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CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2026 Drug List (Pharmacy formulary) — Coverage Criteria

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A pharmacy drug list describing covered drugs, tier placements, special requirements, and administrative processes for Blue Cross Blue Shield of Oklahoma members and their providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List (Pharmacy formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' on the drug list before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+drug entries in this section (approximate)

PA / QL / SPutilization controls present

MyPrime / bcbsokwebsites for current lists

6member payment tiers described

15d / 72hexception decision timeframes

Coverage Criteria and Formulary Stance

General coverage conditions

Covered when the following general conditions are met:

General coverage conditions: Drugs shown on the Drug List are covered; drugs not shown are not covered. Coverage is generally limited to FDA‑approved indications and to recommendations in recognized evidence‑based or clinical practice guidelines. Therapy decisions remain between the member and the prescribing clinician.

See Drug List introduction and Coverage considerations.

Tiering and member cost-share

Member cost-sharing and tiering determine coverage level and member payment responsibility:

Tier placement and member cost: Each prescription product is placed into one of up to six member payment tiers (Preferred Generic, Non‑Preferred Generic, Preferred Brand, Non‑Preferred Brand, Preferred Specialty, Non‑Preferred Specialty). Tier assignment (P/NP/p/np and SP flags) affects member payment amounts and access; consult plan materials or MyPrime.com to verify member cost for a specific drug.

Tier definitions and use per formulary guidance.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Drug List (Pharmacy formulary) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' on the drug list before dispensing.

SourceLink

On This Page

Prior Authorization, Step Therapy, Quantity Limits

Utilization management controls that may apply to listed drugs:

Utilization controls: Prior Authorization (PA), Step Therapy (ST), Quantity/Dispensing Limits (QL/DL) and ACA preventive (AC/’AC’) flags may apply as noted in the Special Requirements column. PA will be indicated with 'PA'; ST with 'ST'; QL with 'QL'; ACA preventive with 'AC'. Exception and expedited review timelines follow the plan's exception process (standard 15 calendar days; expedited 72 hours when applicable).

Providers must submit required documentation per PA/ST/QL rules and may request exceptions per the Exception Process.

Formulary product listings

Formulary entries indicate coverage status, tier placement, and any product-level requirements or limits:

Formulary entries: Each product line on the Drug List shows the Drug Tier and any Requirements/Limits (e.g., PA, QL, SP). The listing itself represents the plan's coverage stance for that product and any special handling notes; clinical criteria (diagnoses) are not provided in this excerpt and must be verified in product‑specific policies when required.

Refer to the per‑product Requirements/Limits field for PA/QL/SP details (see examples across listed chunks).

Covered with product-level PA/QL conditions

Coverage for a listed product is conditional on meeting the product-level utilization controls shown:

Product-level requirements: Coverage is provided when the prescriber obtains any required prior authorization and dispensed quantity does not exceed the product's quantity/dispensing limit. Specialty (SP) designation indicates specialty pharmacy or site‑of‑care processing may be required. This document part provides product flags and QL values but does not include detailed clinical eligibility criteria.See QL values per product lines

Examples: TYVASO (PA, QL 81.2 mL/28 days, SP); UPTRAVI (PA, QL 60 tablets/30 days, SP); NUCALA/TEZSPIRE entries with PA/QL/SP are shown in other chunks.

Coverage contingent on listed utilization controls

Representative examples where coverage is contingent on utilization controls:

Examples of drugs with PA and/or QL: NUCALA: PA, QL (1 syringe/28 days or 3 pens/28 days depending on presentation); TEZSPIRE: PA, QL (1 pen/28 days); ALYFTREK: PA, QL (84 or 56 tablets/28 days depending on strength); KALYDECO: PA, QL (60 tablets/30 days); TRIKAFTA/SYMDEKO: PA, QL (56 or 84 tablets/28 days depending on pack). Coverage requires following the specific PA/QL/SP controls listed for each product line.

These lines are representative extracts from the formulary chunks; follow per‑product Requirements/Limits when submitting authorizations.

Formulary coverage stance

How the formulary determines access and required controls:

Formulary access conditions: Drug tier indicates preferred status (p/np/P/NP) and determines member cost‑sharing; coverage for a product/strength is subject to any Requirements/Limits flags shown (QL = quantity limit per timeframe, ST = step therapy requiring documented failure/intolerance to preferred agents, PA = prior authorization required, SP = specialty pharmacy dispensing).Examples: QL (30 tablets/30 days); ST requires documented trial/failure of required agent(s); PA requires plan approval before coverage.

Verify tier and Requirements/Limits for the specific product/strength when prescribing or submitting a PA.

Exclusions: Coverage may exclude non–FDA-approved drugs, repackaged medications, and certain compounded medications; products used for cosmetic purposes or outside covered age ranges may also be excluded. Additionally, repackaged versions of marketed medications are explicitly not covered. Providers should confirm coverage via the member ID card contact if a drug is not listed. Prior authorization (PA) may be required for some agents and lack of PA can lead to denial. (See Special Requirements column for PA/QL/SP flags.)

This document excerpt is a partial drug list and does not include comprehensive, product‑level medical necessity decision trees. Instead, coverage actions are expressed at the product/strength level using formulary annotations such as PA (prior authorization), QL (quantity limit), ST (step therapy) and tier codes (e.g., P, NP, p). For clinical justification or diagnosis‑specific medical necessity criteria, refer to other policy parts or the plan’s prior authorization guidance; the drug lines themselves indicate the administrative controls required for coverage.

Within the chunks shown there are no explicit narrative exclusions listed beyond the general exclusions noted in the Coverage Considerations section. The entries in these segments primarily convey tier placement and any attached Requirements/Limits (for example, PA or QL) at the product and strength level rather than standalone exclusion statements.

Formulary entries use tier codes (e.g., P, NP, p) and special requirement flags. Some lines use NP or similar non‑preferred indicators without accompanying narrative declaring a product not medically necessary. These tier indicators reflect member cost‑sharing and placement on the drug list rather than explicit denials of medical necessity in this excerpt.

In the document segments provided there are no additional explicit exclusion statements. The listing shows product lines with tier and Requirements/Limits fields; absence of a narrative exclusion in these chunks means that access is governed by the drug’s tier and any PA/QL/ST/SP flags shown on the formulary line.

