2025 Drug List (Pharmacy Benefit) — Formulary and Coverage Criteria
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A formulary/drug list that identifies covered prescription drugs, tiers, special requirements, and coverage rules for Blue Cross and Blue Shield of Oklahoma pharmacy benefits; intended for members, prescribers, and pharmacists.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Listings
General pharmacy coverage criteria
Covered when ALL of the following apply:
From formulary introduction
Non‑FDA‑approved drugs excluded per coverage considerations
Site‑of‑care distinction; see plan materials
PA/ST/QL/SP flags noted next to products
Dispensing limits enforced per coverage considerations
Formulary coverage with tier and administrative controls
Covered according to the product line when ALL of the following apply:
Tier shown on each product line
See individual product Requirements/Limits column
Exact QL per product line
Vaccine and biological product coverage
Vaccine and biological products listed are covered when ALL of the following are met:
Vaccine lines include Drug Tier and Requirements/Limits
AC indicated in Special Requirements column
See plan materials or MyPrime.com for placement
Antineoplastics and specialty drug coverage controls
Antineoplastics and specialty agents are covered subject to the following conditions:
Examples: abiraterone QL 120 tablets/30 days; alectinib PA, QL, SP
PA flags appear in Requirements/Limits
Per‑product QL/SP entries govern dispensing
Palforzia (peanut oral immunotherapy) coverage
Palforzia (peanut oral immunotherapy) products are covered when ALL of the following are met:
Multiple Palforzia levels and packs are enumerated on the list
Requirements/Limits = SP on Palforzia lines
Drug Tier = NP indicated on Palforzia lines
Product-specific coverage entries
Each product line governs coverage when ALL of the following apply:
Per‑product entries describe exact requirement text
See contraceptive product lines
See antidiabetic and insulin product lines
Formulary coverage with per-drug restrictions
Formulary coverage with per‑drug restrictions — apply ALL of the following:
Per‑drug restrictions listed on each product line
See coverage considerations and denial risk notes
Formulary inclusion with annotated restrictions
Coverage of listed products is subject to ALL of the following:
Per formulary entries
Follow per‑product annotations
Formulary product-level coverage rules
Product‑level coverage rules — coverage requires ALL of the following to be met:
Each drug line indicates Drug Tier
Per product Requirements/Limits columns
Formulary coverage indicators
Formulary coverage indicators — apply ALL of the following when determining coverage:
ST denotes step therapy; PA denotes prior authorization; QL denotes quantity limit; SP denotes specialty pharmacy; AC denotes ACA preventive handling
Refer to plan materials for PA forms/timelines
Formulary coverage with administrative controls
Coverage subject to administrative controls — the drug is covered when ALL of the following are satisfied:
Per product Requirements/Limits
Exception request process per coverage considerations
Drugs that are not listed on the 2025 Drug List are not covered under the pharmacy benefit. The formulary further states that non–FDA‑approved drugs, repackaged, and compounded medications may not be covered; members and prescribers should confirm coverage via the member ID card phone number or online at MyPrime.com or the BCBSOK provider portal. Prior authorization (noted as PA in the Special Requirements column) may be required for certain products and must be obtained for coverage when indicated.
Within the excerpted formulary sections there are no product-level clinical exclusion statements (e.g., explicit lists of diagnoses or clinical scenarios that render a drug not covered). The document instead provides per‑product Drug Tier codes and administrative flags (such as PA, QL, SP, or AC) that govern coverage and utilization management.
Some listed entries show Drug Tier codes such as NP or are left blank; these listings are tier annotations used to determine member cost‑share and do not themselves define clinical exclusion criteria. When a product is shown as NP or blank, coverage remains subject to the listed administrative controls (e.g., PA, QL) and the plan’s general terms.
The provided chunks do not state any explicit formulary exclusions (statements such as 'not covered' for specific drugs). Coverage determinations are represented by product-level tier assignments and Requirements/Limits tags rather than by explicit per‑drug exclusion language in this excerpt.
Items listed without a specific Requirements/Limits entry still appear on the drug list and may be subject to the plan’s general terms, tier-based cost sharing, and other benefit provisions. Absence of a PA/QL/SP tag in the excerpt does not guarantee unrestricted coverage; providers should verify benefit details for a member.
