BlueCross Total Prescription Drug Formulary — Coverage Criteria
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This document is the BlueCross Total prescription drug formulary for BlueCross BlueShield of South Carolina describing covered drugs, restrictions (prior authorization, quantity limits, step therapy), tiered cost sharing, and how members and providers can request exceptions; it affects plan members and prescribing providers.
No material clinical or coverage changes in this revision.
Formulary Coverage & Restrictions
Formulary Coverage and Restrictions
Covered drugs on the formulary are subject to general rules, member protections, and exception processes.
Source: formulary description
Immediate substitutions and withdrawal rules
Temporary supplies and exception process
Formulary coverage indicators (partial)"
Each formulary line shows tiering and may include Requirements/Limits flags that affect coverage.
See Requirements/Limits Key in formulary
Examples drawn from listed entries
Covered with conditions
Coverage for individual drugs in this segment is conditional on meeting the specific Requirements/Limits listed on the formulary entry.
Applies per-drug where PA or QL specified
Manufacturer‑label restrictions noted where shown
Specialty drug PA/QL examples
If a drug is not listed on the BlueCross Total formulary and an exception is not approved, the plan will not provide coverage for that drug. Members or prescribers should first contact Customer Service to confirm coverage and, if coverage is not available, may either request a list of clinically similar covered alternatives to discuss with the prescriber or submit a formal exception request per the plan's exception process.
Certain formulary entries are explicitly marked Not Covered within Tier 5 specialty slots and for some covered insulin line items. The formulary shows tiered cost sharing and indicates specific Tier 5 positions as Not Covered; providers should reference the formulary rows (and mail‑order/LTC notes) when assessing coverage and member cost sharing.
The listing uses the flag NDS next to multiple opioid and related products in the Requirements/Limits column, but this excerpt does not provide a definition. The introduction pages of the full formulary must be consulted for the exact meaning and application of NDS in coverage or dispensing rules.
The formulary table in this segment presents each product's Drug Tier and any Requirements/Limits flags (for example PA, QL(...), NDS, or PA NSO). This extract contains tier assignments and utilization‑management flags, but does not include full clinical coverage criteria or rationale — those are defined elsewhere in the formulary introduction and policy pages.
No comprehensive exclusion list appears in these chunks. Where symbols or abbreviations (for example in the Requirements/Limits column) are used, providers should consult the formulary's introduction pages for definitions and for any explicit exclusions referenced there.
Some formulary entries are restricted to specific manufacturer‑labeled products (for example certain ADALIMUMAB entries note Boehringer Ingelheim labeled products only). When such product‑label limitations are shown, coverage is limited to that manufacturer’s labeled presentation unless an exception is granted.
This extract is a formulary table showing Drug Tiers and Requirements/Limits annotations; it does not include an explicit list of items designated as 'Not Medically Necessary' in these chunks. Coverage determinations are driven by the Requirements/Limits flags (e.g., PA, QL) and by exception decisions where applicable.
Formulary Listings & Codes
| QL(30 EA per 90 days) | Quantity limit for JOURNAVX TABLET 50MG |
| QL(60 EA per 30 days) | Quantity limit for celecoxib capsule |
| QL(1000 GM per 30 days) | Quantity limit for diclofenac sodium gel 1% |
| QL(4 EA per 28 days) | Quantity limit for buprenorphine patch weekly |
| QL(20 EA per 30 days) | Quantity limit for ketorolac tromethamine tablet 10mg |
| QL(30 GM per 30 days) | Quantity limit for lidocaine/prilocaine cream 2.5%/2.5% |
| QL(150 GM per 30 days) | Quantity limit for lidocaine ointment/premium lidocaine ointment 5% |
| NDS | Requirement/Limit flag shown next to multiple opioid products (document lists 'NDS' adjacent to various opioid entries) |
| QL(1800 ML per 28 days) | Quantity limit applied to linezolid suspension reconstituted 100mg/5ml |
| QL(120 EA per 30 days) | Quantity limit applied to vancomycin hydrochloride capsule 125mg |