Products that do not carry a specific Requirements/Limits flag in these excerpts are expected to follow standard tier access as indicated by their tier code. In other words, when no PA/QL/ST/SP constraint is shown on a product line, coverage is subject to the usual benefit tier designation and member cost‑sharing for that tier.

The policy’s general coverage considerations state that non–FDA-approved drugs are not covered. This exclusion is applied at the coverage‑level guidance and should be enforced when a product lacks FDA approval.

Across the provided chunks there are no explicit statements labeling products as not medically necessary. The document instead communicates access controls through tier assignments and administrative flags (PA, QL, ST, SP). Absence of an explicit NMN statement in these excerpts does not alter the plan’s clinical review processes for prior authorization requests.

Similarly, this part of the drug list does not contain explicit not medically necessary declarations. Coverage decisions are implemented via the formulary annotations and utilization controls displayed for each product line rather than separate NMN narrative language in these chunks.

When a non‑preferred formulation or product line is listed as NP (non‑preferred) or similar and a preferred alternative is available on the formulary, coverage may effectively be denied or require additional justification if the prescriber does not pursue the preferred option. In practice, a non‑preferred tier combined with PA or ST flags can function as an implicit denial trigger when plan requirements are not met.

Drug Listings and Coding References

Drug list entries (no procedural codes listed)mixed

N/A	Drug listing entries (no CPT/HCPCS/ICD-10 codes present in this chunk)

Drug list (by product/strength)mixed

NDC-like/formulation entries

Drug names and strengths listed (e.g., TYVASO - treprostinil inhalation solution 0.6 mg/ml; TYVASO DPI maintenance cartridges 16 mcg/cartridge, 32 mcg/cartridge, 48 mcg/cartridge, 64 mcg/cartridge)

Formulary items (no procedure/diagnosis codes present)mixed

No codes listed

QBRELIS quantity limit — QL example (2400 mls/30 days)

ProductQBRELIS (lisinopril oral solution 1 mg/mL)

Quantity limit2400 mls per 30 days

RequirementPA (Prior Authorization) required

TierNP (Non-preferred)

Source noteListed as 'QBRELIS - lisinopril oral soln 1 mg/ml... Requirements/Limits = PA, QL (2400 mls/30 days).'

Repatha quantity limit — 6 syringes/28 days

ProductREPATHA / REPATHA SURECLICK (evolocumab)

Quantity limit6 syringes/pens per 28 days

RequirementPA (Prior Authorization) indicated for some evolocumab presentations

Source noteREPATHA entries show 'Requirements/Limits = PA, QL (6 syringes/28 days)' and REPATHA SURECLICK listed with QL (6 syringes/28 days).

Camzyos quantity limit — 30 capsules/30 days

ProductCAMZYOS (mavacamten)

Quantity limit30 capsules per 30 days

RequirementPA (Prior Authorization) required; SP (Specialty) designation

TierNP (Non-preferred)

Source note'CAMZYOS - mavacamten ... Requirements/Limits = PA, QL (30 capsules/30 days), SP.'

UPTRAVI quantity limit — 60 tablets/30 days

ProductUPTRAVI (selexipag)

Quantity limit60 tablets per 30 days

Additional limitTitration pack limited to 1 pack per 180 days

RequirementPA (Prior Authorization) required; SP (Specialty) designation

Source note'UPTRAVI ... Requirements/Limits = PA, QL (60 tablets/30 days) ... UPTRAVI TITRATION PACK ... QL (1 pack/180 days).'

Quantity Limits examples — assorted QL examples across formulary (mls, cartridges, kits)

Treprostinil inhalation solution (TYVASO)QL examples: 81.2 mls/28 days; starter/refill kits: 1 kit/180 days

Treprostinil DPI cartridges (TYVASO DPI)QL examples: 112 cartridges/28 days; 224 cartridges/28 days; 252 cartridges/180 days (titration kit)

WINREVAIR (sotatercept) and other kitsQL example: 1 kit/21 days (WINREVAIR)

Various QL formatsExamples across formulary include volume (mLs), cartridges, syringes/pens, tablets, and kits with timeframes (e.g., mls/28 days; cartridges/28 or 180 days; kit/21 or 180 days)

Source noteDocument lists QL entries such as 'QL (81.2 mls/28 days)', 'QL (112 cartridges/28 days)', 'QL (1 kit/180 days)' among many others.

What Providers Must Do

Prior Authorization

Prior authorization may be required

Prior authorization may be required for certain drugs; such requirements are noted with 'PA' in the Special Requirements column and providers must submit a prior authorization request for coverage when PA is indicated.

PA is shown in the Special Requirements column for drugs that require pre-approval.
Submit prior authorization per payer process before dispensing to avoid denial.

Prior Authorization

PA required for selected products (e.g., ARIKAYCE, posaconazole, EPCLUSA)

Certain products are designated 'PA' in the drug list (examples shown include ARIKAYCE, posaconazole formulations, and EPCLUSA) — providers must obtain prior authorization for these items as indicated.

ARIKAYCE — Requirements/Limits = PA, QL (28 vials/28 days), SP.
NOXAFIL (posaconazole) delayed-release and suspension formulations — Requirements/Limits = PA.
EPCLUSA (sofosbuvir-velpatasvir) — Requirements/Limits = PA, QL (28 tablets/28 days), SP.

Prior Authorization

PA required for select antivirals (HCV and other high-cost agents)

High-cost antivirals and hepatitis C agents are marked 'PA' and require prior authorization (examples: EPCLUSA, HARVONI, MAVYRET); submit PA documentation consistent with the antiviral regimen.

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

Prior Authorization

Prior authorization required for numerous listed drugs

Many drugs listed across the formulary carry a 'PA' designation; providers must obtain prior authorization for those products before coverage will be approved.

Numerous oncology, specialty, and other high-cost agents show PA in Requirements/Limits.
Claims may be denied if PA is not obtained when required.

Prior Authorization

PA generally required where indicated

Numerous agents throughout this segment require prior authorization as indicated next to each product entry; providers must submit PA per payer procedures to secure coverage.

PA appears repeatedly for specialty oncology, pulmonary, and cardiovascular agents.
Follow payer PA submission process to avoid coverage denial.

Prior Authorization

PA required for select testosterone, contraceptive and specialty oral agents

Certain testosterone products, some contraceptives, and specialty oral agents are marked 'PA' — prior authorization must be obtained for coverage of these formulations.

