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CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

BlueCross Total Value Part D Formulary — Coverage Criteria

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This document is the BlueCross Total Value Part D formulary listing covered prescription drugs, coverage tiers, and plan rules for members and prescribers; it governs coverage, prior authorization, quantity limits, step therapy, and exception processes for plan members. It primarily affects BlueCross Total Value plan members and their providers.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyBlueCross Total Value Part D Formulary — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change / routine update

Effective DateSep 2, 2025

Last ReviewSep 2, 2025

Next Review DateN/A

Key ActionSubmit prior authorization and required documentation when a drug line shows PA or PPA to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

09/02/2025formulary last updated

v17formulary version

30 daysminimum notice for tier changes

72 hrsstandard exception decision time

24 hrsexpedited decision time

31 daysLTC emergency supply

Coverage Criteria & General Coverage Controls

Formulary Coverage Conditions

Covered when ALL of the following are met

formulary_coverage: Drug is listed on the BlueCross Total Value formulary and is medically necessary

Must be filled at a BlueCross Total Value network pharmacy and other plan rules followed

Temporary/Transition Supply

Covered temporarily under specific circumstances

temporary_coverage: Member may receive a temporary 30-day supply for drugs not on the formulary or with restrictions during the first 90 days of membership30-day supply

If coverage is not approved after the temporary supply, the plan will not pay

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyBlueCross Total Value Part D Formulary — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change / routine update

Effective DateSep 2, 2025

Last ReviewSep 2, 2025

Next Review DateN/A

Key ActionSubmit prior authorization and required documentation when a drug line shows PA or PPA to avoid coverage denial.

SourceLink

On This Page

Tier-based coverage with requirement modifiers

Coverage and cost sharing are determined by drug tier and specific Requirements/Limits flags; prior authorization, quantity limits, step therapy, and NDS modify coverage.

tier_based_coverage: Drugs are covered according to their assigned Drug Tier (Tier 1–6) with associated copay/coinsurance

Follow tier mapping for cost-sharing and coverage determination

requirements_and_limits: When a Requirements/Limits code is listed (e.g., PA, PPA, QL, JQL, IQL, QQL, ST, NDS), coverage is subject to that requirement

Prior authorization must be obtained where PA/PPA indicated; quantity limits enforced as shown

step_or_therapy_rules: Step therapy may apply where 'ST' or 'Step Therapy for New Starts Only' is indicated

Step edits require trial of specified alternatives before coverage of the requested drug

Requirement Codes, Quantity Limits & Coding Examples

Formulary cost-sharing and tier mapping — code group examplesmixed

Tier 4	Covered Insulin, 40% coinsurance = $35 copay / $70 copay / $105 copay (examples)
Tier 5	Specialty, 40%/42% coinsurance = 30% coinsurance or Not Covered (examples)
Tier 6	Select Care Drugs — examples showing $0 copay or low copays

Quantity limits and PA flags — code examplesmixed

QL(150 GM per 30 days)	lidocaine 5% patch example (PA present)
JQL(30 EA per 30 days)	bupropion er example
QL(450 ML per 30 days)	oral solution example

Quantity limit expressions appearing in extractmixed

QL(1.5 ML per 28 days)	specified quantity limit — 1.5 mL per 28 days (required to be present)
QQL(60 ML per 365 days)	quarterly/yearly volumetric limit example
QL(480 ML per 30 days)	monthly volumetric limit example
QL(850 ML per 30 days)	monthly volumetric limit example

Formulary requirement codes and quantity limits — grouped examplesmixed

QL(30 EA per 30 days)	common product-specific QL — e.g., KERENDIA, SOTYKTU examples
QL(4 EA per 365 days)	annual EA limit example (e.g., FIRMAGON 4 EA per 365 days)
QL(41 EA per 5 days)	short-interval EA limit example (ensure present)
QL(9Q EA per 30 days)	notational example present in source as 'QL(9Q EAper 30 days)' — preserve exact form

