Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Cross Blue Shield SC Formulary Coverage | Ope…
    Ask Trek AI about this page

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

    CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

    BlueCross Total 2025 Formulary (Drug List) — Coverage Criteria

    Customize your policy alerts

    Sign up for all Blue Cross Blue Shield - South Carolina policy alerts

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

    Monitor payer policy activity

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

    Defines the plan's covered prescription drugs, formulary structure, member cost-sharing tiers, and administrative rules (prior authorization, step therapy, quantity limits, exceptions) for BlueCross Total members under BlueCross BlueShield of South Carolina.

    Policy Summary
    PayerBlue Cross Blue Shield - South Carolina
    PolicyBlueCross Total 2025 Formulary (Drug List) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective Date10/01/2025
    Last ReviewOct 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when 'PA' is indicated on the Drug List before prescribing to ensure coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    MonthlyFormulary update frequency
    30 daysAdvance notice for most changes
    72 hrsStandard exception timeframe
    24 hrsExpedited exception timeframe
    10/01/2025Formulary effective as of
    5Cost-sharing tiers

    Coverage Criteria and Transition Rules

    General Formulary Coverage

    Covered when ALL of the following are met

    Formulary Coverage General Conditions: Drug is listed on the BlueCross Total formulary; drug is medically necessary; prescription is filled at a BlueCross Total network pharmacy; and applicable plan requirements (such as prior authorization, quantity limits, and step therapy) are followed.

    From formulary overview and usage instructions.

    Transition and Emergency Coverage

    Temporary coverage allowances

    Transition and Emergency Supplies: For drugs not on the formulary or drugs with restrictions, BlueCross Total will cover a temporary 30-day supply for new or continuing members (refills may be allowed up to a 30-day maximum); long‑term care residents may receive a 31-day emergency supply when eligible; and during discharge or level-of-care changes an outpatient supply may be provided to prevent gaps in therapy.30 days / 31 days
    Policy Summary
    PayerBlue Cross Blue Shield - South Carolina
    PolicyBlueCross Total 2025 Formulary (Drug List) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective Date10/01/2025
    Last ReviewOct 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when 'PA' is indicated on the Drug List before prescribing to ensure coverage.
    SourceLink
    On This Page
    Coverage Criteria and Transition RulesUtilization Flags, Quantity Limits and Example CodesPrior Authorization, Step Therapy, Documentation, and Denial RiskStep Therapy Listings and ApplicabilityProduct-Specific Quantity LimitsAdditional Product-Specific Quantity Limits (continued)Remaining Quantity Limit EntriesRemaining Quantity Limit Entries (continued)Final Quantity Limit EntriesBilling and Site-of-Care NotesBiosimilar and Interchangeable Biosimilar PolicyFormulary Definitions and AbbreviationsBackground and Scope

    See transition and discharge provisions.

    Drugs may be removed from the formulary when they are withdrawn from sale by the manufacturer or if the FDA withdraws them for safety or effectiveness reasons. In those cases BlueCross may immediately remove the drug from the formulary and it will no longer be covered; the plan may subsequently notify affected members. For other formulary changes (for example adding a generic or biosimilar, moving a drug to a different tier, or adding utilization controls), BlueCross will provide notice at least 30 days before the change becomes effective or provide a 30‑day supply at the time a member requests a refill and include notice of the change. Members or prescribers may request an exception to continue coverage when a change affects a member currently taking a drug.

    The formulary includes explicit entries that are designated Not Covered in the table (several Tier 5 and Mail Order/LTC rows show "Not Covered" for specific specialty or mail‑order categories). Where a drug row indicates "Not Covered," claims for that product are not payable under the pharmacy benefit unless an approved exception is obtained.

    The sample formulary excerpts in this document primarily present administrative controls (tier assignment, PA and QL markers) and product‑level quantity limits. The extract does not include standalone clinical‑necessity narrative criteria tied to specific diagnoses; coverage is determined by whether the drug is on the formulary and whether the listed administrative requirements (e.g., prior authorization, quantity limits) are met.

    Within the provided table excerpts there are no explicit clinical exclusion rules stated (for example, lists of diagnoses or clinical conditions that automatically exclude coverage). Entries in these chunks are limited to formulary tiering and utilization controls such as PA and QL, which are enforced administratively rather than by a separate clinical exclusion statement.

