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CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2026 Drug List (pharmacy formulary) — Coverage Criteria

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The document is the Blue Cross and Blue Shield of Oklahoma 2026 Drug List describing covered prescription drugs, tier placements, special requirements, and utilization management policies for plan members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List (pharmacy formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line shows 'PA' in the Requirements/Limits field before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+drug entries in this extract

multiplePA / QL / SP entries

6member payment tiers

30/90day supply examples

15 / 72exception decision timeframes

Formulary Coverage & Requirements

Formulary coverage and supply limits

General coverage rules and supply limits apply to all drug list entries.

Formulary coverage scope: All drugs shown on the drug list are considered covered; drugs not shown are not covered.

From Introduction: 'All available covered drugs are shown on this list. Drugs that are not shown are not covered.'

Indications and limits: Coverage may be limited to FDA‑labeled uses and recognized evidence‑based or clinical practice guidelines.

From Coverage considerations: 'Drug coverage may be limited to recommendations based on FDA‑approved labeling and recognized evidence‑based or clinical practice guidelines.'

Supply and maintenance fills: Most plans provide up to a 30‑day supply; some plans provide up to a 90‑day supply for maintenance medications (e.g., chronic therapies such as hypertension, diabetes, hyperlipidemia).30 days; 90 days for maintenance

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List (pharmacy formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a drug line shows 'PA' in the Requirements/Limits field before dispensing.

SourceLink

On This Page

From Coverage considerations: 'Most prescription drug benefit plans provide coverage for up to a 30‑day supply... up to a 90‑day supply of maintenance medications.'

Formulary updates and verification: The drug list is updated regularly; providers and members should verify current coverage, tiers, and requirements at MyPrime.com or bcbsok.com or by calling the number on the member ID card.

From Introduction: 'This list is regularly updated... For the most up‑to‑date information, visit MyPrime.com or bcbsok.com and log in or call the number on your ID card.'

Product listing coverage annotations

Product listing entries include tier and Requirements/Limits annotations; the document presents these as per‑product annotations rather than structured clinical criteria.

Listing annotations: Each drug line is presented with a Drug Tier (e.g., P, NP) and may include Requirements/Limits annotations such as AC, QL, PA, SP, or ST where applicable.

Examples: contraceptive entries showing 'AC, QL'; antidiabetic entries showing 'PA, QL'.

No prescriptive medical necessity criteria in listings: Product lines in these chunks do not include nested AND/OR medical necessity decision logic; clinical authorization requirements are indicated by the Requirements/Limits codes and any numeric QL values.

From product listing annotations: 'No clinical AND/OR criteria provided in these chunks.'

Formulary product-level coverage indicators

Per‑product coverage indicators (tier, PA/QL/SP flags) drive utilization management and coverage enforcement.

Product‑level indicators: Each listed product entry includes the drug name, strength/formulation, Drug Tier and any Requirements/Limits (e.g., PA, QL with specific numeric limits, SP, ST). Coverage is determined by the drug tier and compliance with any listed PA/QL/SP requirements.

Examples in these chunks: ENALAPRIL oral solution (PA, QL 1200 mls/30 days); REPATHA (PA, QL 6 syringes/28 days); ENTRESTO (PA, QL 240 capsules/30 days).

Requirements/Limits meanings: PA indicates prior authorization is required; QL indicates a numeric quantity limit for a defined time period; SP indicates specialty pharmacy handling; AC indicates an administrative/clinical coverage condition.

Definitions referenced alongside product flags in the listing (see Requirements/Limits annotations).

General drug coverage requirements

Coverage for a listed product requires adherence to the drug tier and any per‑line Requirements/Limits.

Coverage conditional on listed requirements: A drug listed with Requirements/Limits (for example, PA, QL, SP) is covered only when the requirements are met (e.g., an approved prior authorization, dispensing within the stated quantity limit, or dispensing via the specialty channel when SP is indicated).

Examples: INGREZZA (PA, QL 30 capsules/30 days, SP); KESIMPTA (PA, QL 1 pen/28 days, SP); MAVENCLAD therapy packs (PA, QL per therapy pack/301 days, SP).

Provider responsibilities: Providers must submit prior authorization requests and supporting clinical documentation when 'PA' is indicated; pharmacy dispensing must comply with QL values. Failure to obtain required PA or to adhere to QL/SP requirements may result in denial of coverage.

From Coverage and Authorization sections: PA and QL requirements and denial risk statements.

Non‑FDA‑approved drugs are not covered. The plan also may exclude repackaged versions of marketed medications and certain compounded products; consult the member’s benefit materials to confirm coverage for compounded or repackaged preparations. Drugs used for cosmetic purposes may be excluded or limited by age criteria per the benefit design. (See plan materials or MyPrime for member‑specific details.)

Prior authorization (PA) may be required for some specialty or high‑cost agents; when PA commonly applies it is indicated in the drug list under the Special Requirements column. For drugs that are not FDA‑approved for self‑administration, coverage may be through the medical benefit rather than the pharmacy benefit—verify the appropriate benefit channel before dispensing.

No additional explicit product exclusions are stated in the cited portions of the drug list. Where exclusions apply, they are addressed in the member’s benefit plan materials; absence of an exclusion statement in these chunks does not supersede the plan’s governing documents.

Entries in these sections that lack a PA or QL designation have no additional prior authorization or quantity‑limit requirements shown in this excerpt. Do not interpret absence of PA/QL in the listed lines as removal of other plan rules—always verify the member’s specific benefit and the full drug list entry.

The product lines shown in these chunks do not include explicit exclusion conditions for the listed drugs. Coverage for each product follows its Drug Tier and any Requirements/Limits (for example, PA, QL, SP) if present; absence of those flags here does not imply the product is excluded under the member’s benefit.

Drugs that have not received FDA approval are not covered. Coverage is generally limited to FDA‑labeled uses and recognized evidence‑based guidelines unless otherwise specified in the member’s benefit documents.

The cited drug listing excerpts do not contain explicit 'not medically necessary' determinations. Clinical coverage limitations (for example, age restrictions or indication‑specific limits) are referenced in plan materials or implied by the listed Requirements/Limits codes (e.g., AC, PA, QL) rather than stated here as 'not medically necessary.'

These chunks do not include any explicit 'Not Medically Necessary' statements for specific therapies. Medical necessity determinations should follow the member’s benefit rules and any applicable clinical guidance when PA is requested.

The nicotine‑replacement and related product entries shown here contain no explicit 'Not Medically Necessary' language. As with other entries, coverage is determined by the drug’s tier and any Requirements/Limits and by the member’s benefit plan terms.

Codes, Quantity Limits & Examples

Antibiotics listed (sample entries)NDC | drug name textCovered

AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg, 250 mg	Drug Tier = NP
AMOXICILLIN - amoxicillin (trihydrate) cap 250 mg, 500 mg	Drug Tier = p
AMOXICILLIN - amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml	Drug Tier = p
AMOXICILLIN - amoxicillin (trihydrate) tab 500 mg, 875 mg	Drug Tier = p
AMOXICILLIN & K CLAVULANATE - amoxicillin & k clavulanate for susp 200-28.5 mg/5ml	Drug Tier = p
AMOXICILLIN & K CLAVULANATE - amoxicillin & k clavulanate for susp 250-62.5 mg/5ml, 400-57 mg/5ml	Drug Tier = np
AMOXICILLIN & K CLAVULANATE - amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)	Drug Tier = np

NDC/CPT/HCPCS codesmixed

No codes listed

Drug list — no procedure codes in this extractmixed

No codes listed

inv-20: Quantity limits shown — sample list of QL formats and examples

Common QL notation'QL' in the Special Requirements column indicates a quantity or dispensing limit applies for a specified time period (e.g., QL (60 tablets/180 days)).

Formats shownTablet/capsule counts per days (e.g., 60 tablets/180 days; 28 tablets/28 days).

Pack/packet limitsPack/packet limits for pellet packs or starter packs (e.g., 28 packs/28 days; 140 packs/28 days).

Liquid/ML limitsVolume limits for oral or inhalation solutions specified in mls (e.g., 280 mls/56 days; 480 mls/30 days).

