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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Cross Blue Shield Oklahoma drug list Coverage…
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    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

    2026 Drug List (pharmacy formulary) — Coverage Criteria

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    This document is Blue Cross and Blue Shield of Oklahoma's 2026 Drug List describing covered pharmacy drugs, tier placement, special requirements, and member/provider procedures for coverage and exceptions; it affects BCBSOK members and their prescribing providers.

    Policy Summary
    PayerBlue Cross Blue Shield - Oklahoma
    Policy2026 Drug List (pharmacy formulary) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes noted
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization when a drug is marked 'PA' in the Special Requirements column to avoid claim denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ~120+drug entries (excerpt)
    MyPrime.comwebsites
    PA, QL, SPutilization controls
    ACAC flagged biologics
    30/90day supply examples

    Coverage and Coverage Determination

    General formulary coverage conditions

    Coverage is determined by drug list inclusion, tier placement, and any special requirements noted in the Special Requirements column (PA, ST, QL, AC).

    Formulary coverage basic conditions: Drug must appear on the Drug List to be covered; coverage may be limited by plan exclusions, FDA labeling, age restrictions, or specialty vs medical benefit determination.

    See Special Requirements column for PA/ST/QL/AC indicators.

    Formulary utilization controls

    Coverage and utilization controls listed per drug entry

    Formulary entry requirements: Each drug entry specifies Drug Tier and may include one or more of: PA (prior authorization), QL (quantity limit with exact limit and period), SP (specialty pharmacy) or AC (ACA preventive/access control). Coverage and dispensing will follow those controls.

    Examples: 'PA, QL (120 capsules/30 days), SP'

    Policy Summary
    PayerBlue Cross Blue Shield - Oklahoma
    Policy2026 Drug List (pharmacy formulary) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes noted
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization when a drug is marked 'PA' in the Special Requirements column to avoid claim denial.
    SourceLink
    On This Page
    Coverage and Coverage DeterminationProduct Coding, Strengths, and ExamplesPrior Authorization, Step Therapy, and Provider ResponsibilitiesSite of Care and Specialty Pharmacy DesignationStep Therapy — Indicators and InstancesQuantity Limits (QL) — Product-Specific ExamplesKey Terms and Requirement FlagsFormulary Governance and Scope

    Drugs that are not listed on this Drug List are not covered under the pharmacy benefit. The policy also excludes coverage for non‑FDA‑approved drugs, repackaged medications, and, depending on plan terms, some compounded products. Providers should confirm coverage or submit an exception request when a prescribed product is not shown on the list to avoid claim denials.

    When an entry on the Drug List shows no specific Requirements/Limits (for example, no 'PA', 'QL', 'SP' or 'ST' noted), that product is expected to follow the plan’s standard coverage terms as described in the member’s benefit documents. Absence of line‑item controls in the excerpt implies the drug is covered per the member’s benefit without special utilization controls.

    Some medications may be excluded from coverage by plan design when they are intended for cosmetic purposes or when an equivalent is available over the counter. Whether a given cosmetic agent or an OTC‑equivalent product is covered depends on the specific benefit plan; verify coverage in the member’s plan materials.

    Within the provided excerpt there are no individual drugs explicitly labeled “not medically necessary”. Coverage determinations in this section are made by the Drug List entries and their listed Requirements/Limits (PA, QL, SP, ST); absence of a 'not medically necessary' designation in the excerpt means no such blanket NMN statements appear here.

