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 & Specialty Drugs) — Drug List / Coverage Criteria

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A formulary list of preferred prescription and specialty drugs, tier placement guidance, and coverage considerations for Blue Cross Blue Shield - Oklahoma members and their providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy & Specialty Drugs) — Drug List / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes (routine update)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests and required documentation for products annotated with 'PA' before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~165+individual product entries listed in this segment

~200+drug lines or product entries shown in this part

PA/ST/QLutilization controls present

MyPrime.comwebsite for up-to-date list

SPspecialty designation present

Coverage Criteria and Formulary Controls

General pharmacy coverage

Coverage is subject to benefit plan terms and may include quantity limits, step therapy, prior authorization, and exclusions.

Coverage baseline: Drugs are covered according to the member's benefit design; placement into up to six tiers determines member payment and coverage; drugs may be excluded if non-FDA-approved, OTC equivalents, repackaged, compounded, or indicated for cosmetic use.

Refer to member's benefit materials and MyPrime.com for tiering and benefit-specific details.

General product coverage with controls

Coverage and utilization restrictions are product-specific as listed; coverage is available when payer controls (PA, QL, AC, SP, ST) are satisfied per product entry.

Product-level coverage rule: For each listed drug, coverage is provided only when all product-level requirements are met (e.g., prior authorization when 'PA' is present; quantity does not exceed the listed 'QL'; specialty distribution when 'SP' is present; administrative/ACA designation when 'AC' is present; step therapy when 'ST' is indicated).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy & Specialty Drugs) — Drug List / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes (routine update)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests and required documentation for products annotated with 'PA' before dispensing.

SourceLink

On This Page

Refer to each product line for the specific strength/form and associated limits.

Product-level authorization and utilization controls

Coverage and utilization controls applied at the product level as listed below

PA flag: Products marked 'PA' require prior authorization before coverage. Examples in this document include many biologics and specialty agents (e.g., adalimumab presentations, tofacitinib/XELJANZ, migraine biologics) where 'PA' is specified next to the product.

Providers must submit prior authorization per payer process and obtain approval prior to coverage.

QL flag: Products with 'QL' have specific quantity limits and time windows (examples: HUMIRA QL (2 syringes/28 days); ENBREL QL (4 syringes/28 days); XELJANZ QL (60 tablets/30 days); many opioids and insulins have defined mL or tablet limits).see product line

Exact QL per product is provided inline in the formulary listing.

SP flag: Products marked 'SP' are managed through the specialty pharmacy channel and require specialty dispensing and handling (many biologics, coagulation factors, and complex therapies are designated 'SP').

Specialty distribution and associated PA/QL requirements apply as listed.

Formulary control rules

Coverage and utilization controls applied to listed products

General formulary controls: Products listed with 'PA' require prior authorization; products listed with 'QL' are subject to the stated quantity limits and time windows; products with 'SP' are managed as specialty pharmacy items; products with 'AC' or 'ST' carry administrative/ACA or step therapy controls respectively.

These controls are enforced at the product/strength/form indicated in the listing; device items (e.g., DEXCOM) also carry PA/QL as shown.

Coverage under the pharmacy benefit is determined by the member's benefit design and drug tiering. Per the formulary guidance, certain categories of products may be excluded from pharmacy coverage, including drugs indicated for cosmetic purposes (for example, hair-growth agents), products that have not received FDA approval, repackaged medications, some compounded medications, and prescription drugs that have over-the-counter equivalents. Members and providers should consult plan materials or MyPrime.com to confirm whether a particular product is covered under the member's plan.

This segment of the drug list functions primarily as a formulary index: it enumerates products and shows utilization-management flags (e.g., PA, QL, SP, AC, ST) next to individual entries rather than setting out standalone clinical coverage criteria or detailed exclusion language. For clinical coverage decisions, refer to the specific drug policy page or the member's benefit documentation identified on MyPrime.com.

Anti‑obesity and prescription weight‑management agents are called out as a category that may be excluded depending on the member's benefit plan. Coverage for these agents is not universal and will depend on the plan's specific exclusions and prior authorization rules—review the member's plan documents for applicability.