    Utilization Flags, Quantity Limits and Example Codes

    Formulary utilization flags and example quantity limitsmixed
    QL(148 EA per 365 days)Quantity limit example for ELIQUIS STARTER PACK
    QL(84 EA per 28 days)Quantity limit example for ELIQUIS CAPSULE SPRINKLE
    QL(140 EA per 28 days)Quantity limit example for ELIQUIS TABLET SOLUBLE 0.5MG
    PAPrior authorization required (used for multiple specialty agents listed)
    QL(102 EA per 365 days)Quantity limit example for XARELTO STARTER PACK
    QL(30 EA per 30 days)Quantity limit example for XARELTO 10/20mg
    QL(60 EA per 30 days)Quantity limit example for XARELTO 15mg
    QL(240 EA per 30 days)Quantity limit example for ENTRESTO CAPSULE SPRINKLE
    QL(60 EA per 30 days)Quantity limit example for sacubitril/valsartan
    QL(120 EA per 30 days)Quantity limit example for XOLREMDI
    inv-08: Quantity limits examples
    Common QL examplesQL(30 EA per 30 days); QL(60 EA per 30 days); QL(90 EA per 30 days); QL(120 EA per 30 days); QL(180 EA per 30 days); QL(336 EA per 365 days); QL(540 ML per 30 days)
    Formatting noteQuantity limits use the format QL(## <unit> per ## days) as shown in the table
    Provider actionDispensed quantity must not exceed the listed QL without prior authorization or exception request
    inv-09: Example quantity limits
    Quarterly/interval QL examplesQL(91 EA per 91 days); QL(0.65 ML per 90 days); QL(1 EA per 28 days); QL(10 ML per 28 days)
    Contraceptive pack exampleQL(91 EA per 91 days) used for several contraceptive brands
    Injectable/vial exampleQL(0.65 ML per 90 days) for DEPO-SUBQ PROVERA 104
    inv-10: Quantity limits shown
    Additional QL examplesQL(30 EA per 30 days); QL(60 EA per 30 days); QL(270 ML per 30 days); QL(540 ML per 30 days)
    Sleep/wa kefulness agentsQL(30 EA per 30 days) examples for zolpidem and modafinil; sodium oxybate shown as QL(540 ML per 30 days)
    Inhaled/respiratory examplesQL(270 ML per 30 days) used for multiple respiratory products (TRELEGY, wixela, others)

    Prior Authorization, Step Therapy, Documentation, and Denial Risk

    Prior Authorization

    Prior Authorization Required

    Some covered drugs require prior authorization (PA) before the plan will approve payment. When an entry in the formulary is annotated with PA, PA NSO (prior authorization for new starts only), or PA/PA NSO, the prescriber must obtain approval from the plan prior to dispensing. Failure to obtain required prior authorization may result in the drug not being covered.

    • PA markers appear throughout the formulary (e.g., ".PA", "PA NSO", "PA;" annotations).
    • PA applies to many specialty and biologic agents (examples: Dupixent, Otezla, Humira, many oncology agents marked PA NSO).
    • Some antiviral and acute-use products are PA'd (examples: PAXLOVID entries show .PA).
    Prior Authorization

    When Prior Authorization Applies

    Prior authorization is required for listed products when shown in the formulary’s Requirements/Limits column. Examples of PA and PA NSO designations in the formulary include: PA for biologics and injectables (e.g., ORENCIA, RINVOQ, SKYRIZI), PA NSO for many oncology agents and specialty products (e.g., multiple items in Tier 5 flagged PA NSO).

    • Specialty oncology and targeted therapies frequently carry PA NSO.
    • Many monoclonal antibodies and immunological agents are listed with PA and quantity limits.
    • Starter packages and manufacturer-labeled starter kits may have PA plus manufacturer-specific restrictions noted (see adalimumab starter package entries).
    Prior Authorization

    Prior Authorization Noted for Specific Products

    The formulary lists specific products and the corresponding PA, QL, ST, and other flags. Providers should consult the formulary row for the drug to see the exact requirement(s) and any quantity limits or starter-package notes.

    • Topical and oral products may have combined QL+PA entries (e.g., lidocaine topical entries show QL and PA).
    • Anticonvulsants and specialized neurologic therapies show PA NSO or PA for certain formulations (e.g., BRIVIACT = PA NSO; EPIDIOLEX = PA NSO).
    • Starter/package designations and manufacturer-specific restrictions are called out on some biologic starter packs (e.g., Boehringer Ingelheim, AbbVie labeled products).
    Prior Authorization

    PA for Specialty Drugs

    Many specialty, injectable, biologic, enzyme-replacement, gene/rare-disease, and oncology agents require prior authorization. When a specialty product is flagged PA or PA NSO, the prior authorization requirement must be met before the plan will cover the product.

    • Oncology agents in Tier 5 often show PA NSO (e.g., multiple chemotherapy and targeted therapy listings).
    • Immunologic and biologic drugs (Dupixent, Cosentyx, Ocrevus-like entries) show PA and often QL limits.
    • Enzyme replacement, genetic disorder, and cystic fibrosis agents are PA’d (examples: Fabrazyme, Evrysdi, Trikafta).
    Prior Authorization

    Quantity Limits, Step Therapy, and PA

    Quantity limits (QL) and step-therapy (ST/ST NSO) indicators often accompany PA requirements. When QL or ST is present with PA, documentation must support medical necessity for overrides or exceptions.

    • Examples: lidocaine topical products list QL and PA.
    • CGRP migraine injectables show QL and PA (e.g., Aimovig, Emgality).
    • Some agents use ST NSO or ST for new starts only; other PA entries may imply step edits.
    Documentation Required

    Exception Request and Documentation Requirements

    Documentation: when requesting an exception, prior authorization, or step-therapy override, the prescriber must provide a supporting clinical statement explaining the medical necessity. The plan generally must decide within 72 hours of receiving the prescriber's supporting statement; expedited (24-hour) review is available when waiting could seriously harm the patient.

