CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Pharmacy Drug List (therapeutic class and formulary details) — Part 4 of 5

Segment of the 2025 Blue Cross and Blue Shield drug list describing preferred drugs by therapeutic class, member payment tiers, coverage considerations (PA, ST, QL, ACA), specialty drug notes, and examples of drugs with requirements/limits for prescribers, pharmacists, members and billing operations.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPharmacy Drug List (therapeutic class and formulary details) — Part 4 of 5

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJanuary 2026

Next Review Date

Key ActionSubmit prior authorization requests when a medication is noted with 'PA' and follow plan-specific step therapy and quantity limit rules to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6member payment tiers described

manytherapeutic classes listed (partial document)

multipleentries with Prior Authorization (PA)

multipleentries with Quantity Limits (QL)

several

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entries flagged SP (specialty)

Part 4document segment

Scope & Purpose

This segment is part of the Blue Cross and Blue Shield 2025 Drug List and provides a partial listing of preferred medications organized by therapeutic class, with member payment tiers and coverage considerations. It summarizes formulary placement, special requirements such as Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), and Specialty (SP)

Coverage Notes & Criteria

This part does not contain formal medical-necessity criteria trees. Instead, it lists formulary entries together with their Special Requirements (for example, PA, QL, SP, ST, and AC/ACA) and dispensing/quantity limits where applicable. Use the Special Requirements column for coverage flags and follow plan materials or MyPrime.com for any plan-specific clinical protocols or step therapy pathways.

Drug Entries, Limits and Special Requirements

Example drug entries with requirements/limitsmixed

azithromycin for susp 200 mg/5ml	ZITHROMAX — QL (60 tablets/180 days) noted
DIFICID fidaxomicin for susp 40 mg/ml	Listed (no specific limit shown in this part)
EPCLUSA sofosbuvir-velpatasvir	PA, QL (30 tablets/30 days), SP
MAVYRET glecaprevir-pibrentasvir	PA, QL (90 tablets/30 days), SP
BIKTARVY bictegravir-emtricitabine-tenofovir AF	QL (30 tablets/30 days)
FIASP insulin aspart	QL (100 mls/30 days)
MOUNJARO tirzepatide	PA, QL (4 pens/28 days)
OZEMPIC semaglutide	PA, QL (various pen/28 days statements)
Many oncology and specialty agents (e.g., IBRANCE, IMBRUVICA, VENCLEXTA, XTANDI, TAGRISSO)	Mostly marked PA, QL and SP across many entries; QL quantities and days provided for many strengths

Antidiabetic agents, insulins and combinationsmixed

SYNJARDY	empagliflozin-metformin tablets — QL (60 tablets/30 days) for certain strengths
SYNJARDY XR	empagliflozin-metformin ER — QL (30–60 tablets/30 days) depending on strength
TRIJARDY XR	empagliflozin-linagliptin-metformin ER — QL (30–60 tablets/30 days)
TRULICITY	dulaglutide pens — PA, QL (4 pens/28 days)
ZEGALOGUE	dasiglucagon subcutaneous — requirements/limits not specified
FIASP / HUMALOG / NOVOLOG / LYUMJEV / INSULIN GLARGINE / TRESIBA etc.	multiple rapid-, short-, intermediate- and basal insulin products — typically QL (100 mls/30 days)
XULTOPHY	insulin degludec-liraglutide — QL (5 pens/30 days)

Endocrine and metabolic agents (miscellaneous)mixed

GENOTROPIN / OMNITROPE	somatropin products — PA and/or SP indicated for some presentations
FOLLISTIM AQ	follitropin beta inj — QL (various cartridges/30 days), SP
KERENDIA	finerenone tab — Requirements/Limits = .
ORILISSA	elagolix — PA, QL (30–60 tablets/30 days)

Cardiovascular agentsmixed

ENTRESTO	sacubitril-valsartan — PA, QL (240 capsules/30 days)
REPATHA	evolocumab prefilled syringe/auto-injector — PA, QL (6 syringes/pens/28 days)
VERQUVO	vericiguat — PA, QL (30 tablets/30 days)
CORLANOR	ivabradine — PA, QL (600 mls/30 days)
TADALAFIL / SILDENAFIL	ED agents — QL (8 tablets/30 days or other limits noted)