Pen/auto‑injector countsNumber of pens or auto‑injectors per period (e.g., 4 pens/28 days; 8 pens/180 days).

inv-21: Example quantity limits — contraceptive and other examples

Oral contraceptive monthly supplyQL (28 tablets/21 days) is used for many oral contraceptive formulations (e.g., AVERI, multiple desogestrel/ethinyl estradiol products).

Emergency contraceptionLevonorgestrel 1.5 mg: QL (2 tablets/365 days).

Ulipristal (ELLA)ELLA (ulipristal acetate 30 mg): QL (2 tablets/365 days).

Contraceptive ringIntravaginal ring example: QL (1 ring/365 days).

Weight‑management injectables (example)SAXENDA: QL (15 mls/30 days) — listed separately; Wegovy has distinct pen limits.

inv-22: Quantity limits examples — assorted products

Inhaled aminoglycosidesARIKAYCE: QL (28 vials/28 days); KITABIS PAK / TOBI nebulizer solutions: QL (280 mls/56 days) or QL (224 capsules/56 days) for Podhaler.

Hepatitis C antiviralsEPCLUSA, HARVONI: QL (28 tablets/28 days) or QL (28 packs/28 days); MAVYRET: QL (90 tablets/30 days).

Antiviral oral packsPAXLOVID pack-dependent limits: QL (11–30 tablets/90 days) depending on pack size.

Antibiotics (examples)Azithromycin tablets: QL (60 tablets/180 days); Clarithromycin ER 500 mg: QL (28 tablets/180 days).

inv-23: WEGOVY quantity example

WEGOVY (various presentations)WEGOVY (semaglutide) weight‑management soln auto‑injector: Requirements/Limits = PA, QL (8 pens/180 days) for some presentations.

WEGOVY (1.7/2.4 mg presentations)WEGOVY 1.7 mg / 2.4 mg presentations: Requirements/Limits = PA, QL (4 pens/28 days).

Clinical noteWEGOVY entries are marked PA in the Special Requirements column — prior authorization required in addition to QL.

inv-24: SAXENDA quantity example

SAXENDA presentationSAXENDA (liraglutide) soln pen‑injector 18 mg/3 ml (6 mg/ml): Requirements/Limits = PA, QL (15 mls/30 days).

Programmatic noteSAXENDA is assigned PA in the Special Requirements column — prior authorization required in addition to the 15 mL monthly limit.

Related agentsOther weight‑management GLP‑1 agents (e.g., Wegovy, Zepbound) have distinct QL and PA settings.

inv-25: Example quantity limits — assorted capsule/ml examples

Oral capsule limitsExamples include QL (300 tablets/30 days) for some oncology packs and QL (120 capsules/30 days) for select antiviral/antifibrotic agents. (see TUKYSA, PIRFENIDONE examples).

Large-volume oral solutionsFOSRENOL powder packs: QL (540 packs/365 days); ACETAMINOPHEN/CODEINE solution: QL (2700 mls/30 days).

High QL for films/patchesBELBUCA buccal films: QL (60 films/30 days); XTAMPZA ER: QL (240 capsules/30 days).

What Providers Must Do / Risks

Prior Authorization

Prior authorization may be required

Certain drugs listed on the BCBSOK Drug List may require prior authorization (PA) before coverage will be provided; when commonly required, 'PA' is shown in the Special Requirements column and the prescriber must submit a prior authorization request and obtain approval prior to dispensing.

Prior Authorization

Prior authorization required for selected agents

Prior authorization is required for selected agents such as ARIKAYCE (amikacin liposome inhalation) and hepatitis C antivirals like EPCLUSA and HARVONI; these entries show 'PA' in the Requirements/Limits field and must have PA obtained.

ARIKAYCE — Requirements/Limits = PA, QL (28 vials/28 days), SP
EPCLUSA — Requirements/Limits = PA, QL (28 tablets/28 days), SP
HARVONI — Requirements/Limits = PA, QL (28 tablets/28 days), SP

Prior Authorization

Prior Authorization required for select agents

High‑cost and specialty antiviral/oncolytic agents (examples: EPCLUSA, HARVONI, MAVYRET, MAVYRET pellet packs) are indicated with 'PA' and specialty handling; obtain prior authorization prior to dispensing.

EPCLUSA — PA, QL (28 tablets/28 days)
HARVONI — PA, QL (28 tablets/28 days)
MAVYRET — PA, QL (90 tablets/30 days)

Prior Authorization

PA requirement — vaccines and specialty drugs often AC/PA

Many vaccines and several specialty products are assigned Requirements/Limits = AC or PA (e.g., ENGERIX‑B and seasonal influenza vaccines marked AC); follow the Authorization/Administrative Clinical review process when indicated.

ENGERIX‑B — Requirements/Limits = AC
Multiple influenza vaccines — Requirements/Limits = AC

Prior Authorization

PA requirement — oncology and specialty oral agents often require PA

Numerous oncology and specialty oral agents require prior authorization as indicated in the Requirements/Limits column (PA and often QL and SP are present); obtain PA before dispensing these oral specialty oncology agents.

COPIKTRA, COTELLIC, many tyrosine kinase inhibitors — Requirements/Limits = PA, QL, SP
Various therapy packs and oral oncolytics labeled PA

Prior Authorization

Prior authorization required for many specialty drugs

Many specialty‑designated drugs require prior authorization and are expected to be dispensed via the specialty channel; providers must obtain PA prior to dispensing to ensure coverage.

Examples: RETEVMO, INGREZZA — Requirements/Limits include PA and SP
Specialty biologics and enzyme products listed with PA

Prior Authorization

Prior authorization and quantity limits — antidiabetic and specialty agents examples

Some antidiabetic and other specialty agents have both prior authorization and quantity limits (e.g., MOUNJARO, OZEMPIC); submit PA and ensure the requested quantity does not exceed the listed QL.

MOUNJARO — Requirements/Limits = PA, QL (4 pens/180 days)
OZEMPIC — Requirements/Limits = PA, QL (1 pen/28 days)
RYBELSUS — Requirements/Limits = PA, QL (30 tablets/30 days)

Prior Authorization

Prior authorization required for many specialty drugs

Providers must follow per‑line Requirements/Limits where 'PA' is indicated; many specialty drugs list PA in their product entry and require approval before coverage will be provided.

GENOTROPIN, IMCIVREE, other specialty injectables — Requirements/Limits include PA, SP

Prior Authorization

PA and QL requirements — examples include products with PA and QL flags

Several products are listed with both PA and QL flags (for example, EPCLUSA, HARVONI, MAVYRET and numerous specialty biologics); obtain PA and adhere to the QL noted for each product.

EPCLUSA/HARVONI — PA, QL (28 tablets/28 days)
MAVYRET — PA, QL (90 tablets/30 days)
Many biologics — PA, QL, SP

Prior Authorization

Prior authorization required — general reminder

Prior authorization is common across the drug list: entries that show 'PA' in the Requirements/Limits field indicate PA must be obtained before the medication is covered.

Prior Authorization

Prior authorization required — cystic fibrosis and similar specialty drug examples (KALYDECO, ORKAMBI, TRIKAFTA)

Cystic fibrosis modulators (examples: KALYDECO, ORKAMBI, TRIKAFTA) are listed with 'PA' and QL entries; obtain prior authorization and follow the specified quantity limits for these specialty CF products.

KALYDECO — PA, QL (60 tablets/30 days or 60 packets/30 days)
ORKAMBI — PA, QL (120 tablets/30 days)
TRIKAFTA — PA, QL (56 packets/28 days)

Prior Authorization

PA for specialty/biologic agents — examples (GATTEX, CREON, ZENPEP)

Specialty biologics and enzyme replacement products (e.g., GATTEX, CREON, ZENPEP) are listed with PA and often SP; providers must request prior authorization per plan processes for these agents.

GATTEX — Requirements/Limits = PA, SP
CREON — Requirements/Limits = PA
ZENPEP — Requirements/Limits = PA

Prior Authorization

Prior authorization required for select products — FILSPARI, PROCYSBI, VANRAFIA examples

Selected specialty renal and rare‑disease products (examples: FILSPARI, PROCYSBI, VANRAFIA) list 'PA' and often 'SP' in Requirements/Limits; obtain PA and route through specialty pharmacy when required.