    • Prescriber supporting statement required for exception and PA requests.
    • Expedited (fast) requests available — decision within 24 hours if criteria met; standard decisions within 72 hours.
    • Refer to the formulary introduction pages for definitions of PA, QL, NDS, ST, ST NSO and for submission instructions.
    Denial Risk

    Follow Formulary Flags and Avoid Denials

    Use the formulary requirement flags (PA, PA NSO, QL, ST, ST NSO) shown in each drug row when submitting prior authorization and claims. Claims may be denied if the required PA is not obtained or if quantity limits are exceeded.

    • Follow the exact PA/QL/ST markers on the formulary row when requesting approvals.
    • Exceeding a listed QL may require an override and can lead to denial if not supported.
    • Missing PA or unmet ST requirements are common triggers for claim denials.
    Denial Risk

    Prior Authorization Denial Risk

    Denial risk: failure to obtain prior authorization, to meet step-therapy requirements, or to adhere to quantity limits may result in non-coverage. Providers should confirm PA and QL status before dispensing specialty or high-cost medications.

    • Many Tier 4–5 and specialty drugs carry PA/PA NSO flags — high denial risk if PA is missing.
    • Antivirals and acute-course products (e.g., PAXLOVID) include PA and QL entries — confirm before dispensing.
    • Pharmacy claims processing enforces QL and PA — prescribers should submit necessary documentation proactively.
    Documentation Required

    Operational Steps for Providers

    Operational notes: observe quantity limits at dispensing and include PA documentation with the prescription when required. For starter packs, labeled products, or manufacturer-specific kits, note any product-specific restrictions called out in the formulary (e.g., Boehringer Ingelheim or AbbVie labeled starter product restrictions).

    • Starter/package designations may list QL and PA plus manufacturer-specific limits.
    • Prescriptions should match the formulary QL and PA requirements to avoid reimbursement issues.
    • Refer to the formulary introduction for submission instructions and contact information for PA requests.

    Step Therapy Listings and Applicability

    RequirementDescription
    Member must try specified alternative drug(s) before the plan will cover the requested drug.
    If first-line agent(s) do not work or are not tolerated, the plan may cover the requested drug after documentation of trial/failure as required by BlueCross Total.
    IndicatorApplies When
    ST
    Applies where the Drug List row shows 'ST' (step therapy).
    ST NSO
    Applies where the Drug List row shows 'ST NSO' (Step Therapy for New Starts Only; may include NSO handling).
    ControlImplication
    Tier assignments
    Indicate member cost-sharing level and can be associated with utilization controls (PA, QL) that may trigger step edits at point of sale.
    Requirements/Limits keys (PA, QL, NDS)
    Show utilization management applied to the product (e.g., prior authorization required, quantity limits) and signal where step therapy may be enforced.
    DrugStep Therapy Flag
    NAMZARIC CAPSULE EXTENDED RELEASE 24 HOUR
    Marked 'ST' indicating step therapy applies prior to coverage (QL(30 EA per 30 days); ST).
    DrugStep Therapy / Limit
    EXXUA
    Marked 'ST NSO' with QL(30 EA per 30 days); indicates Step Therapy for New Starts Only and NSO handling.
    EXXUA TITRATION PACK
    Marked 'ST NSO' with QL(30 EA per 30 days); step therapy applicable for new starts (NSO).
    ObservationNotes
    No explicit step therapy sequences listed
    The document excerpt often shows only PA and QL markers without detailed step-by-step (fail-first) algorithms for most products.
    Utilization flags present
    Many entries are controlled by PA or QL indicators; where 'ST' or 'ST NSO' appear they indicate step therapy but specifics are not provided in these chunks.
    Drug / ExampleStep Therapy Flag
    RYTARY
    Listed with 'ST' (step therapy) in the formulary excerpt, indicating a step requirement before coverage.
    Product GroupUtilization Flag
    GLP-1 and other antidiabetic injectables (examples: MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY)
    Marked with PA and QL in the table (e.g., OZEMPIC QL; RYBELSUS QL; PA noted) indicating prior authorization and potential step edits though explicit step sequences are not listed.
    Agent TypeManagement
    Specialty / hematopoietic agents (examples: NEULASTA, PROCRIT, PROMACTA, RETACRIT)
    Marked 'PA' (prior authorization) or QL in the table; many require PA but explicit multi-step sequences are not provided in the excerpt.
    Product CategoryQuantity Limit Example
    ADHD stimulant and related products (amphetamine/dextroamphetamine, methylphenidate, atomoxetine)
    Quantity limits applied (examples: QL(60 EA per 30 days), QL(90–180 EA per 30 days) depending on product) as shown in the table.
    Product TypeUtilization Controls
    Diclofenac gel 3%; RELISTOR formulations; XERMELO
    These products are shown with 'ST' in the Requirements/Limits column (diclofenac sodium gel 3% QL(300 GM per 30 days); RELISTOR entries QL and ST), indicating step therapy applies to select agents.
    Other examples (diclofenac gel; RELISTOR; XERMELO)
    Marked 'ST' in the table demonstrating instances where step therapy is used for selected agents.
    ObservationDetail
    No explicit multi-step sequences in many segments
    Across several chunks the formulary lists PA and QL markers primarily; detailed step-by-step (fail-first) algorithms are not provided in these excerpts.
    DesignationNote
    Starter / Starter Package entries
    Some biologic starter packages are shown with QL and PA plus manufacturer-specific notes (e.g., Boehringer Ingelheim labeled products only), implying starter-package controls.
    ObservationExamples
    PA required for many biologic products
    Numerous biologic and specialty products (HUMIRA variants, INFLECTRA, INFLIXIMAB, DUPIXENT, COSENTYX, etc.) are marked with PA and QL; step therapy specifics are not listed in the excerpt.
    ObservationNote
    PA and QL controls present
    Many entries in the respiratory and specialty sections show PA and QL values (examples: cystic fibrosis agents, inhaled products) but do not provide explicit step therapy algorithms in this excerpt.
    Drug(s)Requirement
    armodafinil, modafinil, sodium oxybate
    Marked with 'PA' in the Requirements/Limits column; prior authorization is required for these wakefulness-promoting agents (examples shown with QL values and PA).