This portion of the index does not provide explicit exclusion criteria; entries list product names with any associated utilization flags. Absence of an exclusion statement in this excerpt indicates that exclusions, if any, are addressed in the member's benefit materials or in detailed product‑level policy pages.

No explicit medical‑exclusion determinations are stated in this section. Lines showing 'Requirements/Limits = .' reflect entries where no special prior authorization, quantity limit, or specialty designation is listed in this excerpt and therefore represent standard coverage subject to the member's benefit terms.

The formulary expressly states that drugs that have not received FDA approval are not covered. Providers should confirm FDA approval status and consult benefit materials before submitting coverage requests for non‑approved products.

This extract does not include explicit 'not medically necessary' determinations. Instead, products are presented with utilization management annotations (e.g., PA, QL, SP); clinical determinations of medical necessity are made via the payer's prior authorization and review processes referenced on the individual drug policy pages.

The excerpted index does not contain standalone 'not medically necessary' statements. Where medical necessity determinations apply, they are handled through the prior authorization process for the specific product and are documented on the applicable drug policy page.

Drug Listings, Codes, and Quantity Examples

Drug list entries (product names and strengths)NDC

NDC not listed

No explicit NDC codes provided in this part; products are listed by name and strength.

NDC/HCPCS/CPT not listed in this sectionmixed

No codes listed

Quantity limits examples

QL (30 tablets/30 days)Common example quantity limit for multiple oral medications (e.g., many antiretrovirals, anticoagulants, and targeted agents).

QL (60 tablets/30 days)Used for select agents and strengths (e.g., some oncology and antiviral tablets).

QL (120 tablets/30 days)Applied to higher-count oral oncology or specialty tablet regimens (example: certain kinase inhibitors).

QL (4 bottles/28 days)Example for oral suspensions/oral liquid formulations (e.g., TAFINLAR oral suspension listing).

QL (300 mls/30 days)Used for oral solution volume limits (example: VITRAKVI oral solution).

Example quantity limits

QL (60 tablets/30 days)Example quantity limit applied to many oral agents (e.g., PPIs, select antivirals).

QL (2 pens/28 days)Example limit for certain injectable pen presentations (e.g., some MOUNJARO/OZEMPIC entries show pen limits).

QL (1 kit/180 days)Example limit used for starter or induction kits (e.g., OTEZLA and other starter packs listed as 1 pack/180 days).

Quantity limits examples (selected specialty items)

PYRUKYND TAPER PACK QL7 or 14 tablets per 365 days depending on pack (PYRUKYND TAPER PACK listings).

TAKHZYRO QL2 vials (or 2 mLs) per 28 days (TAKHZYRO entries).

REBINYN QL1 vial per 30 days (REBINYN entries).

DEXCOM sensors QL3 sensors per 30 days for DEXCOM G6/G7 sensors (device listings).

What Providers Must Do / Authorization and Documentation

Prior Authorization

Prior authorization required; submit PA before coverage

Some medications listed in this drug list require prior authorization; prescribers must submit a prior authorization request and obtain approval before the payer will cover the medication.

Prior Authorization

PA required for select specialty antivirals (e.g., EPCLUSA, HARVONI, MAVYRET)

Select specialty antivirals (examples: EPCLUSA, HARVONI, MAVYRET, SOVALDI) are designated PA and often have QL and SP flags; a prior authorization must be obtained per the product listing before coverage.

Prior Authorization

PA enforced at product/strength/form indicated

Prior authorization is enforced at the specific product/strength/form listed in the document; products annotated with 'PA' will require submission of PA information for that exact presentation.

Prior Authorization

PA required for selected specialty/brand drugs (examples listed)

Numerous specialty and brand drugs in this segment are labeled 'PA' and require prior authorization — examples shown include ENTRESTO, UPTRAVI, VERQUVO, VYNDAMAX/VYNDAQEL and others; obtain PA before dispensing.

Prior Authorization

PA required for listed specialty biologics and injectables

Many biologics and specialty injectable agents are noted with 'PA' and require prior authorization; providers must secure approval prior to dispensing (examples include ENTYVIO PEN, OMVOH, SKYRIZI, TREMFYA).