Testosterone enanthate and topical gels — Requirements/Limits include PA and QL.
Some contraceptives show 'AC' and PA flags; follow listed requirements.

Prior Authorization

PA required for specific agents (e.g., Riomet, ER metformin)

Specific agents such as Riomet oral solution and certain extended‑release metformin products are labeled with 'PA' and 'QL' — providers must submit prior authorization and adhere to the stated quantity limits.

Riomet (metformin oral solution 500 mg/5 ml) — Requirements/Limits = PA, QL (780 mls/30 days).
Metformin ER/modified‑release formulations — some entries require PA and list QL values.

Prior Authorization

PA plus quantity limits for specialty cardiovascular/pulmonary agents

Specialty or high-cost cardiovascular and pulmonary agents frequently carry both PA and QL flags; providers must obtain prior authorization and ensure quantities do not exceed the listed limits.

Examples include REPATHA (PA, QL 6 syringes/28 days) and CAMZYOS (PA, QL 30 capsules/30 days).
TYVASO and UPTRAVI are PA and have explicit QL values for dispensing.

Prior Authorization

PA required for TYVASO, UPTRAVI, NUCALA and similar agents

Several drugs (e.g., TYVASO, UPTRAVI, NUCALA and other specialty biologics) are marked 'PA' and require prior authorization before coverage; check the product line for QL and SP designations.

TYVASO — Requirements/Limits = PA, QL (81.2 mls/28 days), SP.
UPTRAVI — Requirements/Limits = PA, QL (60 tablets/30 days), SP.
NUCALA — Requirements/Limits = PA, QL (1 syringe/28 days or 3 pens/28 days), SP.

Prior Authorization

PA required for listed specialty/high‑cost drugs

Many specialty biologics and high‑cost modulators are designated 'PA' — providers must submit prior authorization documentation for these agents before coverage is approved.

Examples: NUCALA, TEZSPIRE, XOLAIR, ALYFTREK, KALYDECO, ORKAMBI, TRIKAFTA are listed with PA (and often QL/SP).
Specialty agents may also require specialty pharmacy dispensing (SP).

Prior Authorization

PA required for select specialty drugs (e.g., BYLVAY, GATTEX, ENTYVIO PEN, TREMFYA, FILSPARI, PROCYSBI)

Selected specialty therapies such as BYLVAY, GATTEX, ENTYVIO PEN, TREMFYA, FILSPARI and PROCYSBI are marked 'PA' indicating prior authorization is required for coverage of these products.

ENTYVIO PEN — Requirements/Limits = PA, QL (2 pens/28 days), SP.
GATTEX — Requirements/Limits = PA, SP.
PROCYSBI — Requirements/Limits = PA, SP.

Prior Authorization

PA required for NUPLAZID and tasimelteon examples

Certain products such as NUPLAZID and tasimelteon (Hetlioz) are listed with 'PA' and require prior authorization; follow the listed Requirements/Limits for coverage.

NUPLAZID — Requirements/Limits = PA, QL (30 capsules/30 days).
tasimelteon (Hetlioz) — Requirements/Limits = PA, QL (30 capsules/30 days), SP.

Step Therapy

Step therapy (ST) may be required when noted

Step therapy may be required for some products and is denoted with 'ST' in the Special Requirements column; members may need to try designated preferred alternatives prior to coverage of the listed product.

If 'ST' is shown next to a product (e.g., AUVELITY, certain antidepressants/antipsychotics), document prior trials and failures per plan rules.
ST notation indicates a fail‑first requirement before the targeted drug is covered.

Note

Utilization controls present; step sequencing not detailed here

The document lists utilization controls (PA, QL, SP) but does not specify full step therapy sequencing for many agents in this excerpt; verify step‑sequence requirements with the payer when 'ST' is not shown but PA/QL/SP apply.

Where 'ST' is not present, primary controls shown are PA, QL and SP.
Contact the payer or refer to plan materials for any detailed step therapy algorithms.

Note

Step therapy not specified in this segment; PA/QL/SP flags prevail

In this section PA, QL and SP flags are the primary utilization controls shown; explicit step therapy sequences are not provided for the majority of listed drugs in these chunks.

When step therapy is not specified, follow PA and QL requirements and confirm ST rules with the plan if needed.
PA and QL entries should be followed as listed to obtain coverage.

Documentation Required

Administrative condition (AC) shown for some contraceptives

Some contraceptive entries are labeled 'AC' (administrative condition) and also include quantity limits; these administrative flags may indicate coverage constraints such as formulary substitutions or other administrative requirements.

ANNOVERA and many combined oral contraceptives show 'AC' with QL values (e.g., 1 ring/365 days; 28 tablets/21 days).
Verify administrative coverage conditions and any required documentation when 'AC' is present.

Note

Step therapy algorithms not included in this section

No explicit fail‑first (step therapy) algorithms are provided in these chunks; where 'ST' is absent, access is controlled primarily by PA, QL, and SP notations.

Confirm step therapy requirements with the plan for products where benefit rules are unclear.
If 'ST' appears for a product, document prior therapy failures per plan requirements.

Note

Step therapy absent for many specialty entries; rely on PA/QL/SP

Products in this portion are largely managed by PA, SP and QL flags; explicit step therapy sequences are absent for these entries and should be confirmed with the payer if required.

Specialty products often require PA and have QL; step sequencing is not defined here.
Follow PA/QL/SP controls and request clarification on ST from the plan when needed.

Note

Step therapy not specified for listed drugs in this part

This portion of the drug list does not include explicit step therapy sequences for the majority of listed drugs; providers should adhere to PA and QL notations and check plan guidance for ST rules.

UPTRAVI and similar products show PA/QL/SP but no ST sequence in this excerpt.
If ST is required for a product, it will be marked 'ST' in the Special Requirements column.

Note

No step therapy algorithm provided in this excerpt

No explicit step therapy algorithm text is present in these chunks; providers must follow the product flags (PA, QL, SP) and consult payer materials for any step‑based requirements.

Formulary entries note PA/QL/SP but do not supply step sequences here.
Request plan guidance when prior trials are required for coverage.

Step Therapy

ST noted for some products (e.g., AUVELITY) — document prior failures

Some agents are shown with 'ST' notation (for example AUVELITY) — providers must document failure or intolerance to required prior agents per the plan's step therapy rules when submitting requests.