    Product-Specific Quantity Limits

    inv-122: Cablivi — quantity example
    Cablivi quantity limit30 tablets per 30 days (example shown in formulary overview)
    ContextProvided as an illustrative QL in the formulary overview describing quantity limits
    inv-123: Multiple small-molecule examples
    CelecoxibQL(60 EA per 30 days)
    Diclofenac sodium gel 1%QL(1000 GM per 30 days)
    Ketorolac tabletQL(20 EA per 30 days)
    Buprenorphine (formulations)QL(4 EA per 28 days) noted for some buprenorphine entries
    Lidocaine productsLidocaine-prilocaine cream QL(30 GM per 30 days); lidocaine ointment QL(150 GM per 30 days)
    inv-124: lidocaine-prilocaine cream — QL 30
    Lidocaine-prilocaine creamQL(30 GM per 30 days)
    AnnotationAlso listed with PA in Requirements/Limits for specific product rows
    inv-126: lidocaine ointment 5% — QL 150
    Lidocaine ointment 5%QL(150 GM per 30 days)
    NoteListed with PA in the Requirements/Limits column for product rows
    inv-127: NAYZILAM — QL 10
    NAYZILAMQL(10 EA per 30 days)
    Formulary tierListed at Tier 4 in the table entries
    inv-128: linezolid tablet — QL 56
    Linezolid tabletQL(56 EA per 28 days)
    Linezolid suspension (reconstituted)QL(1800 ML per 28 days) — separate entry
    inv-129: linezolid suspension reconstituted — QL 1800
    Linezolid suspension (reconstituted)QL(1800 ML per 28 days)
    NotesListed as a distinct formulary entry with its own QL
    inv-130: vancomycin capsule 125mg — QL 120
    Vancomycin capsule 125mgQL(120 EA per 30 days)
    Vancomycin capsule 250mgQL(240 EA per 30 days)
    Dispensing noteSeparate QLs provided per strength in the formulary table
    inv-131: vancomycin capsule 250mg — QL 240
    Vancomycin capsule 250mgQL(240 EA per 30 days)
    Strength-specific QL250mg strength has a larger monthly QL than 125mg
    inv-132: bupropion er 150mg — QL 60
    Bupropion HCl ER 150mgQL(60 EA per 30 days)
    TierListed at Tier 2 in the table
    inv-133: NICOTROL NS — QL 360
    NICOTROL NS (nicotine nasal spray)QL(360 ML per 365 days)
    Usage periodQL expressed over 365 days for nicotine replacement product
    inv-134: TYRVAYA — QL 8.4
    TYRVAYA (nasal formulation)QL(8.4 ML per 30 days)
    NotesListed in Requirements/Limits with QL per 30 days
    inv-135: varenicline starter/tartrate — QL 504
    Varenicline (starter / tartrate)QL(504 EA per 365 days)
    Annual QLQuantity limit expressed over 365 days for varenicline starter/tartrate
    inv-136: BRIVIACT SOLUTION/TABLET — QL noted (chunk references)
    BRIVIACT (solution/tablet)Formulary lists BRIVIACT solution and tablet entries; QL values shown on product rows in the formulary (see corresponding table rows)
    Management flagSome anticonvulsant specialty products carry PA NSO or other management flags in the table
    inv-138: gabapentin capsule 400mg — QL 270
    Gabapentin capsule 400mgQL(270 EA per 30 days)
    Capsule strengths noteOther gabapentin strengths have different QLs (e.g., 100mg/300mg shown separately)
    inv-139: gabapentin 100mg/300mg — QL 360
    Gabapentin 100mg / 300mg capsulesQL(360 EA per 30 days)
    Formulation-specific QLLower-strength capsules have higher numeric QL in table entries
    inv-140: pregabalin capsules — QL 90
    Pregabalin capsules (various strengths)QL(90 EA per 30 days)
    Pregabalin solutionQL(900 ML per 30 days) for solution formulation
    inv-141: pregabalin solution — QL 900