Prior Authorization

PA required for identified PA products (biologics/specialty agents)

Biologic and specialty oral agents shown with 'PA' (e.g., PYRUKYND TAPER PACK, REBINYN, TAKHZYRO) require prior authorization and may also have quantity limits and specialty pharmacy designations; obtain PA before coverage.

Prior Authorization

PA required for many specialty/biologic agents (PA, QL, SP present)

Many listed specialty/biologic agents (examples: PYRUKYND TAPER PACK, REBINYN, DUPIXENT, COSENTYX) carry 'PA' and 'SP' flags; prescribers must submit PA requests and follow QL/SP requirements on the product line.

Note

Index only — no PA rules in this chunk

This index chunk contains only navigational/index entries and does not include prior authorization rules or product-specific PA triggers.

Note

Index listing — see individual drug pages for PA

This segment is an index and does not include product-level prior authorization requirements; providers should refer to the individual drug policy pages for PA instructions.

Note

No PA rules in this index segment

No prior authorization rules are provided in these index chunks; consult the detailed product listings elsewhere in the document for PA requirements.

Step Therapy

Step therapy may be required — look for 'ST' indicator

Step therapy (ST) may apply to some medications; drugs commonly subject to step therapy are marked with 'ST' in the Special Requirements column and require trying preferred alternatives first.

Note

AC indicator — administrative/ACA preventive designation

Some entries are marked 'AC', which may indicate ACA preventive coverage or administrative/alternative coverage requirements; 'AC' may appear alongside QL and PA flags and affect request processing.

Step Therapy

Step therapy applies for select agents (e.g., KERENDIA marked 'ST')

Where products are annotated 'ST' (for example, KERENDIA), step therapy requirements apply and the provider must follow the payer's step sequence as specified by the plan.

Note

Index-only — no explicit provider actions in this chunk

Some index chunks contain only navigational listings with no explicit provider actions, authorizations, or documentation requirements; refer to the full product entries for actionable requirements.

Step Therapy

Step therapy present for select agents (e.g., antipsychotics, BELSOMRA)

Certain agents are annotated 'ST' (e.g., select antipsychotics, BELSOMRA) indicating step therapy applies; providers must comply with required trials of alternatives before coverage for ST drugs is available.

Note

Index only — no step therapy details here

This index-only portion of the document does not list step therapy sequences or explicit step requirements; providers should view the detailed drug lines for step therapy instructions.

Documentation Required

PA/QL present for dermatologics; step sequences not specified

For oral dermatologic systemic agents and some biologics (e.g., CIBINQO, SOTYKTU), PA and QL are indicated but specific step therapy sequences are not specified in this excerpt; submit PA documentation per product page.

Documentation Required

Copay waiver/coverage exception process for ACA preventive meds

You or the prescriber may submit copay waiver or coverage exception requests for ACA preventive medicines; forms and process information are available at bcbs.com/provider or myprime.com.

Documentation Required

Submit PA and QL documentation when indicated (drug/dose/indication/quantity)

Several agents are listed with 'Requirements/Limits = PA, QL (30 tablets/30 days), SP' — when PA or QL is specified, providers must submit documentation sufficient to meet the payer's prior authorization criteria (drug name, dose, quantity, and indication).

Include drug name, formulation/strength, dose, quantity requested and clinical indication in PA requests

Documentation Required

Follow PA process and respect QL limits for annotated products

When a product line includes 'PA', providers must follow the payer's prior authorization process; when 'QL' is listed, do not exceed the stated quantity limit or the claim may be reduced or denied.

Adhere to the exact product/strength/form listed for PA enforcement
Ensure requested quantity does not exceed the product's QL

Documentation Required

Documentation required for PA/QL requests (medical necessity, prior therapy)

Provide prior authorization documentation that demonstrates medical necessity (drug name, dose, diagnosis, prior therapy) for drugs marked 'PA' or with QL to support approval.

Document prior therapy failures or contraindications when applicable

Billing Rule

Provide PA, adhere to QL and route 'SP' items through specialty pharmacy

Prescribers must supply PA documentation for drugs marked 'PA' and adhere to specified quantity limits and specialty pharmacy requirements where indicated; products marked 'SP' must be dispensed via specialty pharmacy.

