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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Cross Blue Shield OK — Drug List Coverage | O…
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    CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

    2026 Drug List (Pharmacy Benefit) — Coverage Criteria

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    Lists covered prescription and specialty drugs, tier placements, and utilization controls (PA, ST, QL, SP); guidance for providers and members about pharmacy benefit coverage for Blue Cross and Blue Shield of Oklahoma.

    Policy Summary
    PayerBlue Cross Blue Shield - Oklahoma
    Policy2026 Drug List (Pharmacy Benefit) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAdministrative — annual drug list publication
    Effective DateApril 2026
    Next Review DateN/A
    Key ActionObtain prior authorization when 'PA' appears in a product's Requirements/Limits before submitting a claim.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2026drug list edition year
    ~120+drug listings in excerpt
    PA / QL / SP / STutilization controls present
    multipleexamples of requirement types
    30/90typical supply limits discussed

    Coverage & Product Controls

    General formulary coverage criteria

    Covered when plan benefit and drug list inclusion criteria are met:

    Formulary inclusion and benefit consistency: Drug is listed on the Drug List and is within the member's pharmacy benefit as defined by the member's plan; drugs not shown on the Drug List are not covered.

    See plan materials and provider portal for plan-specific exclusions and tier assignments.

    Special requirements: If a drug is marked with PA, ST, QL, DL or AC in the Requirements/Limits (Special Requirements) column, the corresponding requirement (prior authorization, step therapy, quantity/dispensing limit, dispensing limit, administrative/clinical criteria) must be satisfied for coverage.

    Requirements/Limits flags are shown next to each product in the drug list.

    Administration site and benefit channel: Medications that require clinician administration (e.g., infusions, injections administered in a clinic) may be billed to the medical benefit rather than the pharmacy benefit; provider should verify site-of-care coverage and channel requirements.
    Policy Summary
    PayerBlue Cross Blue Shield - Oklahoma
    Policy2026 Drug List (Pharmacy Benefit) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAdministrative — annual drug list publication
    Effective DateApril 2026
    Next Review DateN/A
    Key ActionObtain prior authorization when 'PA' appears in a product's Requirements/Limits before submitting a claim.
    SourceLink
    On This Page
    Coverage & Product ControlsFormulary Listings & Code TablesAuthorization, Documentation & Denial TriggersDocumented Quantity Limits (Selected Examples)Terminology & AbbreviationsStep Therapy & Specialty Channel ControlsSpecialty Pharmacy & Dispensing ChannelPolicy Background & Scope

    Some items are designated SP (specialty) and may require specialty pharmacy handling.

    Coverage indicator per product (listing)

    Coverage and access conditions are indicated per product via the Requirements/Limits shorthand and Drug Tier.

    Formulary product requirement: Product must be listed and meet the Requirements/Limits codes shown (for example: AC, PA, QL, SP) and is covered according to its Drug Tier placement.

    Document lists products with Requirement/Limits flags but individual clinical justification is managed via the identified PA/QL/ST rules.

    Listed drugs — coverage subject to product-specific controls

    Covered when listed and when any associated utilization controls are met

    Coverage rule: Drugs listed are covered subject to the specific Requirements/Limits shown (examples include AC, PA, QL, SP); coverage requires adherence to those per-product controls.See individual product QL entries (e.g., 28 tablets/21 days; 1 pen/28 days; 100 mls/30 days)

    This section provides product-level coverage with administrative controls rather than detailed clinical eligibility criteria.

    General formulary coverage with utilization management

    Coverage is indicated by drug entry and may be subject to ALL of the following as listed per product:

    Formulary entry conditions: Drug is listed with a Drug Tier and may have Requirements/Limits such as PA (prior authorization), QL (quantity/dispensing limit), ST (step therapy), or SP (specialty pharmacy); adherence to these requirements is necessary for coverage.

    Specific clinical eligibility criteria, PA forms, or step sequences are maintained separately and must be followed when the product is flagged.

    Drugs that are not listed on the Drug List are not covered. The policy notes common exclusions including non–FDA‑approved drugs, repackaged medications, and many compounded products. Typical supply limits are up to a 30‑day supply (some plans allow up to 90 days for maintenance therapies), and coverage is generally limited to FDA‑approved indications and recognized evidence‑based guidelines. Providers should consult the member’s benefit materials for plan‑specific exclusions and coverage details.

    Several listed products carry a Drug Tier = NP designation (non‑preferred) such as PALFORZIA and ORALAIR; this indicates a non‑preferred formulary placement but does not, by itself, denote that the drug is excluded. Explicit exclusions are not commonly spelled out in the product lines shown; instead, coverage differences are implemented through tier placement and Requirements/Limits codes (e.g., PA, QL, SP).

    Within the excerpted formulary lines there are no explicit clinical exclusion statements (for example, blanket statements that a therapeutic class is not covered). The listings are primarily product entries with tier assignments and shorthand utilization controls (e.g., PA, QL, SP, AC), so clinical eligibility is handled at the product‑level via those controls rather than by broad exclusion language.

    This section intentionally left blank for future coverage notes or plan‑specific exclusion details.