    Product Coding, Strengths, and Examples

    Examples from Penicillins class (formulary entries)NDC | text
    AMOXICILLINamoxicillin (trihydrate) chew tab 125 mg, 250 mg; cap 250 mg, 500 mg; susp various strengths; tab 500 mg, 875 mg
    AMOXICILLIN & K CLAVULANATEamoxicillin & k clavulanate for susp 200-28.5 mg/5ml; 250-62.5 mg/5ml; 400-57 mg/5ml; 600-42.9 mg/5ml
    Formulary product strengths/descriptionsmixed
    80 mg/0.8mlTRYNGOLZA - olezarsen sod subcut soln auto-inject 80 mg/0.8ml
    3120 mcg/1.56mlTYMLOS - abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml
    0.4 mg, 0.56 mg, 1.2 mgVOXZOGO - vosoritide for subcutaneous inj
    168 mcg/0.56ml; 294 mcg/0.98ml; 420 mcg/1.4mlYORVIPATH - palopegteriparatide pen-inj (teriparatide eq)
    Quantity limit valuesmixed
    1920 mls/30 daysSOTYLIZE - sotalol hcl oral solution quantity limit
    300 mls/30 daysKATERZIA / NYMALIZE various oral solution QL examples
    Cardiovascular drugs shownmixed
    ivabradine hcl tab 5 mgCorlanor — listed with PA, QL (60 tablets/30 days)
    ivabradine hcl tab 7.5 mgCorlanor — listed with PA, QL (60 tablets/30 days)
    sacubitril-valsartan tab 24-26 mgEntresto
    sacubitril-valsartan tab 49-51 mgEntresto
    sacubitril-valsartan tab 97-103 mgEntresto
    Pulmonary arterial hypertension and related agentsmixed
    sildenafil citrate for suspension 10 mg/mlPA, QL (224 ml/30 days)
    sildenafil citrate tab 20 mgRevatio — QL (90 tablets/30 days)
    tadalafil tab 20 mg (pah)Adcirca — PA, QL (60 tablets/30 days)
    TYVASO - treprostinil inhalation solution 0.6 mg/mlPA, QL (7 ampules/28 days), SP
    UPTRAVI - selexipag tab (200-1600 mcg)PA, QL (60 tablets/30 days), SP
    VERQUVO - vericiguat tab 2.5 mg, 5 mg, 10 mgPA, QL (30 tablets/30 days)
    Erectile dysfunction agentsmixed
    avanafil tab 50 mg, 100 mg, 200 mgStendra — QL (8 tablets/30 days)
    sildenafil citrate tab 25 mg, 50 mg, 100 mgViagra — QL (8 tablets/30 days)
    tadalafil tab 2.5 mg, 5 mg, 10 mg, 20 mgCialis — various QL
    Allergy and nasal agentsmixed
    cetirizine hcl oral soln 1 mg/mlOTC antihistamine formulation listed
    desloratadine tab 5 mgClarinex
    fluticasone propionate nasal susp 50 mcg/actnasal steroid
    azelastine hcl nasal spray 0.1%nasal antihistamine
    Respiratory & biologic agentsmixed
    albuterol sulfate inhaler 108 mcg/actQL (2 inhalers/30 days)
    ADVAIR HFA - fluticasone-salmeterol inhal aerosolQL (1 inhaler/30 days)
    BREO ELLIPTA - fluticasone furoate-vilanterolQL (1 inhaler/30 days)
    TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterollisted (chunk truncated)
    NUCALA - mepolizumabPA, QL (1 or 3 syringes/pens per 28 days depending on formulation), SP
    FASENRA PEN - benralizumab 30 mg/mlPA, QL (1 pen/28 days), SP
    TEZSPIRE - tezepelumab-ekko 210 mgPA, QL (1 pen/28 days), SP
    Quantity limits — typical tablet/capsule examples
    30 tablets/30 daysCommon oral short-course supply (example QL)
    120 capsules/30 daysCommon capsule QL for extended therapy examples
    3 capsules/28 daysSmall-count capsule QL for some oncology or specialty packs
    Quantity limits — injectable device and vial examples
    1 injection device/28 daysExample QL for auto-inject or single-use injection devices (TRYNGOLZA)
    30 vials/30 daysExample QL for multi-dose vial therapy (VOXZOGO)
    2 pens/28 daysExample QL for pen-delivered biologic therapies (OMVOH/other pens shown)
    Quantity limits — assorted QL examples
    60 tablets/30 daysOral tablet QL example (e.g., various antivirals/antifungals)
    224 mls/30 daysOral suspension QL example for inhaled/neb solutions (TOBI PODHALER examples)
    7 ampules/28 daysAmpule/pack QL example for inhalation therapies (TYVASO)
    112 cartridges/28 daysCartridge QL example for inhaled prostacyclins (TYVASO DPI)
    1 pen/28 daysSingle pen QL example for GLP-1/biologic pens (OZEMPIC example)

    Prior Authorization, Step Therapy, and Provider Responsibilities

    Prior Authorization

    Prior Authorization Required

    Prior Authorization (PA) required for many drugs listed in this formulary. When a medication shows 'PA' in the Requirements/Limits or Special Requirements column, providers must submit and receive approval of a prior authorization before the plan will cover the drug. Many specialty, antineoplastic, and other high-cost agents are PA-designated.

