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

CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Drug List (Pharmacy Benefit) — Drug List / Formulary Coverage Criteria

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Oklahoma policy alerts

Know when Blue Cross Blue Shield - Oklahoma releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

A formulary/drug list governing outpatient pharmacy coverage and benefit tiering for Blue Cross and Blue Shield of Oklahoma members; directed to members, prescribing providers, and pharmacists.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Drug List / Formulary Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change indicated

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization when 'PA' is indicated and document quantity limits on the claim to support coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manydrug entries in section

PA/ST/QLauthorization tools

6member tiers noted

~20+specialty/biologic agents

Coverage Criteria

General coverage conditions

Coverage is provided when ALL of the following are met:

Basic coverage conditions: Drug appears on the Blue Cross Blue Shield of Oklahoma Drug List and is included in the member's benefit plan.

Drugs not shown on the Drug List are not covered; see MyPrime.com or bcbsok.com for the most current Drug List.

Benefit plan rules: Coverage follows the member payment tier assigned to the drug (Tier 1–Tier 6) and applicable plan-specific benefit limits.

Tier definitions and verification: see MyPrime.com or call the number on the member ID card.

Additional controls: When a line-item lists a Special Requirements code (PA, ST, QL, AC, SP), the associated requirement must be satisfied for coverage to be provided.

Prior Authorization must be obtained when 'PA' is indicated; Step Therapy exceptions may be requested as described in plan materials.

Formulary coverage by drug listing

Formulary Codes & Quantity Examples

Formulary requirement codes and example QLsmixed

QL (60 tablets/180 days)	Example quantity limit for azithromycin formulations
QL (28 tablets/30 days)	Quantity limit example for clarithromycin ER 500 mg
QL (235.2 mls/28 days)	Quantity limit for ARIKAYCE amikacin liposome inhalation
QL (56 containers/56 days)	Quantity limit for tobramycin nebulized solutions (KITABIS PAK/TOBRAMYCIN)
QL (224 capsules/56 days)	Quantity limit for TOBI PODHALER tobramycin inhalation capsules
QL (30 tablets/30 days)	Quantity limit example for multiple antiretroviral agents (e.g., BIKTARVY)

Administrative and program codesmixed

PA	Prior authorization required (general flag)
AC	Administrative control code (used on some contraceptive and other entries)
SP	Specialty program / specialty pharmacy designation

Listed drugs and controls (no CPT/HCPCS/ICD-10 codes present)mixed

N/A	This section lists medication names, assigned Drug Tier, and Requirements/Limits (PA, QL, SP) per line-item; no procedure or diagnosis billing codes are provided in these chunks.

Example line-item controls capturedmixed

QL (2.24 mls/28 days)	Quantity limit for teriparatide (Forteo) pen-injector
QL (30 tablets/365 days)	Quantity limit for tolvaptan 15 mg (per year)
QL (60 tablets/365 days)	Quantity limit for tolvaptan 30 mg (per year)
PA	Prior authorization noted for certain specialty agents (e.g., TRYNGOLZA)
QL (1 injection device/28 days)	Quantity limit for TRYNGOLZA (olezarsen sod)
QL (8 kits/180 days)	Quantity limit for FUROSCIX furosemide subcutaneous cartridge kit (from related chunk)

Common QL examples — sample values

30 tablets/30 days

Prescriber & Pharmacy Actions

Prior Authorization

Prior Authorization Required

Prior Authorization (PA) is required as noted with "PA" in the Requirements/Limits or Special Requirements column for many drugs in this Drug List. When PA is listed, the prescriber must submit a prior authorization request and any supporting documentation (clinical notes, prior therapy history, lab results) before the medication will be covered. Coverage may be denied if PA is not obtained when required.

PA indicated next to medication with "PA" in Requirements/Limits/Special Requirements
Prescriber must submit PA and supporting documentation prior to coverage

Prior Authorization

PA Required for Select Agents

Prior authorization is required for select agents across therapeutic classes — examples in this Drug List include certain antifungals (posaconazole, voriconazole), inhaled/nebulaized antibiotics (ARIKAYCE, TOBRAMYCIN), and specific antivirals and specialty medications. Check the Requirements/Limits column for a "PA" flag for each product.