Respiratory agents and biologicsmixed

BREO ELLIPTA / TRELEGY / ASMANEX / SYMBICORT / QVAR etc.	inhaled controllers and combination inhalers — QL (typically 1–3 inhalers/30 days or blister limits)
NUCALA / FASENRA / XOLAIR / TEZSPIRE	mAbs and biologics — many with PA, QL (various pens/syringes/28–30 days), SP
ALBUTEROL NEBU / VENTOLIN HFA	short-acting bronchodilators — QL (2 inhalers/30 days or 125 containers/30 days for nebulizer solutions)

Cystic fibrosis modulatorsmixed

TRIKAFTA / SYMDEKO / KALYDECO / ALYFTREK

CF modulators — PA, QL (various tablets/packets/28–30 days), SP

Gastrointestinal agents and pancreatic enzymesmixed

CREON / ZENPEP	pancrelipase formulations — PA (and specified units)
LINZESS / TRULANCE / MOVANTIK / VIBERZI	GI agents — QL (30 tablets/30 days) or other specified QL

Neurologic / multiple sclerosis / immunomodulatorsmixed

PLEGRIDY / AVONEX / BETASERON / MAVENCLAD / MAYZENT / KESIMPTA	MS therapies — PA, QL (various kits/pens/vials/28–30 days), SP
MEMANTINE	Namenda — listed without QL

Psychotherapeutic agents (antidepressants, antipsychotics, stimulants, hypnotics)mixed

SSRIs (escitalopram, citalopram, fluoxetine, sertraline)	many entries with QL (e.g., escitalopram QL 60 capsules/30 days; fluoxetine QL 60/30 days)
BUPROPION / VENLAFAXINE / DULOXETINE	listed; some strengths have QL
ADHD agents (amphetamine-dextroamphetamine, methylphenidate, dexmethylphenidate)	QL common (e.g., Adderall 60 tablets/30 days; methylphenidate QL 90 tablets/30 days)
ANTIPSYCHOTICS (aripiprazole, olanzapine, quetiapine, risperidone, cariprazine)	various QL limits (30–180 tablets/30 days depending on agent/strength)
HYPNOTICS (zolpidem, eszopiclone, suvorexant)	QL commonly 30 tablets/30 days

Weight management agentsmixed

SAXENDA / WEGOVY / ZEPBOUND

GLP-1 / tirzepatide products for weight management — PA, QL (various pens/periods)

Common Quantity & Dispensing Limits

Quantity Limits examplese.g., QL (30 tablets/30 days), QL (90 tablets/30 days), QL (100 mls/30 days), QL (60 tablets/30 days)

Dispensing limits examplese.g., QL (60 tablets/180 days), QL (126 tablets/365 days)

Typical insulin and many injectables monthly volumeQL (100 mls/30 days) for many insulin products

Common inhaler limit1–3 inhalers/30 days depending on product

What Providers Must Do

Prior Authorization
Prior authorization may be required
Some drugs require prior authorization (PA). If PA is commonly required for a medication, it is generally noted next to the medication with 'PA' under Special Requirements. Providers must submit PA requests to obtain coverage approval before the medication may be covered.

Billing Rule
Quantity Limits (QL) enforcement
Many agents have quantity limits (QL) defining maximum covered units per time period; pharmacies should bill accordingly and expect claims to deny if QL exceeded without PA.
TRULICITY QL: 4 pens/28 days (example) [[see formulary entries]]
Insulin products QL: 100 mls/30 days (typical insulin limit)
Inhalers QL: commonly 1–3 inhalers/30 days (product-dependent)

Key Terms & Acronyms

Formulary & Coverage Terms

Preferred Generic (Tier 1)Lowest cost-share tier for generics when applicable.

Non-Preferred Generic (Tier 2)A generic tier that may have higher member cost-share; not all plans use all tiers.

Preferred Brand (Tier 3)Brand drugs with preferred status — intermediate cost-share.

Non-Preferred Brand (Tier 4)Brand drugs with higher cost-share; some reference brands remain non-preferred.

Preferred Specialty / Non-Preferred Specialty (Tier 5 / Tier 6)Tiers for specialty medications; many specialty drugs are annotated with 'SP' and may have PA/QL requirements.

PAPrior Authorization — requires approval before coverage.