| QL(240 EA per 30 days) | Quantity limit applied to vancomycin hydrochloride capsule 250mg |
| PA | Prior authorization required (flag appears adjacent to multiple products) |
| NSO | NSO flag used with PA for select products (appears as 'PA NSO' in the formulary) |
| sulfadiazine tablet 500mg | Drug Tier = 5 |
| sulfamethoxazole/trimethoprim ds tablet 800mg; 160mg | Drug Tier = 1 |
| doxycycline hyclate capsule 100mg, 50mg | Drug Tier = 2 |
| brivaracetam solution 10mg/ml | Drug Tier = 4; Requirements/Limits = PA NSO |
| BRIVIACT SOLUTION 10MG/ML | Drug Tier = 5; Requirements/Limits = PA NSO |
| EPIDIOLEX SOLUTION 100MG/ML | Drug Tier = 5; Requirements/Limits = PA NSO |
| FINTEPLA SOLUTION 2.2MG/ML | Drug Tier = 5; Requirements/Limits = PA NSO |
| NAYZILAM SOLUTION 5MG/0.1ML | Drug Tier = 4; Requirements/Limits = QL(10 EA per 30 days) |
| clonazepam odt tablet disintegrating 2mg | Drug Tier = 4; Requirements/Limits = QL(300 EA per 30 days) |
| clonazepam odt tablet disintegrating 0.125mg, 0.25mg, 0.5mg, 1mg | Drug Tier = 4; Requirements/Limits = QL(90 EA per 30 days) |
| SIGNIFOR INJECTION 0.3MG/ML, 0.6MG/ML, 0.9MG/ML | Drug Tier = 5; Requirements/Limits = QL(60 ML per 30 days); PA |
| SOMAVERT INJECTION 10MG, 15MG, 20MG, 25MG, 30MG | Drug Tier = 5; Requirements/Limits = PA |
| TRELSTAR MIXJECT INJECTION 22.5MG | Drug Tier = 4; Requirements/Limits = QL(1 EA per 168 days); PA NSO |
| TRELSTAR MIXJECT INJECTION 11.25MG | Drug Tier = 4; Requirements/Limits = QL(1 EA per 84 days); PA NSO |
| COSENTYX (multiple presentations) | Drug Tier = 5; Requirements/Limits = QL(10 ML per 28 days); PA |
| DUPIXENT 200MG/1.14ML and 300MG/2ML | Drug Tier = 5; Requirements/Limits = QL(4.56 ML per 28 days) for 200mg; QL(8 ML per 28 days) for 300mg; PA |
| ORENCIA (various presentations) | Drug Tier = 5; Requirements/Limits = QL varying by presentation (e.g., 4 ML per 28 days for 125mg); PA |
| SKYRIZI (various presentations) | Drug Tier = 5; Requirements/Limits = QL per presentation (e.g., 1 ML per 28 days, 1.2 ML per 56 days, 60 ML per 365 days); PA |
| STELARA (130MG/26ML; 45MG/0.5ML) | Drug Tier = 5; Requirements/Limits = QL(104 ML per 365 days) for 130mg; QL(3 ML per 84 days) for 45mg; PA |
| TREMFYA (multiple presentations) | Drug Tier = 5; Requirements/Limits = QL varies by presentation; PA |
| XELJANZ (tablets and XR) | Drug Tier = 5; Requirements/Limits = QL per presentation (e.g., 30 EA per 30 days XR; 60 EA per 30 days tablets); PA |
| XOLAIR (multiple presentations) | Drug Tier = 5; Requirements/Limits = QL per presentation (e.g., 1 ML per 28 days; 8 EA per 28 days); PA |
| ADALIMUMAB-ADBM and ADALIMUMAB-AATY (many presentations) | Drug Tier = 5; Requirements/Limits = QL per presentation (examples: 6 EA per 28 days; 2 EA per 28 days); PA; some entries limited to specific manufacturer labeled products |
| Various vaccines (multiple entries) | Various tiers; Requirements/Limits vary (e.g., ABRYSVO QL(1 EA per 252 days); AREXVY QL(1 EA per 999 days); MRESVIA QL(0.5 ML per 999 days)) |
Required Provider Actions, Prior Authorization & Denial Risk
Prior Authorization Required — Provider Responsibilities
Certain drugs in this formulary require prior authorization (PA), and many have quantity limits (QL) or step therapy (ST) requirements. Providers must submit a PA request when the Requirements/Limits column shows PA or PA NSO; failure to obtain required PA may result in claim denial. Quantity limits shown (e.g., QL(30 EA per 30 days)) must be followed unless an approved exception is granted. Step therapy flags (ST, ST NSO) indicate that specified first-line agents must be tried before coverage of alternate therapies.
- Prior Authorization (PA) indicated for many products — submit PA before dispensing when PA or PA NSO appears in Requirements/Limits.
- Quantity Limits (QL) are enforced as listed (examples throughout the table such as QL(30 EA per 30 days)); documentation is required to exceed limits or request exceptions.
- Step Therapy (ST or ST NSO) appears for select agents (e.g., RYTARY = ST; AUVELITY, EXXUA, FETZIMA show ST or ST NSO); follow the step sequence where indicated.
- PA NSO = Prior Authorization for New Starts Only or specialty review flags — apply per the Requirements/Limits note.
- Refer to the introduction pages for symbol/abbreviation definitions and the formulary metadata (Formulary ID, Version, Effective Date, Last Updated) when interpreting table entries.