Certain products display different Drug Tier codes depending on the strength or formulation (for example, strengths or dosage forms of the same drug may be assigned to different tiers). Providers should confirm the exact listed strength/formulation on the drug list because tier and member cost‑share can vary by strength/formulation.
Some drugs are present on the formulary but only partially annotated with utilization management flags; the excerpt therefore provides formulary listing and tier placement but does not include detailed medical‑necessity criteria for many entries. Where PA, QL or ST are shown next to a product, those administrative controls apply even if the full clinical documentation requirements are not printed in this excerpt.
Across the sections cited there are no explicit product-level exclusions
The excerpt contains no explicit clinical exclusion statements for the products shown. Instead, coverage is governed by the product’s tier and any associated administrative designations (e.g., PA, QL, SP). Providers may request exceptions per the plan’s process when coverage questions arise.
In the excerpted listing there are no explicit 'Not Medically Necessary' declarations for products or classes. The document instead identifies utilization controls (e.g., PA, QL, AC) and directs prescribers to submit prior authorization requests with supporting documentation where required.
Review of the provided segments shows no explicit 'Not Medically Necessary' statements. The formulary communicates coverage via tiers and requirement flags; determinations about medical necessity would follow the payer’s prior authorization and clinical review processes when applicable.
The document excerpts do not present explicit statements labeling drugs as 'not medically necessary.' Instead, therapeutic coverage is expressed through tier placement and utilization management tags; where clinical denial would be appropriate, that outcome would be reached through the plan’s review of PA submissions against clinical criteria (not shown here).
No individual drug lines in these chunks include explicit 'not medically necessary' language. When utilization controls such as PA or QL are present, the plan requires documentation or authorization for coverage rather than stating a product is categorically not medically necessary in this excerpt.
There are no explicit 'Not Medically Necessary' declarations in the examined sections. The formulary relies on administrative flags (for example, ST for step therapy, PA for prior authorization) to manage appropriate use; adverse medical‑necessity determinations would be made through the payer’s clinical review processes.
Within these excerpted chunks the listing does not include explicit statements that any listed products are 'not medically necessary.' Coverage restrictions are communicated via tier codes and requirement/limit tags; clinical denial rationale is not presented in this portion of the drug list.
Coding and Quantity Limit Examples
| NDCs not listed | No NDC codes provided in this excerpt; only product names and strengths are present. |
| No codes listed |
| No codes listed |
| No codes listed |
| N/A | This section is a drug formulary list; no procedure/CPT/HCPCS/ICD codes provided in these chunks. |
| 1:2000 | epinephrine solution auto-injector 0.15 mg/0.3ml (Epipen-jr 2-pak) — potency notation appears as (1.2000) in document |
| No codes listed |
| No codes listed |
| NDCs not listed | Document lists drug products and strengths but does not provide NDC codes in these chunks. |
| No codes listed |
Prior Authorization, Step Therapy, and Documentation
Obtain prior authorization when 'PA' is listed
Prior authorization is required for medications when the drug listing shows 'PA' in the Special Requirements column; clinicians must submit a prior authorization request and receive approval before the plan will cover the medication. Examples of PA notations are shown across the formulary and described in the Coverage considerations section.
PA required for select inhaled/complex aminoglycosides
Certain listed agents explicitly require prior authorization (PA) — providers must submit PA for those products before dispensing; examples include KITABIS PAK and tobramycin nebulized products which are noted with PA and SP flags.
- KITABIS PAK tobramycin nebu soln — Requirements/Limits = PA, QL (56 containers/56 days), SP
- TOBI PODHALER tobramycin inhal cap — Requirements/Limits = QL (224 capsules/56 days), SP PA
PA required for specialty antineoplastics and high-cost agents
Many specialty and antineoplastic agents are designated with PA and often SP; prescribers must request prior authorization for these specialty drugs before coverage is provided.