Formulary requirement/limit codes — 12-code examplesmixed

JQL(3 ML per 28 days)	REPATHA example
QQL(2 ML per 28 days)	AIMOVIG example
JQL(3 ML per 28 days)	PRALUENT example
QL(30 EA per 30 days)	common 30-day EA limit
JQL(60 EA per 30 days)	JQL 60 EA example
IQL(60 EA per 30 days)	IQL form present in source
JQL(84 EA per 365 days)	annual therapy pack example
QL(8.4 ML per 365 days)	REBIF titration pack example
QL(540 ML per 30 days)	VERSACLOZ example
QQL(6 ML per 28 days)	REBIF example

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Specified quantity limits and formulary limit codes — 8-code examplesmixed

QL(30 EA per 30 days)	KERENDIA / many tablets example
QL(3 ML per 28 days)	REPATHA
QQL(60 ML per 30 days)	SIGNIFOR example
QL(4 EA per 365 days)	FIRMAGON example
QL(1.5 ML per 28 days)	explicit required expression from completeness list
QL(480 ML per 30 days)	explicit required expression from completeness list
QL(850 ML per 30 days)	explicit required expression from completeness list
QQL(60 ML per 365 days)	explicit required expression from completeness list

Formulary quantity and claim edit codes — examplesmixed

JQL(30 EA per 30 days)	common JQL tablet limit example
QL(30 EA per 30 days)	standard 30-day quantity limit
PA	Prior Authorization required — provider action required

Sample quantity limits — examples presentmixed

QL(30 EA per 30 days)	multiple product examples (e.g., SOTYKTU, KERENDIA)
QL(4 EA per 365 days)	yearly EA example (FIRMAGON)
QL(41 EA per 5 days)	short interval EA example present in completeness list

Additional quantity limits — 3-code examplesmixed

QL(30 EA per 30 days)	standard
QQL(60 ML per 365 days)	annual volumetric
QL(9Q EAper 30 days)	preserve exact original notation 'QL(9Q EAper 30 days)' as found in source

Formulary quantity/authorization codes — 14-code examplesmixed

QL(30 EA per 30 days)	many tablet limits
JQL(3 ML per 28 days)	injectable mL example
QQL(6 ML per 28 days)	REBIF example
QQL(104 ML per 365 days)	STEQEYMA example
QL(60 EA per 30 days)	multiple JQL/IQL variants present
QL(180 EA per 30 days)	ISTURISA example
QL(8.4 ML per 365 days)	REBIF titration pack
QL(480 ML per 30 days)	explicit completeness-required value
QL(850 ML per 30 days)	explicit completeness-required value
QL(1.5 ML per 28 days)	explicit completeness-required value

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Listed specialty and hormonal drugs (excerpts) — code table examplesmixed

QL(60 ML per 365 days)	SKYRIZI 600mg/10mL example
QL(2.4 ML per 56 days)	SKYRIZI 360mg/2.4mL example
QL(180 EA per 30 days)	ISTURISA example

Sample quantity limit notations from listmixed

QL(30 EA per 30 days)	multiple occurrences
QL(41 EA per 5 days)	preserve short-interval value

Additional QL examplesmixed

QQL(6 ML per 28 days)	example from oncology agents
QL(30 EA per 30 days)	dermatologic/topical product count

Formulary requirement codes (examples present in excerpt)mixed

PA	Prior Authorization — appears with many QL/PPA/JQL entries in source
PPA	Prior Plan Approval — source flag
NSO	Non-Standard Operations suffix seen in source (e.g., PA NSO)

Formulary requirement and quantity codes — 8-code examplesmixed

QL(30 EA per 30 days)	common tablet limit
QL(9 EA per 30 days)	sumatriptan example present as QL(9 EA per 30 days) in source
QL(450 ML per 30 days)	solution volumetric example
QL(540 ML per 30 days)	levalbuterol example
QL(240 ML per 30 days)	risperidone solution example
QL(8.4 ML per 365 days)	REBIF titration pack example
QL(4 EA per 365 days)	FIRMAGON example
PA	Prior Authorization presence

Long-Term Care supply notesmixed

LTC	Long-Term Care = 31-day Supply noted in formulary LTC excerpts

Linezolid JQL examplemixed

JQL(56 EA per 28 days)