FILSPARI — Requirements/Limits = PA, QL (30 tablets/30 days), SP
PROCYSBI — Requirements/Limits = PA, SP
VANRAFIA — Requirements/Limits = PA, SP

Prior Authorization

Prior authorization required — weight-management and high-cost medications (Saxenda, Wegovy)

Weight‑management and other high‑cost agents (e.g., SAXENDA, WEGOVY) require prior authorization and have specified quantity limits; submit PA and ensure requested supplies match the QL.

SAXENDA — Requirements/Limits = PA, QL (15 mls/30 days)
WEGOVY — Requirements/Limits = PA, QL (8 pens/180 days or 4 pens/28 days depending on presentation)

Prior Authorization

Prior authorization required for specific products — numerous specialty products listed with PA

Numerous specialty products across therapeutic areas show 'PA' in their Requirements/Limits (e.g., INGREZZA, LUMRYZ, MAVENCLAD, KESIMPTA, MAYZENT); obtain prior authorization per the product entry before dispensing.

INGREZZA — PA, QL (30 capsules/30 days), SP
LUMRYZ — PA, QL (30 packets/30 days), SP
MAVENCLAD — PA, QL (8–10 tablets/301 days), SP

Step Therapy

Step therapy — overview

Step therapy programs may apply when a product is marked 'ST' in the Special Requirements column; the plan may require trial of preferred alternatives before coverage of the requested drug is approved.

If 'ST' appears (example: KERENDIA shows ST), follow the step therapy rules noted in plan materials

Note

Step therapy not specified — no explicit sequences provided

No structured step‑therapy sequences are detailed in this excerpt of the Drug List; most entries show PA, QL, SP flags rather than explicit step progressions.

Step Therapy

Step therapy present for select drugs (KERENDIA example)

Some agents are specifically flagged 'ST' in the Requirements/Limits (example: KERENDIA is labeled with ST); when present, follow the documented step therapy requirement for that agent.

KERENDIA — Requirements/Limits include QL (30 tablets/30 days) and ST

Documentation Required

Exception process documentation — timelines for standard and expedited requests

BCBSOK allows prescribers or members to request a Drug List exception; the plan will notify the decision within 15 calendar days for standard requests and within 72 calendar hours for expedited reviews.

Standard exception decision timeframe: 15 calendar days
Expedited review timeframe (when health jeopardy): 72 calendar hours

Documentation Required

Auth documentation for antivirals — submit PA with supporting clinical info

For antiviral/hepatitis agents listed with PA (e.g., EPCLUSA, HARVONI, MAVYRET), providers must submit authorization documentation with the prior authorization request as indicated in the Requirements/Limits field.

EPCLUSA — PA, QL (28 tablets/28 days)
HARVONI — PA, QL (28 tablets/28 days)
MAVYRET — PA, QL (90 tablets/30 days)

Documentation Required

Quantity limit documentation — adhere to listed QLs

Quantity limits (QL) are specified for many products and must be adhered to; when requesting quantities that exceed listed QL, provide supporting justification or expect claims to be denied.

EPCLUSA/HARVONI — QL (28 tablets/28 days)
Azithromycin tabs — QL (60 tablets/180 days)
Clarithromycin ER — QL (28 tablets/180 days)

Documentation Required

Clinical justification implied — documentation expected with PA/AC requests

The presence of 'PA' or 'AC' on a product line implies clinical justification and supporting documentation will be required when submitting the authorization request, even though templates are not provided in this excerpt.

Billing Rule

Quantity limit adherence — prescriptions must not exceed listed QL per timeframe

Prescriptions must not exceed the listed quantity limits for a product (for example, QL entries such as 30 tablets/30 days, 56 packets/28 days); dispense and request quantities consistent with these limits.

Example QLs: EPCLUSA — 28 tablets/28 days; TRIKAFTA — 56 packets/28 days

Documentation Required

Match prescription to listed QL — include correct strength/formulation

Ensure the prescription (strength, formulation, and quantity) matches the QL entry for the listed product (e.g., tablet vs packet presentations) when submitting a PA or dispensing under QL constraints.

Match tablet vs packet presentation to the QL shown (EPCLUSA/HARVONI pellet packs vs tablets)

Documentation Required

PA documentation — MOUNJARO and GLP‑1 agents marked PA

GLP‑1 and GLP‑1–related agents such as MOUNJARO and other tirzepatide/semaglutide products are marked 'PA' (e.g., MOUNJARO PA, QL 4 pens/180 days); submit PA with clinical indication and requested duration.

MOUNJARO — PA, QL (4 pens/180 days)
RYBELSUS — PA, QL (30 tablets/30 days)
TRULICITY — QL (4 pens/28 days)

Documentation Required

Documentation for PA or QL requests — submit supporting clinical info

When requesting PA or overrides for products with PA or QL (examples: ORILISSA, OVIDREL), submit supporting clinical information that documents medical necessity and the rationale for the requested quantity or exception.

ORILISSA — Requirements/Limits = PA, QL (30 or 60 tablets depending on strength)
OVIDREL — Requirements/Limits = QL (2 syringes/30 days)

Documentation Required

Documentation for PA/QL — provide medical necessity and quantity justification

For products listed with 'PA, QL', providers must provide documentation supporting medical necessity and justification for the requested quantity as part of the authorization request.

Enalapril oral solution (Epaned) — PA, QL (1200 mls/30 days)
FUROSCIX — PA, QL (8 kits/180 days)

Documentation Required

General documentation — include indication, dose, duration with PA requests

When requesting prior authorization for PA or specialty (SP) drugs, prescribers should include the indication, dose, and duration in the authorization request because the plan requires such information to make coverage determinations.

Documentation Required

Prior Authorization Documentation — prescribers must supply clinical details

Prescribers are required to supply necessary clinical information to satisfy PA requirements (for example, condition being treated, prior therapies tried, and dosing) for products that list PA in their Requirements/Limits.

Include clinical indication, prior treatment history, dose and duration when submitting PA

Documentation Required

PA documentation expectation — specialty agents require PA per plan process

Specialty agents (examples Kesimpta, Lumryz, Mavenclad, Ingrezza) list PA and QL in their product lines; providers must submit PA per the plan's prior authorization processes to obtain coverage prior to dispensing.

KESIMPTA — Requirements/Limits = PA, QL (1 pen/28 days), SP
LUMRYZ — Requirements/Limits = PA, QL (30 packets/30 days), SP
MAVENCLAD — Requirements/Limits = PA, QL (8–10 tablets/301 days), SP

Billing Rule

Quantity limits and specialty dispensing — adhere to QL and specialty channel requirements

Pharmacies and prescribers must dispense and prescribe within the stated quantity limits (QL) for products (e.g., 30 capsules/30 days, 540 mls/30 days for sodium oxybate); specialty drugs may also require dispensing via the specialty channel.

XYWAV/XYWAV (sodium oxybate) — PA, QL (540 mls/30 days), SP
ZEPOSIA — PA, QL (30 capsules/30 days), SP

Denial Risk

Coverage and prior authorization risk — non‑listed drugs not covered; obtain PA to avoid denial

Drugs not listed on the Drug List are not covered; failure to obtain required prior authorization, or to comply with QL/SP requirements, may result in claim denial or denial of coverage.

Denial Risk

PA/QL enforcement risk — failure to meet PA/QL may trigger denial

Claims may be denied or rejected if PA, QL or SP requirements are not met (examples include antiviral agents EPCLUSA, HARVONI, MAVYRET which list 'PA' and can be denied without PA).

EPCLUSA/HARVONI/MAVYRET — PA noted; requests may be denied without PA

Billing Rule

Specialty/PA requirement — specialty routing and PA may be required

Specialty‑designated products and those with PA flags (e.g., Arikayce, tobramycin inhalation products, EPCLUSA) may require specialty pharmacy billing or routing; dispensing outside the specialty channel or without PA can lead to denial or redirecting of the claim.