- Examples: ALECENSA (alectinib) — Requirements/Limits = PA, QL, SP; ALUNBRIG (brigatinib) — Requirements/Limits = PA, QL, SP
- Numerous other oncology/specialty entries show PA and SP in Requirements/Limits
Request PA for listed products (antivirals/antifungals)
Selected drugs across the formulary include PA annotations (or AC) next to the product line; providers must obtain authorization where indicated (e.g., certain antivirals and antifungals).
- NOXAFIL (posaconazole) formulations — Requirements/Limits = PA
- EPCLUSA and HARVONI (hepatitis C agents) — Requirements/Limits include PA, SP
Request PA and specialty routing where indicated
When a drug's Requirements/Limits field shows 'PA' or 'SP', providers must request prior authorization and follow specialty pharmacy routing where applicable prior to dispensing.
Submit PA and comply with stated quantity limits
Some products are listed with both prior authorization (PA) and specific quantity limits (QL); providers must obtain PA and ensure prescriptions adhere to the stated QL (claims may be denied if limits are exceeded).
- Enalapril maleate oral solution (Epaned) — Requirements/Limits = PA, QL (1200 mls/30 days)
- QBRELIS lisinopril oral solution — Requirements/Limits = PA, QL (2400 mls/30 days)
- FUROSCIX furosemide subcutaneous cartridge kit — Requirements/Limits = PA, QL (8 kits/180 days)
PA required for many specialty/high-cost medications
Multiple specialty and higher-cost drugs require prior authorization — providers must submit PA requests for these products (examples include REPATHA, NEXLETOL/NEXLIZET, VASCEPA, ENTRESTO, and biologics such as NUCALA/FASENRA).
- REPATHA evolocumab — Requirements/Limits = PA, QL (6 syringes/28 days)
- NUCALA mepolizumab — Requirements/Limits = PA, QL (3 mL/28 days), SP
Obtain PA for listed biologic/specialty products
Specific high-cost biologics and specialty agents are listed with PA (and often SP); prescribers must obtain prior authorization for these products before coverage (examples: SKYRIZI, TREMFYA, ZYMFENTRA).
- SKYRIZI risankizumab — Requirements/Limits = PA, QL (1 cartridge/56 days), SP
- TREMFYA guselkumab — Requirements/Limits = PA, QL (1 syringe/28 days), SP
- ZYMFENTRA infliximab‑dyyb — Requirements/Limits = PA, QL (2 kits/28 days), SP
PA required for specified formulary products
Certain listed products explicitly include 'PA' in their Requirements/Limits; providers must obtain prior authorization for these items prior to adjudication (examples in the formulary segment include SKYRIZI, TREMFYA, VOWST).
- VOWST fecal microbiota spores, live — Requirements/Limits = PA, QL (12 capsules/12 months), SP
PA required for PA‑designated products
Products explicitly labeled 'PA' in the drug list require prior authorization before coverage; prescribers must submit PA requests as directed by the plan.
- Examples: Hetlioz oral suspension (tasimelteon) — Requirements/Limits = PA, QL; Wegovy, Zepbound, Saxenda — Requirements/Limits = PA, QL
Follow payer PA procedures and submit required requests
The formulary notes that many products require prior authorization; providers must follow the payer's prior authorization procedures and submit required documentation for approval.
Obtain PA for listed biologics and follow QL/SP handling
Some injectable biologic therapies list PA plus QL and specialty pharmacy (SP) handling; prescribers must obtain prior authorization and adhere to the QL where specified for biologic products.
- PLEGRIDY peginterferon beta‑1a — Requirements/Limits = PA, QL (2 syringes/28 days), SP
- REBIF interferon beta‑1a — Requirements/Limits = PA, QL (12 syringes/28 days), SP
PA required for listed biologics and targeted agents
Many biologic and targeted agents (including multiple adalimumab biosimilars) require prior authorization and often have quantity limits; providers must secure PA and comply with the QL for these agents.
- Adalimumab biosimilars — Requirements/Limits = PA, QL (e.g., 2 pens/28 days), SP
- SIMPONI golimumab — Requirements/Limits = PA, QL, SP
Obtain PA for migraine biologics and follow QL
Migraine monoclonal antibody products are listed with PA and specific quantity limits; prescribers must obtain prior authorization and follow the stated QL (e.g., AIMOVIG PA, QL 1 injection/28 days).