AUVELITY — Requirements/Limits = ST.
When ST applies, include documentation of prior therapy trials and reasons for discontinuation or intolerance.

Step Therapy

Step therapy products (ST) require documented prior therapy failure/intolerance

Products marked 'ST' require demonstration of failure or intolerance to the designated prior agent(s) before coverage; include supporting documentation with the request.

Document dates, medications tried, doses, durations, and reason for discontinuation.
Submit ST exception documentation if the member cannot try required agents due to contraindication.

Documentation Required

Exception request process and decision timelines

To request a Drug List exception, providers or members must call the number on the member's ID card; BCBSOK will notify the prescriber or member of the decision within 15 calendar days (expedited decisions within 72 hours for urgent requests).

Standard exception decision timeline: 15 calendar days.
Expedited (urgent) review timeline: 72 calendar hours.

Billing Rule

Adhere to stated quantity limits (QL); document accordingly

Some products list explicit quantity limits (QL) — dispense within the stated limits and ensure documentation supports the requested quantity when submitting prior authorization.

EPCLUSA — QL (28 tablets/28 days).
Examples of QL across the list (e.g., ARIKAYCE QL 28 vials/28 days).

Documentation Required

Documentation expectations for PA drugs (indication and quantity)

When PA is indicated, prescribers must document the clinical indication and the quantity consistent with the regimen requested; antiviral/HCV regimens require documentation supporting the specific regimen and pack sizes.

For HCV agents (EPCLUSA, HARVONI, MAVYRET), include diagnosis and regimen details and match quantity to QL (e.g., 28‑day packs).
Attach relevant lab results or specialist notes when applicable.

Documentation Required

Provide documentation for PA and QL when both apply

When products carry both 'PA' and 'QL' flags, submit prior authorization documentation or adhere to the specified quantity limits; documentation should justify the requested quantity relative to the QL.

If requesting above the QL, include clinical rationale and supporting records.
Follow payer guidance for PA submission to avoid claim denial.

Documentation Required

Document quantity and specialty pharmacy requirements with PA

For products flagged 'QL' or 'SP', prescribers should supply documentation supporting the prescribed quantity and the intended dispensing site (specialty pharmacy) when submitting a PA.

SP designation often indicates specialty pharmacy dispensing or limited distribution.
Include site‑of‑care or dispensing channel details when required.

Prior Authorization

Submit PA per payer process and follow QL rules

Submit prior authorization per the payer's process for products labeled 'PA'; where quantity limits (QL) are listed, adhere to those limits when submitting claims or provide supporting documentation if requesting above the limit.

Follow payer PA submission procedures to obtain coverage approval.
Claims exceeding QL may be denied unless supported by approved PA or exception.

Prior Authorization

When 'PA' or 'QL' is shown, submit PA or adhere to QL

Providers must submit prior authorization documentation or otherwise follow quantity limits for products labeled with 'PA' or 'QL' in the Requirements/Limits field; failure to do so may result in claim denial.

Examples: Riomet requires PA and QL (780 mls/30 days); MOUNJARO and OZEMPIC have PA and pen/period QLs.
Include clinical justification, prior therapy history, and requested quantity details in PA submissions.

Documentation Required

QBRELIS requires PA and QL (2400 mL/30 days)

QBRELIS (lisinopril oral solution) is listed with Requirements/Limits = PA and a quantity limit of 2400 mL per 30 days; prior authorization and adherence to this QL are required for coverage.

QBRELIS — PA, QL (2400 mls/30 days).
Ensure PA documentation specifies the formulation and required volume.

Documentation Required

UPTRAVI requires PA and QL; titration pack limited

UPTRAVI (selexipag) requires prior authorization and has a quantity limit of 60 tablets per 30 days; the UPTRAVI titration pack is limited to 1 pack per 180 days — include these limits when requesting authorization.

UPTRAVI — PA, QL (60 tablets/30 days); titration pack QL (1 pack/180 days).
Include titration plan and justification in PA documentation.

Documentation Required

Documentation expectations for specialty biologic PA requests

Prescribers must supply documentation supporting PA requests for specialty biologics and other specialty agents marked with PA and SP (examples include NUCALA, TEZSPIRE, XOLAIR); include diagnosis and prior therapies as applicable.

NUCALA — PA, QL (1 syringe/28 days or 3 pens/28 days depending on presentation).
TEZSPIRE — PA, QL (1 pen/28 days), SP.
Include relevant specialty documentation (e.g., specialist notes, prior biologic trials).

Billing Rule

Follow quantity limits (QL) when submitting requests/claims

Adhere to the specified quantity limits when submitting prior authorization or claims; many products have explicit QL values (for example CF modulators and other specialty agents) that must be followed.

ALYFTREK — QL 84 tablets/28 days or 56 tablets/28 days depending on strength.
KALYDECO — QL 60 tablets/30 days; TRIKAFTA/SYMDEKO have packet/tablet QLs as listed.

Documentation Required

Supply diagnosis and prior therapy documentation to support PA

When submitting prior authorization requests, prescribers should include diagnosis, prior therapies, and other supporting records to substantiate the need for the requested drug when 'PA' is indicated.

Provide relevant diagnostic information and documentation of prior medication trials and outcomes.
Specialty agents frequently require more detailed clinical documentation.

Documentation Required

Provide supporting documentation for ST or QL exceptions

If requesting an exception to a step therapy or quantity limit, expect to provide supporting documentation (e.g., contraindication, intolerance, prior treatment history) when the product is flagged 'ST' or 'QL'.

ST exceptions require documentation of failure or intolerance to designated prior agents.
QL exceptions should provide clinical rationale for exceeding the listed limit.

Denial Risk

Triggers for denial: non‑formulary, non‑FDA, repackaged, missing PA/ST

Coverage may be denied if the drug is not on the drug list, is non‑FDA‑approved, is repackaged, or if prior authorization or step therapy requirements are not met; providers should verify coverage and submit required authorizations.

Non‑FDA‑approved drugs and repackaged medications are not covered.
Failure to obtain required PA or to meet ST requirements can result in denial.

Denial Risk

Denial risk when PA/QL/SP controls not met

Pharmacy claims for products listed with 'PA', 'SP' or 'QL' may be denied if prior authorization is not obtained, if specialty distribution requirements are not met, or if quantity limits are exceeded.