    • PA is typically noted next to the medication in the Requirements/Limits or Special Requirements column.
    • Specialty (SP) designation often accompanies PA for specialty drugs and biologics; SP enrollment or specialty pharmacy dispensing may be required.
    • Many antineoplastic and oncology agents are flagged PA + QL + SP — obtain PA to avoid claim denials.
    Documentation Required

    Exception / Prior Authorization Submission and Timelines

    PA submissions and exception requests must be made by the prescriber or an authorized representative. Standard coverage decisions will be communicated to the prescriber (or authorized rep) within 15 calendar days; expedited requests (where life/health/function is jeopardized) will be decided within 72 hours.

    • Call the number on the member's ID card to submit PA or exception requests, or use the plan/third‑party portals referenced in plan materials (e.g., MyPrime.com or bcbsok.com) when available.
    • If PA is denied, the plan will provide reason(s) and offer a covered alternative when applicable.
    Billing Rule

    Dispensing / Quantity Limits

    Quantity Limits (QL) and Dispensing Limits (DL) are enforced as shown next to medications (e.g., QL (28 tablets/28 days)). If a prescriber orders more than the plan allows, the member may be responsible for the full cost for the excess quantity and claims may be denied. Certain state laws may further restrict coverage for controlled substances dispensed beyond QL.

    • QL values are shown for many products (e.g., 28 tablets/28 days, 120 capsules/30 days).
    • Prescribers should document the clinically appropriate days' supply and rationale when requesting exceptions to QL.
    • Dispensing beyond QL may result in member financial responsibility or denied benefits.
    Prior Authorization

    Additional Utilization Controls (SP, QL, ST, AC)

    Specialty drugs, antineoplastic agents, biologics, and other select products commonly require additional utilization controls beyond PA — for example: QL, SP (specialty program/dispensing), ST (step therapy), and AC (administrative/ACA preventive coverage). Providers must comply with all indicated controls on the drug entry to avoid denials.

    • SP indicates specialty program — many SP drugs require specialty pharmacy dispensing and prior enrollment.
    • ST indicates step therapy — if 'ST' is listed, members may need to try specified alternatives first; specific step sequences are not detailed in this section.
    • AC marks ACA preventive products; AC entries may have special copay/coverage rules and require a copay waiver or exception submission for $0 cost‑sharing when criteria are met.
    Documentation Required

    Documentation for Prior Authorization and Quantity Limit Requests

    Documentation required for PA and QL exceptions: prescribers should provide clinical rationale, diagnosis, prior therapy history (including dates and responses), and any supporting lab or genetic testing when applicable. Lack of adequate documentation may result in denial.

    • PA requests for specialty/biologic/oncology agents commonly require prior treatment history and supporting clinical notes.
    • For drugs with genetic or biomarker indications (e.g., many oncology agents), include test results when applicable.
    • Vaccines and biologics marked AC may require administrative documentation for preventive coverage.
    Denial Risk

    Denial Risk and Provider Responsibilities

    Denial risk if PA/QL/SP/ST/AC requirements are not met. Claims for drugs designated PA, QL, or SP are at risk of denial if prior authorization is not approved, quantity limits are exceeded without exception, or specialty dispensing/enrollment requirements are not satisfied.

    • Obtain PA before dispensing PA‑designated medications to avoid claim denials.
    • Enroll the member in the specialty program or use the specialty pharmacy when SP is indicated.
    • If a medication is not listed on the drug list (non‑listed drug), it is not covered unless an exception is approved.
    Denial Risk

    Non‑Listed and Non‑FDA‑Approved Drugs

    Non‑covered categories: Drugs not listed on the drug list and non‑FDA‑approved drugs are not covered. Providers seeking coverage for non‑listed or investigational products must submit an exception request with supporting clinical justification; coverage is not guaranteed.

    • If an exception is denied, BCBSOK will provide the reason and, when applicable, suggest a covered alternative.
    • Non‑FDA approved drugs will be denied per plan rules.
    Note

    Formulary Requirement Annotations

    Formulary annotations: The drug list displays per‑product formulary indicators (Drug Tier, Requirements/Limits) adjacent to each medication. Providers should review these annotations on the formulary entry to determine PA, QL, SP, ST, and AC applicability before prescribing or dispensing.

    • Examples: 'PA' = prior authorization required; 'QL (X/period)' = quantity limit; 'SP' = specialty program; 'ST' = step therapy; 'AC' = ACA preventive.
    • Formulary annotations are operational — follow the Requirements/Limits field on each drug entry.

    Site of Care and Specialty Pharmacy Designation

    Billing Rule

    Route SP‑designated prescriptions through specialty pharmacy and obtain PA

    Specialty-designated products (SP) are generally managed through specialty pharmacy channels; providers should route prescriptions accordingly and obtain PA when SP is indicated to avoid claim rejection.