- AIMOVIG (erenumab) — Requirements/Limits = PA, QL (1 injection/28 days)
- EMGALITY (galcanezumab) — Requirements/Limits = PA, QL (1 injection/28 days)
- AJOVY (fremanezumab) — Requirements/Limits = PA, QL (3 pens/84 days)
Follow step therapy when 'ST' is indicated
Step therapy may apply when the formulary shows 'ST' in the Special Requirements column — providers should document prior trials of required agents per the plan before the requested drug will be covered.
- Step Therapy is denoted by 'ST' next to products (e.g., aripiprazole oral solution = ST, FANAPT = ST)
- If ST applies, clinicians must show prior use of required alternatives as part of authorization
Check authorization flags (AC/PA) for antivirals — step specifics not listed
Some antiviral and other products include access/authorization flags (AC, PA) but the document does not define step sequences here; providers must follow the payer's authorization guidance when AC/PA/other flags are present.
- APRETUDE and some antiviral entries include AC/PA annotations; verify payer-specific authorization rules
If step therapy is not detailed, expect PA/QL controls
Where step therapy sequences are not specified in the formulary excerpt, providers should still expect PA and QL controls to be the primary utilization management tools and follow prior authorization rules accordingly.
Use the ID‑card number for exception requests; follow decision timeframes
Providers or members requesting an exception (coverage or copay waiver) must call the number on the member ID card; standard decisions are provided within 15 calendar days and expedited requests within 72 hours.
- Call the number on the member ID card to request an exception
- Standard decision timeframe: 15 calendar days; expedited: 72 hours
Provide supporting clinical documentation with PA requests
The presence of 'PA' implies supporting clinical documentation must be submitted with the prior authorization request; although the formulary does not include templates, providers should attach relevant clinical rationale and records.
- Include clinical justification and pertinent medical records with PA submissions
- If QL is specified, document the clinical need for quantities above the limit when applicable
Document quantity and dosing when PA involves QL
When quantity limits (QL) are specified, documentation supporting the requested dose/quantity may be required for PA; providers must ensure claims match the formulary QL or include justification for overrides.
- Examples: many oral oncology and insulin products have explicit QLs (e.g., QL 120 tablets/30 days; insulin QL 100 mL/30 days)
- Document dosing schedule and medical necessity when requesting amounts beyond QL
Include authorization and QL details on claims for AC/PA products
Claims for products marked 'AC' or 'PA' must include authorization per payer procedures; quantity limits (QL) should appear on the claim and be supported by documentation when applicable.
- Oral contraceptives with AC/QL (e.g., QL 28 tablets/21 days) require documentation of authorization on claim
- Follow payer submission instructions to ensure PA/AC codes are billed correctly
Ensure claims adhere to QL documentation
Adhere to the formulary's quantity‑limit documentation when submitting claims; QL values (e.g., syringe counts, mL volumes, tablet counts) must match the coverage limits unless PA is approved for exceptions.
- Follow QL examples such as OVIDREL QL (2 syringes/30 days) and insulin QL (100 mLs/30 days)
- If requesting quantities above the QL, submit PA with clinical justification
PA + QL entries require documentation for both authorization and quantity
Product lines that show 'PA, QL' indicate the provider must submit a prior authorization request and support the requested quantity per the QL; examples include enalapril oral solution, QBRELIS, and FUROSCIX which list PA plus explicit QLs.
- Enalapril (Epaned) oral solution — PA, QL (1200 mL/30 days)
- QBRELIS lisinopril oral solution — PA, QL (2400 mL/30 days)
- FUROSCIX furosemide kit — PA, QL (8 kits/180 days)
Submit PA and route through specialty pharmacy when 'SP' is indicated
For drugs listed with 'PA' or 'SP', prescribers must submit prior authorization requests per payer processes and comply with any specialty pharmacy routing or quantity limits indicated on the formulary line.
- Expect specialty pharmacy handling (SP) for many biologics and specialty agents
- Follow PA submission instructions and include QL details as applicable
Ensure PA/QL/SP requirements are met to avoid denials
Providers must submit prior authorization when indicated and adhere to stated quantity limits and specialty pharmacy routing for PA/QL/SP drugs; failure to obtain PA or to route through SP may result in denial.