Ensure dispensing channel is specialty pharmacy for 'SP' items

Billing Rule

Specialty (SP) products must be dispensed via specialty pharmacy

Products designated 'SP' indicate specialty pharmacy distribution is required; prescribing providers must ensure dispensing via the specialty channel to meet coverage requirements.

Documentation Required

CGM device PA/QL — submit medical necessity documentation (DEXCOM G6/G7)

Requests for continuous glucose monitoring devices (DEXCOM G6/G7) list PA and QL (e.g., 3 sensors/30 days, 1 receiver/365 days); submit supporting documentation of medical necessity when requesting coverage.

Include clinical rationale and prior monitoring data as applicable

Note

Index-only content — no PA/documentation rules in this part

This part contains only index listings and does not include authorization, documentation, or prior authorization requirements; consult the product-specific sections for actionable requirements.

Note

Index-only — no documentation/PA instructions present

Index-only chunks do not include documentation or prior authorization instructions; providers must refer to detailed drug entries for requirements.

Note

Index chunk — no documentation requirements here

No documentation requirements are present in these index chunks; see the full product listings for documentation expectations when PA/QL/SP apply.

Denial Risk

Denial risk — claims may be denied without PA

Prior authorization is required for certain drugs; claims for products labeled 'PA' may be denied without an approved prior authorization.

Denial Risk

Denial risk — PA/QL/SP flags require compliance

Many entries show 'Requirements/Limits = PA' or 'QL' or 'SP'; prescribing or dispensing without meeting those requirements may trigger denial or processing limits.

Denial Risk

Denial risk — obtain PA when 'PA' is noted or claim may deny

Claims for products with 'PA' specified next to the product may be denied if prior authorization is not obtained; verify PA status before dispensing.

Denial Risk

Denial risk — PA + SP products risk denial without approved PA and specialty dispensing

Products labeled with both 'PA' and 'SP' indicate specialty products that are at risk of denial if dispensed without an approved prior authorization and correct specialty routing.

Denial Risk

Denial risk — biologic respiratory agents require PA (examples listed)

Biologic respiratory therapies (for example, FASENRA, NUCALA, TEZSPIRE, XOLAIR) list 'PA' and 'SP' — claims may be denied if an approved prior authorization and specialty dispensing are not documented.

Denial Risk

Denial risk — PA required for many specialty biologics

Many specialty biologics (e.g., CREON, ZENPEP, ENTYVIO PEN, SKYRIZI, TREMFYA) are subject to prior authorization; lack of an approved PA may result in denial of coverage.

Denial Risk

Denial risk — confirm PA to avoid claim denial

Claims for products labeled 'PA' may be denied without an approved prior authorization; confirm authorization prior to dispensing high-cost or specialty medications.

Denial Risk

Denial risk — claims may be reduced or denied if QL exceeded

Claims exceeding stated quantity limits ('QL') may be rejected or partially paid if the requested quantity exceeds the documented limit; adhere to QL values in the product entry.

Denial Risk

Denial risk — failure to obtain PA may result in denial

Products listed with 'PA' will be subject to prior authorization; failure to obtain PA may result in denial of coverage for the drug.

Note

Index-only — no authorization triggers here

This index section contains only navigational entries and does not provide authorization triggers; consult the detailed product pages for PA requirements.

Note

Index segment — no PA/denial criteria stated

No prior authorization or denial criteria are explicitly stated in this index segment; providers must use the product-level entries for actionable guidance.

Note

Index chunks — no authorization/denial rules included

No authorization or denial criteria are present in these index chunks; refer to the full drug listings for PA/QL/SP requirements and denial risk details.