ARIKAYCE — PA, QL (28 vials/28 days), SP
TOBI/KITABIS PAK — PA, QL, SP
EPCLUSA — PA, QL, SP

Prior Authorization

Prior Authorization triggers for selected antivirals — obtain PA for DAAs

Requests for hepatitis C direct‑acting antivirals (EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI) include 'PA' in Requirements/Limits and may be denied without prior authorization and adherence to the listed QL.

EPCLUSA/HARVONI/SOVALDI/VOSEVI — Requirements/Limits = PA, QL, SP

Prior Authorization

Prior authorization likely required — obtain PA when indicated

If a product line is labeled 'PA' (or 'AC/PA'), prior authorization is likely required and claims submitted without approved PA are at risk of denial; confirm and secure PA prior to dispensing.

Denial Risk

PA and quantity limits enforceable — meeting PA/QL/SP is required to avoid denial

Products marked with PA, QL, or SP (for example many antineoplastics and PAH agents) will be enforced — failure to obtain PA, exceed QL, or bypass SP channel may result in denial or redirection of coverage.

FUROSCIX — PA, QL (8 kits/180 days)
ADEMPAS/OPSUMIT/ORENITRAM — PA, QL, SP

Denial Risk

Prior authorization required — claims may be denied without PA

Claims may be denied if no prior authorization is obtained for medications that list 'PA' in their Requirements/Limits field; verify PA before claim submission.

Billing Rule

PA and specialty routing noted — ensure specialty pharmacy routing and PA

Specialty products often note specialty pharmacy (SP) plus PA; prescriptions for these agents may require specialty dispensing and prior authorization—ensure the specialty channel is used and PA is approved.

Adalimumab products — PA, QL (1–2 pens/syringes per period), SP
KESIMPTA — PA, QL (1 pen/28 days), SP

Denial Risk

Denial risk from missing required PA/QL/SP — missing requirements may cause claim denial

If a required PA/QL/SP is missing on a claim (for example many specialty agents like Arikayce, TRIKAFTA, KALYDECO), the claim may be denied or payment refused—obtain necessary authorizations and follow QL restrictions.

Denial Risk

Quantity limit and AC enforcement — exceeding QL may cause denial

Exceeding an item's listed quantity limit (e.g., 28 tablets/21 days, 8 kits/180 days) can trigger a denial; dispense and bill only up to the QL unless an approved exception or PA with justification is obtained.

Examples: QL (28 tablets/21 days); FUROSCIX — QL (8 kits/180 days)

Denial Risk

Denial risk from missing required PA/QL/SP — missing required authorizations may lead to denial

Failure to secure required PA, QL approval, or to use the specialty pharmacy for SP‑designated products increases the risk of claim denial; verify requirements before prescribing or dispensing.

Note

Key Terms & Codes

inv-91: Specialty drugs — definition and notes

Specialty drugs — definitionSpecialty drugs may be oral, topical, or injectable medications used for complex conditions (e.g., hepatitis, hemophilia, multiple sclerosis, rheumatoid arthritis) and may require administration by a health care professional.

Coverage channelMedications administered by a health care professional may be covered under the medical benefit rather than the pharmacy benefit.

Specialty list locationFor a current list of specialty medications, visit MyPrime.com or bcbsok.com as referenced in the drug list guidance.

inv-92: Tier — member payment tier classification

Tier — member payment classificationDrugs are placed into up to six member payment tiers (Preferred Generic, Non‑Preferred Generic, Preferred Brand, Non‑Preferred Brand, Preferred Specialty, Non‑Preferred Specialty) which determine member cost‑share.

Tier display conventionsPreferred Generics are marked with 'p'; Non‑Preferred Generics 'np'; Preferred Brands 'P'; Non‑Preferred Brands 'NP'; specialty items include an 'SP' marking in Special Requirements.

inv-93: PA — Prior authorization definition and usage

Prior Authorization (PA) — definition'PA' indicates insurer prior approval is required for coverage before the medication will be dispensed; PA is shown in the Special Requirements column for applicable drugs.

Usage noteMany high‑cost or specialty medications (e.g., MOUNJARO, EPCLUSA, HARVONI) are listed with PA and require submission of authorization documentation.

Exception consequenceClaims may be denied if PA is not obtained when 'PA' is indicated.

inv-94: QL — Quantity Limit definition

QL — definition'QL' denotes a quantity limit: the maximum quantity allowed in a specified time period (e.g., QL (28 tablets/28 days), QL (60 tablets/180 days)).

PurposeDispensing limits encourage use consistent with FDA labeling and may be enforced per prescription or over a time window.

EnforcementDispensed quantities exceeding the QL may not be covered or may require provider/member to pay the full cost. State law may further restrict controlled substances.

inv-95: SP — Specialty Pharmacy definition

SP — Specialty Pharmacy definition'SP' indicates the medication is managed and dispensed through a specialty pharmacy channel, commonly applied to high‑cost biologics, injectables, and complex therapies.

Operational impactEntries marked SP often also have PA and QL requirements and may require specialty distribution or routing.

inv-96: Requirements/Limits = AC — explanation of AC label

AC — Requirements/Limits code'AC' is used in the Requirements/Limits column to indicate an authorization code or administrative/clinical review requirement applies (e.g., certain vaccines and contraceptives).

Example useAC appears on vaccine lines (ENGERIX‑B) and contraceptive entries (many oral contraceptives show AC, QL).

inv-97: Requirements/Limits = PA, QL, SP — shorthand definitions

PA, QL, SP — shorthandCommon shorthand in Requirements/Limits: PA = prior authorization required; QL = quantity limit; SP = specialty pharmacy designation.

Combination usageDrugs frequently appear with multiple flags (e.g., PA, QL, SP) indicating combined authorization, quantity, and specialty distribution requirements.

inv-98: PA (additional reference)

PA — definition referenceStep therapy and coverage rules note: when 'PA' is shown in the Special Requirements column, insurer prior approval must be obtained before coverage. (Coverage considerations and step therapy guidance).

Supporting noteThe drug list marks 'PA' next to numerous specialty and high‑cost agents.

inv-99: QL (additional reference)

QL — definition referenceQuantity limits are described in the Coverage Considerations module and are shown as 'QL' for affected drugs (examples include 28 tablets/28 days; 60 tablets/180 days).

Example entryMacrolide and antiviral entries show numerous QL examples in the product lines.

inv-100: SP (additional reference)

SP — definition referenceSpecialty Pharmacy (SP) designation appears in the Special Requirements column for many biologics, injectables, and specialty oral agents indicating specialty management/dispensing.

Distribution implicationRequests for SP drugs may be denied or redirected if not dispensed through the specialty channel.

inv-101: AC — authorization code indicator

AC — authorization code indicator'AC' used on drug list lines denotes an authorization code/administrative clinical review requirement that may apply to the product (e.g., contraceptives, rings).

ExampleAce‑ethinyl estradiol vaginal ring line shows Requirements/Limits = AC, QL (1 ring/365 days).

inv-102: PA — examples of drugs marked PA (MOUNJARO, OZEMPIC, etc.)

PA — examples of drugs marked PAExamples of products marked 'PA' include MOUNJARO (tirzepatide), OZEMPIC (semaglutide), TRULICITY (dulaglutide), RYBELSUS (semaglutide tablets) among antidiabetic/weight‑management agents.

Entry noteThese agents often also include QL (e.g., MOUNJARO QL 4 pens/180 days; OZEMPIC QL 1 pen/28 days).

inv-103: QL — example QL entries (28 tablets/21 days, etc.)

QL — example QL entriesExamples in the antipsychotic/CNS section include QL (30 tablets/30 days), QL (60 tablets/30 days), QL (480 mls/30 days) for liquid formulations and other per‑period limits.

ST overlapSome QL entries coexist with ST (step therapy) flags for specific formulations.

inv-104: PA (definition reference)

PA — definition referencePrior Authorization (PA) requires insurer approval before coverage; noted in Coverage Considerations and shown on product lines.

Operational implicationFailure to obtain PA when required may result in claim denial or full member financial responsibility.

inv-105: QL (definition reference)

QL — definition referenceQuantity Limit (QL) indicates the maximum quantity allowed in a specified period; examples provided throughout the drug list (e.g., 28 tablets/28 days).