    • Examples: ARIKAYCE and EPCLUSA show SP designation; specialty dispensing may be required.
    Note

    SP designation indicates specialty program/site controls

    Some specialty products carry SP designation indicating site or specialty program controls (examples: ARIKAYCE, EPCLUSA); providers must follow the specialty program/site requirements when present.

    • SP designation often accompanies PA and QL for complex or infusion/clinic‑administered therapies.
    Billing Rule

    Dispense SP‑designated drugs via specialty pharmacy

    Many drugs are designated for specialty pharmacy (SP) dispensing; when 'SP' appears in Requirements/Limits, providers must use the specialty dispensing channel specified by the plan.

    • Specialty products include many injectables, biologics and complex therapies requiring SP.
    Note

    Follow SP/site‑of‑care rules for injectable/complex therapies

    SP designation applies to many injectable or complex therapies that may be administered in infusion centers or dispensed via specialty pharmacy; follow the plan's SP/site‑of‑care requirements where indicated.

    • ACTHAR and other injectables show SP and PA in Requirements/Limits, indicating specialty handling.
    Documentation Required

    Coordinate with specialty pharmacy for SP‑designated products

    Products marked 'SP' are designated for specialty pharmacy dispensing; prescribers must coordinate with specialty pharmacy channels and obtain PA when required.

    • Specialty designation is common among rare disease, biologic and oncology agents in this segment.
    Billing Rule

    SP designation requires specialty dispensing and enrollment

    Many listed specialty products include the 'SP' designation indicating they must be dispensed through specialty channels; providers must ensure SP enrollment and PA where applicable.

    • Examples across the list include biologics, CF modulators, and specialty injectables.
    Note

    SP‑marked products — follow specialty pharmacy program instructions

    Products marked 'SP' are intended for specialty pharmacy channels; no additional site‑of‑care rules are specified in this excerpt, so follow the specialty program instructions provided by the plan or specialty pharmacy.

    • Where SP appears, check the plan/specialty pharmacy for program‑specific enrollment and dispensing steps.

    Step Therapy — Indicators and Instances

    Product / NotesSpecial Requirement
    ST flag — plan may require trying a proven, cost-effective alternative before coverage
    If an ST is commonly required it will be noted with 'ST' in the Special Requirements column
    Product / ExampleSpecial Requirement
    Voriconazole (Vfend) — listed with Requirements/Limits = PA
    EPCLUSA (sofosbuvir‑velpatasvir) — Requirements/Limits = PA, QL (28 tablets/28 days), SP
    ProductSpecial Requirement / Program
    PALFORZIA (initial, levels 0–11, maintenance, titration packets) — multiple SKU levels listed
    Requirements/Limits = SP (specialty program management) for all PALFORZIA levels shown
    ObservationPolicy note
    This excerpt does not define explicit step-by-step ST sequences for most products
    Products are primarily controlled via PA, QL, and SP annotations in the Requirements/Limits field
    Contraceptive / ExampleRequirement Indicators
    ANNOVERA (vaginal ring) — Requirements/Limits = AC, QL (1 ring/365 days)
    Multiple oral and patch/ring contraceptives — many entries show 'AC' and some include 'PA' and QL as indicated per product
    ProductSpecial Requirement
    KERENDIA (finerenone) 10 mg, 20 mg
    Requirements/Limits = QL (30 tablets/30 days), ST (step therapy) indicated
    ObservationPolicy note
    No explicit step therapy sequences are provided for the products in these chunks
    Coverage controls are shown as PA and QL where applicable rather than detailed ST algorithms
    ObservationPolicy note
    This excerpt does not present explicit step therapy sequences for respiratory and related products
    Entries instead include tiering, PA, QL, and SP annotations to manage utilization
    ProductSpecial Requirement
    AUVELITY (dextromethorphan‑bupropion) — listed as dextromethorphan hbr‑bupropion tab ER 45‑105 mg
    Requirements/Limits = ST (step therapy) as shown in the listing
    Product / ExampleRequirement (ST indicated)
    AUVELITY — Requirements/Limits = ST
    DESVENLAFAXINE ER — Requirements/Limits = ST (per antidepressant listings)
    ESCITALOPRAM OXALATE — Requirements/Limits = ST (cap 15 mg shown with ST)