Note

Step Therapy Indicators and Notes

Item	Interpretation
Entries annotated 'AC', 'PA', or 'QL' in the drug list
May indicate administrative/alternative coverage (AC) or utilization management requiring prior authorization (PA) and/or quantity limits (QL); these flags are applied per product/strength rather than as an explicit step sequence

Product	Step therapy (ST) designation	Implication
KERENDIA (finerenone) 10 mg, 20 mg
ST
Annotated 'ST' indicating the product is subject to step therapy requirements as specified by the payer; providers should follow payer ST procedures

Observation	Notes
ST references appear as flags in the Special Requirements column
The document provides utilization management flags (PA, QL, SP, ST) but does not list detailed sequential step-therapy algorithms in these excerpts

Example agent	Flag shown	Comment
BELSOMRA (suvorexant) tab 5–20 mg
ST
Listed with QL (30 tablets/30 days) and 'ST' indicating step therapy applies

Finding	Policy implication
No explicit step-by-step algorithms present in these sections
Products are primarily tagged with PA/QL/SP (and occasional ST) flags; specific required prior agents, failure criteria, or sequence details are not provided in this excerpt

Product group	Controls shown	Step therapy specified?
Systemic dermatology agents (examples: CIBINQO, SOTYKTU, risankizumab, guselkumab, ustekinumab)
PA and QL are listed for many of these agents; SP designation applies to biologics
Step therapy sequences are not specified in these excerpts; only PA/QL/SP flags are provided

Quantity Limits per Product

azithromycin tab — quantity limit

azithromycin tab60 tablets per 180 days.

formTablets; listed under MACROLIDES.

reference brandZithromax (reference shown in source).

BIKTARVY — quantity limit

BIKTARVY30 tablets per 30 days.

strengths listedbictegravir-emtricitabine-tenofovir AF tab 30-120-15 mg and 50-200-25 mg.

requirementsRequirements/Limits = QL (30 tablets/30 days).

Specialty antivirals — quantity limits

Specialty antivirals (EPCLUSA, HARVONI, MAVYRET, SOVALDI)Typically limited to 30 tablets per 30 days (varies by product/pack); many products also list PA and SP designations.

EPCLUSA pellet packExample: EPCLUSA pellet pack listed with QL (28 tablets/28 days) in one presentation.

MAVYRETListed with PA and QL (90 tablets/30 days) or pellet pack QL (140 tablets/28 days) depending on presentation.

TABRECTA — quantity limit

TABRECTA (capmatinib) 150 mg, 200 mgQuantity limit = 120 tablets.

RequirementsRequirements/Limits = PA, QL (120 tablets/30 days), SP.

product classOral targeted oncology agent (capmatinib).

TAFINLAR — capsules quantity limit

TAFINLAR (dabrafenib) capsulesQuantity limit = 120 capsules.

RequirementsRequirements/Limits = PA, QL (120 capsules/30 days), SP.

alternative formulationOral suspension listed separately with its own QL (4 bottles/28 days).

TAFINLAR — oral suspension limit

TAFINLAR oral suspensionQuantity limit = 4 bottles (per 28 days).

RequirementsRequirements/Limits = PA, QL (4 bottles/28 days), SP.

formOral suspension for patients unable to take capsules.

TAGRISSO — quantity limit

TAGRISSO (osimertinib)Quantity limit = 30 tablets.

RequirementsRequirements/Limits = PA, QL (30 tablets/30 days), SP.

strengths40 mg and 80 mg strengths are listed in source.

TALZENNA 0.25 mg — quantity limit

TALZENNA 0.25 mgQuantity limit = 90 capsules.

RequirementsRequirements/Limits = PA, QL (90 capsules/30 days), SP.

strength examplesMultiple capsule strengths (0.25 mg among others) listed in source.

TASIGNA — quantity limit

TASIGNA (nilotinib)Quantity limit = 120 capsules.

RequirementsRequirements/Limits = PA, QL (120 capsules/30 days), SP.

strengthsIncludes 50 mg, 150 mg, 200 mg capsule presentations listed in source.

TIBSOVO — quantity limit

TIBSOVO (ivosidenib)Quantity limit = 60 tablets.

RequirementsRequirements/Limits = PA, QL (60 tablets/30 days), SP.

indicationOral oncology agent (ivasidenib) listed under targeted therapies.

VENCLEXTA — strength-specific limits

VENCLEXTA 10 mgQuantity limit = 60 tablets.

VENCLEXTA 50 mgQuantity limit = 30 tablets.

VENCLEXTA 100 mgQuantity limit = 180 tablets.