    In the provided excerpt there are no explicit exclusions listed for the vaginal and genitourinary product lines shown; entries are presented with Drug Tier and, where applicable, Requirements/Limits but not with standalone exclusion statements. Verify member benefits for any plan‑level exclusions that may apply.

    The document states that drugs used for cosmetic purposes (for example, agents for hair growth) and medications prescribed outside the FDA‑approved age range for a member may not be covered. Members and providers should confirm whether such uses are excluded under the member’s specific benefit plan.

    When a product is marked NP (non‑preferred) in the formulary it denotes a higher‑cost or non‑preferred tier placement but is distinct from a determination of not medically necessary. The listing and tier notation indicate formulary preference and potential cost‑sharing differences; clinical denial or lack of coverage would instead be driven by explicit Requirements/Limits (e.g., PA) or by documented exclusions in the member’s plan materials.

    This block is reserved for additional exclusion or coverage clarification content if needed.

    In this excerpt there are no statements explicitly labeled ‘not medically necessary’. The formulary uses tiering (P/NP) and Requirements/Limits codes (e.g., PA, QL, SP, ST, AC) to manage coverage and access; absence of an explicit NMN statement in the excerpt means NMN determinations would be handled via benefit rules, clinical review, or separate policy language.

    Formulary Listings & Code Tables

    Selected formulary entries from Anti-infective/PenicillinsmixedCovered
    AMOXICILLINamoxicillin (trihydrate) chew tab 125 mg, 250 mg — Drug Tier = NP
    amoxicillin (trihydrate) cap 250 mg, 500 mgDrug Tier = p
    amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5mlDrug Tier = p
    amoxicillin (trihydrate) for susp 400 mg/5ml (Amoxicillin)Drug Tier = p
    amoxicillin (trihydrate) tab 500 mg, 875 mgDrug Tier = p
    amoxicillin & k clavulanate for susp 200-28.5 mg/5mlDrug Tier = p
    amoxicillin & k clavulanate for susp 250-62.5 mg/5ml, 400-57 mg/5mlDrug Tier = np
    Formulary entries (drug names and strengths with tiers/requirements)mixed
    No codes listed
    Formulary product lines and Requirements/Limitsmixed
    COMIRNATY 2025-26covid-19 mrna vac tris-pfizer im susp pref syr 30 mcg/0.3ml; Requirements/Limits = AC; Drug Tier = P
    COMIRNATY/5-11Y/2025-26covid-19 mrna vac tris-s 5-11y-pfizer im susp 10 mcg/0.3ml; Requirements/Limits = AC; Drug Tier = P
    ENGERIX-Bhepatitis b vaccine (recombinant) susp pref syr 10 mcg/0.5ml, 20 mcg/ml; Requirements/Limits = AC; Drug Tier = P
    FLUAD 2025-2026influenza vac type a&b surface ant adj susp pref syr 0.5 ml; Requirements/Limits = AC; Drug Tier = P
    FLUARIX 2025-2026influenza virus vaccine split pf susp pref syringe 0.5 ml; Requirements/Limits = AC; Drug Tier = P
    GARDASIL 9human papillomavirus (hpv) 9-valent recomb vac; Requirements/Limits = AC; Drug Tier = P
    HEPLISAV-Bhepatitis b vaccine recomb adjuvanted pref syr 20 mcg/0.5ml; Requirements/Limits = AC; Drug Tier = P
    JYNNEOSsmallpox & monkeypox vac, live, non-replicating inj 0.5 ml; Requirements/Limits = AC; Drug Tier = P
    PNEUMOVAX 23pneumococcal vaccine polyvalent soln pref syr 25 mcg/0.5ml; Requirements/Limits = AC; Drug Tier = P
    PREVNAR 20pneumococcal 20-valent conjugate vaccine sus pref syr 0.5 ml; Requirements/Limits = AC; Drug Tier = P
    1–10 of 24
    1/3
    Contraceptives and progestins (sample)mixedCovered
    ARANELLEnorethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg- mcg
    AVERIdesogestrel-ethinyl estradiol-fe tab 0.15-0.03 mg
    DEPO-SUBQ PROVERA 104medroxyprogesterone acetate susp pref syr 104 mg/0.65ml
    ELLAulipristal acetate tab 30 mg
    NUVARINGetonogestrel-ethinyl estradiol va ring 0.12-0.015 mg/24hr
    TWIRLAlevonorgestrel-ethinyl estradiol td ptwk 120-30 mcg/24hr
    Antidiabetics, glucagon, insulins (sample)mixedCovered
    BAQSIMIglucagon nasal powder 3 mg/dose (ONE PACK / TWO PACK)
    MOUNJAROtirzepatide soln auto-injector (various strengths)
    OZEMPICsemaglutide soln pen-inj (various dosings)
    RYBELSUSsemaglutide tab (3 mg, 7 mg, 14 mg)
    TRULICITYdulaglutide soln auto-injector (various strengths)