Examples include ARIKAYCE, KITABIS PAK, TOBRAMYCIN, EPCLUSA where PA/SP/QL are present.
Ensure specialty dispensing (SP) requirements are followed to avoid denial.

Prior Authorization

PA triggers for select antiviral agents

Drugs listed with 'PA' (examples: EPCLUSA, HARVONI, MAVYRET, SOVALDI) require prior authorization prior to coverage; submit PA to avoid claim denials.

EPCLUSA, HARVONI, MAVYRET, SOVALDI — all marked PA for hepatitis C treatment regimens.
Provide relevant clinical documentation with PA submission.

Billing Rule

Specialty (SP) designation may require specialty dispensing

Products labeled 'SP' indicate specialty pharmacy handling or limited distribution; claims may be denied if the medication is not processed through the appropriate specialty channel.

Many HCV and specialty biologic products include 'SP' designation.
Use the specialty pharmacy channel when required by the product line.

Denial Risk

Denial risk if PA is not obtained when required

Coverage may be denied if prior authorization is not obtained when listed as a requirement for a medication; providers must obtain required PA to secure coverage.

PA absence may result in claim denial or additional review.
Check the Special Requirements column for PA flags prior to dispensing.

Denial Risk

PA required for many listed drugs — risk of denial without PA

Many listed drugs require prior authorization; requests submitted without the required PA for 'PA'‑flagged products may be denied or delayed.

Providers should confirm PA requirements before prescribing high‑cost or specialty agents.
Use payer resources or call the number on the member ID card for PA submission guidance.

Denial Risk

PA/AC/QL flagged products carry higher administrative review and denial risk

Products flagged with 'PA' or 'AC' and those exceeding QL may trigger denial if appropriate authorization or administrative conditions are not satisfied; adhere to listed controls and provide required documentation.

AC flags on contraceptives indicate administrative constraints; follow plan rules.
Exceeding QL without approved PA or exception may cause denial.

Prior Authorization

PA/QL triggers for specific formulations (Riomet, ER metformin, tirzepatide, semaglutide)

Requests for certain formulations (for example Riomet solution, ER metformin formulations, tirzepatide, semaglutide, dulaglutide) may be subject to PA or QL per the drug list; ensure PA and QL compliance to avoid denials.

Riomet — PA, QL (780 mls/30 days).
MOUNJARO, OZEMPIC, RYBELSUS — PA and specified pen/tablet QLs.

Denial Risk

Prior authorization risk for specialty/SP agents

Specialty agents that are designated 'SP' and 'PA' are subject to coverage limits and may be denied without prior authorization and appropriate specialty handling; providers should submit required documentation and use specialty pharmacies when indicated.

Examples: TYVASO, UPTRAVI, NUCALA — PA and SP designations with QL values.
Failure to meet SP/PA/QL requirements can result in claim denial.

Denial Risk

Noncompliance with PA/QL may result in denial (TYVASO, UPTRAVI examples)

Requests that do not meet PA or QL requirements for listed drugs (e.g., TYVASO, UPTRAVI) may be denied; providers should ensure PA approvals and adherence to QL prior to dispensing.

TYVASO — PA, QL (81.2 mls/28 days), SP; UPTRAVI — PA, QL (60 tablets/30 days), SP.
Obtain PA and follow QL to prevent denials.

Prior Authorization

PA required where indicated — obtain approval to avoid denial

Prior authorization is required for the drugs listed with 'PA' — absence of required PA risks coverage denial; confirm PA status on the product line before dispensing.

PA is required for many specialty biologics and modulators in this segment.
Submit PA per payer instructions to secure coverage.

Prior Authorization

PA required when shown — verify before dispensing

Prior authorization is required where indicated in the drug list; failure to obtain PA when shown may result in claim denial.

Always check the Special Requirements column for PA before dispensing.
Claims submitted without PA for PA‑flagged drugs risk denial.

Denial Risk

Quantity limit exceedance may trigger denial (VOWST example)

Quantity limits are enforced per product; exceeding the listed QL (for example VOWST limited to 12 capsules/12 months) may trigger claim denial unless an approved exception or PA is in place.

VOWST — QL 12 capsules/12 months; exceeding this may lead to denial.
Request exception or PA with supporting documentation to exceed QL.

Prior Authorization

PA may be required for NUPLAZID and Hetlioz

Prior authorization may be required for products such as NUPLAZID and tasimelteon (Hetlioz) as noted on the formulary; providers should obtain PA and adhere to any QL to prevent denial.

NUPLAZID — PA, QL (30 capsules/30 days).
tasimelteon (Hetlioz) — PA, QL (30 capsules/30 days), SP.

Billing Rule

QL examples for CNS agents; adhere to QL or provide documentation

Quantity limits for CNS and related agents are specified (examples include zuranolone and aripiprazole oral solution) — ensure dispensed quantities do not exceed the listed QL or provide supporting documentation with PA/exception requests.

zuranolone — QL 28 or 14 capsules per 365 days depending on strength.
aripiprazole oral solution — QL 900 mL/30 days.

Step Therapy Controls

Product	Formulation / Note	Flags / Controls
{"text":"AUVELITY","status":""},{"text":"dextromethorphan-bupropion ER tablet 45-105 mg","status":""},{"text":"ST (listed)","status":""}
{"text":"CITALOPRAM","status":""},{"text":"citalopram hydrobromide cap 30 mg","status":""},{"text":"ST (listed)","status":""}
{"text":"DESVENLAFAXINE ER","status":""},{"text":"desvenlafaxine ER 50 mg, 100 mg","status":""},{"text":"ST (listed)","status":""}
{"text":"QUETIAPINE","status":""},{"text":"quetiapine fumarate (multiple strengths)","status":""},{"text":"ST (listed for some formulations)","status":""}
{"text":"AUVELITY / Antidepressant class examples","status":""},{"text":"See antidepressant/antipsychotic section","status":""},{"text":"ST indicated in Special Requirements column for select agents","status":""}