Posaconazole (NOXAFIL) — PA noted

Definitions

Specialty drugs — definition

DefinitionMedications used for serious, complex conditions (oral, topical, or injectable) that may require special handling, site-of-care considerations, or specialty pharmacy processes

AdministrationMay be self-administered or administered by a health care professional; provider-administered medications may be covered under the medical benefit rather than pharmacy

ManagementOften designated with 'SP' in the Requirements/Limits column indicating specialty pharmacy handling

Payment tiers — definitions

Tier 1 — Preferred GenericPreferred Generic (marked with 'p')

Tier 2 — Non-Preferred GenericNon-Preferred Generic (marked with 'np')

Initial Therapy Criteria by Drug Group

Contraceptives / Progestins

Contraceptive products listed below are covered when ALL of the following are met:

Formulary listing: Contraceptive (combined oral, ring, patch) or progestin product appears on the Drug List and is included in the member's benefit.

See specific line-item for Drug Tier assignment.

Dispensing limits: Dispensing must not exceed the listed quantity limits (examples: 28 tablets per pack/21-day dispensing cycle; 1 vaginal ring per 21 days; 3 patches per 21 days).

Requirements/Limits column indicates AC and QL where applicable (e.g., many combined oral contraceptives show AC, QL (28 tablets/21 days)).

Administrative controls: When 'AC' or other administrative codes are listed, the administrative condition must be satisfied for coverage (claim-level reporting/attachment as required).

See the Drug List and plan materials for AC processing instructions.

Step Therapy / Prior Trial Requirements

Agent / example	Requirement code(s)	Notes
Various agents (examples: combination antiretrovirals, macrolides)	AC / PA / SP	Some agents are designated with administrative control (AC), prior authorization (PA), or specialty (SP) flags indicating additional authorization or specialty pharmacy handling prior to coverage.

Agent	Coverage requirement	Notes
MOUNJARO (tirzepatide soln auto-injector)	PA	MOUNJARO entries list Requirements/Limits = PA and QL (e.g., 4 pens/28 days or pens/180 days), indicating prior authorization is required before coverage.

Agent / formulation	Requirement	Notes
OZEMPIC (semaglutide) pen-injector — 0.25/0.5 mg, higher-dose presentations	PA / QL	OZEMPIC line items show Requirements/Limits = PA and specified QL (e.g., 1 pen/28 days; 3 mls/28 days), indicating PA is required for listed formulations.

Agent	Flag	Interpretation
KERENDIA (finerenone)	ST	KERENDIA entry includes 'ST' in Requirements/Limits (QL 30 tablets/30 days, ST), indicating step therapy may apply prior to coverage when indicated.

Agent / group	Requirement codes	Notes
Selected non-preferred or specialty agents (examples: TRYNGOLZA, teriparatide, many biologics)	PA / SP	Multiple specialty or non-preferred products list PA and/or SP in Requirements/Limits, indicating prior authorization is required before coverage; explicit step therapy edits are not provided in these excerpts.

Agent	Flag	Notes
FETZIMA (levomilnacipran) and titration pack	ST	FETZIMA entries show Requirements/Limits = ST, indicating a step therapy requirement must be satisfied prior to coverage.

Agent	Flag	Notes
FLUOXETINE DR (fluoxetine 90 mg DR)	ST	FLUOXETINE DR line-item lists Requirements/Limits = ST, indicating step therapy is required prior to coverage.

Quantity Limits (QL) — Selected Drug Examples

Site of Care / Specialty Pharmacy

Note

SP designation denotes specialty pharmacy handling

SP designation indicates specialty pharmacy handling for injectables and high-cost specialty products; coordinate dispensing through the specialty pharmacy when 'SP' is listed.

SP entries appear for many injectables (e.g., FOLLISTIM AQ, GENOTROPIN, TERIPARATIDE).
Specialty pharmacy processes and PA requirements should be followed for SP-designated products.

Note

Coordinate with specialty pharmacy for SP-designated drugs

SP designation for many specialty drugs implies specialty pharmacy distribution; prescribers should coordinate with the specialty pharmacy for fulfillment and prior authorization processes.

SP entries are common for infusion/injectable biologics and high-cost specialty agents.
No explicit site-of-care restrictions are provided beyond specialty handling in this extract.

Biosimilars & Reference Biologics

Billing Rule

Adalimumab products require PA and have QLs (commonly 2/28 days)

Adalimumab reference and biosimilar products are listed with prior authorization and quantity limits (commonly 2 syringes/pens per 28 days); obtain PA and bill within the listed QL to avoid denial.