    FIASPinsulin aspart (with niacinamide) inj 100 unit/ml
    HUMALOGinsulin lispro inj soln 100 unit/ml and pen/cartridge forms
    Formulary entries (no billing codes)mixed
    N/ANo CPT/HCPCS/ICD-10/NDC/other billing codes present in this excerpt; only drug names, strengths, tiers, and requirements.
    Formulary drug entries (partial)mixed
    WINREVAIRsotatercept-csrk for subcutaneous soln kit 45 mg, 60 mg, 2 x 45 mg, 2 x 60 mg
    YUTREPIAtreprostinil sodium inhal cap 26.5 mcg, 53 mcg, 79.5 mcg, 106 mcg
    avanafilavanafil tab 50 mg, 100 mg, 200 mg (Stendra)
    CAVERJECTalprostadil for inj 20 mcg, 40 mcg
    Erectile dysfunction agentsmixed
    sildenafilsildenafil citrate tab 25 mg, 50 mg, 100 mg (Viagra)
    tadalafiltadalafil tab 2.5 mg; tadalafil tab 5 mg (Cialis); tadalafil tab 10 mg, 20 mg (Cialis)
    vardenafilvardenafil hcl orally disintegrating tab 10 mg; vardenafil hcl tab 2.5 mg, 5 mg, 10 mg, 20 mg
    Respiratory and CF specialty agentsmixed
    ADVAIR HFAfluticasone-salmeterol inhal aerosol 45-21 mcg/act, 115-21 mcg/act, 230-21 mcg/act
    ALYFTREKvanzacaftor-tezacaftor-deutivacaftor tab (CFTR modulator) multiple strengths
    TRELEGY ELLIPTAfluticasone-umeclidinium-vilanterol aepb 100-62.5-25 mcg/act, 200-62.5-25 mcg/act
    XOLAIRomalizumab subcutaneous soln multiple strengths
    NUCALAmepolizumab subcutaneous solution multiple presentations
    FASENRA PENbenralizumab subcutaneous soln auto-injector 30 mg/ml
    TEZSPIREtezepelumab-ekko subcutaneous soln auto-inj 210 mg/1.91ml
    TRIKAFTAelexacaftor-tezacaftor-ivacaftor combinations various strengths/forms
    Sample listed products (not exhaustive)mixed
    TRIKAFTA - elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor 75 mg tbpkProduct line entry with Drug Tier = P; Requirements/Limits = PA, QL (56 packets/28 days), SP
    TRIKAFTA - elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor 75 mg tbpkAlternate strength entry with QL (84 tablets/28 days)
    TRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg & ivacaftor 150 mg tbpkProduct line entry with Drug Tier = P; Requirements/Limits = PA, QL (84 tablets/28 days), SP
    Formulary drug entries (partial)mixed
    estradiol vaginal tab 10 mcg (Vagifem)listed drug with Drug Tier = np
    ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs)Drug Tier = P
    GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal cream 2%Drug Tier = NP
    metronidazole vaginal gel 0.75%Drug Tier = np
    Specialty / PA required drugsmixedCovered
    FILSPARI - sparsentan tab 200 mg, 400 mgDrug Tier = NP; Requirements/Limits = PA, QL (30 tablets/30 days), SP
    PROCYSBI - cysteamine bitartrate delayed release granules packet 75 mg, 300 mgDrug Tier = NP; Requirements/Limits = PA, SP
    PROCYSBI - cysteamine bitartrate cap delayed release 25 mg (base equiv), 75 mg (base equiv)Drug Tier = NP; Requirements/Limits = PA, SP
    VANRAFIA - atrasentan hcl tab 0.75 mgDrug Tier = NP; Requirements/Limits = PA, SP
    Products with quantity limitsmixedCovered
    ZURZUVAE - zuranolone cap 20 mg, 25 mgDrug Tier = P; Requirements/Limits = QL (28 capsules/365 days)
    ZURZUVAE - zuranolone cap 30 mgDrug Tier = P; Requirements/Limits = QL (14 capsules/365 days)
    aripiprazole oral solution 1 mg/mlDrug Tier = np; Requirements/Limits = QL (900 mls/30 days)
    clozapine susp 50 mg/ml (VERSACLOZ)Drug Tier = NP; Requirements/Limits = QL (540 mls/30 days), ST
    Formulary control codes and tier labelsmixed
    QL (60 tablets/30 days)Quantity limit example
    QL (30 tablets/30 days)Quantity limit example
    QL (120 tablets/30 days)Quantity limit example
    QL (480 mls/30 days)Quantity limit example for liquid risperidone
    QL (158 mls/30 days)Quantity limit example for tasimelteon oral suspension
    PAPrior authorization required
    SPSpecialty designation
    STStep therapy indicator
    Drug Tier = PPreferred tier
    Drug Tier = NPNon-preferred tier
    1–10 of 12
    1/2
    Supply duration — typical
    Typical supplyUp to 30-day supply is standard under most prescription drug benefit plans
    Maintenance medicationsSome plans allow up to a 90-day supply for maintenance medications (e.g., HTN, diabetes, hyperlipidemia)