Utilization Control	Common examples in list	Role (summary)
{"text":"Prior Authorization (PA)","status":""},{"text":"EPCLUSA, HARVONI, MAVYRET, ARIKAYCE, many specialty agents (e.g., NUCALA, TYVASO, UPTRAVI)","status":""},{"text":"Primary gate requiring prescriber to obtain plan approval before coverage","status":""}
{"text":"Quantity Limit (QL)","status":""},{"text":"EPCLUSA QL (28 tablets/28 days), UPTRAVI QL (60 tablets/30 days), NUCALA QL (1 syringe/28 days or 3 pens/28 days)","status":""},{"text":"Controls dispensed amount per time period; claims may be limited/denied if exceeded","status":""}
{"text":"Specialty Pharmacy / Site-of-care (SP)","status":""},{"text":"EPCLUSA, MAVYRET, many biologics (NUCALA, TEZSPIRE), TYVASO, UPTRAVI marked SP","status":""},{"text":"Requires specialty dispensing channel and may impose additional handling/site controls","status":""}
{"text":"Step Therapy (ST)","status":""},{"text":"Examples shown (AUVELITY, select antidepressants/antipsychotics); but explicit sequences not listed in this excerpt","status":""},{"text":"Flag indicating a fail‑first requirement when present; sequencing algorithms not provided here","status":""}
{"text":"Administrative Condition (AC)","status":""},{"text":"Multiple contraceptives (ANNOVERA, many oral contraceptives) labeled AC","status":""},{"text":"Administrative constraint (e.g., formulary substitution or special handling) — not full clinical step details","status":""}

Product	Formulation / Example line	Designation (as listed)
{"text":"EPCLUSA","status":""},{"text":"sofosbuvir-velpatasvir tab / pellet pack","status":""},{"text":"PA, QL (28 tablets/28 days or 28 packs/28 days), SP","status":""}
{"text":"HARVONI","status":""},{"text":"ledipasvir-sofosbuvir tab / pellet pack","status":""},{"text":"PA, QL (28 tablets/28 days or 28 packs/28 days), SP","status":""}
{"text":"MAVYRET","status":""},{"text":"glecaprevir-pibrentasvir tab / pellet pack","status":""},{"text":"PA, QL (90 tablets/30 days or 140 packs/28 days), SP","status":""}
{"text":"ARIKAYCE","status":""},{"text":"amikacin liposome inhalation suspension 590 mg/8.4 ml","status":""},{"text":"PA, QL (28 vials/28 days), SP","status":""}

Product	Formulation / Note	Absence of step details (note)
{"text":"Various oncology agents (e.g., STIVARGA, sunitinib, TAGRISSO)","status":""},{"text":"Multiple oral oncology packs with PA, QL, SP noted","status":""},{"text":"PA/QL/SP present; no step therapy sequence or step-by-step algorithm provided in this excerpt","status":""}
{"text":"UPTRAVI","status":""},{"text":"selexipag tablets and titration pack","status":""},{"text":"PA, QL and SP listed but no explicit step therapy sequence provided in the document part","status":""}
{"text":"Biologics (e.g., NUCALA)","status":""},{"text":"mepolizumab pref syringe/pen","status":""},{"text":"Listed PA/QL/SP controls; step therapy sequencing not specified here","status":""}
{"text":"Contraceptives (e.g., ANNOVERA, many oral contraceptives)","status":""},{"text":"multiple formulations labeled AC and QL","status":""},{"text":"Administrative conditions noted; step therapy details absent","status":""}

Product	Formulation / Example	Administrative control (AC) / Note
{"text":"ANNOVERA","status":""},{"text":"segesterone acetate-ethinyl estradiol vaginal ring","status":""},{"text":"AC, QL (1 ring/365 days) — administrative condition noted in Special Requirements","status":""}
{"text":"Many combined oral contraceptives","status":""},{"text":"various 28-tablet packs (multiple brands)","status":""},{"text":"AC, QL (28 tablets/21 days) — administrative conditions applied; no step therapy details","status":""}
{"text":"LEVONORGESTREL (emergency contraception)","status":""},{"text":"levonorgestrel 1.5 mg tablet","status":""},{"text":"AC, QL (2 tablets/365 days) — labeled AC in Special Requirements column","status":""}

Product	Formulation / Presentation	PA / QL / Step therapy note
{"text":"MOUNJARO","status":""},{"text":"tirzepatide auto-injector (5–15 mg)","status":""},{"text":"PA, QL (4 pens/28 days) — prior authorization required; quantity limit noted","status":""}
{"text":"OZEMPIC","status":""},{"text":"semaglutide pen-injector (multiple dose strengths)","status":""},{"text":"PA, QL (1 pen/28 days)","status":""}
{"text":"RYBELSUS","status":""},{"text":"semaglutide oral tablets (3 mg/7 mg/14 mg)","status":""},{"text":"PA, QL (3 mg: 30 tabs/180 days; 7/14 mg: 30 tabs/30 days)","status":""}

Product	Formulation / Strength	PA / QL / SP / Step note
{"text":"OZEMPIC","status":""},{"text":"semaglutide solution pen-injector","status":""},{"text":"PA, QL (1 pen/28 days)","status":""}
{"text":"RYBELSUS","status":""},{"text":"semaglutide oral tablet 3/7/14 mg","status":""},{"text":"PA, QL (3 mg: 30 tabs/180 days; 7/14 mg: 30 tabs/30 days)","status":""}
{"text":"MOUNJARO","status":""},{"text":"tirzepatide auto-injector presentations","status":""},{"text":"PA, QL (4 pens/28 days) — prior authorization and quantity limits applied","status":""}

Product	Formulation / Detail	PA / QL / Note
{"text":"UPTRAVI","status":""},{"text":"selexipag tablets; titration pack (therapy pack)","status":""},{"text":"PA, QL (60 tablets/30 days); titration pack PA, QL (1 pack/180 days), SP — no step therapy sequence specified","status":""}
{"text":"UPTRAVI TITRATION PACK","status":""},{"text":"therapy pack 200 mcg (140) & 800 mcg (60)","status":""},{"text":"PA, QL (1 pack/180 days), SP — titration pack rule present; step sequencing not given","status":""}
{"text":"NUCALA","status":""},{"text":"mepolizumab pref syringe / pen presentations","status":""},{"text":"PA, QL (1 syringe/28 days or 3 pens/28 days), SP — specialty/PA gates present; step therapy not defined in these chunks","status":""}