HUMIRA and multiple biosimilars (HADLIMA, SIMLANDI, ADALIMUMAB-AATY, etc.) list 'PA' and QL (2 pens/syringes/28 days).
SP designation often accompanies these entries; coordinate with specialty pharmacy as needed.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Drug List / Formulary Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change indicated

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization when 'PA' is indicated and document quantity limits on the claim to support coverage.

SourceLink

On This Page

Covered when ALL of the following are met:

Formulary inclusion: Medication is listed on the payer Drug List with an assigned Drug Tier and is eligible under the member's specific benefit plan.

Presence on the Drug List indicates coverage subject to any listed Requirements/Limits (QL, PA, AC, SP).

Compliance with line-item controls: Any Requirements/Limits annotated on the drug line (for example QL, PA, AC, SP, ST) must be satisfied prior to coverage or adjudication at the indicated tier.

Examples: QL (60 tablets/180 days) for azithromycin; PA indicated for certain antifungals (see listings).

Refer to full drug list: For product-specific coverage conditions (exact QL amounts, PA requirements, ST flags), refer to the full Drug List online or the provider portal.

This document excerpt contains representative entries; use MyPrime.com / bcbsok.com for current line-item details.

Coverage with per-drug utilization controls

Formulary coverage is provided when ALL of the following per-drug utilization controls are satisfied:

Line-item utilization controls: Medications are assigned a Drug Tier and may list Requirements/Limits such as Prior Authorization (PA), Quantity Limits (QL), Specialty designation (SP), or Administrative Controls (AC) that must be met for coverage.

Follow the specific line-item Requirements/Limits for authorization and dispensing quantities; failure to meet PA/QL/SP may result in denial.

Quantity limit adherence: Dispensing must not exceed the specified QL for the defined time period (e.g., mls/30 days, tablets/30 days, kits/180 days).

Examples in the Drug List: enalapril oral solution QL (1200 mls/30 days); FUROSCIX QL (8 kits/180 days).

Prior authorization when required: Prescriber must obtain prior authorization and submit required documentation when 'PA' is listed for the product before coverage will be approved.

PA requirements are indicated on the Drug List line; see provider documentation guidance for submission details.

Coverage is provided for medications that appear on the payer's Drug List when the member's benefit allows. Drugs that are not shown are not covered. The listing also indicates per-product controls (for example, Prior Authorization (PA), Quantity Limits (QL), Administrative Controls (AC), Specialty (SP), or Step Therapy (ST)) that must be met for coverage. For the most current Drug List and any updates, providers and members should refer to MyPrime.com or bcbsok.com or call the number on the member's ID card.

The excerpted section does not include explicit exclusion statements for individual drugs beyond the general rule that only drugs on the Drug List are covered. Therefore, the absence of a specific product in this excerpt should not be interpreted as an affirmative exclusion — confirm coverage by checking the full, up-to-date Drug List or the member's benefit materials.

Within the endocrine and insulin product listings shown, there are no explicit exclusions noted in these chunks. Line-item entries include drug tier assignments and utilization controls (for example, QL entries for many insulin products) but do not state that the listed endocrine agents are excluded from coverage.

This excerpt contains no standalone clinical exclusion statements. Coverage determinations are driven by each line-item's listed Drug Tier and any associated Requirements/Limits (such as PA, QL, or SP); adherence to those line-item controls determines whether an item is covered under the pharmacy benefit.

The listing format shows each product with an assigned formulary tier and any administrative controls in the Requirements/Limits column (e.g., PA, QL, SP, ST). These flags indicate administrative or utilization management controls; specific medical necessity criteria and detailed PA or ST clinical rules may be published separately or in the full Drug List documentation and are not included in these excerpted chunks.

In the provided excerpt there are no explicit statements designating any listed agents as 'Not Medically Necessary.' Coverage language here focuses on formulary inclusion, tiering, and administrative controls rather than NMN determinations.

Similarly, this segment does not contain explicit 'Not Medically Necessary' (NMN) determinations. If an NMN policy or determination applies to a drug, that information would be documented elsewhere in plan materials or a separate medical necessity policy.

