pack — quantity limit
    ProductVENCLEXTA STARTING PACK (venetoclax)
    Quantity limit1 pack/180 days
    RequirementsPA, SP
    ZEJULA — quantity limit
    ProductZEJULA - niraparib tosylate tablets
    Quantity limit30 tablets/30 days
    RequirementsPA, SP
    XPOVIO — quantity limit examples
    ProductXPOVIO - selinexor tablet therapy packs
    Quantity limitExample entries show therapy pack limits (e.g., 16 tablets/28 days for certain pack configurations)
    RequirementsPA, SP
    METHITEST — quantity limit
    ProductMETHITEST - methyltestosterone oral tablet 10 mg
    Quantity limit600 tablets/30 days
    RequirementsPA
    methyltestosterone (capsules) — quantity limit
    Productmethyltestosterone capsules 10 mg
    Quantity limit600 capsules/30 days
    RequirementsPA
    testosterone TD gel 20.25 mg — quantity limit
    Producttestosterone transdermal gel 20.25 mg/1.25 gm
    Quantity limit30 packets/30 days
    RequirementsPA
    testosterone TD gel 10 mg/act — quantity limit
    Producttestosterone TD gel 10 mg/act (2%) pump
    Quantity limit2 pumps/30 days
    RequirementsPA
    testosterone cypionate IM — quantity limit
    Producttestosterone cypionate IM injection in oil (100 mg/ml and 200 mg/ml)
    Quantity limit10 ml/28 days
    RequirementsQL noted; PA present for some formulations
    testosterone enanthate IM — quantity limit
    Producttestosterone enanthate IM injection 200 mg/ml
    Quantity limit5 ml/28 days
    RequirementsPA for some presentations
    Androgel — quantity limit
    Producttestosterone TD gel 25 mg/2.5 gm and 20.25 mg/act (Androgel presentations)
    Quantity limit150 grams/30 days
    RequirementsPA
    testosterone TD gel 50 mg — quantity limit
    Producttestosterone TD gel 50 mg/5 gm
    Quantity limit300 grams/30 days
    RequirementsPA
    testosterone TD gel 12.5 mg — quantity limit
    Producttestosterone TD gel 12.5 mg/act
    Quantity limit300 (units)/30 days (grams where specified)
    RequirementsPA
    testosterone TD solution — quantity limit
    Producttestosterone TD solution 30 mg/act
    Quantity limit180 ml/30 days
    RequirementsPA
    XYOSTED — quantity limit
    ProductXYOSTED — testosterone enanthate auto-injector
    Quantity limit2 ml/28 days
    RequirementsPA
    MYFEMBREE — quantity limit
    ProductMYFEMBREE (relugolix-estradiol-norethindrone acetate)
    Quantity limit30 tablets/30 days
    RequirementsPA
    ORIAHNN — quantity limit
    ProductORIAHNN (elagolix-estradiol-norethindrone acetate pack)
    Quantity limit56 capsules/28 days
    RequirementsPA
    estradiol patches/gels — quantity limit
    Productestradiol patches and gels (various brands)
    Quantity limit30 patches/30 days (where specified)
    RequirementsQL varies by presentation
    ANNOVERA — quantity limit
    ProductANNOVERA — segesterone-ethinyl estradiol vaginal ring
    Quantity limit1 ring/365 days
    RequirementsAC, QL
    Combined oral contraceptives — quantity limit
    Product classCombined oral contraceptives (multiple brands)
    Quantity limit28 tablets/21 days (standard cycles) where specified
    RequirementsOften listed with AC and QL
    FARXIGA — quantity limit
    ProductFARXIGA (dapagliflozin)
    Quantity limit30 tablets/30 days
    RequirementsQL specified
    GLYXAMBI — quantity limit
    ProductGLYXAMBI (empagliflozin-linagliptin)
    Quantity limit30 tablets/30 days
    RequirementsQL specified
    QL flag — numeric limits present
    NoteMany listed items indicate 'QL' where numeric limits are specified in the formulary line; see each product line for exact numeric QL and time window
    ActionClaims and prior authorizations must adhere to the per-product QL values shown
    ExamplesSee product-level entries for capsule/tablet/ml/device limits per specified window

    Site-of-care and specialty routing

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    Terminology and abbreviations

    Background and context

    Specialty drugs treat complex, often chronic conditions and may require special handling or administration; many are dispensed via specialty pharmacy or covered under the medical benefit when provider‑administered. The Drug List and the plan’s provider guidance should be used to determine benefit routing and any authorization requirements.