PurposeQLs are intended to encourage use consistent with FDA‑approved dosing and limit excess dispensing.

inv-106: SP (definition reference)

SP — definition referenceSpecialty (SP) denotes medications that are typically high‑cost or clinically complex and are managed via specialty pharmacy; SP appears in Special Requirements for many biologics and enzyme therapies.

Coverage noteSP drugs commonly also require PA and have QL entries.

inv-107: PA (definition reference)

PA — concise definitionPA indicates prior authorization is required before coverage will be provided for certain medications; noted in Special Requirements.

Document guidanceCoverage considerations explain PA usage and that PA flags appear next to medications when commonly required.

inv-108: QL (definition reference)

QL — concise definitionQL indicates a dispensing limit, the maximum quantity allowed within a specified time window (e.g., per 28, 30, 90, or 180 days).

Examples availableMultiple examples throughout the drug list illustrate QL formats (tablets, packs, mls, pens).

inv-109: SP (definition reference)

SP — concise definitionSP denotes specialty pharmacy dispensing expected/required for the product; entries marked SP often include PA and QL.

Provider actionSpecialty products may require routing to specialty pharmacies and adherence to PA/QL for coverage.

inv-110: PA (definition reference)

PA — carrier definitionPrior Authorization (PA) is an approval required before coverage/dispensing when indicated in the Special Requirements column.

Example linesSeveral contraceptive and other product lines are marked AC and PA where applicable.

inv-111: QL (definition reference)

QL — carrier definitionQuantity Limit (QL) is the maximum quantity allowed in the indicated time period; QL values accompany product listings (e.g., QL (28 tablets/28 days)).

Enforcement noteDispensing beyond QL may result in member financial liability or denial per Coverage Considerations.

inv-112: SP (definition reference)

SP — carrier definitionSpecialty designation (SP) indicates specialty pharmacy management and may affect site‑of‑care and dispensing channels.

ExamplesMany biologics, enzyme products, and complex therapies carry the SP flag (e.g., ARIKAYCE, GATTEX, KESIMPTA).

Initial Therapy / Medical Necessity

Initial therapy — Not specified

No explicit initial‑therapy criteria are specified in the provided extracts.

Initial therapy not specified: The document excerpts do not define separate initial‑therapy (first‑line) medical necessity criteria or step‑by‑step initial treatment algorithms for specific products.

Prescribers should follow the per‑line Requirements/Limits (PA/QL/ST) where indicated; step therapy sequences are not enumerated in these chunks.

Initial therapy (not specified)

No initial therapy criteria are available in these chunks.

Initial therapy — none provided: No explicit initial therapy criteria or branching clinical requirements appear in the source excerpts provided.

See Requirements/Limits annotations for per‑product authorization guidance.

Step Therapy Rules & Listings

Context	Policy summary	Special Requirements
General step therapy guidance
Step therapy programs may require trying another proven, cost-effective medication before coverage is available; when commonly applied, 'ST' will be noted in the Special Requirements column next to the medication.
ST (marked on drug list when applicable)

Context	Policy summary	Special Requirements
Product-level listings (example section)
No explicit step therapy sequences are specified for most listed agents in this extract; entries primarily show PA, QL, SP or AC flags rather than structured step sequences.
No ST sequence specified

Drug	Policy note	Special Requirements
KERENDIA (finerenone) 10 mg, 20 mg
Listed with utilization management flags; follow step therapy where indicated in the Special Requirements field.
ST (marked on drug list)

Representative agents	Policy note	Special Requirements
FETZIMA titration pack (levomilnacipran)
Titration packs and select antidepressant/antipsychotic presentations are flagged to indicate step therapy applies for these formulations where listed.
ST
FANAPT (iloperidone) and FANAPT titration packs
Titration packs include QL and are listed with ST where applicable; follow step therapy instructions noted on the product line.
ST
CLOZAPINE ODT (example clozapine formulations)
Certain clozapine oral-dispersible and suspension presentations are subject to step therapy as indicated on the drug list.
ST
RISPERRIDONE ODT (risperidone orally disintegrating tabs)
Some ODT strengths are listed with quantity limits and explicit ST marking for specific presentations.
ST (for selected ODT strengths)

Product examples	Policy note	Special Requirements
Risperidone ODT (0.25 mg and select strengths)
ODT presentations include QL entries; selected ODT strengths are marked with ST in the Requirements/Limits field.
ST (selected ODT strengths)
SECUADO (asenapine) transdermal patch
SECUADO patch presentations show QL and, for certain presentations, are labeled with ST indicating step therapy applies.
ST (patch presentations)

Product category	Policy note	Special Requirements
Nicotine replacement therapies and varenicline (examples: NICORETTE gum/lozenge/patch, varenicline entries)
Several nicotine replacement presentations and related smoking-cessation products are listed with an 'AC' requirement; specific step progression (e.g., trial of one therapy then another) is not detailed in this extract.
AC (administrative/coverage condition) — no ST sequence specified

Product group	Policy note	Special Requirements / Limits
Contraceptives and estrogen products (examples: AVERI ring, desogestrel-ethinyl estradiol tablets, estradiol patches)
These contraceptive and estrogen formulations are listed with Authorization Code 'AC' and various quantity limits (QL) such as 28 tablets/21 days or 1 ring/365 days. The document does not specify step therapy sequencing for these products in this extract.
AC; QL (as noted per product line) — no ST specified

Quantity Limits — Product Examples

inv-128: QL overview — quantity limits noted with 'QL' in Special Requirements

QL flag overviewQuantity limits are noted with 'QL' in the Special Requirements column for affected drugs; QL entries specify a quantity and time period.

Where to find QLsSpecific QL values appear on each product line in the formulary (examples across macrolides, antivirals, specialty agents).

inv-129: azithromycin tab 250 mg, 500 mg (Zithromax) — QL 60

Azithromycin tabletsAzithromycin tablets 250 mg, 500 mg (Zithromax): Requirements/Limits = QL (60 tablets/180 days).

Formulation contextBoth suspension and tablet presentations are listed; the tablet lines show the QL.

inv-130: clarithromycin tab er 24hr 500 mg — QL 28

Clarithromycin ERClarithromycin tab ER 24‑hour 500 mg: Requirements/Limits = QL (28 tablets/180 days).

Class noteClarithromycin suspension and immediate‑release tabs also appear in the macrolide section with varying QLs.

inv-131: ARIKAYCE — amikacin liposome inhal suspension — QL 28

ARIKAYCEARIKAYCE (amikacin liposome inhalation suspension): Requirements/Limits = PA, QL (28 vials/28 days), SP.

TOBI PODHALER / KITABISTOBI PODHALER and KITABIS PAK tobramycin inhalation products: Requirements/Limits include PA and QL (224 capsules/56 days for Podhaler; 280 mls/56 days for nebulized solution), SP.

inv-132: KITABIS PAK — tobramycin nebu soln — QL 280

KITABIS PAK (tobramycin neb)KITABIS PAK tobramycin nebulizer solution 300 mg/5 ml: Requirements/Limits = PA, QL (280 mls/56 days), SP.

TOBI PODHALERTOBI PODHALER tobramycin inhalation capsules 28 mg: Requirements/Limits = PA, QL (224 capsules/56 days), SP.

inv-133: TOBI PODHALER — tobramycin inhal cap — QL 224

TOBI PODHALER QLTOBI PODHALER inhalation capsules 28 mg: Requirements/Limits = PA, QL (224 capsules/56 days), SP.

Specialty flagProduct is marked SP indicating specialty pharmacy dispensing.

inv-134: EPCLUSA — QL 28

EPCLUSA QLEPCLUSA (sofosbuvir‑velpatasvir) tablets and pellet packs: Requirements/Limits = PA, QL (28 tablets/28 days) or QL (28 packs/28 days), SP.

HARVONI QLHARVONI (ledipasvir‑sofosbuvir) tablets and pellet packs: Requirements/Limits = PA, QL (28 tablets/28 days) or QL (28 packs/28 days), SP.

inv-135: HARVONI — QL 28

HARVONI — tablet QLHARVONI (ledipasvir‑sofosbuvir) tablet presentations: Requirements/Limits = PA, QL (28 tablets/28 days), SP.