Common short-term oral QL example (e.g., antiretroviral tablet regimens)

60 tablets/180 daysExample longer-interval QL (e.g., azithromycin variants shown as QL 60/180 days)

56 containers/56 daysInhaled/nebulized product QL example (tobramycin/kit entries)

235.2 mls/28 daysLiquid inhalation QL example (ARIKAYCE)

Common quantity limit — example

100 mls/30 daysStandard quantity-limit frequently applied to insulin vials/cartridges/pens

100 mls/30 days (pen/cartridge/vial)Example appears repeatedly across rapid-, short-, intermediate-, and basal insulin entries

QL applied per 30-day supplyDenotes maximum milliliters allowed in a 30-day period for many insulin products

Contraceptive dispensing pack limits — examples

28 tablets/21 daysTypical dispensing pack limit for combined oral contraceptives (listed as QL (28 tablets/21 days))

1 ring/21 daysNUVARING dispensing pack limit example (QL (1 ring/21 days))

28 capsules/21 daysCapsule-form contraceptive pack example (QL (28 capsules/21 days))

Common insulin QL — example

100 mls/30 daysStandard insulin quantity-limit used for vials, cartridges and pens (e.g., HUMALOG, NOVOLOG entries list QL (100 mls/30 days))

Applies across rapid-, short-, intermediate- and basal insulinsMultiple insulin product lines specify the same QL format (mls/30 days)

Used to control monthly dispensing volumesQuantity expressed as milliliters per 30 days reflecting total insulin supply

Orphan/specialty QL example

14 capsules/28 daysGALAFOLD (migalastat) QL example listed as QL (14 capsules/28 days)

PA + SP noted for orphan/specialty productsGALAFOLD entry includes PA and SP alongside the QL in the listing

Orphan/specialty QLs often use capsule counts per 28 daysExample demonstrates how orphan drug QLs are expressed (capsules/28 days)

Quantity limits examples — assorted specialty/oral solution entries

TRYNGOLZA — 1 injection device/28 daysTRYNGOLZA entry specifies QL (1 injection device/28 days) with PA and SP

FUROSCIX — 8 kits/180 daysFUROSCIX listing shows QL (8 kits/180 days) and PA

Enalapril oral solution (Epaned) — 1200 mls/30 daysOral solution QL example listed as QL (1200 mls/30 days)

QBRELIS lisinopril oral solution — 2400 ml/30 daysLarge-volume oral solution QL example listed as QL (2400 ml/30 days)

Example quantity limits — assorted

30 tablets/30 daysExample QL for weight-management or short-course therapies (e.g., Qsymia shows QL 30 tablets/30 days)

15 mls/30 daysLiquid pen/solution QL example (SAXENDA listed as QL (15 mls/30 days))

60 tablets/30 daysCommon tablet QL (e.g., certain antiviral or CNS agents listed at 60 tablets/30 days)

Specialty QLs — examples

540 mls/30 daysSodium oxybate oral solution QL example listed as QL (540 mls/30 days)

30 syringes/30 daysFollistim/other cartridge/syringe-based QL examples expressed as syringes per 30 days (e.g., ganirelix, OVIDREL entries)

2 pens/28 daysPen-based specialty biologic/teriparatide QL example (YORVIPATH, teriparatide entries list 2 pens/28 days or 2.24 mls/28 days)

Voriconazole (Vfend) — PA noted

ARIKAYCE, TOBRAMYCIN — PA and QL noted

Prior Authorization

PA Required for Listed Specialty Agents

Prior authorization is required for many listed specialty agents and biologics. These products frequently also have Quantity Limits (QL) and Specialty (SP) program requirements. Examples include ACTHAR, GENOTROPIN, GALAFOLD, TREMFYA, OMVOH, ENTYVIO PEN, and multiple adalimumab/etanercept biosimilars.

ACTHAR — PA, SP
GENOTROPIN — PA, SP
GALAFOLD — PA, QL, SP
TREMFYA, OMVOH, ENTYVIO PEN — PA, QL, SP
Multiple adalimumab and etanercept products — PA, QL, SP

Prior Authorization

Products Requiring Prior Authorization

Many products in the Drug List explicitly require prior authorization. When the Requirements/Limits field lists 'PA' (often alongside QL and/or SP), PA must be obtained before the claim will adjudicate as covered. Examples span weight-loss agents, GLP-1s, specialty injectables, and infusion/biologic therapies.

