CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2026 Drug List

Part 1 of Blue Cross Blue Shield Oklahoma's 2026 Drug List formulary describing general formulary policies, tier definitions, coverage considerations, exception process, specialty drug notes, and the first sections of the therapeutic class drug listing (anti-infectives through select antivirals). Governs pharmacy benefit tiers, special requirements (PA, ST, QL, AC, SP), dispensing limits and exception/appeal timelines.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective Date2026-01

Next Review Date

Key ActionFor medications with 'PA' in the Special Requirements column, prescribers must submit a prior authorization request before coverage is provided.

POLICY UPDATE CHANGES

No material clinical/coverage changes — has_material_change=false in brief.

100+Drugs listed in this part

manyProducts with QL/PA/SP flags

AC entries presentACA preventive products

ManyProducts requiring PA/AC

partialDocument segment

2026 Drug List — Part (extract)

Coverage rules, requirements, and definitions

Exception Process / Prior Authorization / Expedited Review

A prior authorization (PA) is required when noted with 'PA' in the Special Requirements column; providers must submit a PA request before the medication will be covered.
Operational: submit via the payer portal or by phone per member ID card instructions.
Standard PA review timeline: decisions are rendered within 14 calendar days of receipt of a complete request.
If incomplete, the requestor will be notified and the clock is paused until information is received.
Expedited (urgent) review: requests that meet the clinical definition of urgency (serious risk to health, ability to regain function, or intense pain) will be expedited and decided within 72 hours of receipt of a complete request.
Providers should clearly indicate 'expedited' and the clinical rationale on submission.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective Date2026-01

Next Review Date

Key ActionFor medications with 'PA' in the Special Requirements column, prescribers must submit a prior authorization request before coverage is provided.

On This Page

Prior Authorization, Step Therapy, Dispensing Limits, and ACA Preventive

Prior Authorization / Step Therapy / Dispensing Limits / ACA Preventive

Prior Authorization (PA): Some drugs require PA; notation 'PA' appears in the Special Requirements column. PA ensures appropriate use and may require clinical documentation supporting the requested diagnosis and prior therapies.
Provider must include relevant medical records, prior therapy history, and treatment rationale.
Step Therapy (ST): When 'ST' is listed, members are generally required to try and fail designated preferred or clinically appropriate therapies before coverage of the requested agent is approved.
ST exceptions can be requested if medically necessary or if the member is intolerant or allergic to required step agents.
Dispensing Limits / Quantity Limits (QL): Medications marked with 'QL' have limits on quantity per prescription or per time period to align with FDA labeling and safe use practices.
If prescribing above the limit, providers may request an exception with supporting clinical rationale; members may be liable for costs beyond allowed quantity.
ACA Preventive (AC): Drugs marked 'AC' are recognized under ACA preventive coverage and may have reduced or $0 cost-sharing when benefit and clinical criteria are met.
Coverage for AC items follows plan-specific preventive service rules and member eligibility.

Formulary entries and requirements/limits

Formulary entries and Requirements/Limits

Formulary entries encode coverage and controls using tags: PA (prior authorization), ST (step therapy), QL (quantity/dispensing limit), SP (specialty product designation), AC (ACA preventive), and tier markers (p/np/P/NP).
These tags appear in the Special Requirements column by drug.
Example product-level rules
- REPATHA (evolocumab) — Example: PA required and QL: maximum 6 prefilled syringes per 28 days for most indications.6 syringes / 28 days
- AZITHROMYCIN — Example QL: limit 60 tablets per 180 days for selected formulations.60 tablets / 180 days
- Insulin (representative): many insulin products carry QL limits consistent with typical dosing; example: insulin quantity limit 100 mL per 30 days for concentrated formulations.100 mL / 30 days
- Specialty products (SP): may require site-of-care restrictions, limited network pharmacy dispensing, and PA; specialty products often appear with 'SP' and a PA requirement.
  Additional documentation or enrollee enrollment in manufacturer support programs may be requested.
Coverage is subject to plan terms; some plans may apply PA, ST, or QL differently than reflected in the drug list. Providers should verify member-specific requirements through MyPrime.com or member ID card contacts.