Pellet pack QLPellet pack formulations carry analogous QL (28 packs/28 days).

inv-136: EPCLUSA — 28 tablets

EPCLUSA tablets exampleEPCLUSA tablet entry explicitly lists QL (28 tablets/28 days) for tablet presentations.

PA and SPEPCLUSA lines include PA and SP in the Requirements/Limits column.

inv-137: HARVONI — 28 tablets

HARVONI tablets exampleHARVONI tablet presentations list QL (28 tablets/28 days) and are marked PA, SP.

Pellet pack notePellet packs have a separate QL entry (28 packs/28 days).

inv-138: MAVYRET — 90 tablets

MAVYRET QLMAVYRET (glecaprevir‑pibrentasvir) tablet presentations: Requirements/Limits = PA, QL (90 tablets/30 days), SP.

Pellet pack QLMAVYRET pellet packs: Requirements/Limits = PA, QL (140 packs/28 days), SP.

inv-139: PAXLOVID — 11-30 tablets

PAXLOVID pack limitsPAXLOVID (nirmatrelvir & ritonavir) pack examples: Requirements/Limits = QL (11 tablets/90 days), QL (20 tablets/90 days), QL (30 tablets/90 days) depending on pack configuration.

Tier notePAXLOVID is listed with Drug Tier = P in the product line.

inv-140: Zytiga 250 mg — 120 tablets

Zytiga 250 mg QLAbiraterone acetate 250 mg (Zytiga): Requirements/Limits = PA, QL (120 tablets/30 days), SP.

Zytiga 500 mg QLAbiraterone acetate 500 mg (Zytiga): Requirements/Limits = PA, QL (60 tablets/30 days), SP.

inv-141: Zytiga 500 mg — 60 tablets

Zytiga 500 mgAbiraterone acetate 500 mg (Zytiga): Requirements/Limits = PA, QL (60 tablets/30 days), SP.

Specialty flagEntry is marked SP indicating specialty distribution.

inv-142: ALUNBRIG initiation pack — 30 tablets

ALUNBRIG initiation packALUNBRIG brigatinib initiation therapy pack 90 mg & 180 mg: Requirements/Limits = PA, QL (30 tablets/180 days), SP.

Initiation vs maintenanceSeparate QL entries exist for initiation packs and ongoing tablet strengths.

inv-143: ALUNBRIG 30 mg — 120 tablets

ALUNBRIG 30 mg QLALUNBRIG brigatinib 30 mg tablet: Requirements/Limits = PA, QL (120 tablets/30 days), SP.

Maintenance supplyHigher per‑month QL reflects ongoing dosing needs post‑initiation.

inv-144: ALECENSA 150 mg — 240 capsules

ALECENSA QLALECENSA (alectinib) 150 mg capsules: Requirements/Limits = PA, QL (240 capsules/30 days), SP.

Specialty handlingALECENSA lines include SP marking indicating specialty pharmacy distribution.

inv-145: COPIKTRA — 56 capsules

COPIKTRA QLCOPIKTRA (duvelisib) 15 mg, 25 mg capsules: Requirements/Limits = PA, QL (56 capsules/28 days), SP.

Dose pack noteListed with PA and SP, indicating specialty dispensing and authorization requirements.

inv-146: COTELLIC — 63 tablets

COTELLIC QLCOTELLIC (cobimetinib) 20 mg tablet: Requirements/Limits = PA, QL (63 tablets/28 days), SP.

Specialty flagEntry is marked SP and requires PA per the product line.

inv-147: IMBRUVICA suspension — 216 mls

IMBRUVICA suspension QLIMBRUVICA (ibrutinib) oral suspension 70 mg/ml: Requirements/Limits = PA, QL (216 mls/30 days), SP.

Multiple formulationsIMBRUVICA appears in multiple strengths and formulations with PA/QL and SP designations.

inv-148: ROZLYTREK pellet pack 50 mg — 336 packets

ROZLYTREK pellet pack QLROZLYTREK (entrectinib) pellet pack 50 mg: Requirements/Limits = PA, QL (336 packets/28 days), SP.

Alternate formulationsCapsule presentations have different QLs (e.g., 30 capsules/30 days).

inv-149: REVUFORJ 25 mg — 240 tablets

REVUFORJ 25 mg QLREVUFORJ (revumenib) 25 mg tablets: Requirements/Limits = PA, QL (240 tablets/30 days), SP.

Other strengthsREVUFORJ 110 mg and 160 mg have respective QLs (120 and 60 tablets/30 days).

inv-150: REVUFORJ 110 mg — 120 tablets

REVUFORJ 110 mg QLREVUFORJ 110 mg: Requirements/Limits = PA, QL (120 tablets/30 days), SP.

Programmatic noteMultiple strength‑specific QLs are listed per product line.

inv-151: REVUFORJ 160 mg — 60 tablets

REVUFORJ 160 mg QLREVUFORJ 160 mg: Requirements/Limits = PA, QL (60 tablets/30 days), SP.

Coverage implicationStrength‑specific QLs indicate supply limits tied to dosing regimens.

inv-152: TAFINLAR suspension — 4 bottles

TAFINLAR suspension QLTAFINLAR (dabrafenib) oral suspension 10 mg: Requirements/Limits = PA, QL (4 bottles/28 days), SP.

Tablet vs suspensionSuspension formulation has a separate QL entry for bottles.

inv-153: TUKYSA 50 mg — 300 tablets

TUKYSA 50 mg QLTUKYSA (tucatinib) 50 mg: Requirements/Limits = PA, QL (300 tablets/30 days), SP.

TUKYSA 150 mg QLTUKYSA 150 mg: Requirements/Limits = PA, QL (120 tablets/30 days), SP.

inv-154: TUKYSA 150 mg — 120 tablets

TUKYSA 150 mgTUKYSA 150 mg: Requirements/Limits = PA, QL (120 tablets/30 days), SP.

Specialty handlingBoth strengths are marked SP and require PA.

inv-155: AVERI — 28 tablets contraceptive example

AVERI contraceptive QLAVERI (desogestrel‑ethinyl estradiol) tablet: Requirements/Limits = AC, QL (28 tablets/21 days).

Monthly pack conventionMany oral contraceptives list QL (28 tablets/21 days) to align with typical 28‑day cycles.

inv-156: levonorgestrel tab 1.5 mg — QL 2

Levonorgestrel emergency contraceptive QLLevonorgestrel 1.5 mg: Requirements/Limits = AC, QL (2 tablets/365 days).

Coverage implicationLimit reflects single‑use emergency contraception policy.

inv-157: ELLA — 2 tablets

ELLA QLELLA (ulipristal acetate 30 mg): Requirements/Limits = AC, QL (2 tablets/365 days).

Annual limitELLA is limited to 2 tablets per 365‑day period per the product entry.

inv-158: TRULICITY — QL 4

TRULICITY QLTRULICITY (dulaglutide) soln auto‑injector: Requirements/Limits = PA, QL (4 pens/28 days).

Dose frequency noteQL reflects monthly pen supply limits for injectable antidiabetic agents.

inv-159: MOUNJARO — QL 4 pens

MOUNJARO QLMOUNJARO (tirzepatide) auto‑injector: Requirements/Limits = PA, QL (4 pens/180 days) for some presentations; alternate line shows QL (4 pens/28 days) depending on strength. (product lines list 4 pens/180 days and 4 pens/28 days for different strengths).

Authorization noteMOUNJARO entries include PA marking — prior authorization required.

inv-160: RYBELSUS — 30 tablets

RYBELSUS QLRYBELSUS (semaglutide tablets) 7 mg, 14 mg: Requirements/Limits = PA, QL (30 tablets/30 days) for higher strengths and QL (30 tablets/180 days) for lower strength listings.

Tablet supply30‑tablet monthly limits are applied to oral semaglutide formulations.

inv-161: ganirelix — 12 syringes

Ganirelix QLGanirelix acetate 250 mcg/0.5 ml prefilled syringe: Requirements/Limits = QL (12 syringes/30 days), SP.