Qsymia — PA, QL
SAXENDA, WEGOVY — PA, QL
MOUNJARO, OZEMPIC, TRULICITY, RYBELSUS — PA and QL indicated

Prior Authorization

PA Required Where Listed

Where 'PA' is listed in Requirements/Limits the prescriber must obtain authorization prior to dispensing. Claims submitted without required PA are subject to denial or reversal. Always verify the Requirements/Limits entry for the product/formulation and enforce PA prior to treatment start.

OZEMPIC and RYBELSUS show PA flags — verify formulation-specific PA
MOUNJARO and TRULICITY list PA with specific QLs

Prior Authorization

PA Required for Many Specialty Biologics

Many specialty biologics and specialty-administered therapies require prior authorization and are managed under a specialty program (SP). Examples include adalimumab variants, etanercept products, OMVOH, TREMFYA, KEVZARA and other self-inject/infusion biologics.

Adalimumab products — PA, QL, SP
Etanercept (ENBREL) — PA, QL, SP
KEVZARA, OMVOH — PA, QL, SP

Denial Risk

Denial Triggers

Claims may be denied if prior authorization is not obtained when required, if Quantity Limits (QL) are exceeded, or if Specialty Program (SP) enrollment/requirements are not met. PA, QL and SP are enforceable coverage controls — lack of compliance is a common denial trigger.

Denial triggers include missing PA, exceeding QL, and not meeting SP criteria
Some drugs are not covered if not FDA-approved for the indication

Denial Risk

Denial Triggers: QL or PA Not Met

Exceeding a Quantity Limit (QL) or failing to obtain an applicable PA are specific, frequent reasons for claim denial. Providers should verify per-prescription and time-period limits (e.g., per 28/30/180/365 days) before dispensing or submitting a claim.

QL examples: AZITHROMYCIN (60 tablets/180 days), many antiretrovirals (30/30 days), GLP-1 pens (per 28/180 days)
FUROSCIX — PA and QL (8 kits/180 days) — failure to meet these results in denial

Prior Authorization

Prior Authorization Triggers

Prior authorization triggers are product- and formulation-specific. For GLP-1 agents and other high-cost metabolic agents, PA is commonly required and quantity limits are applied. Confirm the exact NDC/formulation and Requirements/Limits entry before prescribing.

GLP-1 examples: MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY — PA and QL flags vary by strength/formulation
Weight-management biologics (WEGOVY, SAXENDA) — PA and QL applied

Prior Authorization

PA for GLP-1 Agents

GLP-1 agents (injectable and oral semaglutide, tirzepatide, dulaglutide) are often subject to PA and QL. Ensure PA is obtained for the specific product and that dispensing does not exceed the QL stated in the Requirements/Limits.

OZEMPIC — PA, QL (pen-specific mL/pen limits)
RYBELSUS — PA, QL (tablet-based limits)
MOUNJARO, TRULICITY — PA and QL per-pen limits

Documentation Required

PA/QL Triggers and Quantity Limits

When PA is listed it is often accompanied by Quantity Limits (QL) and Specialty Program (SP) requirements. These controls should be documented in the PA request. Examples include GALAFOLD (PA, QL, SP), GENOTROPIN (PA, SP), and many injectables with QLs specified.

GALAFOLD — PA, QL (14 capsules/28 days), SP
GENOTROPIN — PA, SP with cartridge-based QLs
TREMFYA — PA with QL per pen/induction pack

Prior Authorization

FUROSCIX PA/QL

FUROSCIX (subcutaneous furosemide) requires prior authorization and has a quantity limit of 8 kits per 180 days. Prescribers must include supporting clinical information demonstrating medical necessity for subcutaneous administration.

FUROSCIX — Requirements/Limits = PA, QL (8 kits/180 days)

Denial Risk

PA/QL/SP Adherence Required

Adherence to PA, QL and SP requirements is mandatory. Claims not meeting these rules risk denial. Specialty program rules may include site-of-service, specialty pharmacy dispensing, or additional clinical review steps.

Specialty program (SP) designations often require specialty pharmacy or prior authorization routing
Site-of-service or infusion-related rules may apply for some biologics

Documentation Required

Prior Authorization Indicated in Requirements/Limits

The Requirements/Limits column explicitly indicates when prior authorization is required ("PA"). Providers should use the Drug List Requirements/Limits when preparing PA requests and when submitting claims so the claim reflects the required controls.