    Plan variabilityIndividual benefit plans may exclude certain agents or categories (e.g., erectile dysfunction, weight-loss) or limit coverage by age
    Coverage basisCoverage may be limited to FDA‑approved uses and recognized evidence‑based clinical practice guidelines
    Quantity limits examples (selected)
    Azithromycin (Zithromax z‑pak)QL 60 tablets/180 days
    Tobramycin nebu soln (KITABIS PAK / Tobi)QL 280 mls/56 days
    Itraconazole cap 100 mg (Sporanox)QL 120 capsules/30 days
    Clarithromycin ER 500 mgQL 28 tablets/180 days
    Quantity limits — antiviral / ARV examples
    Multiple antiretroviral oral productsCommon QL: 30 tablets/30 days
    GENVOYA (elvitegravir-cobicistat-emtricitab-tenofovir)QL 30 tablets/30 days (alternate listing shows QL 120 tablets/30 days)
    HARVONI (ledipasvir-sofosbuvir)PA; QL 28 tablets/28 days or QL 28 packs/28 days
    MAVYRET (glecaprevir-pibrentasvir)PA; QL 90 tablets/30 days or QL 140 packs/28 days
    Quantity limits — contraceptive and insulin examples
    Contraceptives — typical QLMost oral contraceptives QL 28 tablets/21 days (example listings)
    Ella (ulipristal acetate) emergency contraceptiveQL 2 tablets/365 days
    Contraceptive rings/patchesExamples: 1 ring/365 days (ANNOVERA); norelgestromin patch QL 3 patches/21 days
    Insulin pen/pen limitsExamples in listing: 1 pen/28 days (some products), 4 pens/28 days (MOUNJARO listed for GLP‑1 class)
    Insulin monthly volume limit
    Insulin monthly volume limit (standard)QL 100 mls per 30 days
    Insulin pen/cartridge examplesMultiple rapid‑ and short‑acting insulins listed with QL 100 mls/30 days (e.g., HUMALOG, NOVOLOG, FIASP)
    ApplicabilityQL 100 mls/30 days is commonly applied across listed insulin presentations (pens, cartridges, vials)
    Quantity limits — specialty product examples
    Specialty product capsule limitsExamples include QL 14 capsules/28 days and QL 60 capsules/30 days
    Specialty product liquid limitsExamples include QL 120 mls/30 days for select oral solutions
    Vials/packsSome specialty products have QL expressed as vials/packs (e.g., QL 10 vials/30 days in sample entries)
    Quantity limits — assorted specialty/large-volume examples
    Large-volume oral solutionsEpaned (enalapril oral solution) QL 1200 mls/30 days; QBRELIS (lisinopril oral solution) QL 2400 mls/30 days
    REPATHA (evolocumab)QL 6 syringes per 28 days
    TYVASO (treprostinil inhalation solution)QL 81.2 mls per 28 days
    Quantity limits — kits / capsules / tablets examples
    Kits and multi-dose itemsExamples: 1 kit/21 days (WINREVAIR), 112 capsules/28 days (YUTREPIA), 8 tablets/30 days (avanafil)
    Inhaler/inhalation device limitsExamples: COMBIVENT RESPIMAT QL 2 inhalers/30 days; TYVASO DPI kits have cartridge QLs
    Patch/kit QLsSome injection/kit products listed with QL per kit or syringe (e.g., AVONEX 1 kit/28 days)
    Quantity limits — packets / cartridges examples
    Cartridges / packets / cartridges packsExamples include TYVASO DPI maintenance kits with QL in cartridges (e.g., 112 cartridges/28 days) and TRIKAFTA QL 56 packets/28 days
    Inhalation cartridgesTYVASO listings show QL expressed as cartridges or refill kits with multi‑day QLs
    Packet limitsSome products (e.g., esomeprazole suspension packets) have packet QLs such as 60 packets/30 days
    Quantity limits — assorted psychotropic examples
    Psychotropic QLs — examplesAripiprazole oral solution QL 900 mls/30 days; risperidone solution QL 480 mls/30 days; clozapine OD/tabl formulations QLs vary by strength (e.g., 90–270 tablets/30 days)
    Oral tablet QLsBrexpiprazole (Rexulti) QL 60 or 30 tablets/30 days; risperidone ODT QL 60 tablets/30 days; risperidone 4 mg QL 120 tablets/30 days
    Transdermal patch QLsAsenapine transdermal patch (Secludo) QL 30 patches/30 days
    Quantity limits — multiple variations across list
    Common tablet/capsule QL patternsVarious examples across the listing include 30 tablets/30 days, 60 tablets/30 days, 120 tablets/30 days depending on product and strength
    Liquid formulationsMultiple liquid QLs shown (e.g., 480 mls/30 days for risperidone solution; 158 mls/30 days for tasimelteon suspension)
    Long‑interval QLsSome therapies use extended QL windows (e.g., 180 days, 301 days) for therapy packs or starter kits

