CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Drug List (formulary) - Blue Cross Blue Shield of Oklahoma (Part 1)

Pharmacy benefit drug list (formulary) describing covered prescription drugs, tier placement, special requirements (PA, ST, QL, AC, SP), dispensing/quantity limits, step therapy and exception processes for BCBSOK members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (formulary) - Blue Cross Blue Shield of Oklahoma (Part 1)

Policy CodePolicy N/A

Change TypeFormulary update (no material change)

Effective DateOct 1, 2025

Next Review Date

Key ActionPrescribers must submit a prior authorization request for medications noted with 'PA' in the Special Requirements column before coverage will be provided.

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported in this brief.

MultipleTherapeutic classes listed (partial)

ManyDrugs with Special Requirements (PA/ST/QL/SP/AC)

NumerousSpecialty Pharmacy (SP) items

ManyRequire Prior Authorization (PA)

NumerousHave Quantity Limits (QL)

Coverage Summary & Scope

General Coverage Considerations

Covered when ALL of the following are met:

Operator: all

The drug is approved by the U.S. Food and Drug Administration (FDA) for the indicated use, or there is recognized evidence-based or clinical practice guideline support for the use.

The drug is listed on the plan’s drug list for the member’s benefit plan and subject to the plan’s tiering and member cost-share rules.

For drugs subject to Prior Authorization (PA), a completed PA request with supporting clinical documentation is received and approved by the plan.

For drugs subject to Step Therapy (ST), required initial-step medications have been tried and failed or a step therapy exception has been approved.

If a Dispensing Limit/Quantity Limit (QL) applies, the prescribed quantity does not exceed the allowed limit or an approved exception is on file.

For drugs with an ACA Preventive designation (ACA), coverage is applied consistent with plan preventive service rules and member eligibility.

Limitations: Some products (including compounded, repackaged, non-FDA-approved, or OTC-equivalent products) may be excluded from coverage or require medical benefit review.

Note: Prior authorization, step therapy, quantity limits, and other special requirements will generally be noted in the drug list Special Requirements column; plans may apply additional requirements not listed in this document.

Per-product Requirements/Limits

Formulary Requirements / Limits by Drug — Per-product requirements and limits (ANY of the following individual product-level entries may apply):

Operator: any

Prior Authorization (PA) required for specific drugs as noted on the drug list — prescribers must submit PA requests with clinical justification and relevant documentation.

Step Therapy (ST) applies for select drugs — members must try specified first-line therapies before coverage is available for the requested agent unless an exception is approved.

Dispensing Limits / Quantity Limits (DL/QL) — quantity or days’ supply limits may apply per prescription or per time period; exceeding limits may result in member financial responsibility for the excess quantity.

Specialty drug routing — certain specialty medications may be required to be filled at a designated specialty pharmacy or via the specialty distribution channel.

Exceptions, Prior Authorization, Step Therapy

Unsupported block type: list

Product Codes, Coverage Status & Limits

Formulary Requirements & Quantity Thresholds

Formulary Requirements/Limits by Drug

Formulary product entries include operational requirements or limits (examples below preserve PA/QL/SP/ST/AC flags and numeric thresholds).

Formulary Requirements/Limits by Drug (examples)

Oncology / targeted agents: CAPRELSA 100 mg — PA, QL (60 tablets/30 days), SP; CAPRELSA 300 mg — PA, QL (30 tablets/30 days), SP; COMETRIQ kits — PA, QL (1 carton/28 days), SP; many oncology agents listed with PA, QL and SP as shown.
Hepatitis / antivirals: HARVONI and SOVALDI — PA, QL (30 tablets/30 days), SP; MAVYRET — PA, QL (90 tablets/30 days or pack-specific), SP.
HIV / antiretrovirals: Multiple HIV agents (e.g., ISENTRESS, BIKTARVY, TRIUMEQ) — QL specified per product (commonly 30 tablets/30 days or product-specific values); some require PA.

Background & Definitions

Committee & selection: drugs on this formulary are selected and maintained by a committee of physicians and pharmacists; BCBSOK contracts with Prime Therapeutics for pharmacy benefit administration. Selection criteria include FDA regulation, safety, efficacy, cost and comparisons to other drugs on the list. The formulary is updated regularly and the full, current list (and specialty drug list) is published at MyPrime.com and bcbsok.com.