Use Requirements/Limits on claim submissions to indicate PA/QL/SP (where supported)
Verify product/formulation-specific PA flags before billing

Prior Authorization

Prior Authorization Required for Specialty Biologics

Many biologic therapies and biosimilars require prior authorization (PA) and have quantity limits. Examples in this Drug List include multiple branded and biosimilar adalimumab products, etanercept (ENBREL), sarilumab (KEVZARA), and other TNF/IL-targeted agents.

Adalimumab and biosimilars — PA, QL, SP
Etanercept (ENBREL) products — PA, QL, SP
Sarilumab (KEVZARA) — PA, QL, SP

Billing Rule

Quantity Limit Enforcement

Quantity limits are enforced per the Requirements/Limits entry (example: per 28, 30, 56, 180, or 365 day intervals). Exceeding these limits without clinical justification or approved PA may result in denial or member financial liability.

Examples: TOBRAMYCIN QL (56 containers/56 days), many HIV agents QL (30/30 days), GLP-1 pens (per 28/180 days)
Providers should request PA for exceptions and document medical necessity

Billing Rule

Use Requirements/Limits on Claim

Providers and pharmacies must follow the Drug List Requirements/Limits when submitting claims: include PA identifiers where applicable, code quantities to match QL, and route specialty drugs per SP requirements. Failure to include required PA or to observe QL/SP rules can lead to claim denial or member cost exposure.

Include PA/authorization codes or PA reference on claim when system allows
Ensure dispensed quantity matches QL windows to avoid denial

Step Therapy

Step Therapy Requirement

Step Therapy (ST) may require trial of first-line preferred medication(s) before coverage for a non-preferred product will be approved. ST requirements are noted with an "ST" in Requirements/Limits; prescribers may submit a step therapy exception if clinically appropriate.

ST flagged where noted (e.g., KERENDIA shows ST; FETZIMA, FLUOXETINE DR, TRINTELLIX have ST)
Prescriber can request step therapy exception by calling number on member ID

Documentation Required

Step/Authorization Notes for Antivirals

Certain antivirals and antiretroviral regimens have quantity limits and prior-authorization/authorization controls (AC) in addition to QL. Validate QL and AC/authorization fields for antiviral products and include required documentation with PA requests.

BIKTARVY — QL (30 tablets/30 days)
Many antiretroviral products include QL and may include AC/authorization controls

Step Therapy

Step Therapy Indicated Where Noted

Step therapy is indicated for selected products where an "ST" designation appears. When ST applies, ensure the member has completed required trials or obtain an approved exception before dispensing the non-preferred product.

KERENDIA — ST flagged
FETZIMA and certain antidepressant formulations — ST flagged

Note

Step Therapy Not Specified Here

Some products in the list have step therapy but the detailed step path is not specified in this Drug List extract. Refer to the plan's complete Drug List or call the number on the member ID card to confirm the required first-line agents and exception pathways.

If step therapy is not fully described here, contact BCBSOK or refer to plan materials
Prescribers may request exceptions via the phone number on the member ID card

Note

Specialty Program / Step Notes

Specialty program (SP) designations may add additional management steps (specialty pharmacy distribution, site-of-service requirements, or extra clinical review). When SP is shown, follow the specialty program routing and documentation requirements described by the plan.

SP examples: many injectables and biologics (adalimumab products, TREMFYA, OMVOH, MAVENCLAD)
Specialty routing may require dispensing by a contracted specialty pharmacy

Note

Exception Request Process

Exception requests (step therapy or Drug List exceptions) can be initiated by the member or the prescribing provider. Call the number on the member's ID card to request an exception. Standard exception decisions are provided within three business days; expedited reviews (when condition jeopardizes life/health) are decided within 24 hours.

Standard exception decision timeframe: 3 business days
Expedited review timeframe: 24 calendar hours (when applicable)

Documentation Required

Documentation of Requirements/Limits

Document all Requirements/Limits in the PA submission. Include quantity requested, previous therapies tried, clinical rationale, and any supporting labs or diagnostic testing. When AC (additional clinical) or SP is listed, include the specified documentation to prevent delays or denials.

Include clinical notes, prior therapy history, and labs with PA
For SP products, include speciality program enrollment details as requested

Documentation Required

Quantity Limits and Specialty Program Documentation

Quantity limits and specialty program documentation are often formulation- or device-specific (pens, cartridges, syringes). When QL is present, confirm the QL unit (pens, mL, tablets, cartridges, kits) and request PA if a greater quantity is clinically necessary.