- Examples: TREMFYA, SKYRIZI, and other biologics show PA, QL, SP — follow PA and SP requirements
- Claims without required PA/SP routing risk denial
Prepare for PA and specialty pharmacy routing where 'PA' + 'SP' present
Expect PA and specialty pharmacy routing for items labeled 'PA' and 'SP' in the formulary; verify routing and authorization before dispensing high‑cost specialty products (e.g., VOWST).
- VOWST — Requirements/Limits = PA, QL (12 capsules/12 months), SP
- SKYRIZI and OMVOH list PA, QL and SP — confirm PA and specialty routing
Verify product strength and requirement tags when requesting authorization
Use the formulary listing details (product name, strength, and requirement/limit tags such as QL, PA, ST, SP) to verify authorization and dispensing limits when submitting PA requests or claims.
- Check exact product strength and the Special Requirements column before submitting authorization
- Reference the QL value on the PA/claim submission to align with coverage rules
Document QL on PA/claims for QL‑listed products
Quantity‑limit documentation is expected for products with a QL entry (for example, PLEGRIDY lists QL 2 syringes/28 days); providers should ensure claims and PA requests reflect the stated QL.
- PLEGRIDY peginterferon beta‑1a — QL 2 syringes/28 days, PA, SP
- Include QL on claims to align with formulary limits
Route SP‑designated products through specialty pharmacy and obtain PA
Specialty‑designated products ('SP') require specialty pharmacy handling; providers should arrange dispensing through the specialty channel and obtain PA when indicated (examples: OTEZLA, TREMFYA).
- OTEZLA — Requirements/Limits = PA, QL (60 tablets/30 days), SP
- TREMFYA — Requirements/Limits = PA, QL, SP
PA listing triggers requirement to obtain authorization
Prior authorization triggers on the formulary — drugs marked 'PA' require PA or coverage may be denied; providers must secure authorization before dispensing to avoid claim denial.
- If prior authorization is not obtained for a PA‑listed drug, coverage may be denied
Exceeding dispensing/quantity limits risks full cost to member
Dispensing quantities that exceed plan dispensing or quantity limits may result in the member being responsible for the full cost with no benefits applied; providers must adhere to QL/DL values or obtain PA for overrides.
- Certain controlled substance rules may prohibit coverage beyond limits — patient may be liable for full cost
PA required for selected inhaled/complex aminoglycosides
PA is required for select inhaled/complex aminoglycoside products (e.g., KITABIS PAK, TOBI PODHALER, TOBRAMYCIN nebulized solutions); failure to obtain PA risks denial and specialty routing may apply.
- KITABIS PAK — Requirements/Limits = PA, QL (56 containers/56 days), SP
- TOBI PODHALER — Requirements/Limits = QL (224 capsules/56 days), SP PA
Obtain PA for specified antifungals (posaconazole, voriconazole)
Some antifungal agents and posaconazole formulations are marked 'PA' and will require prior authorization; providers must obtain PA to avoid claim denial for these antifungals.
- NOXAFIL posaconazole (packets, suspension, tablets) — Requirements/Limits = PA
PA/SP required for select hepatitis C antivirals
Certain hepatitis C antivirals and high‑cost antivirals are designated PA and SP; providers must ensure PA and specialty pharmacy routing are in place before dispensing these agents.
- EPCLUSA sofosbuvir‑velpatasvir — Requirements/Limits = QL (30 tablets/30 days), SP PA
- HARVONI ledipasvir‑sofosbuvir — Requirements/Limits = PA, QL (30 packets/30 days), SP
Claims may be denied if PA/SP/QL requirements are not satisfied
Drugs listed with Requirements/Limits = PA, SP, or QL may be denied if prior authorization, specialty pharmacy channel, or quantity‑limit requirements are not met; providers should verify and document compliance before dispensing.
Document authorization and QL for contraceptives (AC/QL)
Contraceptives listed with AC or QL require documentation and adherence to the QL (e.g., many combined oral contraceptives show AC, QL 28 tablets/21 days); providers should include authorization on the claim when required.