Term	Definition (exact wording / code from source)
{"text":"PA","status":""},{"text":"Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication may be covered under your plan. If a prior authorization is commonly required, it will generally be noted next to the medication with a \"PA\" under the Special Requirements column.","status":""}
{"text":"ST","status":""},{"text":"Your benefit plan may include a step therapy program. This means you may need to try a first-line, cost-effective medication before coverage may be available for the drug included in the program. If a step therapy is commonly required, it will generally be noted next to the medication with an \"ST\" under the Special Requirements column.","status":""}
{"text":"QL","status":""},{"text":"Drug dispensing limits help encourage medication use as intended by the FDA. If a dispensing limit applies, it will generally be noted next to the medication with a \"QL\" under the Special Requirements column. Limits may include: quantity of covered medication per prescription or quantity of covered medication in a given time period (examples: 30 tablets/30 days; 60 tablets/30 days; 100 mls/30 days).","status":""}
{"text":"DL","status":""},{"text":"Dispensing Limits (DL) / Quantity Limits (QL): Limits may include quantity of covered medication per prescription or quantity in a given time period; if greater quantity is dispensed, member may be responsible for full cost beyond coverage.","status":""}
{"text":"AC / ACA","status":""},{"text":"Medicines marked as \"AC\" in the Special Requirements column are under the Affordable Care Act coverage of preventive services. These products may have limited or $0 member cost-sharing (copay or coinsurance) when meeting the regulatory conditions. Copay waiver and coverage exception requests may be submitted per plan instructions.","status":""}
{"text":"SP","status":""},{"text":"Specialty drugs: Some medications are designated as specialty (noted as \"SP\" in Special Requirements). Specialty drugs may require specialty pharmacy dispensing and program enrollment; they are used to treat complex conditions and often have PA and QL noted alongside the drug entry.","status":""}
{"text":"P / NP (tier indicators)","status":""},{"text":"Formulary tier indicators shown in the document (e.g., P, NP, p, np) denote placement in the payer's drug tiers (Preferred Generic, Non-Preferred Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty, Non-Preferred Specialty). Exact tier meanings are defined elsewhere in the full formulary; source shows these notations alongside products.","status":""}

Policy Revision History

2025-10-01EffectiveLatest

Effective date for this drug list part; no dated revision history provided in extract.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (formulary) - Blue Cross Blue Shield of Oklahoma (Part 1)

Policy CodePolicy N/A

Change TypeFormulary update (no material change)

Effective DateOct 1, 2025

Next Review Date

Key ActionPrescribers must submit a prior authorization request for medications noted with 'PA' in the Special Requirements column before coverage will be provided.

On This Page

ACA Preventive (ACA) — selected medications designated as ACA preventive are covered consistent with plan preventive benefits and member eligibility.

Age or indication restrictions — coverage may be limited to members within an approved age range or for specific FDA-approved indications or recognized guideline-supported uses.

Site-of-care or administration-route limits — drugs that are not self-administered may be covered under the medical benefit; prior authorization or facility-claim requirements may apply.

Clinical documentation requirements — supporting records (e.g., prior therapy history, lab results, diagnosis codes) may be required to approve coverage.

Step therapy exception process — prescribers may submit clinical rationale for a step therapy exception when first-line agents are contraindicated, not tolerated, or otherwise inappropriate.

Quantity override/exception process — medical necessity documentation may be required to exceed published quantity limits.

Formulary status substitutions — generic equivalents and preferred agents are encouraged; member cost-share may differ if a non-preferred or brand product is requested.

Repackaged/compounded exclusions — repackaged or compounded versions of covered drugs are not routinely covered unless specifically allowed by plan policy.

Non-FDA-approved products — investigational or non-FDA-approved drugs are not covered unless explicitly specified.

Special requirements will be indicated in the drug list Special Requirements column (PA, ST, QL, ACA, SP, etc.); plans may apply additional limits not shown in this document.

Specialty injectables/biologics: Many biologics (e.g., REPATHA, NUCALA, SKYRIZI, TREMFYA, DUPIXENT) — PA and QL thresholds plus SP designation (examples: REPATHA SureClick QL 6 pens/28 days; NUCALA 1 syringe/28 days; SKYRIZI 1 cartridge/56 days).

Insulins and GLP-1 agents: Insulins commonly have QL (100 mls/30 days); OZEMPIC, RYBELSUS, MOUNJARO, TRULICITY have PA and product-specific QLs (e.g., OZEMPIC 1 pen/28 days or package-specific QLs).

Contraceptives and preventive (AC): Many contraceptives and vaccines are flagged AC (ACA preventive) and may have QL (e.g., oral contraceptives QL 28 tablets/21 days; ANNOVERA QL 1 ring/365 days).

Quantity limit examples: Explicit QL thresholds are provided per product (examples: 30 tablets/30 days; 60 capsules/30 days; 112 tablets/28 days; 1 syringe/84 days; 3 sensors/30 days; 204 test strips/30 days).

Step therapy and clinical codes: Some products include ST (step therapy) or AC (clinical/administrative) flags; ST and AC are noted per product where applicable.

Special Program (SP): Products marked SP require specialty pharmacy handling and may have additional enrollment/documentation requirements (examples: VOWST, ZYMFENTRA, many biologics and enzyme therapies).

Common Quantity Limits & Thresholds

REPATHA (cartridge)QL: 2 cartridges/30 days (REPATHA PUSHTRONEX SYSTEM)

REPATHA (pens/syringe)QL: up to 6 pens or 6 syringes/28 days (prefilled 140 mg)

Common insulin volumeQL: 100 mls per 30 days (many insulins/pen cartridges listed with 100 mls/30 days)

Oral contraceptives (typical dispensing)QL: typically 28 tablets/21 days for many oral contraceptives (multiple entries shown)

Contraceptive rings/patchesExamples: ANNOVERA ring QL 1 ring/365 days; NUVARING QL 1 ring/21 days; some patches QL 3 patches/21 days or 30 patches/30 days

Representative QL numeric examplesExamples from the list: 30 tablets/30 days; 60 tablets/30 days; 90 tablets/30 days; 56 capsules/28 days; 112 tablets/28 days; 240 capsules/30 days

Other product QLs (selected)e.g., VASCEPA 0.5 g QL 240 caps/30 days; VASCEPA 1 g QL 120 caps/30 days; ADEMPAS QL 90 tabs/30 days