Anticonvulsants & Specialty Agents — PA / QL
Selected anticonvulsants and specialty neurologic agents require PA or PA NSO; quantity limits apply to some anticonvulsants (e.g., NAYZILAM QL(10 EA per 30 days), clonazepam QL entries, gabapentin QLs). Examples: BRIVIACT and EPIDIOLEX are listed as PA NSO; FINTEPLA and DIACOMIT show PA NSO.
- Brivaracetam (BRIVIACT) — PA NSO for tablets and solution.
- EPIDIOLEX solution — PA NSO.
- FINTEPLA solution — PA NSO.
- DIACOMIT (stiripentol) — PA NSO; follow specialty PA procedures.
- Clonazepam, gabapentin and NAYZILAM have stated quantity limits that must be adhered to or justified in PA/exception requests.
Oncology & Specialty Biologics — PA NSO / QL
Many specialty, oncology, biologic and high-cost agents are designated PA NSO or PA with specific QLs. Providers must follow PA submission rules and include supporting clinical documentation. Examples include multiple molecular-targeted therapies and monoclonal antibodies listed with PA NSO.
- Molecular target inhibitors and many oncology drugs (e.g., ALECENSA, BRUKINSA, VENCLEXTA, VERZENIO) — PA NSO.
- Monoclonal antibodies/ADCs and other specialty oncology therapies — PA NSO; follow specialty pharmacy or network-site-of-care guidance if applicable.
- Some oncology agents also carry quantity limits alongside PA NSO (see QL entries where present).
Cardiovascular & Metabolic Agents — PA / QL Examples
Several cardiovascular, metabolic and specialty injectables/tablets require PA and/or have QLs. Examples include metyrosine (PA), sacubitril/valsartan (ENTRESTO) with QL, PCSK9 inhibitors with QL and PA, and KERENDIA with QL/PA. Claims exceeding QL or lacking PA risk denial.
- Metyrosine 250 mg capsule — PA required.
- ENTRESTO (sacubitril/valsartan) — QL(240 EA per 30 days); document when requesting exceptions.
- PCSK9 agents (PRALUENT, REPATHA) — QL and PA apply (e.g., PRALUENT QL(2 ML per 28 days); PA).
- KERENDIA — QL(30 EA per 30 days); PA required.
- VERQUVO, NEXLETOL/NEXLIZET and other CV agents listed carry QL and PA as indicated.
Depot & Specialty Injections — PA / PA NSO
Select depot and specialty injections require PA NSO or PA and often have quantity limits. Providers should confirm whether PA NSO (new-starts only) applies and follow site-of-care instructions.
- Depot gonadotropin-releasing hormone agents (LUPRON DEPOT, FIRMAGON) — PA NSO; QL entries for 1-, 3-, 4-, 6-month formulations.
- Leuprolide acetate and other depot injections — PA NSO or PA; check QL (e.g., LUPRON DEPOT QL per dosing interval).
- Follow specialty injection PA procedures and provide required supportive clinical documentation.
Immunologic & Specialty Therapies — PA / QL
Many immunologic and specialty immunoglobulin agents require PA and may carry QLs (e.g., PRIVIGEN, CINRYZE, BIVIGAM, BENLYSTA, DUPIXENT, ORENCIA, SKYRIZI). Submit PA with complete documentation to avoid denials.
- Immunoglobulins (PRIVIGEN, GAMASTAN, BIVIGAM, HIZENTRA) — PA required; some products list QLs.
- Biologics and immunologic agents (BENLYSTA, DUPIXENT, ORENCIA, COSENTYX, SKYRIZI) — QL and PA often apply; follow formulary Requirements/Limits.
- Immunosuppressants and adalimumab biosimilars — QL and PA noted; some entries reference manufacturer labeling requirements (e.g., Boehringer Ingelheim labeled products only).
Documentation & Exception Requests — What to Submit
When PA or QL is indicated, providers must submit supporting clinical documentation with the PA request. Documentation should explain the medical necessity, prior therapies tried (if step therapy applies), and any reason for exceeding QL. Exception requests follow standard timelines: 72 hours for routine decisions and 24 hours for expedited requests when delay could seriously harm the patient.
- Include prescriber's supporting statement and relevant medical records or rationale when requesting an exception or PA.
- Routine exception decisions are made within 72 hours of receiving the prescriber's supporting statement; expedited requests are decided within 24 hours when appropriate.
- Submit documentation to justify prior use of step-therapy alternatives or to request a waiver of QLs or PA requirements.
How to Interpret Requirements/Limits & Formulary Metadata
Follow the Requirements/Limits field for each drug entry. Use the introduction pages for symbol and abbreviation definitions (e.g., PA, PA NSO, QL, NDS, ST, ST NSO) and check the formulary metadata (Formulary ID, Version, Effective Date, Last Updated) when referencing coverage rules.