VENCLEXTA STARTING PACKQuantity limit = 1 pack (starter pack), Requirements/Limits = PA, QL (1 pack/180 days).

VERZENIO — quantity limit

VERZENIO (abemaciclib)Quantity limit = 60 tablets.

RequirementsRequirements/Limits = PA, QL (60 tablets/30 days), SP.

strengthsListed strengths include 50 mg, 100 mg, 150 mg, 200 mg in source.

VITRAKVI — solution and capsule limits

VITRAKVI oral solutionQuantity limit = 300 mls per 30 days.

VITRAKVI capsules 25 mgQuantity limit = 180 capsules per 30 days.

VITRAKVI capsules 100 mgQuantity limit = 60 capsules per 30 days.

VORANIGO — quantity limits

VORANIGO 10 mgQuantity limit = 60 tablets.

VORANIGO 40 mgQuantity limit = 30 tablets.

RequirementsRequirements/Limits = PA, QL (per strength), SP.

XALKORI — quantity limits

XALKORI caps 200/250 mgQuantity limit = 60 capsules.

XALKORI sprinkle 20/50 mgQuantity limit = 120 capsules.

XALKORI sprinkle 150 mgQuantity limit = 180 capsules.

MYFEMBREE — quantity limit

MYFEMBREEQuantity limit = 30 tablets per 30 days.

formulationrelugolix-estradiol-norethindrone acetate tablet listed under estrogens/contraceptives.

requirementsRequirements/Limits = PA, QL (30 tablets/30 days).

ORIAHNN — quantity limit

ORIAHNNQuantity limit = 56 capsules per 28 days (elagolix pack & cap pack).

formelagolix-estradiol-norethindrone pack & 300 mg cap pack listed with PA and QL.

requirementsRequirements/Limits = PA, QL (56 capsules/28 days).

Contraceptives — example quantity limits

Contraceptive tablet forms (examples)Quantity limit commonly listed as 28 tablets per 21 days for multiple oral contraceptive formulations (AC, QL applied).

NUVARINGQuantity limit = 1 ring per 21 days (AC, QL).

designationEntries often show AC (administrative control) with QL (28 tablets/21 days) for many contraceptives.

NUVARING — quantity limit

NUVARINGQuantity limit = 1 ring per 21 days.

RequirementsRequirements/Limits = AC, QL (1 ring/21 days).

formVaginal ring (etonogestrel-ethinyl estradiol).

FARXIGA / GLYXAMBI / JANUMET — quantity limits

FARXIGAQuantity limit = 30 tablets per 30 days.

GLYXAMBIQuantity limit = 30 tablets per 30 days.

JANUMETQuantity limit = 60 tablets per 30 days.

JANUMET XR — quantity limit variations

JANUMET XRQuantity limit = 30 or 60 tablets depending on strength (listed in source).

JANUMETStandard JANUMET listed with QL (60 tablets/30 days).

requirementsRequirements/Limits = QL per listing; strength-dependent for XR formulations.

GLP-1 agonist pen quantity limits

MOUNJARO standard pensQuantity limit = 4 pens (various listings show 4 pens/28 or 180 days).

OZEMPIC pensQuantity limit = 1 or 3 pens depending on presentation (source lists both 1 pen/28 days and 3 mls/28 days entries).

TRULICITYQuantity limit = 4 pens per 28 days.

GENOTROPIN / OMNITROPE — designation

GENOTROPIN, OMNITROPE (somatropin)Designation includes PA and SP for certain presentations (somatropin entries show PA, SP).

presentationsCartridges and prefilled syringes listed with PA/SP depending on formulation.

siteManaged as specialty product in many presentations.

ORILISSA — strength-specific limits

ORILISSA 150 mgQuantity limit = 30 tablets per 30 days.

ORILISSA 200 mgQuantity limit = 60 tablets per 30 days.

RequirementsRequirements/Limits = PA, QL (per strength) for ORILISSA formulations.

ENTRESTO — quantity limits and alternatives

ENTRESTO112 tablets per 28 days (alternate entries show 2 cartridges/30 days or 600 mL/30 days).

form variantsENTRESTO listed as tablets and also cartridge/mL alternatives with respective QLs.

requirementsRequirements/Limits = PA, QL, SP for selected presentations.