    Authorization, Documentation & Denial Triggers

    Prior Authorization

    Prior Authorization Required

    Prior Authorization (PA) is commonly required for many specialty, antiviral, antineoplastic, and other high‑cost medications listed in this Drug List. When a medication requires PA, it will generally be noted with a 'PA' in the Requirements/Limits (Special Requirements) column. Obtain PA before dispensing to avoid claim denial or member liability.

    • Examples of agents commonly requiring PA: HARVONI, MAVYRET, SOVALDI, TRIKAFTA, many hepatitis/HIV antivirals and specialty antivirals — see listings.
    • Specialty and oncology agents frequently require PA and specialty pharmacy handling (SP) — examples include ALECENSA, ALUNBRIG, POMALYST, many TKIs and biologics.
    • Select high‑cost metabolic and weight‑management drugs require PA (e.g., MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, WEGOVY, ZEPBOUND).
    • Numerous specialty endocrine and growth agents require PA and specialty handling (e.g., ACTHAR, CRENESSITY, GENOTROPIN, OMNITROPE).
    • Many listed PA products also have Quantity Limits (QL) and Specialty Pharmacy (SP) designations — check the Requirements/Limits field for combined controls (PA, QL, SP).
    Step Therapy

    Step Therapy, Quantity Limits & Specialty Handling

    Step therapy (ST), quantity/dispensing limits (QL/DL), and specialty pharmacy (SP) handling are additional utilization controls noted in the Requirements/Limits column. If a step therapy requirement is present it will be noted as 'ST'; if a dispensing or quantity limit applies it will be noted as 'QL'. Specialty pharmacy handling will be noted as 'SP'.

    • If the prescribed quantity exceeds the QL or DL, the member may be responsible for the full cost for the amount beyond coverage.
    • Certain controlled substances may be subject to state laws that prohibit coverage beyond dispensing limits; in such cases the member will be responsible for the full cost if limits are exceeded.
    • ST indicates a required trial of a preferred, typically lower‑cost medication before coverage of the requested product may be approved.
    Denial Risk

    Authorization & Denial Triggers

    Failure to obtain required PA or to adhere to QL/ST requirements can result in claim denial or coverage limitations. PA and QL indicators in the Requirements/Limits field are operational triggers — prescribers should submit supporting clinical documentation with PA requests.

    • Claims may be denied if PA is required but not obtained prior to dispensing.
    • Requests that exceed quantity limits (QL) may be denied or require additional documentation to support medical necessity.
    • Noncompliance with ST may result in non‑coverage until step requirements are met or an exception is approved.
    Documentation Required

    Documentation Requirements for PA/QL Requests

    When submitting PA or exception requests, include complete clinical documentation to demonstrate medical necessity and to support requests for quantities beyond listed QL. Documentation improves the chance of timely approval and reduces reversal or denial risk.

    • Provide indication, prior therapies and responses, relevant labs or diagnostic results, dosing and duration rationale.
    • If requesting an exception to ST or QL, document why the preferred therapy is inappropriate or why additional quantity is medically necessary.
    • Use the PA forms and submission process indicated by the payer; prescribers or authorized representatives may call the number on the member ID card for exception requests and PA assistance.
    Note

    Coverage Exclusions & Exception Process

    Coverage exclusions and other conditions may trigger denials even when PA is not at issue. Repackaged products, compounded medications, non‑FDA‑approved drugs, and medications with OTC equivalents may be excluded from coverage.

    • If a drug is not on the Drug List, request a Drug List exception; exception decisions are provided within 15 calendar days (72 hours for expedited requests when applicable).
    • Over‑the‑counter equivalents and repackaged versions of marketed drugs are generally not covered under many plans — verify benefits prior to dispensing.
    • Call the number on the member’s ID card for questions or to initiate an exception.

    Documented Quantity Limits (Selected Examples)