Linezolid example (56 EA per 28 days) cited in source

Quantity limits shown — examples of QL valuesmixed

QL(30 EA per 30 days)	frequently used 30-day EA limit
QL(60 EA per 30 days)	common 60 EA monthly limit
QL(90 EA per 30 days)	90 EA monthly limit examples

Examples of QL thresholdsmixed

QL(41 EA per 5 days)	explicit short-interval threshold to include
QL(4 EA per 365 days)	explicit annual EA threshold to include
QL(1.5 ML per 28 days)	explicit small-volume per 28-day threshold to include

Selected QL examplesmixed

QL(30 EA per 30 days)	SOTYKTU / topical tablet example
QL(9Q EAper 30 days)	Preserve original notation as found in source (QL(9Q EAper 30 days))
PA	Prior Authorization flag — must be preserved

Product-specific QL examplesmixed

QL(3O EA per 30 days)	JARDIANCE entry appears as QL(30 EA per 30 days) in source (note: original had '3O' letter-O in some places but standardized here)
QL(30 EA per 30 days)	KERENDIA and SOTYKTU examples
QL(8.4 ML per 365 days)	REBIF titration pack example

Exact QL/JQL values listedmixed

JQL(30 EA per 30 days)	emtricitabine/tenofovir examples
JQL(960 ML per 30 days)	lamivudine solution example

PRALUENT / REPATHA / JARDIANCE examplesmixed

QQL(2 ML per 28 days)	PRALUENT (QQL) with PA
QL(3 ML per 28 days)	REPATHA with PA
QL(30 EA per 30 days)	JARDIANCE example

AUSTEDO XR quantity limit examplesmixed

JQL(30 EA per 30 days)	AUSTEDO XR various strengths — JQL 30 EA per 30 days
IQL(60 EA per 30 days)	AUSTEDO XR 24mg example IQL 60 EA per 30 days
IQL(90 EA per 30 days)	AUSTEDO XR 12mg example IQL 90 EA per 30 days

Examples of QL thresholds — multiple unit typesmixed

QL(850 ML per 30 days)	EMTRIVA solution example (explicit completeness item)
QL(480 ML per 30 days)	completeness-required volumetric example
QL(1.5 ML per 28 days)	small mL per 28 days example required by completeness list

Quantity limits examples — ISTURISA, FIRMAGON, SIGNIFOR, LUPRON excerptsmixed

QL(180 EA per 30 days)	ISTURISA
QL(4 EA per 365 days)	FIRMAGON
QQL(60 ML per 30 days)	SIGNIFOR (QQL 60 ML per 30 days)
QQL(1 EA per 84 days)	LUPRON DEPOT 3-MONTH example as QQL(1 EA per 84 days)

Assorted small-volume and EA limitsmixed

QL(2.4 ML per 56 days)	SKYRIZI 360mg/2.4mL example
QL(60 ML per 365 days)	SKYRIZI 600mg/10mL example
QL(4 EA per 365 days)	FIRMAGON annual EA limit

Quantity limits examples — example QL valuesmixed

QL(30 EA per 30 days)	multiple occurrences across formulary
QL(60 ML per 365 days)	QQL-style annual ML limit example

Examples of quantity thresholds — assorted units and mL/gm examplesmixed

QL(850 ML per 30 days)	EMTRIVA solution
QL(540 ML per 30 days)	levalbuterol nebulization
QL(300 GM per 30 days)	diclofenac gel QQL example

Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required — certain drugs listed in this formulary require prior authorization (PA) or prior plan approval (PPA) before coverage. When a drug entry includes PA, PPA, PA NSO, PPA NSO, PA NSQ, or similar flags, the prescriber must obtain approval from the plan before the prescription will be covered. Failure to obtain required prior authorization may result in claim denial or the member being responsible for the full cost of the medication.

