2025 Drug List (Pharmacy formulary) — Coverage Criteria

Prior Authorization Required

Prior Authorization (PA) is required for many medications listed in this document. When a PA is indicated, the prescriber must submit and receive approval before the drug will be covered. Items marked with “PA” or shown with PA/SP/QL flags in the formulary may be denied at point-of-sale or returned if authorization is not obtained.

• Obtain PA prior to dispensing for drugs noted with PA or PA, SP flags (e.g., many specialty and oncology agents).
• PA denials: BCBSOK will notify the prescriber and offer a covered alternative when applicable.

Prior Authorization for Select Antivirals

Several high-cost antivirals and hepatitis C agents require prior authorization and often have additional program flags (SP, QL). Examples include MAVYRET, VOSEVI, SOVALDI, HARVONI, and other direct-acting antivirals — claims may deny without PA.

• Commonly PA-required antivirals: MAVYRET, VOSEVI, SOVALDI, HARVONI.
• Expect quantity limits (QL) and specialty program (SP) flags alongside PA for these agents.

Administrative Coverage (AC) for Vaccines

Some vaccines and certain administration products are flagged with an Administrative Coverage (AC) requirement. Confirm appropriate administration and billing codes before submission to ensure coverage.

• Vaccines commonly marked AC include seasonal influenza products, COVID-19 vaccine formulations, HPV (GARDASIL 9), and pediatric conjugate vaccines.
• Verify CPT/administration coding and member eligibility prior to billing.

PA for Select Antidiabetic / Weight-Management Products

Select antidiabetic and weight-management agents require prior authorization and may have QL/SP constraints. Examples include MOUNJARO, OZEMPIC, RYBELSUS, SAXENDA, WEGOVY and similar GLP-1 or dual-agonist products.

• PA is required before coverage for many GLP-1 and weight-management agents.
• Quantity limits (pens/doses per days supply) and specialty program flags commonly apply.

Prior Authorization for Many Specialty and Oncology Agents

Many specialty, biologic, and oncology agents require prior authorization and are often subject to quantity limits and specialty program management. Examples include TALZENNA, REPATHA, OMNITROPE, SKYTROFA, NUCALA, FASENRA, TEZSPIRE, TRIKAFTA and numerous oncology therapies.

• Obtain PA for listed specialty and oncology drugs prior to dispensing to avoid denial.
• Specialty program (SP) and quantity limits (QL) are frequently applied and must be documented.

Prior Authorization and Exception Submissions; Documentation Required

Prior authorization requests and exception submissions must include adequate supporting documentation of medical necessity. Providers should use the contact information on the member ID card to initiate PA or exception requests and may request expedited review when the condition is urgent.

• Include diagnosis, prior medication trials (when applicable), relevant labs or imaging, and intended quantity/days' supply when submitting PA.
• Expedited review available for conditions that jeopardize life, health, or function (72-hour decision timeframe).

Formulary Requirement Fields and How to Interpret Flags

Formulary requirement fields include flags such as PA (Prior Authorization), QL (Quantity Limits), SP (Specialty Program), AC (Administrative Coverage), and ST (Step Therapy). These indicators signal additional actions required by the provider or risks at point-of-sale.

• PA = prior authorization required; QL = quantity or dispensing limit; SP = specialty program; AC = administrative coverage (often vaccines/administration); ST = step therapy required.
• Failure to adhere to flagged requirements may result in claim denial or non-covered dispensing.

Quantity Limit and Step Therapy Documentation

Quantity limits (QL) and step therapy (ST) requirements commonly accompany PA. When requesting PA or exceptions, include documentation to support requests to exceed QL or to bypass ST (prior trials, rationale, and clinical records).

• Document prior medication trials, clinical rationale to exceed QL, and the specific days' supply requested.
• When step therapy applies, include evidence of intolerance or failure of required prior agents to request exception.

Step Therapy — When It Applies and When Details May Be Absent

Step therapy (ST) is applied to selected agents across multiple classes (e.g., certain CNS/antipsychotic agents, migraine, and others). Some entries in this segment do not specify a step sequence — review plan materials for exact ST requirements.

• If ST is indicated (ST flag), providers must document that required prior agents were tried and failed or were not tolerated before PA will be approved.
• When step details are not specified in the formulary document, use the member’s benefit plan materials or PA criteria to determine required prior steps.

Denial Risk and Consequences

Failure to obtain required prior authorization or to adhere to quantity limits/step therapy may result in denial or a requirement to pay the full cost of the medication. BCBSOK will notify the prescriber and (when applicable) offer a covered alternative if a PA or exception is denied.

• Claims presented without required PA may be denied at point-of-sale.
• If dispensed in excess of QL (including certain controlled substances), state law or plan rules may prevent coverage and member may be responsible for full cost.

Verify site‑of‑care billing for provider‑administered drugs

Drugs administered by a health care professional (e.g., in hospital outpatient or clinic) may be covered under the medical benefit rather than the pharmacy benefit; verify site‑of‑care billing before submitting claims.

• Provider‑administered drugs may need to be billed to medical benefit (hospital outpatient) instead of pharmacy.
• Confirm benefit channel and billing prior to administration.

Palforzia handled via specialty program (SP)

Palforzia product levels are designated with Requirements/Limits = SP; providers must route dispensing via the specialty program and follow specialty handling processes.

• Palforzia Initial Dose and Level entries list Requirements/Limits = SP.
• Specialty program handling applies; follow specialty pharmacy procedures for dispensing.

Use specialty pharmacy for SP‑flagged agents

Many specialty/oncology oral agents are designated 'SP' indicating specialty pharmacy handling; providers must use specialty pharmacy channels for SP‑flagged drugs.

• Examples include multiple oncology agents with SP and PA flags.
• SP designation implies specialty channel dispensing and associated PA processes.

Dispense SP‑designated drugs through specialty channels

Drugs marked 'SP' must be dispensed via specialty pharmacy channels per the formulary; ensure prescriptions for SP products are routed to the specialty pharmacy.

• SP designation appears on many high‑cost and specialty products (e.g., OMNITROPE, TRIKAFTA).
• Coordinate with the specialty pharmacy for enrollment and dispensing.

Follow specialty pharmacy management for SP products

Specialty products flagged SP are managed under specialty pharmacy channels and may have additional PA and QL requirements; providers must follow specialty program processes.

• Biologics and CF therapies with SP require specialty management and PA.
• Confirm specialty pharmacy routing and PA requirements before prescribing.

Coordinate PA and specialty dispensing for SP‑flagged injectables/pens

SP‑marked drugs (including certain injectables and pens) are managed under specialty pharmacy channels and may require specialty handling and prior authorization.

• Certain auto‑injectors and pens (e.g., REPATHA pens, ZYMFENTRA auto‑injectors) are SP‑flagged.
• Coordinate PA and specialty pharmacy dispensing to secure coverage.