    Pregabalin solutionQL(900 ML per 30 days)
    Formulation noteSolution formulation has ML-based QL separate from capsule EA limits
    inv-142: FETZIMA TITRATION PACK — QL 56
    FETZIMA titration packQL(56 EA per 365 days)
    Step therapy flagListed with ST NSO in the table for titration pack
    inv-143: terbinafine tablet — QL 84
    Terbinafine HCl tabletQL(84 EA per 180 days)
    Dosing intervalQL provided over 180-day interval for terbinafine tablets
    inv-144: clotrimazole cream — QL(90 GM per 30 days)
    Clotrimazole creamQL(90 GM per 30 days)
    Topical QL formatTopical products commonly list grams (GM) per 30 days in QL entries
    inv-146: AIMOVIG injection — QL(1 ML per 28 days)
    AIMOVIG injection 140mg/mlQL(1 ML per 28 days)
    Alternate strengthAIMOVIG 70mg/ml listed with QL(2 ML per 28 days) for that strength
    inv-147: EMGALITY injection — QL(2 ML per 28 days)
    EMGALITY injection 120mg/mlQL(2 ML per 28 days)
    Other strengthsEMGALITY 100mg/ml listed with QL(3 ML per 28 days)
    inv-148: ALUNBRIG tablet 30mg — QL(120 EA per 30 days)
    ALUNBRIG tablet 30mgQL(120 EA per 30 days)
    PA NSOALUNBRIG entries also marked PA NSO in table
    inv-149: RETEVMO tablet 40mg — QL(90 EA per 30 days)
    RETEVMO tablet 40mgQL(90 EA per 30 days)
    PA NSO flagRETEVMO entries include PA NSO in the formulary rows
    inv-150: TAGRISSO tablet 40mg — QL(30 EA per 30 days)
    TAGRISSO tablet 40mgQL(30 EA per 30 days)
    PA NSOTAGRISSO entries are marked PA NSO in the table
    inv-151: VENCLEXTA tablet 10mg — PA noted; tier 4
    VENCLEXTA tablet 10mgPA noted; listed on Tier 4 (PA requirement) — see Requirements/Limits
    Coverage actionPrior authorization is required for VENCLEXTA starting pack and some tablet strengths
    inv-152: aripiprazole ODT 15/10mg — QL(60 EA per 30 days)
    Aripiprazole ODT 15mg/10mgQL(60 EA per 30 days)
    Psychotropic QLsODT and tablet forms commonly have 30-day EA limits listed
    inv-153: clozapine ODT 100mg/25mg — QL(270 EA per 30 days)
    Clozapine ODT 100mg/25mgQL(270 EA per 30 days)
    Formulation-specificClozapine strengths/formulations carry distinct QLs in the table
    inv-154: MAVYRET tablet — QL(336 EA per 365 days)
    MAVYRET tabletQL(336 EA per 365 days)
    Hepatitis C therapy packAnnual QL shown (336 EA per 365 days) consistent with course-based therapy
    inv-155: BARACLUDE solution — QL(600 ML per 30 days)
    BARACLUDE solutionQL(600 ML per 30 days)
    Antiviral liquid formulationSolution QL expressed in mL per 30 days
    inv-156: COMPLERA — QL 30
    COMPLERAQL(30 EA per 30 days)
    DELSTRIGO / EDURANTDELSTRIGO QL(30 EA per 30 days); EDURANT QL(30 EA per 30 days); EDURANT PED QL(180 EA per 30 days)
    inv-157: DELSTRIGO — QL 30
    DELSTRIGOQL(30 EA per 30 days)
    EDURANT PEDQL(180 EA per 30 days) for pediatric formulation
    inv-158: EDURANT — QL 30
    EDURANT (adult)QL(30 EA per 30 days)
    EDURANT PEDQL(180 EA per 30 days) for pediatric strength
    inv-159: EDURANT PED — QL 180
    Edurant pediatricQL(180 EA per 30 days)
    Separate pediatric QLPediatric formulations have distinct monthly QLs
    inv-160: etravirine 100mg — QL 60
    Etravirine 100mgQL(60 EA per 30 days)
    Other strengths200mg strength also listed with QL(60 EA per 30 days)
    inv-161: INTELENCE 25mg — QL 120
    INTELENCE 25mgQL(120 EA per 30 days)
    Antiretroviral QLHigher EA limits shown for some HIV agents (INTELENCE example)