    Quantity Limits (QL) — Product-Specific Examples

    Class-level note on dispensing limits
    Plan-specific dispensing limits applyDispensing limits are set by the plan and shown in the Special Requirements column as QL; providers must follow listed QL to avoid member cost exposure.
    Azithromycin — quantity limit
    Azithromycin (tab 250/500/600 mg)QL = 60 tablets (per 180 days as listed)
    Clarithromycin ER — quantity limit
    Clarithromycin ER 500 mgQL = 28 tablets (per 180 days as listed)
    ARIKAYCE — quantity limit
    ARIKAYCE (amikacin liposome inhalation)QL = 28 vials/28 days
    Tobramycin inhalation products — quantity limits
    TOBI PODHALER (tobramycin inhalation)QL = 224 capsules/56 days (example)
    Tobramycin nebulization solutions (e.g., Kitabis Pak, Tobi, Bethkis)QL = volumes listed (e.g., 280 mls/56 days or 224 mls/56 days) depending on SKU
    Itraconazole — quantity limits
    Itraconazole capsules 100 mgQL = 120 capsules/30 days
    Itraconazole oral solution 10 mg/ml (Sporanox)QL = 1200 mls/30 days
    EPCLUSA — tablet pack QL
    EPCLUSA (sofosbuvir-velpatasvir) tabletsQL = 28 tablets/28 days
    EPCLUSA — pellet pack QL
    EPCLUSA pellet packQL = 28 packs/28 days
    Antiretroviral agents — typical QL
    Antiretroviral agents (e.g., BIKTARVY, DOVATO, DESCOVY)QL often = 30 tablets/30 days (examples shown per product)
    Vancomycin (Vancocin) — quantity limit
    Vancomycin (Vancocin) oral capsules 125/250 mgQL = 120 capsules/30 days
    Rifaximin 200 mg — quantity limit
    Rifaximin 200 mg tabletsQL = 9 tablets/30 days
    Abiraterone acetate — quantity limits
    Abiraterone acetate 250 mgQL = 120 tablets/30 days
    Abiraterone acetate 500 mgQL = 60 tablets/30 days
    Alectinib (Alecensa) — quantity limit
    Alectinib (Alecensa) 150 mg capsQL = 240 capsules/30 days
    BESREMI — quantity limit options
    BESREMI (ropeginterferon alfa-2b-njft)QL = 30 tablets/30 days or 2 syringes/28 days (alternate listing)
    BRAFTOVI — quantity limit
    BRAFTOVI (encorafenib) 75 mgQL = 180 capsules/30 days
    COPIKTRA — quantity limit
    COPIKTRA (duvelisib)QL = 56 capsules/28 days
    ERIVEDGE — quantity limit
    ERIVEDGE (vismodegib)QL = 30 capsules/30 days
    IBRANCE — quantity limit
    IBRANCE (palbociclib)QL = 21 capsules/28 days
    IMBRUVICA — quantity limit
    IMBRUVICA (ibrutinib)QL = 30 tablets/30 days (varies by formulation)
    JAKAFI — quantity limit
    JAKAFI (ruxolitinib)QL = 60 tablets/30 days
    Nilotinib (Tasigna) — quantity limit
    Tasigna (nilotinib)QL = 120 capsules/30 days
    PIQRAY 200 mg pack — quantity limit
    PIQRAY (alpelisib) 200 mg packQL = 28 tablets/28 days
    TAGRISSO — quantity limit
    TAGRISSO (osimertinib)QL = 30 tablets/30 days
    VENCLEXTA 100 mg — quantity limit
    VENCLEXTA (venetoclax) 100 mgQL = 180 tablets/30 days
    RAYOS — prednisone delayed release QLs
    RAYOS prednisone delayed release 1 mgQL = 90 tablets/30 days
    RAYOS prednisone delayed release 2 mgQL = 60 tablets/30 days
    RAYOS prednisone delayed release 5 mgQL = 360 tablets/30 days
    Testosterone formulations — quantity limits (selected)
    Testosterone TD gel packets (various strengths)Examples: 30 packets/30 days (20.25 mg/1.25 gm), 60 packets/30 days (25 mg/2.5 gm)
    Testosterone TD gel 10 mg/actQL = 2 bottles/30 days
    Testosterone cypionate IM 100 mg/mlQL = 1 vial/28 days
    Testosterone cypionate 200 mg/ml — quantity limit
    Testosterone cypionate IM 200 mg/mlQL = 10 mls/28 days
    XYOSTED — quantity limit
    XYOSTED (testosterone auto-injector)QL = 4 pens/28 days