Product	Listing detail	Step therapy presence
{"text":"UPTRAVI","status":""},{"text":"PA, QL, SP; titration pack limited to 1 pack/180 days","status":""},{"text":"No explicit step therapy sequence provided in these document chunks","status":""}
{"text":"EPCLUSA / HARVONI / MAVYRET","status":""},{"text":"HCV regimens listed with PA, QL, SP (e.g., EPCLUSA QL 28 tablets/28 days)","status":""},{"text":"No — step sequences are not specified in this excerpt; PA/QL/SP are primary controls","status":""}
{"text":"ARIKAYCE","status":""},{"text":"amikacin liposome inhalation suspension; PA, QL (28 vials/28 days), SP","status":""},{"text":"No step therapy sequencing documented in these chunks","status":""}

Product	Formulation / Example	Administrative control (AC) / Note
{"text":"ANNOVERA","status":""},{"text":"segesterone acetate-ethinyl estradiol vaginal ring","status":""},{"text":"AC, QL (1 ring/365 days) — administrative condition applied","status":""}
{"text":"Combined oral contraceptives (multiple brands)","status":""},{"text":"various 28-tablet packs","status":""},{"text":"Requirements/Limits = AC, QL (28 tablets/21 days) for many listed products — administrative condition noted","status":""}
{"text":"DEPO-SUBQ PROVERA 104","status":""},{"text":"medroxyprogesterone acetate subcutaneous pref syringe 104 mg/0.65 ml","status":""},{"text":"AC (administrative condition) listed; specific step edits not provided","status":""}
{"text":"LEVONORGESTREL / emergency contraception","status":""},{"text":"levonorgestrel tab 1.5 mg","status":""},{"text":"AC, QL (2 tablets/365 days) — labeled AC in Special Requirements column","status":""}

Product	Formulation	ST flag present?
{"text":"AUVELITY","status":""},{"text":"dextromethorphan-bupropion ER tablet 45-105 mg","status":""},{"text":"ST (listed) — requires step therapy prior to coverage when applied","status":""}
{"text":"CITALOPRAM","status":""},{"text":"citalopram hydrobromide cap 30 mg","status":""},{"text":"ST (listed on formulary line)","status":""}
{"text":"DESVENLAFAXINE ER","status":""},{"text":"desvenlafaxine ER tablets 50 mg, 100 mg","status":""},{"text":"ST (listed) — step therapy requirement indicated on Special Requirements column","status":""}

Product	Formulation / Example	ST flag (summary)
{"text":"AUVELITY","status":""},{"text":"dextromethorphan-bupropion ER 45-105 mg","status":""},{"text":"ST (requires trial of step agents as indicated)","status":""}
{"text":"CITALOPRAM","status":""},{"text":"citalopram hydrobromide 30 mg","status":""},{"text":"ST (listed) — step therapy applies per Special Requirements","status":""}
{"text":"QUETIAPINE","status":""},{"text":"quetiapine fumarate (various strengths)","status":""},{"text":"ST marked for certain formulations (e.g., quetiapine fumarate listed with ST in document)","status":""}

Quantity Limit Details

Quantity limit (QL) — general note

DefinitionQuantity Limit (QL): a dispensing/quantity restriction noted in the Special Requirements column; limits reported per time period (e.g., 30/28/365 days)

Varies by drugQL values differ by product formulation and presentation (tablets, mLs, cartridges, kits, pens, syringes)

IndicatorDrugs with a quantity restriction are flagged with 'QL' in the formulary listing

QL examples — selected products

AZITHROMYCINQL examples: 60 tablets/180 days for several azithromycin tablet strengths

CLARITHROMYCINQL example: 28 tablets/180 days for clarithromycin ER 500 mg

ARIKAYCE / TOBRAMYCINARIKAYCE: PA, QL (28 vials/28 days); TOBI PODHALER: QL (224 capsules/56 days)

PAXLOVIDPack-based QL: 11–30 tablets/90 days depending on pack size

EFAVIRENZ‑EMTRICITABINE‑TENOFOVIR (Symfi) — QL example

DrugEFAVIRENZ-LAMIVUDINE-TENOFOVIR (Symfi variants)

Quantity limit30 tablets per 30 days

Formulary noteListed with QL in Special Requirements

Emtricitabine solution 10 mg/mL — QL example

DrugEmtricitabine oral solution 10 mg/mL (Emtriva solution)

Quantity limit720 mLs per 30 days

Formulary noteMarked with QL in Special Requirements

Isentress chewable/tablets — QL example

DrugIsentress (raltegravir) chewable/pack/tablets

Quantity limitExamples include up to 180 tablets per 30 days for chewable formulation

Formulary noteIsentress presentations show differing QL values by formulation

MAVYRET — QL example

DrugMAVYRET (glecaprevir-pibrentasvir)

Quantity limit90 tablets per 30 days

Formulary noteListed with PA, QL and SP where applicable

PAXLOVID packs — QL examples

DrugPAXLOVID (nirmatrelvir/ritonavir packs)

Quantity limitPack-dependent QL: examples include 11, 20, or 30 tablets per 90 days depending on pack configuration

Formulary noteQL expressed based on pack size in the Special Requirements column

SUNLENCA / YEZTUGO — QL example

DrugSUNLENCA / YEZTUGO (lenacapavir)

Quantity limit4 tablets per 365 days

Formulary noteLong-interval QL noted in Special Requirements

XIFAXAN 550 mg — QL example

DrugXIFAXAN 550 mg (rifaximin)

Quantity limit126 tablets per 365 days

Formulary noteQL specified in Special Requirements

BALVERSA — duplicate QL entries noted

DrugBALVERSA (erdafitinib) 5 mg tab

Quantity limitsDuplicate entries noted: 60 tablets/30 days and 30 tablets/30 days

Formulary noteListed with PA, QL and SP

Multiple listed drugs — assorted QL examples

ScopeMultiple drugs across oncology, specialty and other classes show product-specific QL values (tablets, capsules, kits, syringes, pens)

Representative QLsExamples include 30, 60, 90, 120, 180 tablets per 30 days; 1 kit/28–180 days; 2 syringes/28 days; 3 pens/28 days

Formulary notePA and SP flags frequently accompany QL entries for specialty agents

NINLARO — QL example

DrugNINLARO (ixazomib citrate)