    Azithromycin (Zithromax z‑pak)
    Azithromycin (Zithromax z‑pak)QL 60 tablets/180 days
    Azithromycin other strengthsOther tablet strengths also listed with QL 60 tablets/180 days
    Tier notesDrug Tier entries shown; QL applied in Requirements/Limits column
    Tobramycin nebulized solution (Tobi)
    Tobramycin nebu solution 300 mg/5 ml (Tobi / KITABIS PAK)QL 280 mls/56 days
    RequirementsListings often include PA and SP for inhaled aminoglycosides
    Multiple presentationsNebulized solution and kit presentations shown with same QL
    TOBI PODHALER — inhalation capsules
    TOBI PODHALER — tobramycin inhalation capsules 28 mgQL 224 capsules/56 days
    RequirementsPA and SP designation are applied to podhaler presentation in listings
    Equivalent solution QLNebulized solution QL shown separately (280 mls/56 days)
    Itraconazole cap 100 mg (Sporanox)
    Itraconazole capsule 100 mg (Sporanox)QL 120 capsules/30 days
    Oral solutionItraconazole oral solution also listed with QL 1200 mls/30 days
    PA/TierListed with Drug Tier = NP in segment and QL applied
    Antiretroviral oral products — common QL
    Multiple antiretroviral oral productsCommon QL applied: 30 tablets/30 days
    GENVOYA noteGENVOYA shown with QL 30 tablets/30 days (also alternate entry QL 120 tablets/30 days)
    Step/PASome antiviral agents also have PA and SP flags where indicated
    GENVOYA — quantity limit examples
    GENVOYAQL 30 tablets/30 days (alternate listing shows QL 120 tablets/30 days)
    RequirementsListed with Drug Tier = P and QL in Requirements/Limits column
    ApplicationQL varies by packaging/entry — check specific product line entry
    HARVONI — QL examples
    HARVONI (ledipasvir‑sofosbuvir)PA; QL 28 tablets/28 days or QL 28 packs/28 days
    SP designationListed HARVONI entries include SP (specialty) where shown
    Packaging variantsQL depends on tablet vs pellet pack presentation
    MAVYRET — QL examples
    MAVYRET (glecaprevir‑pibrentasvir)PA; QL 90 tablets/30 days or QL 140 packs/28 days
    SP designationMAVYRET entries include SP where indicated
    Pack vs tablet unitsQL varies by tablet vs pellet pack presentation
    PAXLOVID — pack‑dependent quantity limits
    PAXLOVID (nirmatrelvir + ritonavir)QL varies by pack: QL 11–30 tablets/90 days depending on pack configuration
    Pack-specific QLExamples include QL 11, 20, or 30 tablets/90 days tied to pack size
    TierListed with Drug Tier = P in segment
    PREVYMIS — annual quantity limit
    PREVYMIS (letermovir)QL 200 tablets/365 days
    PA/SPEntries include Requirements/Limits where applicable in listing
    Long‑interval QLQL expressed over 365‑day period for this product
    Vancomycin HCl capsules — QL
    Vancomycin HCl capsules (oral)QL 120 capsules/30 days
    Alternative oral solutionVancomycin oral solution (Firvanq) listed separately with its own QL entries
    Tier/RequirementsListed with Drug Tier = NP in segment
    Abiraterone acetate — example QLs
    Abiraterone acetate (Zytiga)Example QLs: 120 tablets/30 days (e.g., 250 mg) and 60 tablets/30 days (e.g., 500 mg)
    RequirementsListed with PA and QL in Requirements/Limits column
    SP designationMany antineoplastic entries also show SP where applicable
    ALECENSA — QL example
    ALECENSA (alectinib) 150 mgQL 240 capsules/30 days
    RequirementsListed with PA and SP designations in Requirements/Limits
    ApplicationQL reflects high daily dosing schedules for select oncology agents
    BRUKINSA — QL examples
    BRUKINSA (zanubrutinib) 80 mg / 160 mgQL examples: 120 capsules/30 days (80 mg) and 60 tablets/30 days (160 mg)
    RequirementsPA and SP are shown in Requirements/Limits for listed strengths
    Dose‑dependent QLDifferent strengths have different QLs as shown
    DAURISMO — glasdegib QL examples (25 mg / 100 mg)
    DAURISMO — glasdegib maleate 25 mgQL 60 tablets (per listing)
    DAURISMO — glasdegib maleate 100 mgQL 30 tablets (per listing)
    RequirementsEntries include PA and SP where indicated
    ERIVEDGE — QL example
    ERIVEDGE — vismodegib cap 150 mgQL 30 capsules
    RequirementsListed with PA and SP where applicable
    Typical oncology QL30 capsules is a common monthly QL for this agent
    LORBRENA — QL examples
    LORBRENA — lorlatinib 25 mgQL 120 tablets/30 days
    Alternate strengthLorlatinib 100 mg entry shown with QL 30 tablets/30 days
    RequirementsPA and SP are indicated for lorlatinib listings
    RUBRACA — QL example
    RUBRACA — rucaparib (various strengths)QL 120 tablets/30 days
    RequirementsListed with PA and SP designations
    ApplicabilityCommon QL for several oral targeted oncology agents
    PIQRAY — QL example
    PIQRAY (alpelisib) 300 mg daily dose packQL 56 tablets/28 days
    RequirementsEntry shows PA and QL in Requirements/Limits
    Pack dosingPack configured daily dosing reflected in 28‑day QL
    POMALYST — QL example
    POMALYST (pomalidomide)QL 21 capsules/28 days
    RequirementsListed with PA and SP designations
    Typical scheduleQL aligns with 28‑day cycle common for this agent
    ROZLYTREK — QL example
    ROZLYTREK — entrectinib pellet pack 50 mgQL 336 packets/28 days
    Alternate presentationsAlso listed with capsule QLs for other strengths (e.g., 30 capsules/30 days)
    RequirementsPA and SP indicated in Requirements/Limits column
    VENCLEXTA — QL example
    VENCLEXTA — venetoclax 100 mgQL 180 tablets/30 days
    Starter packStarting packs also listed with specific QLs (e.g., 1 pack/180 days)