    Additional Product-Specific Quantity Limits (continued)

    inv-162: nevirapine er 400mg — QL 30
    Nevirapine ER 400mgQL(30 EA per 30 days)
    Nevirapine ER 100mgQL(60 EA per 30 days) — lower strength has higher numeric QL
    inv-163: nevirapine er 100mg — QL 60
    Nevirapine ER 100mgQL(60 EA per 30 days)
    Formulation noteExtended-release tablet strengths have separate QLs listed
    inv-164: nevirapine suspension — QL 1200
    Nevirapine suspensionQL(1200 ML per 30 days)
    Liquid antiviral QLLarge-volume ML QL shown for suspension formulations
    inv-165: abacavir tablet — QL 60
    Abacavir tabletQL(60 EA per 30 days)
    Abacavir-containing combosAbacavir combination products listed with varying QLs (30–60 EA per 30 days)
    inv-166: EMTRIVA solution — QL 850
    EMTRIVA solutionQL(850 ML per 30 days) (also appears as 960 mL in other rows)
    Liquid antiretroviral QLEMTRIVA solution listed with a high mL-per-month QL
    inv-167: TRIZIVIR — QL 60
    TRIZIVIRQL(60 EA per 30 days)
    Combination NRTI QLStandard 30–60 EA per 30 days limits used for many combination HIV tablets
    inv-168: VIREAD powder — QL 240
    VIREAD powderQL(240 GM per 30 days)
    VIREAD tabletsVIREAD tablets (150/200/250mg) QL(30 EA per 30 days)
    inv-169: VIREAD tablet (various strengths) — QL 30
    VIREAD tablets (various strengths)QL(30 EA per 30 days)
    Strength noteListed QL applies across multiple tablet strengths per table rows
    inv-170: acyclovir capsule 200mg — QL (chunk referenced)
    Acyclovir capsule 200mgQL shown in antiviral sections (see acyclovir entries) — formulary lists capsule entry (QL referenced in table)
    ValacyclovirQL(120 EA per 30 days)
    inv-171: valacyclovir hydrochloride — QL 120
    Valacyclovir HClQL(120 EA per 30 days)
    Antiviral QLCommon 30-day EA limits used for oral antiherpetic agents
    inv-172: PAXLOVID therapy pack — QL 11
    PAXLOVID therapy pack (standard)QL(11 EA per 5 days); PA
    Alternative pack sizesAlternative PAXLOVID pack entries show QL(20 EA per 5 days) and QL(30 EA per 5 days)
    inv-173: PAXLOVID alternative pack — QL 20
    PAXLOVID alternative pack (20)QL(20 EA per 5 days)
    PA annotationPAXLOVID entries include .PA in Requirements/Limits indicating PA requirement
    inv-174: PAXLOVID alternative pack — QL 30
    PAXLOVID alternative pack (30)QL(30 EA per 5 days)
    Therapy-pack formatPack QLs are expressed per 5-day therapy course in the formulary
    inv-175: alprazolam 0.25-1mg — QL 120
    Alprazolam 0.25–1mgQL(120 EA per 30 days)
    Alprazolam 2mgQL(150 EA per 30 days)
    PA flagMany benzodiazepine entries include PA with associated QLs
    inv-176: alprazolam 2mg — QL 150
    Alprazolam 2mgQL(150 EA per 30 days)
    Higher-strength limit2mg tablet has a higher monthly EA QL than lower strengths
    inv-177: BYDUREON BCISE — QL 3.4
    BYDUREON BCISEQL(3.4 ML per 28 days)
    Injectable diabetic agentQL expressed in mL per 28 days for injectables
    inv-178: BYETTA 10MCG — QL 2.4
    BYETTA 10mcgQL(2.4 ML per 28 days)
    BYETTA 5mcgQL(4.8 ML per 28 days)
    inv-179: BYETTA 5MCG — QL 4.8
    BYETTA 5mcgQL(4.8 ML per 28 days)
    PA notedEntries indicate PA alongside QL for these injectable agents
    inv-180: EMTRIVA SOLUTION — QL 960
    EMTRIVA solution (alternate row)QL(960 ML per 30 days) appears in other table rows; EMTRIVA also listed as 850 mL in adjacent entries
    Document varianceSome solution QLs appear with slightly different numeric values across sections (850 vs 960 mL) — see product rows
    inv-181: MOUNJARO — QL 2
    MOUNJARO (GLP-1)QL(2 ML per 28 days)
    Injectable GLP-1 examplesOZEMPIC, MOUNJARO and TRULICITY entries show mL-based QLs per 28 days
    inv-182: OZEMPIC 2MG/1.5ML — QL 1.5
    OZEMPIC 2mg/1.5mlQL(1.5 ML per 28 days)
    Other OZEMPIC strengthsOther OZEMPIC strengths listed with QL(3 ML per 28 days)
    inv-183: OZEMPIC other strengths — QL 3
    OZEMPIC other strengthsQL(3 ML per 28 days)
    Strength-differentiated QLDifferent presentations of same product have distinct mL QLs
    inv-184: RYBELSUS 14/4/7/9mg — QL 30
    RYBELSUS (14/4/7/9mg)QL(30 EA per 30 days)
    RYBELSUS (1.5/3mg)QL(60 EA per 365 days)
    inv-185: RYBELSUS 1.5/3mg — QL 60
    RYBELSUS 1.5/3mgQL(60 EA per 365 days)
    Lower-dose annual QL1.5/3mg strengths expressed with annual QL in formulary