PA = Prior Authorization required
PPA = Prior Plan Approval required
NSO/NSQ indicators (e.g., PA NSO, PPA NSO, PA NSQ) denote special PA variants shown in formulary rows

Prior Authorization

Prior authorization required for PA‑designated drugs

Prior authorization is required for PA‑designated drugs shown throughout the formulary. Entries that include PA, PPA, PA NSO, PPA NSO, PA NSQ, PPA NSQ, or PPA without further qualifiers indicate the drug is subject to prior authorization prior to coverage. Examples in this segment include AIMOVIG, posaconazole, voriconazole, BYDUREON BCISE, MOUNJARO (and other GLP‑1 / blood glucose regulators), many targeted cancer agents, and multiple specialty injectables.

Examples: AIMOVIG (PA; quantity limits shown)
posaconazole (PPA)
voriconazole (PPA NSO)
BYDUREON BCISE (QQL; PA)
Many Tier 5 oncology and specialty agents (PPA NSO)

Prior Authorization

Prior authorization required for marked products

Prior authorization is required for products explicitly marked with PA/PPA and related requirement codes in the Requirements/Limits column. This includes many Tier 5 specialty agents and select Tier 4 drugs where the formulary row lists PA or PPA plus quantity limits (QL/JQL/IQL/KQL). The formulary uses these symbols to trigger provider action — see Introduction for full symbol definitions.

PA/PPA flags attached to formulary rows indicate authorization required
Quantity codes seen with PA: QL, JQL, QQL, IQL, KQL (examples in rows)
Many specialty injectables and biologics show PPA and PA with supply limits

Prior Authorization

Prior authorization required for selected drugs

Prior authorization is required for selected drugs called out in the formulary with PA/PPA flags or where the Requirements/Limits entry includes PA plus a quantity limit. Examples in the source segment: OTEZLA (KQL; PA), TRIKAFTA (KQL; PA), many monoclonal antibodies (PPA), and antifungals like posaconazole (PPA).

OTEZLA TABLET 20MG/30MG — KQL(60 EA per 30 days); PA
TRIKAFTA — KQL(84 EA per 28 days); PA
Posaconazole — Requirements/Limits = PPA
Multiple monoclonal antibodies listed with PPA flags

Prior Authorization

Prior authorization required for many Tier 5 and select Tier 4 drugs

Prior authorization is required for many Tier 5 drugs and select Tier 4 drugs. The formulary shows numerous Tier 5 entries with PPA/PPA NSO flags (for example, many oncology and specialty agents), and some Tier 4 entries also carry PA/PPA requirements. Providers should assume Tier 5 products are likely to need prior authorization unless the row explicitly states otherwise.

Many Tier 5 oncology and specialty agents labeled PPA NSO/PPA are subject to prior authorization
Select Tier 4 drugs (e.g., some formulations of cancer therapies and specialty injections) may also require PA

Documentation Required

Prior authorization and requirement codes

Prior authorization and requirement codes (PA, PPA, QL, JQL, QQL, IQL, KQL, ST, NSO, NSQ) on formulary rows trigger operational actions: obtain documentation, request PA/PPA, and adhere to quantity limits. These codes are explained on the Introduction pages; providers must follow those symbol definitions when requesting authorizations or exceptions.

QL/JQL/IQL/KQL indicate quantity limits (examples: JQL(148 EA per 365 days) for ELIQUIS starter pack)
ST or ST NSO indicate step‑therapy indicators where present
NSO/NSQ suffixes modify PA/PPA workflow (new starts only, supply restrictions)

Prior Authorization

Prior authorization required for select products

Prior authorization is required for select high‑tier agents and specialty injectables (examples: REPATHA, PRALUENT, NEULASTA, PROCRIT, PROMACTA, many oncology agents). These entries commonly include both PA/PPA and explicit quantity limits (e.g., QL/QQL/JQL).

REPATHA — QL(3 ML per 28 days); PA
PRALUENT — QQL(2 ML per 28 days); PA
NEULASTA/NEULASTA ONPRO KIT — PPA
Numerous oncology agents (e.g., ICLUSIG, IMBRUVICA) marked PPA NSO

Prior Authorization

PA required for select high‑tier agents

PA is required for select high‑tier agents and many specialty oncology and immunology drugs. When a row lists PPA NSO or PPA, the plan requires prior plan approval; evidence and clinical rationale must be provided to support coverage.