- Many contraceptives — Requirements/Limits = AC, QL (28 tablets/21 days); NUVARING — AC, QL (1 ring/21 days)
PA and QL apply to antidiabetic and insulin products
Antidiabetic agents and insulin products commonly have PA and/or QL notations (for example, MOUNJARO requires PA and QL; many insulins have QL 100 mL/30 days); providers must obtain PA where listed and adhere to QL.
- MOUNJARO — Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on strength)
- Insulin products (FIASP, HUMALOG, etc.) — Requirements/Limits = QL (100 mLs/30 days)
Comply with PA and SP requirements for specialty drugs
Providers must meet PA or specialty pharmacy (SP) requirements for listed specialty drugs; failure to obtain PA/SP or to route through specialty channels may result in claim denial or non‑coverage.
- CRENESSITY — Requirements/Limits = PA, QL, SP
- Many biologics and specialty injectables require SP routing and PA
PA and QL for select oral solutions and kits
Coverage of select oral solutions and kits lists explicit PA and QL designations (e.g., enalapril oral solution, QBRELIS, FUROSCIX); providers must obtain PA and ensure claims reflect the QL to avoid denials.
- Epaned enalapril oral solution — PA, QL (1200 mLs/30 days)
- QBRELIS lisinopril oral solution — PA, QL (2400 mLs/30 days)
- FUROSCIX furosemide kit — PA, QL (8 kits/180 days)
Follow PA/QL/SP controls for specialty/high‑tier drugs
Products designated 'PA/QL/SP' are subject to prior authorization, quantity limits, and specialty pharmacy controls; prescribers must submit PA, document quantity needs, and arrange specialty dispensing as required.
- Examples include REPATHA, OTEZLA, TREMFYA, and numerous specialty injectables that carry PA, QL, and SP flags
PA + QL presence requires authorization and adherence to limits
Where a PA and QL are both present for a product (e.g., XELJANZ shown with PA and QL), providers must secure prior authorization and ensure the dispensed quantity does not exceed the QL unless supported by an approved PA.
- XELJANZ 5 mg — Requirements/Limits = PA, QL (60 tablets/30 days)
Quantity Limits and Dispensing Restrictions
Site-of-Care and Specialty Pharmacy Routing
Biosimilar Listings and Handling
Definitions and Abbreviations
Initial Therapy Controls (High-Level)
PA/SP for specialty and certain high-cost drugs
Prior authorization (PA) or specialty pharmacy (SP) requirements — coverage requires ALL of the following when the product line indicates PA or SP:
PA flags are shown next to specific agents
SP designation present for many biologics and specialty agents
Documentation expectations noted across product lines
Step therapy where indicated (initial therapy)
When step therapy applies (ST shown) coverage requires ALL of the following:
ST notation appears adjacent to affected product lines
Specific alternative agents and failure definitions are defined in the plan step program (not fully included in the excerpt)
PA/QL/SP remain primary utilization controls where ST absent
Step Therapy Flags and Tables
| Drug / Drug Group | Special Requirements | Notes |
|---|---|---|
| Aripiprazole (oral solution, ODT, tablets) | ||
| ST; QL (900 mL/30 days for oral solution; QL 60 tablets/30 days for some tabs) | ||
| Step therapy indicated where 'ST' appears; per source aripiprazole oral solution and many aripiprazole tablet entries show 'ST' in Special Requirements. |
| Drug / Drug Group | Special Requirements | Notes |
|---|---|---|
| EPCLUSA (sofosbuvir-velpatasvir) | ||
| PA; SP; QL (30 tablets/30 days) | ||
| High-cost hepatitis C antiviral listed with PA and specialty pharmacy handling per formulary entry. |
| Observation | Special Requirements Present? | Source / Rationale |
|---|---|---|
| Presence of PA and QL flags across multiple sections but no step-by-step sequences provided | ||
| No (explicit sequences absent) | ||
| Document shows PA/QL flags for many drugs (e.g., oncology, antidiabetics) but does not define sequential step therapy algorithms in the cited chunks. |
| Drug | Special Requirements | Notes |
|---|---|---|
| MOUNJARO (tirzepatide) | ||
| PA; QL (4 pens/28 days or 4 pens/180 days depending on strength) | ||