FOLLISTIM AQ — QL by cartridges/30 days
MOUNJARO/TRULICITY — QL by pens/28 or pens/180 days
GALAFOLD — QL (14 capsules/28 days)

Tier 3 — Preferred BrandPreferred Brand (marked with 'P')

Tier 4 — Non-Preferred BrandNon-Preferred Brand (marked with 'NP')

QL — definition and format

Quantity Limit (QL)Maximum quantity of a drug allowed over a specified time period, expressed as 'quantity / days' (e.g., 30 tablets/30 days or 100 mls/30 days)

PurposeUsed to control dispensing frequency and overall supply on the pharmacy claim

Format examplesCommon formats include tablets per 30/90/365 days or mls per 30 days (e.g., 60 tablets/180 days; 235.2 mls/28 days)

PA — prior authorization definition

Prior Authorization (PA)Approval required before coverage is provided for specified drugs; prescriber must submit PA documentation and receive approval prior to dispensing

When usedShown as 'PA' in the Requirements/Limits column for many specialty or high-cost drugs (examples include ARIKAYCE, IQIRVO, TRYNGOLZA)

Denial riskClaims may be denied if PA is required but not obtained

AC / SP — definitions

AC (Administrative Control)Coverage control code used in the Requirements/Limits column to denote administrative coverage rules or dispensing controls

SP (Specialty)Indicates the drug is managed under specialty pharmacy processes and may require specialty distribution or site-of-care handling

UsageBoth AC and SP appear alongside QL/PA to clarify claim handling requirements

QL (insulin example)

100 mls/30 days (insulin)Example insulin QL shown repeatedly across insulin product entries (e.g., FIASP, HUMALOG, NOVOLOG specify QL (100 mls/30 days))

Applies to vials, cartridges, pensThe insulin QL format covers multiple presentation types listed in the insulin sections

Used to limit monthly supplyExpressed as milliliters per 30 days to standardize dispensing across insulin formulations

PA — alternate definition

PA — clinical/administrative approvalPrior Authorization requires submission of clinical or administrative information and approval before coverage is granted

ContextUsed for many specialty, high-cost, or orphan drugs where medical necessity must be documented

Shown in listingFlagged as 'PA' in Requirements/Limits column for applicable products

SP — specialty designation

SP — Specialty designationIndicates a product is managed under specialty pharmacy processes; often accompanies PA/QL for biologics and high-cost injectables

ImplicationMay require specialty distribution, additional documentation, or site-of-care considerations

ExamplesEntries such as GENOTROPIN, SKYRIZI, and many monoclonal antibodies are marked SP

SP — alternate definition

SP — specialty (alternate)Specialty designation applied to certain drugs indicating specialty pharmacy handling or management

Use on claimProviders should follow SP instructions and submit required documentation when SP is listed

Common with injectables/biologicsMany injectables and biologics in the listing include SP in Requirements/Limits

PA — alternate wording

PA — prior approval before coveragePrior authorization is an approval required before coverage is provided and is indicated by 'PA' in the Requirements/Limits column

Provider actionPrescribers must obtain PA to avoid claim denial when PA is listed

Examples in listingMultiple entries (e.g., ARIKAYCE, IQIRVO, ENTYVIO PEN) show PA requirements

QL — alternate definition

QL — maximum quantity over timeframeQuantity Limit denotes the maximum allowed amount of a drug over a specified period (e.g., 30 tablets/30 days)

Expressed as quantity/timeCommonly shown as tablets/30 days, mls/30 days, pens/28 days, kits/180 days

EnforcementExceeding the QL may result in denial unless clinical justification or PA is provided

PA — alternate definition 2

PA — approval prior to dispensingPrior authorization requires approval prior to dispensing for drugs flagged with PA; lack of PA risks claim denial

DocumentationProviders must submit required clinical documentation to support PA requests for listed drugs

Listed examplesPA is shown for drugs such as HARVONI, IQIRVO, ENTYVIO PEN, among others

QL — example (30-tablet insulin/antiviral format)

30 tablets/30 daysExample QL frequently used for antiretroviral and other chronic oral tablet regimens (e.g., BIKTARVY, DESCOVY entries)

60 tablets/180 daysLonger-interval QL example used for some short-course or special agents (e.g., azithromycin lists 60/180 days)