Fertility agent handlingFertility injectables carry specific syringe/vial QLs and specialty handling.

inv-162: OVIDREL — 2 syringes

OVIDREL QLOVIDREL (choriogonadotropin alfa) 250 mcg/0.5 ml prefilled syringe: Requirements/Limits = QL (2 syringes/30 days), SP.

Reproductive therapy noteSmall syringe counts reflect dosing and typical cycle use.

inv-163: MENOPUR — 60 vials

MENOPUR QLMENOPUR (menotropins) 75 unit for injection: Requirements/Limits = QL (60 vials/30 days), SP.

Specialty dispensingFertility biologics listed with SP designation and QL.

inv-164: VOXZOGO — 30 vials

VOXZOGO QLVOXZOGO (vosoritide) subcutaneous injection: Requirements/Limits = PA, QL (30 vials/30 days), SP.

Pediatric specialtyListed with PA and SP consistent with specialty medication management.

inv-165: SOMAVERT — 30 vials

SOMAVERT QLSOMAVERT (pegvisomant) injections: Requirements/Limits = PA, QL (30 vials/30 days), SP.

Endocrine specialtyHigh‑cost endocrine biologics are managed with PA and QL.

inv-166: enalapril oral solution (Epaned) — 1200

Enalapril oral solution QLEnalapril oral solution (Epaned) 1 mg/ml: Requirements/Limits = PA, QL (1200 mls/30 days).

Liquid ACE inhibitorLarge liquid QL reflects chronic oral solution dosing needs.

inv-167: QBRELIS lisinopril oral solution — 2400

QBRELIS lisinopril solution QLQBRELIS lisinopril oral solution 1 mg/ml: Requirements/Limits = PA, QL (2400 mls/30 days).

High‑volume solution limitsExtremely large QL values reflect unit concentration and chronic use.

inv-168: FUROSCIX — 8 kits

FUROSCIX QLFUROSCIX (furosemide subcutaneous cartridge kit): Requirements/Limits = PA, QL (8 kits/180 days).

Specialty/administeredPA and QL apply; kit supply limited per 180‑day window.

inv-169: REPATHA — 6

REPATHA QLREPATHA (evolocumab) prefilled syringes/pens: Requirements/Limits = PA, QL (6 syringes/28 days), SP.

Cardiovascular biologicPCSK9 inhibitors are managed with PA and monthly syringe/pen limits.

inv-170: NEXLETOL / NEXLIZET — 30

NEXLETOL / NEXLIZET QLNEXLETOL / NEXLIZET: Requirements/Limits = PA, QL (30 tablets/30 days).

Statin‑adjacent therapyListed with PA and monthly tablet QL.

inv-171: VASCEPA 0.5 gm — 240

VASCEPA 0.5 g QLVASCEPA 0.5 gm: Requirements/Limits = PA, QL (240 capsules/30 days).

VASCEPA 1 g QLVASCEPA 1 gm: Requirements/Limits = PA, QL (120 capsules/30 days).

inv-172: VASCEPA 1 gm — 120

VASCEPA 1 gmVASCEPA 1 gm: Requirements/Limits = PA, QL (120 capsules/30 days).

Strength‑dependent QLDifferent strengths have distinct capsule QLs.

inv-173: ADEMPAS — 90

ADEMPAS QLADEMPAS (riociguat): Requirements/Limits = PA, QL (90 tablets/30 days), SP.

PA and SPPA and SP are commonly applied to pulmonary hypertension agents.

inv-174: ATTRUBY — 112

ATTRUBY QLATTRUBY (acoramidis) pack: Requirements/Limits = PA, QL (112 tablets/28 days), SP.

High monthly supplyLarge tablet counts reflect therapy dosing schedules and specialty management.

inv-175: ENTRESTO sprinkle capsules — 240

ENTRESTO sprinkle capsules QLENTRESTO sprinkle capsules: Requirements/Limits = PA, QL (240 capsules/30 days).

Formulation noteSprinkle capsule presentation has a high capsule QL and is marked PA.

inv-176: TYVASO inhalation solution — 7 packs

TYVASO inhalation solution QLTYVASO treprostinil inhalation solution: Requirements/Limits = PA, QL (7 packs/28 days), SP.

TYVASO DPI cartridges QLTYVASO DPI cartridges: Requirements/Limits = PA, QL (112 cartridges/28 days), SP.

inv-177: TYVASO DPI cartridges — 112

TYVASO DPI cartridgesTYVASO DPI maintenance cartridges: Requirements/Limits = PA, QL (112 cartridges/28 days), SP.

Device vs solutionBoth solution packs and DPI cartridges have separate QL entries.

inv-178: ENTRESTO — 240 capsules

ENTRESTO QL (capsules)ENTRESTO (sacubitril‑valsartan) sprinkle capsules: Requirements/Limits = PA, QL (240 capsules/30 days).

PA flagEntry is marked PA as well as the QL.

inv-179: sildenafil for suspension (Revatio) — 2 bottles

Revatio suspension QLSildenafil for suspension (Revatio) 10 mg/ml: Requirements/Limits = PA, QL (2 bottles/30 days), SP.

Oral suspension limitsLiquid formulations often have small bottle counts per month reflected in QL.

inv-180: tadalafil (Adcirca) 20 mg — 60 tablets

Adcirca QLTadalafil (Adcirca) 20 mg for PAH: Requirements/Limits = PA, QL (60 tablets/30 days), SP.

Viagra QLSildenafil (Viagra) 25–100 mg for ED: Requirements/Limits = QL (8 tablets/30 days).

inv-181: UPTRAVI — 60 tablets

UPTRAVI QLUPTRAVI (selexipag) titration/therapy packs: Requirements/Limits = PA, QL (1 pack/180 days) or QL (60 tablets/30 days) depending on presentation.

Pulmonary agentsPA and QL commonly applied across PAH therapeutic class.

inv-182: VYNDAMAX — 30 capsules

VYNDAMAX QLVYNDAMAX (tafamidis) 61 mg: Requirements/Limits = PA, QL (30 capsules/30 days), SP.

VYNDAQEL QLVYNDAQEL (tafamidis meglumine 20 mg): Requirements/Limits = PA, QL (120 capsules/30 days), SP.

inv-183: VYNDAQEL — 120 capsules

VYNDAQEL QLVYNDAQEL: Requirements/Limits = PA, QL (120 capsules/30 days), SP.

Cardiac transthyretin agentsHigh monthly capsule counts reflect chronic therapy and specialty handling.

inv-184: WINREVAIR — 1 kit

WINREVAIR QLWINREVAIR (sotatercept) injection kit: Requirements/Limits = PA, QL (1 kit/21 days), SP.

Dosing intervalKit‑based products may have shorter interval QLs (21 days) tied to dosing schedules.

inv-185: YUTREPIA — 112 capsules

YUTREPIA QLYUTREPIA (treprostinil inhal capsules): Requirements/Limits = PA, QL (112 capsules/28 days), SP.

Inhaled capsule limitsLarge capsule counts reflect inhalation device dosing regimens.

inv-186: avanafil (Stendra) — 8 tablets

Avanafil (Stendra) QLAvanafil (Stendra): Requirements/Limits = QL (8 tablets/30 days).

ED agent limitsErectile dysfunction agents commonly have low monthly tablet QLs (e.g., 8 tablets/30 days).

inv-187: sildenafil (Viagra) 25-100 mg — 8 tablets

Sildenafil (Viagra) QLSildenafil (Viagra) 25–100 mg: Requirements/Limits = QL (8 tablets/30 days).

Alternate PAH vs ED entriesSildenafil listed for PAH (Revatio) has different QLs (e.g., 90 tablets/30 days or 2 bottles/30 days for suspension).

inv-188: ADVAIR HFA — 1 inhaler

ADVAIR HFA QLADVAIR HFA: Requirements/Limits = QL (1 inhaler/30 days).

Albuterol inhaler QLAlbuterol inhaler (Proventil/Ventolin HFA): Requirements/Limits = QL (2 inhalers/30 days).

inv-189: albuterol inhaler — 2 inhalers

Albuterol inhaler QLAlbuterol inhaler: Requirements/Limits = QL (2 inhalers/30 days).