| Listed with prior authorization and quantity limits; explicit multi-step requirements are not provided in these chunks. |
| Drug class / Examples | Special Requirements | Notes |
|---|---|---|
| GLP-1 agents (e.g., OZEMPIC, RYBELSUS, TRULICITY) | ||
| PA; QL as listed (examples: OZEMPIC PA, QL 1 pen/28 days or 3 mL/28 days) | ||
| GLP-1s in the listing show PA and QL flags; the document does not include detailed step therapy criteria for these agents in the cited chunks. |
| Drug | Special Requirements | Notes |
|---|---|---|
| KERENDIA (finerenone) | ||
| QL (30 tablets/30 days); ST | ||
| KERENDIA is specifically noted with 'ST' in Requirements/Limits indicating a step edit applies per the formulary excerpt. |
| Observation | Special Requirements Present? | Source / Rationale |
|---|---|---|
| Many product lines list Drug Tier with occasional PA/QL annotations but no ST sequences | ||
| No | ||
| Chunks show tier and occasional PA/QL annotations (e.g., digoxin entries) but do not present explicit step therapy rules in these excerpts. |
| Examples (selected high-cost agents) | Special Requirements | Notes |
|---|---|---|
| REPATHA (evolocumab - pens/cartridge) | ||
| PA; QL (6 syringes/28 days or 2 cartridges/30 days); SP | ||
| High-cost biologic with PA/QL and specialty designation suggesting utilization controls; explicit step sequences are not shown in these chunks. |
| Product / Formulation | Special Requirements | Notes |
|---|---|---|
| APRETUDE (cabotegravir - long-acting injection) and select bowel prep/access-class items | ||
| AC (access class) or similar designation shown for some formulations; PA/SP present for others | ||
| Access class (AC) designations are present for some formulations per brief/source; step therapy details for these entries are not provided in the cited chunks. |
| Drug / Formulation | Special Requirements | Notes |
|---|---|---|
| Aripiprazole (oral solution); Clozapine (ODT and suspension); FANAPT (iloperidone) | ||
| ST; QL as listed (e.g., aripiprazole oral solution QL 900 mL/30 days; FANAPT QL 60 tablets/30 days), other QLs for clozapine | ||
| Multiple antipsychotic/psychiatric oral formulations in the listing are marked 'ST' indicating step therapy applies where shown. |
| Drug | Special Requirements | Notes |
|---|---|---|
| FANAPT (iloperidone) and VERSACLOZ (clozapine suspension) | ||
| ST; QL (FANAPT QL 60 tablets/30 days; FANAPT titration packs QL as listed; VERSACLOZ QL 540 mL/30 days) | ||
| Entries explicitly show 'ST' for FANAPT and VERSACLOZ indicating step therapy applies; document does not provide the required prior agents or failure durations in these chunks. |
| Drug / Examples | Special Requirements | Notes |
|---|---|---|
| INGREZZA (valbenazine); XELJANZ (tofacitinib); selected biologics (e.g., evolocumab) | ||
| PA; QL; SP for many (e.g., Ingrezza PA, QL 28 caps/180 days, SP; XELJANZ PA, QL, SP) | ||
| Some agents are marked 'SP' (specialty) indicating specialty handling; many such entries also include PA and QL but explicit step-therapy sequences are not present in these chunks. |
| Observation | Special Requirements Present? | Source / Rationale |
|---|---|---|
| Overall: the document shows ST flags on selected products but does not define step-by-step algorithms in the provided excerpts | ||
| Mostly ST indicated on specific lines; PA/QL/SP are primary controls elsewhere | ||
| Source explains ST convention (chunk 10) and shows multiple product lines where 'ST' appears (psychiatric entries chunk 214-221, selected drugs like KERENDIA chunk 136) while many other sections rely on PA/QL/SP without step sequences. |
Background
Specialty drugs are described as high‑cost or complex therapies that may be oral, topical, or injectable and are used to treat conditions such as hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis. Some specialty medications are provider‑administered and may be covered under the medical benefit rather than the pharmacy benefit; providers should verify benefit placement and site‑of‑care routing with the payer.
Revision History
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.