56 containers/56 daysNebulized/inhaled product QL example used for tobramycin KITABIS entries

SP — specialty product context

Specialty product handlingSpecialty products (SP) require dedicated management and may have PA and QL controls; providers must adhere to these on the claim

ExamplesGENOTROPIN, GALAFOLD, TERIPARATIDE, SKYRIZI and many others are listed with SP and QL/PA

Implication for dispensingSP designation typically implies specialty pharmacy distribution and potential site-of-care processes

AC — Administrative control definition

AC — Administrative controlAdministrative control code used to denote non-clinical coverage rules (e.g., packaging/dispensing constraints such as contraceptive pack limits)

Use casesApplied to OTC-equivalent products, nicotine replacement, or contraceptive dispensing limits in the listing

Shown with QLOften appears alongside a QL to define allowable dispensing units (e.g., AC, QL (28 tablets/21 days))

Antidiabetics

Antidiabetic agents are covered when ONE of the following applies and any listed requirements are met:

Agents with no special requirements: Antidiabetic agent is listed without a PA or QL and is covered per tier and benefit rules.

Refer to the Drug List for tier and benefit verification.

Agents with QL/PA: If the antidiabetic agent line lists QL and/or PA (for example: MOUNJARO, OZEMPIC, TRULICITY, RYBELSUS), the specified quantity limits and prior authorization must be satisfied for coverage.

Examples: OZEMPIC pen QL (1 pen/28 days) with PA; TRULICITY QL (4 pens/28 days) with PA as indicated on line-items.

Step therapy exceptions: Where 'ST' is indicated for an antidiabetic, step therapy must be met or a documented exception approved prior to coverage.

Prescribers may request a step therapy exception per plan processes if first-line therapy is not appropriate.

Insulins

Insulins are covered when ALL of the following apply:

Formulary listing: Insulin product (vials, cartridges, pens) is listed on the Drug List and is within the member's covered benefit.

Verify specific brand/formulation and tier on the Drug List.

Quantity limit: Most insulin presentations in this section have a standard quantity limit of 100 mls per 30 days unless the line-item specifies otherwise.100 mls/30 days

Applies across rapid-, short-, intermediate-, and many basal insulin formulations as indicated (see line-items for exceptions).

Authorization and specialty handling: If a product line lists PA or SP, prior authorization or specialty pharmacy handling must be followed as required for coverage.

Examples: selected basal insulins (SEMGLEE, INSULIN GLARGINE-YFGN) list QL (100 mls/30 days) and may have SP designation in full listing.

Initial therapy controls

Initial therapy controls for listed products:

Initial coverage determination: Initial coverage and tier assignment are determined by the Drug Tier and any Requirements/Limits (PA, QL, SP, AC) specified on the product line-item.

Prescribers should consult the Drug List for product-specific initial therapy rules and follow PA/QL requirements when indicated.

Agent	Flag	Notes
TRINTELLIX (vortioxetine)	ST	TRINTELLIX entry lists Requirements/Limits = ST, indicating a step therapy requirement applies prior to coverage.

Observation	Implication	Notes
No explicit step therapy sequences present in excerpt	PA / QL / SP flags only	The provided chunks list many Requirements/Limits codes (PA, QL, SP) but do not describe explicit step therapy paths or required prior agents to be tried first in these excerpts.

Common requirements	Coverage implication	Notes
Prior Authorization (PA) and Quantity Limits (QL)	PA required before coverage when listed; QL limits apply	Multiple entries indicate PA and QL requirements — claims may be denied if PA is not obtained or QL exceeded; specific step sequences are generally not detailed in these chunks.

Note

Specialty pharmacy management for SP-designated agents

Many specialty injectables and high-cost products are managed via specialty pharmacy (SP); prescribers must follow specialty program processes and submit PA where indicated.

Examples include adalimumab and etanercept products showing 'PA, QL, SP'.
Specialty pharmacy may handle prior authorization submission and fulfillment.

Billing Rule

Route SP-designated injectables via specialty pharmacy

Many specialty injectables listed with 'SP' imply management through specialty pharmacy distribution; ensure prescriptions are routed to the appropriate specialty channel and PA is secured when required.

SP designation appears across multiple biologic and specialty product line-items.
Providers should confirm specialty pharmacy requirements and PA workflows before initiating therapy.