Quantity limit3 capsules per 28 days

Formulary noteListed with PA, QL and SP where applicable

PAZOPANIB — QL example

DrugPAZOPANIB (pazopanib HCl) 200 mg tab

Quantity limit120 tablets per 30 days

Formulary noteListed with PA and QL

VENCLEXTA — QL example

DrugVENCLEXTA (venetoclax) 100 mg tab

Quantity limit180 tablets per 30 days

Formulary noteListed with PA and QL

Prednisone DR — QL examples

DrugPREDNISONE DR delayed release 1 mg

Quantity limit90 tablets per 30 days

DrugPREDNISONE DR delayed release 2 mg — 60 tablets per 30 days

Testosterone cypionate 100 mg/mL — QL example

DrugTestosterone cypionate IM inj in oil 100 mg/mL

Quantity limit1 vial per 28 days

Related strengths200 mg/mL presentation shown with QL = 10 mLs/28 days

Testosterone cypionate 200 mg/mL — QL example

DrugTestosterone cypionate IM inj in oil 200 mg/mL

Quantity limit10 mLs per 28 days

Formulary noteListed with QL (and PA for some testosterone formulations)

Testosterone enanthate 200 mg/mL — QL example

DrugTestosterone enanthate IM inj in oil 200 mg/mL

Quantity limit5 mLs per 28 days

Formulary noteListed with PA and QL

Testosterone topical formulations — QL varies

Product typesTopical testosterone gels/packets/tubes and pumps vary by formulation

Typical QL rangeExamples include 30–60 packets/tubes/boxes per 30 days or 2 bottles per 30 days depending on product

Formulary noteSome topical presentations also require PA

ORIAHNN pack — QL example

DrugORIAHNN (elagolix-estradiol-norethindrone) pack

Quantity limit56 capsules per 28 days

Formulary noteListed with PA and QL in Special Requirements

MYFEMBREE — QL example

DrugMYFEMBREE (relugolix-estradiol-norethindrone acetate)

Quantity limit30 tablets per 30 days

Formulary noteListed with PA and QL where applicable

Estradiol TD patches — QL example

ProductEstradiol transdermal (TD) patches (various brands)

Quantity limit30 patches per 30 days

Formulary noteQL shown in Special Requirements for TD patch presentations

Contraceptives and levonorgestrel — QL examples

Product groupCombined oral contraceptives (many products)

Typical quantity limit28 tablets per cycle (common QL shown for many combined oral contraceptives)

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

FARXIGA / GLYXAMBI — QL examples

Drug classSGLT2 and combination antidiabetics (FARXIGA, GLYXAMBI, etc.)

Quantity limitCommon QL: 30 tablets per 30 days for FARXIGA/GLYXAMBI and similar agents

Formulary noteListed QL shown in Special Requirements for oral antidiabetics

XYOSTED auto-injector — QL example

DrugXYOSTED auto-injector (testosterone enanthate auto-injector)

Quantity limit4 pens per 28 days

Related productSimilar auto-injector presentations for testosterone shown with 4 pens/28 days QL

MOUNJARO — QL examples

DrugMOUNJARO (tirzepatide) — some presentations

Quantity limit4 pens per specified period (4 pens/180 days or 4 pens/28 days depending on presentation)

Formulary noteListed with PA and QL in Special Requirements

GLP‑1 and insulin QL examples

DrugsOZEMPIC, RYBELSUS, TRULICITY, common insulins

Quantity limitsOZEMPIC: 1 pen/28 days; RYBELSUS (3/7/14 mg): 30 tablets; TRULICITY: 4 pens/28 days; Common insulins: 100 mLs/30 days

Formulary notePA and QL applied as indicated per product presentation

Riomet oral solution — QL example

DrugRiomet (metformin oral solution 500 mg/5 mL)

Quantity limit780 mLs per 30 days

Formulary noteListed with PA and QL in Special Requirements where applicable

QBRELIS — reiterated QL example

DrugQBRELIS (lisinopril oral solution) — restated

Quantity limit2400 mLs per 30 days (listed with PA and QL)

Formulary noteMust adhere to QL when submitting PA or claim

REPATHA / REPATHA SURECLICK — QL examples

DrugREPATHA / REPATHA SURECLICK (evolocumab)

Quantity limit6 syringes/pens per 28 days

Formulary noteListed with PA and QL in Special Requirements

ADEMPAS / CAMZYOS — QL examples

DrugADEMPAS (riociguat) / CAMZYOS (mavacamten)

Quantity limitsADEMPAS: 90 tablets/30 days; CAMZYOS: 30 capsules/30 days

Formulary notePA and QL noted in Special Requirements

UPTRAVI / TYVASO — QL examples

DrugUPTRAVI (selexipag) / TYVASO (treprostinil)

Quantity limitsUPTRAVI: 60 tablets/30 days (titration pack 1/180 days); TYVASO solution: 81.2 mLs/28 days; TYVASO DPI cartridges: 112 cartridges/28 days

Formulary notePA, QL and SP flags apply — adhere to listed QL when requesting PA or submitting claims

Site-of-Care and Specialty Distribution

Billing Rule

Site‑of‑care: provider‑administered drugs may be medical benefit

Medications administered by a health care professional may be covered under the medical benefit rather than the pharmacy benefit; check site‑of‑care guidance for applicable agents.

Drugs administered in outpatient infusion centers, offices, or hospitals may be billed to the medical benefit.
Refer to plan/site‑of‑care rules to determine appropriate billing pathway.

Billing Rule

Specialty pharmacy required for 'SP'‑flagged products

Products flagged 'SP' require specialty pharmacy dispensing; providers should arrange specialty fulfillment through the appropriate channel to ensure coverage.

Many specialty biologics and high‑cost agents carry the 'SP' designation.
Claims may be denied if SP requirements are not met.

Billing Rule

Specialty distribution: use specialty pharmacy channels for SP items

Specialty agents designated 'SP' are expected to be dispensed through specialty pharmacy channels and may have limited/distribution requirements; ensure use of the correct specialty vendor when filling these products.

ENTYVIO PEN, TRIKAFTA, many biologics and modulators include SP designation and QL values.
Confirm specialty distribution requirements and route orders accordingly.

Note

Background and Definitions

Specialty drugs are used to treat complex conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis and may be administered orally, topically, or by injection. Some specialty products require dispensing through specialty pharmacy channels or are administered in a clinical setting; drugs that must be administered by a health care professional may be billed and covered under the medical benefit rather than the pharmacy benefit. Formulary entries for specialty agents commonly include PA, QL and SP designations to reflect these controls and handling requirements.