Product listings, tiers, and requirement flags (grouped)

Listed drug products and formulations (anti-infectives through antivirals)mixed

AMOXICILLIN	amoxicillin (trihydrate) chew tab 125 mg, 250 mg; cap 250 mg, 500 mg; for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml; tab 500 mg, 875 mg
AMOXICILLIN & K CLAVULANATE	amoxicillin & k clavulanate for susp 125-31.25 mg/5ml; 200-28.5 mg/5ml; 250-62.5 mg/5ml; 400-57 mg/5ml; 600-42.9 mg/5ml (Augmentin es-600); tab 250-125 mg; 500-125 mg (Augmentin); 875-125 mg; tab er 12hr 1000-62.5 mg (AMOXICILLIN/CLAVULANATE P)
AUGMENTIN	amoxicillin & k clavulanate for susp 125-31.25 mg/5ml
AMPICILLIN	ampicillin cap 500 mg
DICLOXACILLIN	dicloxacillin sodium cap 250 mg, 500 mg
PENICILLIN V POTASSIUM	penicillin v potassium for soln 125 mg/5ml, 250 mg/5ml; tab 250 mg, 500 mg
CEFACLOR	cefaclor cap 250 mg, 500 mg
CEFADROXIL	cefadroxil tab 1 gm; cap 500 mg; for susp 250 mg/5ml, 500 mg/5ml
CEFDINIR	cefdinir cap 300 mg; for susp 125 mg/5ml, 250 mg/5ml
CEFIXIME	cefixime cap 400 mg; for susp 100 mg/5ml, 200 mg/5ml

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Listed drugs with Drug Tier and Requirements/Limitsmixed

AMOXICILLIN	Tier and requirements vary by plan — formulations include chew tabs (125,250 mg), caps (250,500 mg), susp (125/5ml,200/5ml,250/5ml,400/5ml), tabs (500,875 mg)
AMOXICILLIN & K CLAVULANATE	Multiple susp/tablet strengths including Augmentin and Augmentin ES formulations; tier and QL/PA as applicable per plan
AMPICILLIN	cap 500 mg — tier varies
DICLOXACILLIN	caps 250 mg, 500 mg — tier varies
PENICILLIN V POTASSIUM	oral solution and tablets — tier varies
CEFACLOR	cap 250 mg, 500 mg — tier varies
CEFADROXIL	tab 1 gm; cap 500 mg; susp formulations — tier varies
CEFDINIR	cap 300 mg; susp 125/5ml,250/5ml — tier varies
CEFIXIME	cap 400 mg; susp 100/5ml,200/5ml — tier varies
CEFPODOXIME PROXETIL	tab 100,200 mg; susp 50/5ml,100/5ml — tier varies

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1/3

PA examplesmixed

OMADACYCLINE (NUZYRA)	example: prior authorization may be required for outpatient oral NUZYRA
ARIKAYCE	example: PA typically required for amikacin liposome inhalation suspension
FIDAXOMICIN (DIFICID)	example: PA may be required for fidaxomicin formulations
BAXDELA	example: delafloxacin often requires PA

QL examplesmixed

AMOXICILLIN	example: quantity limits may apply to certain formulations (e.g., 10-day supply limits for suspensions)
AZITHROMYCIN	example: z-pak (5-day) common dispensing limit
OS EL TAMIVIR	example: oseltamivir may have per-prescription QL depending on plan

ST/SP examplesmixed

STEP THERAPY EXAMPLES	see group for full list
SPECIALTY (SP) EXAMPLES	see group for full list

No requirements specifiedmixed

COMMON GENERICS	Many of the listed generic antibiotics (penicillins, cephalosporins, tetracyclines) have no special PA/QL/ST by default — see plan specifics
FLUCONAZOLE	commonly available generic antifungal with no special requirements in many plans

OpenPayer

2026 Drug List

2026 Drug List — Part (extract)

Coverage rules, requirements, and definitions

Product listings, tiers, and requirement flags (grouped)

What providers must do

Representative product examples and quantity thresholds

Document dates and change history