Document Dates & Changes

Effective: January 2026. This formulary segment is current as published and does not contain a material change from the prior published segment. No policy number is provided in this segment. See the document change log or MyPrime.com for ongoing updates and the most current drug list.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPharmacy Drug List (therapeutic class and formulary details) — Part 4 of 5

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJanuary 2026

Next Review Date

Key ActionSubmit prior authorization requests when a medication is noted with 'PA' and follow plan-specific step therapy and quantity limit rules to avoid claim denials.

SourceLink

On This Page

Nebulizer solution (albuterol) QL: 125 containers/30 days

Step Therapy
Step therapy
Step therapy (ST) may be required for certain drugs and will be noted with 'ST' under Special Requirements. Providers should follow plan-specific step therapy protocols or submit exception requests per plan materials.
If a step is required it is noted with 'ST' in the Special Requirements column.
Submit exception requests per the member's benefit plan when appropriate.

Billing Rule
Quantity / Dispensing limits
Quantity limits (QL) and dispensing limits (DL) are applied to many medications; if dispensed quantity exceeds limits, members may be responsible for the full cost beyond coverage.
Dispensing limits are noted with 'QL' next to medications in the Special Requirements column.
State laws may further restrict coverage for certain controlled substances dispensed beyond limits; member bears full cost if limit exceeded.

Prior Authorization
Prior Authorization required for specific products
Numerous specialty and high-cost medications require prior authorization (PA). Providers must submit PA per payer process for these drugs.
Examples include TRULICITY; REPATHA; ENTRESTO; biologics such as NUCALA, FASENRA, XOLAIR, TEZSPIRE; CF modulators (e.g., TRIKAFTA, KALYDECO, ALYFTREK); and specialty somatropins/enzymes (e.g., GENOTROPIN, OMNITROPE).

Documentation Required
Specialty (SP) handling
Several medications are designated SP (specialty). Providers must route prescriptions via the specialty pharmacy channel and be prepared to provide documentation/supporting clinical information during prior authorization.
Specialty drugs may be oral, topical or injectable and may require specialty pharmacy handling; see MyPrime.com for current specialty list.
Documentation/supporting clinical information should be available at PA submission and dispensing.

Denial Risk
Risk of denial if PA or QL exceeded
Prescriptions that do not meet PA requirements or exceed specified QL without prior authorization are at risk of denial or payment reduction.
Claims may deny or have payment reduced if PA is not obtained or QL is exceeded without authorization.

Documentation Required
Verify member payment and benefit design
Providers and pharmacists should verify a member's payment amount, tier placement, and any additional plan-specific requirements via MyPrime.com or by calling the number on the member's ID card because coverage and tiering vary by benefit design.
Use MyPrime.com (the pharmacy benefit website) or the phone number on the member's ID card to confirm tiering, copay/coinsurance, and any plan-specific restrictions.

Documentation Required
ACA preventive coverage exceptions
For ACA preventive medicines, providers or members can submit a copay waiver or coverage exception request by calling the number on the ID card; copay waiver and coverage exception forms are available at bcbs.com/provider or MyPrime.com.
If the request is denied, the plan will explain why and offer a covered alternative drug if applicable.

Billing Rule
Many products subject to multi-period QLs
Many products are subject to quantity limits defined per period (e.g., per 28 days, 30 days, 84 days, 180 days, 365 days).
Examples of QL periods in the formulary: 28 days (e.g., many kits/pens), 30 days (typical tablet/30 days limits), 84 days (some CF modulator QLs), 180 days (starter/therapy packs), 365 days (annual QLs for some products).
Specific product QLs are listed next to each drug entry in the formulary.

Billing Rule
Specialty product designation for billing
Many high-cost injectable and biologic agents are designated SP and should be billed through specialty pharmacy channels per payer rules.
Examples: ADALIMUMAB products, HEMLIBRA, coagulation factors, EMGALITY, OTEZLA, many MS agents (e.g., AVONEX, PLEGRIDY).
Follow specialty channel billing and payer direction for dispensing and claims.

Documentation Required
Use listed QL and PA values when requesting coverage
When submitting prior authorization requests or claims, include the exact formulation, kit size and quantity consistent with the QL periods shown (for example, kits per 28 days or tablets per 301 days). Reference the listed QL and PA values for therapy packs and kit compositions.
Reference the formulary entry's kit size, pack composition and the exact QL period when requesting coverage or submitting claims.
Use the PA/QL values shown next to the medication to avoid processing delays or denials.

Quantity Limit — maximum quantity covered in specified time period.