    RequirementsPA and SP applied to therapy listings
    ALORA — patch quantity limit
    ALORA — estradiol transdermal patchQL 30 patches/30 days
    Patch dosing frequencyALORA is twice‑weekly patch; QL reflects 30 patches per 30‑day period
    TierListed with Drug Tier = NP in segment
    ORIAHNN — QL example
    ORIAHNN — elagolix‑estradiol‑norethindrone packQL 56 capsules/28 days
    RequirementsEntry shows PA and QL in Requirements/Limits
    Pack configurationPack QL corresponds to combination pack dosing schedule
    ANNOVERA — QL example
    ANNOVERA — segesterone ringQL 1 ring (1 ring/365 days)
    RequirementsANNOVERA entry includes AC and QL in Requirements/Limits
    DurationQL reflects single‑ring annual replacement per labeling
    Contraceptive and GLP‑1 / insulin examples across list
    Common contraceptive QLsMost oral contraceptives QL 28 tablets/21 days (typical listing)
    Emergency contraceptive (Ella)QL 2 tablets/365 days
    GLP‑1 pen examplesMOUNJARO QL 4 pens/28 days; OZEMPIC QL 1 pen/28 days; insulin pens often QL 100 mls/30 days
    Insulin products — common monthly volume
    Most listed insulin products — standard QLQL 100 mls per 30 days
    Products listed with QL 100 mls/30 daysExamples include HUMALOG, LYUMJEV, NOVOLOG, FIASP and multiple pen/cartridge presentations
    Applies to pens/cartridges/vialsQL 100 mls/30 days used across pen, cartridge, and vial presentations in listings
    Examples of specialty product limits — assorted
    Specialty product limits — assortedExamples include QL 14 capsules/28 days (GALAFOLD), QL 60 capsules/30 days, QL 10 vials/30 days, QL 120 mls/30 days
    VariabilityQLs vary by product type (capsules, vials, mls) and therapeutic area
    SP and PAMany specialty limits accompany PA and SP designations
    ORILISSA — quantity limit examples
    ORILISSA (elagolix)QL 30 tablets/30 days (150 mg) or QL 60 tablets/30 days (200 mg)
    RequirementsEntries include PA and QL in Requirements/Limits column
    Dose‑dependent QLQL differs by strength as listed
    Teriparatide (Forteo) — QL
    Teriparatide (Forteo) pen solutionQL 2.24 mls/28 days
    RequirementsListed with PA and QL and SP designations where applicable
    Monthly volumeQL corresponds to pen reservoir volume used per month
    VOXZOGO — QL example
    VOXZOGO (vosoritide)QL 30 vials/30 days
    RequirementsEntry includes PA, QL, and SP where indicated
    Vial‑based QLLarge QL reflects vial‑based dosing and supply needs
    Enalapril oral solution (Epaned) — QL
    Enalapril maleate oral solution (Epaned)QL 1200 mls/30 days
    Use caseLarge‑volume oral solutions have QLs expressed in mls per 30 days
    PA indicatedEpaned listing includes PA in Requirements/Limits column
    QBRELIS — QL example
    QBRELIS (lisinopril oral solution 1 mg/ml)QL 2400 mls/30 days
    Large‑volume oral solutionQL reflects dispensing for oral solution formulation
    RequirementsListed with PA and QL in Requirements/Limits column
    REPATHA — QL example
    REPATHA (evolocumab)QL 6 syringes per 28 days
    RequirementsListed with PA and QL; often SP handled
    Syringe QLQL expressed as syringes for injectable biologic
    TYVASO — QL example
    TYVASO (treprostinil inhalation solution)QL 81.2 mls (per 28 days) for listed presentation
    Cartridge/kit QLsTYVASO DPI entries include cartridge QLs (e.g., 112 cartridges/28 days) and refill kit QLs
    PA and SPPA and SP flags accompany TYVASO listings
    UPTRAVI / WINREVAIR / YUTREPIA — QL examples
    UPTRAVI (selexipag)QL 60 tablets/30 days
    WINREVAIR (sotatercept) kitQL 1 kit/21 days
    YUTREPIA (treprostinil inhal capsules)QL 112 capsules/28 days
    Erectile dysfunction agents — example QLs
    Avanafil (Stendra)QL 8 tablets/30 days
    Sildenafil (Viagra)QL 8 tablets/30 days
    Erectile dysfunction QL patternMost PDE5 agents listed with small monthly tablet QLs (e.g., 8 tablets)
    TRIKAFTA — QL examples
    TRIKAFTA (certain formulations)QL 56 packets/28 days or QL 84 tablets/28 days depending on formulation
    RequirementsListed with PA, QL and SP where applicable
    Formulation‑dependent QLPacket vs tablet presentation determines QL applied
    Esomeprazole suspension packets — QL
    Esomeprazole magnesium suspension packets (Nexium)QL 60 packets/30 days
    Oral suspension packet QLPacket formulations commonly have packet‑based QLs
    Tier/RequirementsEntries show Drug Tier and QL in Requirements/Limits column
    Sevelamer carbonate packets — QL
    Sevelamer carbonate packet 0.8 gm (Renvela)QL 510 packets/30 days
    High‑volume packet QLLarge packet QLs reflect frequent dosing for phosphate binders
    Alternate strengths2.4 gm packet listing shown with different QL (150 packets/30 days)
    FILSPARI — QL example
    FILSPARI (sparsentan)QL 30 tablets/30 days
    RequirementsListed with PA, QL and SP in Requirements/Limits column
    Therapeutic areaRenal/proteinuric agent treatment reflected in QL
    ZURZUVAE — QL (annual)
    ZURZUVAE — zuranolone 20/25 mgQL 28 capsules/365 days
    ZURZUVAE — zuranolone 30 mgQL 14 capsules/365 days
    Annual QLThese entries use 365‑day QLs reflecting short‑course treatment windows
    Aripiprazole / Clozapine — liquid and tablet QLs
    Aripiprazole oral solution 1 mg/mlQL 900 mls/30 days
    Clozapine (VERSACLOZ) suspensionQL 540 mls/30 days (example for liquid presentation)
    Clozapine tablets/ODTVarious QLs by strength: e.g., 90–270 tablets/30 days depending on strength