UPTRAVI titration pack — quantity limits

UPTRAVI TITRATION PACKQuantity limits include 1 pack per 180 days or 30 tablets per 30 days (multiple entries in source).

formTitration pack and tablet presentations listed with differing QLs.

requirementsRequirements/Limits = PA, QL, SP for UPTRAVI titration pack entries.

VYNDAMAX / VYNDAQEL / VERQUVO — quantity limits

VYNDAQEL (tafamidis) / VYNDAMAXVYNDAQEL: 120 capsules per 30 days; VYNDAMAX entries show similar QL (120 capsules/30 days).

VERQUVO (vericiguat)Quantity limit = 30 tablets per 30 days (source lists 30 tablets/30 days).

requirementsRequirements/Limits = PA, QL (per product), SP for these cardiology agents.

FASENRA / NUCALA — quantity limits

FASENRAQuantity limit = 1 pen per 28 days.

NUCALAQuantity limit = 1 syringe per 28 days or 3 mL per 28 days depending on presentation.

requirementsBoth entries are listed with PA and SP designations.

Inhalers — typical quantity limits

Inhaler typical QLsExamples include 1 inhaler/30 days, 3 inhalers/30 days, or 60 blisters/30 days for devices such as BREO, TRELEGY, BREZTRI, SYMBICORT.

BREZTRIListed with QL (1 inhaler/30 days) in source.

BREO ELLIPTAListed with QL (60 blisters/30 days) in source.

PPIs — quantity limits (examples)

PPIs (esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole)Quantity limit = 60 capsules/tablets per 30 days for multiple agents (e.g., omeprazole, esomeprazole entries).

omeprazole (Prilosec)Listed with QL = 60 (tablets) in source.

esomeprazole (Nexium)Listed with QL = 60 (tablets) in source.

ALYFTREK — quantity limits

ALYFTREKQuantity limit = 84 tablets/28 days or 56 tablets/28 days depending on strength.

requirementsRequirements/Limits = PA, QL, SP listed for ALYFTREK in source.

indicationCF modulator product with strength-dependent QLs.

omeprazole / esomeprazole / Tobramycin limits

omeprazole (Prilosec)Quantity limit = 60 tablets per 30 days (listed in source).

esomeprazole (Nexium)Quantity limit = 60 tablets per 30 days (listed in source).

tobramycin ophthalmic solution 0.3%Quantity limit = 15 mL per 30 days.

ENTYVIO / SKYRIZI / DEXCOM devices limits

ENTYVIO PEN (vedolizumab)Quantity limit = 2 pens per 28 days.

SKYRIZI (risankizumab)Quantity limit = 1 cartridge per 56 days.

DEXCOM G6/G7 sensorsQuantity limit = 3 sensors per 30 days (device listing).

HUMIRA / ENBREL — biologic syringe limits

HUMIRA (adalimumab) prefilled syringe kitQuantity limit examples include 2 syringes (some presentations) or 3 pens/180 days for starter kits per source listings.

ENBREL prefilled syringeQuantity limit = 4 syringes per 28 days (listed in source).

requirementsBoth products listed with PA and SP designations in source.

Selected immunomodulators / JAK inhibitors limits

OTEZLA (apremilast)Quantity limit = 60 tablets per 30 days (OTEZLA listing).

RINVOQ (upadacitinib) 15 mg ERQuantity limit = 30 tablets per 30 days.

XELJANZ (tofacitinib) 5 mgQuantity limit = 60 tablets per 30 days.

PYRUKYND / REBINYN / TAKHZYRO / DEXCOM — quantity limits

PYRUKYND TAPER PACKQL = 7 or 14 tablets per 365 days depending on pack (source lists both 7 and 14 tablets/365 days).

REBINYNQL = 1 vial per 30 days (coagulation factor entries).

TAKHZYROQL = 2 vials (or 2 mLs) per 28 days.

DEXCOM G6/G7 sensorsQL = 3 sensors per 30 days (device listing).

REBINYN — quantity limit

REBINYN (various vial sizes)Quantity limit = 1 vial per 30 days as listed in source.