    Remaining Quantity Limit Entries

    inv-186: TRULICITY — QL 2
    TRULICITYQL(2 ML per 28 days)
    Injectable GLP-1 noteTRULICITY listed with 2 mL per 28 days QL and PA annotation
    inv-187: ELIQUIS starter pack — QL 148 EA
    ELIQUIS starter packQL(148 EA per 365 days)
    ELIQUIS sprinkle / soluble examplesELIQUIS capsule sprinkle QL(84 EA per 28 days); soluble 0.5mg QL examples include 140/420/560 EA per 28/365 days
    inv-188: ELIQUIS capsule sprinkle — QL 84 EA
    ELIQUIS capsule sprinkleQL(84 EA per 28 days)
    Soluble tablet QLsSoluble 0.5mg shown with multiple QL examples (140/420/560 EA) in table rows
    inv-189: ELIQUIS soluble 0.5mg — QL examples (140/420/560 EA)
    ELIQUIS soluble 0.5mgExamples include QL(140 EA per 28 days), QL(420 EA per 28 days), QL(560 EA per 28 days)
    Multiple QLsTable displays alternative QL examples for soluble formulation
    inv-190: XARELTO starter pack — QL 102 EA
    XARELTO starter packQL(102 EA per 365 days)
    XARELTO tablet QLsXARELTO 10/20mg QL(30 EA per 30 days); 15mg QL(60 EA per 30 days)
    inv-191: ENTRESTO capsule sprinkle — QL 240 EA
    ENTRESTO capsule sprinkleQL(240 EA per 30 days)
    Sacubitril/valsartanAlso listed with QL(60 EA per 30 days) for certain strengths
    inv-192: sacubitril/valsartan — QL 60 EA
    Sacubitril/valsartanQL(60 EA per 30 days)
    Cardiovascular QL examplesMultiple CV agents show 30-day EA limits in the formulary rows
    inv-193: XOLREMDI — QL 120 EA
    XOLREMDIQL(120 EA per 30 days)
    Hematology agent noteListed with PA in many specialty sections; QL shown per 30 days
    inv-194: NEXLETOL — QL 30
    NEXLETOLQL(30 EA per 30 days)
    NEXLIZETQL(30 EA per 30 days)
    inv-195: NEXLIZET — QL 30
    NEXLIZETQL(30 EA per 30 days)
    PABoth NEXLETOL and NEXLIZET rows include PA in Requirements/Limits
    inv-196: PRALUENT — QL 2
    PRALUENTQL(2 ML per 28 days)
    PAPRALUENT entries include PA alongside QL
    inv-197: REPATHA — QL 3
    REPATHAQL(3 ML per 28 days)
    REPATHA PUSHTRONEXQL(7 ML per 28 days)
    inv-198: REPATHA PUSHTRONEX — QL 7
    REPATHA PUSHTRONEX systemQL(7 ML per 28 days)
    Administered device QLPushtroNex system has a distinct QL compared with other presentations

    Remaining Quantity Limit Entries (continued)