    Terminology & Abbreviations

    Step Therapy & Specialty Channel Controls

    Product / classListing notes
    Selected antiviral / antiretroviral products (e.g., GENVOYA, HARVONI, ISENTRESS)
    Listed with administrative/clinical controls (AC) or Requirements/Limits = PA and/or QL (examples: GENVOYA QL (120 tablets/30 days) or QL (30 tablets/30 days); HARVONI Requirements/Limits = PA, QL (28 tablets/28 days), SP). Step therapy implications may apply but explicit step sequences are not provided in the listing.
    Product / channelManagement controls
    PALFORZIA (peanut allergen powder) and other specialty items
    Designated SP (specialty) with Requirements/Limits = SP; many specialty products also require PA and have QL entries. Explicit step therapy steps are not included in the listing.
    Numerous oncology and specialty agents (e.g., ALECENSA, ALUNBRIG, CAMZYOS)
    Many are managed through specialty pharmacy (SP) and Requirements/Limits often include PA and QL; step therapy details are not specified in the excerpt.
    AgentRequirements / Quantity limit
    MOUNJARO (tirzepatide auto-injector)
    Requirements/Limits = PA, QL (4 pens/28 days)
    OZEMPIC (semaglutide pen)
    Requirements/Limits = PA; typical QL entries shown for semaglutide products (e.g., 1 pen/28 days for some presentations) as listed across the document.
    RYBELSUS (semaglutide tablets)
    Requirements/Limits = PA, QL (30 tablets/180 days for 3 mg; 30 tablets/30 days for 7/14 mg as listed)
    TRULICITY (dulaglutide auto-injector)
    Requirements/Limits = PA with associated QL entries (pen supply limits noted elsewhere in the listing)
    ProductStep therapy indicator
    KERENDIA (finerenone tablets 10 mg, 20 mg, 40 mg)
    Requirements/Limits = QL (30 tablets/30 days), ST (listed with 'ST' indicating step therapy may apply per formulary rules)
    Summary pointImplication
    Document excerpt does not specify step-therapy sequences for most products
    PA (prior authorization) and QL (quantity limits) are the primary utilization controls shown in the listing; where 'ST' appears it indicates step therapy may apply but detailed steps are not included in this excerpt.
    Product groupControls noted
    Pulmonary arterial hypertension / specialty PAH agents (e.g., CAMZYOS, OPSUMIT, ORENITRAM entries)
    Many PAH agents are designated SP and have Requirements/Limits = PA and QL; explicit step therapy specifics are not provided in the excerpt.
    Product classAuthorization requirement
    Cystic fibrosis modulators and specialty agents (e.g., TRIKAFTA entries)
    Requirements/Limits = PA, QL and SP for many CF modulators (TRIKAFTA shown with PA, QL (56 packets/28 days or 84 tablets/28 days), SP). PA is required before coverage per listing.
    Drugs labeled 'ST'Formulary action
    FETZIMA (levomilnacipran ER) and FETZIMA titration packs
    Requirements/Limits = ST (step therapy) — subject to step therapy edits per formulary rules before coverage of the listed product
    FANAPT (iloperidone) titration packs
    Requirements/Limits = QL (1 pack/180 days), ST — step therapy edit indicated
    SECUADO (asenapine transdermal patch) and VERSACLOZ (clozapine suspension)
    Requirements/Limits include ST (and QL for some presentations) indicating step therapy edits apply where shown
    Product typeManagement flags
    Specialty biologics and high-cost injectables (e.g., adalimumab biosimilars, ARCALYST)
    Designated SP (specialty) with Requirements/Limits often including PA and specific QL (examples: adalimumab biosimilins Requirements/Limits = PA, QL (2 syringes/28 days), SP). Additional management (PA/QL) may apply as listed.

    Specialty Pharmacy & Dispensing Channel

    Note

    Specialty pharmacy (SP) handling required

    When a product shows 'SP' the specialty pharmacy channel is required for dispensing; providers should coordinate with the plan's specialty pharmacy vendors for these medications.

    • SP designation indicates specialty pharmacy handling and processes

    Policy Background & Scope

    Specialty drugs are used to treat complex, chronic, or rare conditions and often require specialized handling. These products may be self‑administered or clinician‑administered, and many are managed under specialty pharmacy processes with utilization controls such as Prior Authorization (PA), Quantity Limits (QL), and Specialty (SP) designation. Clinician‑administered medications can be covered under the medical benefit rather than the pharmacy benefit, so providers should verify the appropriate benefit channel and any site‑of‑care requirements.