- Submit prior authorization when the table shows PA or PA NSO; PA NSO may restrict coverage for new starts only.
- Interpret table symbols using the introduction pages — this avoids misinterpretation of NDS, B/D, ST NSO and similar flags.
- Formulary metadata: Formulary ID 26216, Version 13, Effective Date 06/01/2026; Last Updated 05/01/2026 (use these when citing formulary status).
Denial Risk — Common Triggers
Denial risk is triggered when required prior authorization is not obtained, quantity limits are exceeded without approval, or step therapy requirements are not met. Specialty/PA NSO designations and noncompliant site-of-care or manufacturer restrictions may also lead to denial.
- Claims submitted without required PA or with QL exceedances may be denied — obtain PA or submit an exception request prior to dispensing.
- PA NSO and site-of-care restrictions (NSO) can result in noncoverage for new starts if PA NSO conditions are not satisfied.
- Manufacturer/label restrictions (e.g., Boehringer Ingelheim labeled products only) and failure to follow specialty program rules increase denial risk.
Key Terms & Abbreviations
Step Therapy Rules & Identified Products
| Scope | Policy |
|---|---|
| When 'ST' or 'ST NSO' appears in the Requirements/Limits column | Step therapy applies; 'ST NSO' is defined as 'Step Therapy for New Starts Only' in the Requirements/Limits key and indicates step therapy applies to new starts only. |
| Example products | Requirement |
|---|---|
| BRIVIACT (solution and tablet), EPIDIOLEX (solution) | Listed with 'PA NSO' in the Requirements/Limits column — prior authorization (PA) with NSO designation is required and may imply step or specialty review prior to coverage. |
| Product | Flag shown |
|---|---|
| AUVELITY tablet extended release 105 mg/45 mg | Requirements/Limits = QL(60 EA per 30 days); ST NSO (step therapy for new starts only). |
| EXXUA titration pack and tablets | Requirements/Limits include ST NSO on titration and tablet presentations (some strengths show QL and ST NSO). |
| EMSAM transdermal patch (MAOI) — general class reference | 'ST NSO' is listed in the Requirements/Limits key as a step-therapy indicator for new starts (EMSAM listed among antidepressant/patch products in the same section). |
| Item | Requirements/Limits |
|---|---|
| FETZIMA titration pack and FETZIMA capsules | Requirements/Limits = QL(30 EA per 30 days); ST NSO — step therapy applies for new starts as indicated in the key. |
| Examples | Step therapy flag |
|---|---|
| RYTARY capsule extended release | Requirements/Limits = ST (step therapy) as shown in the formulary extract. |
| FANAPT titration packs (A/B/C) and FANAPT tablets | Requirements/Limits = QL(...) and ST NSO on titration packs and ST NSO on some FANAPT entries indicating step therapy for new starts. |
| INVEGA HAFYERA injection | Requirements/Limits = ST NSO — step therapy for new starts only as listed in the Requirements/Limits column. |
| Product examples | Interpretation |
|---|---|
| NEULASTA, PROCRIT, UDENYCA (selected high-cost injectable/supportive care agents) | These products are designated 'PA' in the Requirements/Limits column; the PA designation may reflect specialty handling or program review rather than an explicit step-therapy edit in the excerpt. |
| Agents | Controls shown |
|---|---|
| PRALUENT and REPATHA (PCSK9 inhibitors) | Requirements/Limits list QL values (e.g., QL(2 ML per 28 days) for PRALUENT; QL(3 ML or 7 ML per 28 days) for REPATHA) and 'PA' — no explicit step sequence is provided in the cited excerpts. |
| Product | Step therapy flag |
|---|---|
| Diclofenac sodium gel 3% | Requirements/Limits = QL(300 GM per 30 days); ST — listed with an explicit 'ST' step therapy flag. |
| RELISTOR injection and tablet presentations | RELISTOR entries appear in the same section and are described in the brief as having 'ST' flags (diclofenac/RELISTOR examples cited). |
| Context | Policy note |
|---|---|
| Higher‑tier agents and specialty products (examples in extract include various Tier 5 specialty drugs) | Many higher‑tier agents are designated 'PA' in the Requirements/Limits column indicating prior authorization is required before coverage; the excerpt does not show explicit step edits for these agents. |
Documented Quantity Limits (Selected Examples)
Background & Scope
Biological products are complex and may have biosimilar alternatives. The formulary distinguishes between original biological products and biosimilars; where a biosimilar is designated as interchangeable, substitution may occur consistent with state law and plan policy. Providers should consult the formulary introduction for substitution rules and any preferences the plan has for biosimilars versus reference biologics.
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