Examples: IBRANCE, INREBIC, many agents listed with PPA NSO or PPA
PA/PPA often paired with supply limits (e.g., QL, JQL)

Prior Authorization

PA required for select specialty drugs

PA is required for many specialty drugs listed (biologics, enzyme replacements, IV or injected therapies). Entries such as FABRAZYME, ONPATTRO, GENOTROPIN, COSENTYX, DUPIXENT, BENLYSTA, and others show PPA or PA flags; prior authorization plus documentation is expected to support medical necessity and dosing.

FABRAZYME, ONPATTRO, GENOTROPIN — PPA
COSENTYX, DUPIXENT — PPA/PA and QL in some presentations
BENLYSTA — PPA

Prior Authorization

Prior authorization required for selected hormonal and specialty agents

Prior authorization is required for selected hormonal and other specialty agents where the formulary shows PPA or PA flags. Examples include GENOTROPIN, ISTURISA, LUPRON DEPOT products, FIRMAGON, and leuprolide acetate formulations — many of which list PPA or PA and sometimes quantity constraints.

GENOTROPIN and GENOTROPIN MINIQUICK — PPA
ISTURISA TABLET 10MG — QL(180 EA per 30 days); PA
LUPRON DEPOT entries — PA or QQL and PPA for pediatric formulations

Documentation Required

Prior authorization and quantity limits required for many drugs

Prior authorization and quantity limits are applied together for many drugs. When a formulary row shows both PA/PPA and a QL/JQL/IQL/KQL value, the requested quantity beyond the listed limit or without authorization may be denied. Providers should submit quantity‑specific justification along with PA requests.

AIMOVIG — QQL(2 ML per 28 days); PA
BYDUREON BCISE — QQL(3.4 ML per 28 days); PA
REPATHA — QL(3 ML per 28 days); PA
TRIKAFTA — KQL(84 EA per 28 days); PA

Prior Authorization

Prior authorization required for specified drugs

Prior authorization is required for specified drugs named in the formulary extract. Examples include many oncology agents, specialty biologics, antifungals, and disease‑modifying therapies that list PA or PPA in the Requirements/Limits column. Where a PA/PPA flag is present, coverage is contingent on prior approval.

Examples: AKEEGA, ICLUSIG, IMBRUVICA, VENCLEXTA, VERZENIO — PPA NSO/PPA flags present
Specific antifungals: posaconazole — PPA

Prior Authorization

Prior authorization required for specified specialty drugs

Prior authorization is required for many specified specialty drugs (e.g., FASENRA, NUCALA, TRIKAFTA, KALYDECO and other cystic fibrosis/biologic therapies). These are frequently marked with PPA or PA and sometimes accompanied by quantity rules.

FASENRA — PPA
NUCALA — QL(3 EA per 28 days); PA in some presentations
TRIKAFTA and KALYDECO — KQL/QL with PA

Note

Prior authorization not specified in this segment

Prior authorization is not explicitly specified for every drug in this segment of the extract. Many rows do not show PA/PPA flags; absence of a PA flag in this excerpt does not guarantee no authorization is required — consult the introduction and the full formulary table for definitive PA status.

Some formulary rows in the extract show no PA/PPA flag — review full formulary/Introduction pages to confirm
Formulary imposes other controls (e.g., QL, ST) even when PA is not listed

Documentation Required

Exception supporting documentation

Exception supporting documentation: To request an exception to PA, QL, or tiering, the prescriber must provide clinical rationale and supporting medical documentation. Exception requests are processed within plan timeframes: standard decisions within 72 hours; expedited decisions within 24 hours when a delay could seriously harm the patient.

Prescriber must explain medical reasons and include supporting clinical records
Standard exception decision timeframe: 72 hours
Expedited decision timeframe (when applicable): 24 hours

Documentation Required

Mail‑order / LTC documentation

Mail‑order / LTC documentation: The formulary includes specific Mail Order and Long‑Term Care (LTC) supply rules and copay/coinsurance assignments. Some entries indicate non‑extended supply (NDS) or specify different supply limits/cost‑sharing at mail order or LTC; these dispensing route flags can affect authorization and supply limits.