RECOMBINATE / RIXUBISListed with PA and QL (1 mL/30 days) for certain coagulation factor presentations.

TAKHZYROAlso listed with QL (2 vials/28 days) and PA/SP designations.

TAKHZYRO — quantity limit

TAKHZYROQuantity limit = 2 vials (or 2 mLs) per 28 days.

formulationsListed both as vial and prefilled syringe presentations with same QL in source.

requirementsRequirements/Limits = PA, QL, SP.

Ophthalmic solutions — quantity limits

Latanoprost / LUMIGANQuantity limit = 2.5 mLs per 20 days (ophthalmic solution listings).

Tobramycin ophthalmic solution 0.3%Quantity limit = 15 mLs per 30 days (source lists Tobrex with QL 15 mL/30 days).

ST site noteLUMIGAN listed with ST indicating site-of-therapy considerations for some ophthalmic agents.

Tobramycin / DEXCOM / diagnostic limits

Tobramycin ophthalmic solution 0.3%Quantity limit = 15 mLs per 30 days (Tobrex listing).

DEXCOM sensorsQuantity limit = 3 sensors per 30 days (device listing).

devices/test stripsGlucose test strips listed with QL (204 strips/30 days) in source.

DEXCOM devices and glucose supplies limits

DEXCOM G6/G7 sensorsQuantity limit = 3 sensors per 30 days (Requirements/Limits = PA, QL listed in source).

DEXCOM receivers/transmittersReceivers: PA, QL (1 receiver/365 days); transmitters: PA, QL (1 box/90 days).

Glucose test stripsCommon QL = 204 strips per 30 days for multiple brands listed in source.

Glucose test strips & related supply limits

Glucose test strips (multiple brands)Quantity limit = 204 strips per 30 days (listed for CONTOUR, FREESTYLE, PRECISION, OPTIUMEZ, etc.).

pen needles / syringesInsulin pen needles and syringes listed with QL 300 needles/30 days and 300 syringes/30 days respectively.

device kitsSome insulin pump kits listed with longer QL windows (e.g., 1 kit/720 days).

Dispensing and Administration Settings

Note

Biosimilar Listings and Handling

Note

Policy Background

The drug list and index were developed by a clinical review process to identify preferred brand and representative generic agents. Selection reflects FDA approval status and clinical evidence; specialty drugs and agents requiring administration by a health care professional are identified and may be managed differently (for example, routed to the medical benefit or dispensed via specialty pharmacy). Refer to individual product lines for specific utilization controls (PA, QL, SP) and to MyPrime.com for the most current formulary.

Definitions and Notation

Drug name formatting convention

Drug name formattingPreferred brand and generic formatting convention: generic drugs are shown in lower-case boldface and brand drugs in ALL CAPITALS followed by the generic name (per 'How to use this list').

exampleExample given: atorvastatin (Lipitor); NOVOLOG - Insulin aspart inj 100 unit/ml.

purposeFormatting guides help distinguish preferred generics from brand references in the list.

Generic types definitions

Generic equivalent vs alternativeGeneric equivalent: same active ingredient and dosage as reference brand. Generic alternative: different active ingredient used to treat same condition. (definitions per source).

FDA standardsGeneric drugs must be FDA-approved and meet the same safety and efficacy standards as brand drugs.

cost implicationGenerics typically have lower member cost-share; requesting brand may incur additional member payment.

Coverage control definitions (PA / QL / SP / AC)

PA (Prior Authorization)Prior Authorization — coverage requires prior approval as indicated by 'Requirements/Limits = PA'; prescribers must submit a PA request and obtain approval before payer will cover the medication.

QL (Quantity Limit)Quantity Limit — a maximum amount allowed over a specified time period (examples: 30 tablets/30 days, 2 vials/28 days).

SP (Specialty)Specialty — medication designated as a specialty drug and typically requiring specialty pharmacy dispensing (noted as 'SP').

AC (Administrative control)Administrative control (AC) — utilization designation used for some products (e.g., contraceptives) indicating plan-specific handling; often paired with QL.

Revision History & Document Notes

2025-10-01policy_effective_dateLatest

Document effective date for the 2025 Drug List (pharmacy & specialty drugs).