    Final Quantity Limit Entries

    Billing and Site-of-Care Notes

    Note

    Biosimilar and Interchangeable Biosimilar Policy

    Note

    Formulary Definitions and Abbreviations

    inv-75: Formulary / Drug List definition
    Cablivi (summary)30 tablets per 30 days (illustrative QL in formulary overview)
    ReferenceOverview mentions Cablivi as an example of a 30-tablet-per-month QL
    inv-76: Biosimilar / Interchangeable biosimilar definition
    Biosimilar definitionBiosimilars are alternatives to original biological products; interchangeable biosimilars may be substituted per state law
    Substitution ruleInterchangeable biosimilars may be substituted without a new prescription depending on state law
    inv-77: PA definition — Prior Authorization
    PA (Prior Authorization)PA = Prior Authorization: payer approval required before coverage; absence of PA may result in non-coverage
    Where usedDrugs listed with 'PA' or '.PA' in Requirements/Limits require prior authorization per formulary rows
    inv-78: QL definition — Quantity Limits
    QL (Quantity Limits)QL = Quantity Limits; specifies the maximum allowed quantity within a stated time period (format: QL(## <unit> per ## days))
    Example formatsEA per 30 days, ML per 30 days, GM per 30 days, EA per 365 days are all used in table examples
    inv-79: NDS definition — Non-Extended Day Supply
    NDS definitionNDS = Non-Extended Day Supply — item is not available for extended days' supply
    Use in tableNDS appears next to certain opioid products indicating dispensing restriction
    inv-80: ST / ST NSO definitions
    ST / ST NSOST = Step Therapy; ST NSO = Step Therapy for New Starts Only
    ApplicationApply where Drug List denotes ST or ST NSO in Requirements/Limits
    inv-81: PA NSO definition
    PA NSOPA NSO = Prior Authorization with non-standard office or specialty handling designation (see formulary introduction for full definition)
    ImplicationPA NSO flags indicate specialized prior authorization workflows for some specialty agents
    inv-82: QL exact format
    QL exact formatQL entries give exact allowed quantity and time period (e.g., QL(10 EA per 30 days))
    Units usedEA (each), ML (milliliters), GM (grams) are common units in QL entries
    inv-83: PA NSO table flag — reference to intro pages
    Intro/table flags referenceThe formulary introduction pages define symbols and abbreviations (PA, QL, ST, NSO, B/D) used in Requirements/Limits
    Provider actionProviders should consult the introduction pages for exact documentation/submission requirements when flags appear
    inv-84: QL format examples
    QL example formatsCommon example formats include QL(## EA per 30 days) and QL(## EA per 365 days) and ML/GM per 30 days (e.g., QL(270 ML per 30 days))
    Topical exampleTopicals often show GM per 30 days (e.g., QL(120 GM per 30 days))
    inv-85: QL explanatory note
    Explanatory note on QLQuantity limits listed per drug must be followed at dispensing; exceeding a QL may require prior authorization or an exception request
    EnforcementFormulary indicates QL enforcement and that providers should align dispense quantity and days' supply with QL entries
    inv-86: .PA annotation definition
    .PA annotation'.PA' in the Requirements/Limits field indicates prior authorization is required for that product entry
    ExamplePAXLOVID entries include .PA and QL values in the formulary rows
    inv-87: Tier definition
    Tier definitionTier = formulary tier level indicating member cost-sharing or coverage category
    Use in tableEach drug row lists a Tier value alongside Requirements/Limits (PA/QL) in the formulary
    inv-88: Quantity Limit brief definition
    Quantity Limit (brief)QL = maximum units allowed in the specified time frame as listed in the table
    Documentation requirementProviders must ensure dispensed quantity matches QL or obtain PA/exception if exceeding QL
    inv-89: Prior Authorization brief definition
    Prior Authorization (brief)PA = Prior Authorization; coverage requires payer pre-approval per formulary row
    ImpactLack of PA may result in claims denial as noted in denial-risk sections
    inv-90: QL definition with example formats
    QL — time period examplesQL commonly expressed per 30 days, 28 days, 365 days, or other interval depending on product (e.g., QL(120 GM per 30 days))
    Topical and solution unitsTopicals use GM per 30 days; solutions use ML per 30 days in QL entries
    inv-91: PA definition (repeated)
    PA (short)PA indicates prior authorization required before coverage
    Where seenPA flags appear across many specialty and high-cost drug entries
    inv-92: QL example (120 GM per 30 days)
    QL topical exampleQL(120 GM per 30 days) used for several topical creams (e.g., desonide, calcipotriene cream)
    Dermatologic QLsMultiple dermatology products list grams per 30 days limits in the formulary
    inv-93: PA definition (repeated)
    PA (concise)Prior authorization required (plan approval before coverage)
    ReferenceSee Requirements/Limits Key and product rows for PA indicators
    inv-94: ST definition
    ST (concise)ST = Step Therapy: prior trial of specified alternative(s) required before coverage of the requested drug
    ST NSOST NSO indicates step therapy limited to new starts only
    inv-95: prior authorization (short)
    Prior authorization (short)PA — payer pre-approval required; may be annotated '.PA' in Requirements/Limits
    ConsequenceClaims may be denied if PA is not obtained where indicated
    inv-96: quantity limit (short)
    Quantity limit (short)QL — maximum quantity allowed in the specified period (e.g., QL(30 EA per 30 days))
    Dispensing implicationDispensed quantity should align with the QL to avoid denial or need for PA/exception
    inv-97: QL — quantity limit definition
    QL conciseQL entries specify numeric limits per time period using EA/ML/GM units
    ExamplesForms include QL(60 EA per 30 days), QL(1 ML per 28 days), QL(336 EA per 365 days)
    inv-98: PA / PA NSO definition
    PA / PA NSOPA = Prior Authorization; PA NSO = Prior Authorization with non-standard office designation — both require authorization before coverage
    Specialty examplesMany biologic and specialty products are marked PA or PA NSO in the Requirements/Limits column
    inv-99: QL exact format
    QL (format)QL(## EA per ## days) is the standard format shown in the document's Requirements/Limits column
    Provider noteIntroduction pages define these formats and abbreviations used throughout the table
    inv-100: PA (definition short)
    PA (short) — definitionPrior Authorization: approval required before the product will be covered
    Reference actionWhen PA appears in Requirements/Limits, providers must follow payer PA procedures
    inv-101: Tier definition
    Tier (definition)Tier = formulary cost-sharing category assigned to each drug row
    UseTier appears alongside QL/PA flags and affects member cost-sharing
    inv-102: Quantity Limit format QL(## per ## days)
    Quantity Limit format (examples)QL(## EA per ## days) or QL(## ML per ## days) — used consistently across formulary product rows
    Unit examplesEA, ML, GM commonly used units in QL expressions
    inv-103: Prior Authorization (short)
    Prior Authorization (short) — reminderPA = prior authorization required before coverage (see product row for .PA or PA flags)
    Provider actionObtain PA per payer procedures when PA is listed
    inv-104: Quantity Limit (QL) examples
    Quantity Limit examples summaryExamples include QL(30 EA per 30 days), QL(60 EA per 30 days), QL(270 ML per 30 days), QL(540 ML per 30 days)
    ApplicabilityThese QL examples appear across respiratory, sleep, and other therapeutic classes in the formulary
    inv-105: Prior Authorization (PA) — final definition
    PA final notePA indicates payer pre-approval required; see Requirements/Limits for '.PA' or PA annotations
    ConsequenceFailure to obtain PA may lead to denial or non-coverage

    Background and Scope

    The formulary is a list of covered prescription drugs selected by BlueCross Total in consultation with providers to represent clinically appropriate therapies. Coverage generally requires that a drug be listed on the formulary, be medically necessary, and be dispensed at a BlueCross Total network pharmacy, subject to administrative rules such as Prior Authorization (PA), Step Therapy (ST), and Quantity Limits (QL). When a biosimilar is added to the formulary the plan may add the biosimilar and change coverage or tiering of the original biological product; interchangeable biosimilars may be substituted per applicable state law and the formulary introduction guidance.