Nebulizer vial limitsNebulizer vials and solution presentations have larger vial/volume QLs (e.g., 125 vials/30 days).

inv-190: FASENRA PEN — 1 pen

FASENRA PEN QLFASENRA PEN (benralizumab) auto‑injector 30 mg/ml: Requirements/Limits = PA, QL (1 pen/28 days), SP.

Asthma biologicsAsthma biologics commonly have PA, QL and SP designations.

inv-191: NUCALA — 3 pens

NUCALA pens QLNUCALA (mepolizumab) pens/prefilled syringes: Requirements/Limits = PA, QL (3 pens/28 days) or QL (1 syringe/28 days) depending on presentation, SP.

Dose form differentiationDifferent device presentations have separate QLs.

inv-192: TEZSPIRE — 1 pen

TEZSPIRE QLTEZSPIRE (tezepelumab) auto‑injector 210 mg: Requirements/Limits = PA, QL (1 pen/28 days), SP.

Severe asthma biologicListed with PA and SP consistent with specialty biologic management.

inv-193: ALYFTREK — 84 tablets

ALYFTREK QLALYFTREK (vanzacaftor‑tezacaftor‑deutivacaftor) tablet 4‑20‑50 mg: Requirements/Limits = PA, QL (84 tablets/28 days), SP.

CF modulatorsCystic fibrosis modulators generally have PA, QL and SP designations.

inv-194: KALYDECO — 60 tablets

KALYDECO QLKALYDECO (ivacaftor) tablets/packets: Requirements/Limits = PA, QL (60 tablets/30 days) or QL (60 packets/30 days depending on presentation), SP.

TRIKAFTA QLTRIKAFTA products (various) listed with Requirements/Limits = PA, QL (56 packets/28 days) for packet presentations, SP.

inv-195: TRIKAFTA products — 56 packets

TRIKAFTA packets QLTRIKAFTA packet presentations: Requirements/Limits = PA, QL (56 packets/28 days), SP.

ORKAMBI QLORKAMBI (lumacaftor‑ivacaftor) tablets/packets: Requirements/Limits = PA, QL (120 tablets/30 days or 60 packets/30 days), SP.

inv-199: esomeprazole suspension packets — 60

Esomeprazole suspension packets QLEsomeprazole magnesium delayed‑release suspension packets (Nexium): Requirements/Limits = PA, QL (60 packets/30 days).

GI prep and suspension QLsGI and suspension products show packet‑based QLs in the formulary.

inv-200: FOSRENOL powder packs — 540

FOSRENOL powder pack QLFOSRENOL (lanthanum carbonate) powder packs: Requirements/Limits = QL (540 packs/365 days) or other pack counts per year.

Chronic therapy QLsLarge annual pack QLs are specified for chronic phosphate binder therapy.

inv-201: VOWST — 12

VOWST QLVOWST (fecal microbiota spores, live) capsules: Requirements/Limits = PA, QL (12 capsules/12 months), SP.

Yearly QLSome specialty oral products carry annual capsule limits rather than monthly.

inv-202: FILSPARI — 30 tablets

FILSPARI QLFILSPARI (sparsentan) tablets: Requirements/Limits = PA, QL (30 tablets/30 days), SP.

Renal specialtyListed with PA and SP consistent with specialty renal therapies.

inv-203: FANAPT TITRATION PACK — 1 pack

FANAPT titration pack QLFANAPT titration pack (iloperidone): Requirements/Limits = QL (1 pack/180 days), ST (step therapy).

Step therapy overlapSome titration packs show ST in addition to QL, indicating required prior steps.

inv-204: multiple antipsychotics and CNS agents — various QL examples per product

Antipsychotics — variable QLsMultiple antipsychotics and CNS agents carry QLs (examples include QL 30/30, 60/30, 90/30, 120/30 depending on product and strength).

Liquid formulationsSome oral solutions (e.g., aripiprazole solution) list large mls QLs (e.g., 900 mls/30 days).

inv-205: paliperidone ER 1.5/3/9 mg — 30 tablets

Paliperidone ER 1.5/3/9 mg QLPaliperidone ER 1.5 mg, 3 mg, 9 mg (Invega): Requirements/Limits = QL (30 tablets/30 days).

Paliperidone ER 6 mg QLPaliperidone ER 6 mg (Invega): Requirements/Limits = QL (60 tablets/30 days).

inv-206: paliperidone ER 6 mg — 60 tablets

Paliperidone ER 6 mg QLPaliperidone ER 6 mg: Requirements/Limits = QL (60 tablets/30 days).

Titration/formulation noteDifferent ER strengths have separate QLs per 30‑day period.

inv-207: rexulti — 30 tablets

Rexulti QLREXULTI (brexpiprazole) tablets: Requirements/Limits = QL (30 tablets/30 days).

Antipsychotic class patternMany antipsychotic oral products carry 30‑day tablet QLs.

inv-208: WEGOVY — 8 pens (various presentations)

WEGOVY (various) QLWEGOVY semaglutide weight‑management auto‑injector lines: Requirements/Limits = PA, QL (8 pens/180 days) for some presentations; Requirements/Limits = PA, QL (4 pens/28 days) for 1.7/2.4 mg presentations.

Pen count examplesDifferent WE GO WY presentations carry distinct pen counts per period depending on strength/packaging.

inv-209: WEGOVY 1.7/2.4 mg — 4 pens

WEGOVY 1.7/2.4 mg QLWEGOVY 1.7 mg and 2.4 mg presentations: Requirements/Limits = PA, QL (4 pens/28 days).

Short‑interval supplyThis listing provides a 28‑day pen limit for higher‑dose presentations.

inv-210: SAXENDA — 15 mls

SAXENDA QLSAXENDA (liraglutide) soln pen‑injector 18 mg/3 ml: Requirements/Limits = PA, QL (15 mls/30 days).

Weight‑management agentsSAXENDA is PA‑required and has a 15 mL monthly supply limit per the formulary entry.

inv-211: risperidone solution — 480 mls

Risperidone solution QLRisperidone solution 1 mg/ml (Risperdal): Requirements/Limits = QL (480 mls/30 days).

Liquid antipsychotic limitsLarge solution volumes are captured as mls in QL entries for liquid formulations.

inv-212: INGREZZA — 30 capsules

INGREZZA QLINGREZZA (valbenazine) capsules: Requirements/Limits = PA, QL (30 capsules/30 days), SP.

Tardive dyskinesia agentINGREZZA is listed with PA and SP in the Special Requirements column.

inv-213: SODIUM OXYBATE — 540 mls

Sodium oxybate QLSODIUM OXYBATE / XYWAV / XYWAV equivalents: Requirements/Limits = PA, QL (540 mls/30 days), SP.

Pack vs bottleER pack and starter pack presentations have distinct QL entries (e.g., 28 packets/180 days for starter packs).

inv-214: ZEPOSIA — 30 capsules

ZEPOSIA QLZEPOSIA (ozanimod) capsules: Requirements/Limits = PA, QL (30 capsules/30 days), SP.

Starter kit QLStarter kit and 7‑day starter pack entries show alternate QLs (e.g., 28 capsules/180 days).

Site of Care & Specialty Pharmacy

Note

Background & Scope

Specialty drugs on the drug list treat complex, often chronic conditions (examples include hepatitis, cystic fibrosis, pulmonary arterial hypertension, autoimmune diseases and other conditions requiring biologics or specialty oral agents). These agents may be high‑cost, require monitoring, and are frequently dispensed through a specialty pharmacy channel (SP) or administered by a health care professional and billed to the medical benefit.

Most entries specify a Drug Tier and may include Requirement/Limits flags such as PA (prior authorization), QL (quantity limit) and SP (specialty pharmacy). Providers should review the drug list line for each product and follow the payer’s prior authorization and documentation processes when PA or QL is indicated.

For routine maintenance medications the plan generally provides up to a 30‑day supply, with some plans allowing up to a 90‑day supply for maintenance therapy; verify permitted day supply and any QL on the product line before dispensing. If a medication is administered by a clinician, confirm whether coverage is through the pharmacy or the medical benefit per the member’s plan.