    MYFEMBREE — quantity limit
    MYFEMBREE (relugolix-estradiol-norethindrone)QL = 30 tablets/30 days
    ORIAHNN — quantity limit
    ORIAHNN (elagolix pack)QL = 56 capsules/28 days
    Contraceptives — quantity limits (examples)
    ANNOVERA ringQL = 1 ring/365 days
    Oral contraceptives (various)QL = 28 tablets per 21- or 30-day pack as indicated per product
    Patch/ring contraceptives (examples)QL examples: 3 patches/21 days per product listings
    Antidiabetic agents and pens — quantity limits (selected)
    FARXIGA (dapagliflozin)QL = 30 tablets/30 days
    GLYXAMBI (empagliflozin-linagliptin)QL = 30 tablets/30 days
    Riomet (metformin oral solution)QL = 780 mls/30 days
    MOUNJARO pens (2.5 mg and higher dose pens)QL = 4 pens (varies by dosing period: 4 pens/180 days for 2.5 mg; 4 pens/28 days for higher-dose packs)
    GLP-1 pens — quantity limits
    OZEMPIC pens (semaglutide)QL = 1 pen/28 days
    TRULICITY (dulaglutide)QL = 4 pens/28 days
    Insulin — example quantity limit
    Multiple insulin products (FIASP, HUMALOG, NOVOLOG)QL = 100 mls/30 days (example for cartridges/solutions)
    Selected specialty/rare disease QLs
    CRENESSITY (crinecerfont)QL = 60 capsules/30 days or 120 mls/30 days for solution
    FOLLISTIM AQ cartridgesQL = 15 cartridges/30 days (300 unit) or alternate QLs by pack (8 cartridges/30 days for 600 unit; 5 cartridges/30 days for 900 unit)
    GALAFOLDQL = 14 capsules/28 days
    Additional specialty product QLs
    MYCAPSSAQL = 120 capsules/30 days
    SKYTROFAQL = 8 capsules/28 days
    TRYNGOLZAQL = 1 injection device/28 days
    Bone/rare disease and cardiovascular QLs
    TYMLOSQL = 1.56 mls/30 days
    VOXZOGOQL = 30 vials/30 days
    Ivabradine (Corlanor)QL = 60 tablets/30 days
    Pulmonary & ED agent QLs (examples)
    Sildenafil suspension 10 mg/mlQL = 224 mls/30 days
    Revatio (sildenafil 20 mg)QL = 90 tablets/30 days
    UPTRAVI (selexipag)QL = 60 tablets/30 days
    Respiratory biologics and inhaler QLs
    NUCALA (mepolizumab)QL = 3 pens/28 days (100 mg formulation) or 1 syringe for 40 mg formulation
    FASENRA PEN (benralizumab)QL = 1 pen/28 days
    QVAR REDIHALERQL = 1 inhaler/30 days (40 mcg) or 2 inhalers/30 days (80 mcg)
    Cystic fibrosis modulators and select biologics — QLs
    CF modulators (ALYFTREK, KALYDECO, ORKAMBI, SYMDEKO, TRIKAFTA)QL varies by product (examples: 56–84 tablets/packets per 28–30 days)
    CIMZIAQL varies by SKU (examples: 2 kits/28 days, 4 syringes/28 days, or 1 kit/180 days)
    ENTYVIO PEN (vedolizumab)QL = 2 pens/28 days
    Gastrointestinal / renal binder / dermatologic biologic QLs
    Sucralfate suspensionQL = 1200 mls/30 days
    FERRIC CITRATEQL = 1080 tablets/365 days
    SKYRIZIQL = 1 cartridge/56 days
    Sevelamer — multiple QL options by strength
    Sevelamer carbonate packets/tabsMultiple annual QL options depending on strength (examples: 1530 packets/365 days; 450 packets/365 days; 1530 tablets/365 days)
    CNS agents and anxiolytics — QLs (selected)
    Lorazepam tabletsQL = 150 tablets/30 days (example)
    Aripiprazole oral solution 1 mg/mlQL = 900 mls/30 days
    Various tablets (antipsychotics/antidepressants)QL examples: 30, 60, 120 tablets/30 days per product listing

    Key Terms and Requirement Flags

    Formulary Governance and Scope

    The Drug List and associated formulary are compiled and maintained by a clinical review committee composed of physicians and pharmacists. The committee reviews FDA‑regulated drugs for safety, efficacy, cost, and comparative value when deciding inclusion, tier placement, and utilization controls.