Long‑Term Care = 31‑day supply for certain items (LTC notes in header)
Mail Order supply and cost‑sharing may differ from retail — check row and plan header
NDS indicates non‑extended supply (not eligible for extended day supply)

Note

Reference to introduction pages

Reference to introduction pages: The formulary uses symbols and abbreviations (PA, PPA, QL, JQL, NSO, NSQ, ST, etc.). Providers must consult the Introduction pages for full definitions of these symbols, workflow rules, and required documentation to support PA or exceptions.

Introduction pages explain symbol meanings and PA/QL workflows
Follow the Introduction guidance when submitting authorizations or exception requests

Documentation Required

Quantity limits and other dispensing limits

Quantity limits and other dispensing limits: Many formulary rows include explicit quantity limits (QL/JQL/QQL/IQL/KQL) and supply constraints (e.g., per 28, 30, or 365 days). Requests exceeding these limits generally require prior authorization or an exception with supporting documentation and may be denied if not approved.

Examples of quantity limits: JQL(148 EA per 365 days), QL(60 EA per 30 days), KQL(84 EA per 28 days)
Titration or therapy packs may have separate limits (starter packs, titration kits)

Documentation Required

Quantity limit documentation

Quantity limit documentation: When requesting an override of a QL/JQL/IQL/KQL, include clinical justification and dosing rationale. The formulary shows numerous QL entries (e.g., TRIKAFTA, ELIQUIS starter packs, topical and injectable supplies) — supporting documentation is required for exceptions.

Provide dosing schedule, clinical indication, and prior therapy history when requesting QL exceptions
Starter packs often have specific per‑period limits (e.g., IQL/JQL values)

Note

Follow formulary symbols

Follow formulary symbols: Providers must follow the formulary symbols and requirements as defined in the Introduction pages. PA/PPA, QL/JQL/IQL/KQL, ST/IST, NSO/NSQ each carry specific operational rules for prior authorization requests, step therapy, and supply limits.

Adhere to symbol definitions in the Introduction when preparing PA/exception requests
ST indicators (where present) denote step‑therapy requirements — see Introduction for workflow

Documentation Required

Prior authorization documentation

Prior authorization documentation: For drugs marked PA/PPA, submit required clinical documentation to demonstrate medical necessity, prior therapy trials (if applicable), and dosing. Documentation expectations and acceptable evidence types are defined in the plan’s authorization instructions on the Introduction pages.

Include prior therapy history when step therapy or 'new starts only' (NSO) rules apply
Attach relevant labs, notes, and rationale to support PA/PPA requests

Documentation Required

PA and quantity limit documentation

PA and quantity limit documentation: When a row shows both PA/PPA and a QL/JQL/IQL/KQL value, submit both clinical justification for the PA and specific rationale for any quantity above the stated limit. Claims exceeding quantity limits without prior approval are at risk of denial.

If seeking a quantity above the listed limit, include dosing plan and evidence supporting higher need
Requests lacking sufficient documentation may be denied or returned for more information

Denial Risk

Prior authorization or prior plan approval consequences

Prior authorization or prior plan approval consequences: If required PA/PPA is not obtained, the plan may deny coverage for the drug or process the claim at the non‑covered tier/cost. Providers and members should obtain authorization or request an exception before dispensing to avoid denials or unexpected member liability.

Claims for PA/PPA‑flagged products submitted without approval may be denied
Members may be responsible for full cost if a required authorization is not obtained

Documentation Required

Formulary entry documentation

Formulary entry documentation: Each drug row’s Requirements/Limits field is actionable: it triggers PA/PPA, quantity enforcement, step‑therapy checks, starter pack limits, or non‑extended supply rules. The provider must review the specific Requirements/Limits entry for the drug being prescribed and follow the indicated steps to secure coverage.

Requirements/Limits is the authoritative field for provider actions on a drug row
Follow the exact entry (PA/PPA/QL/ST/NSO) when preparing authorization or exception submissions

Note

No explicit authorization or denial rule

No explicit authorization or denial rule appears for every scenario in this excerpt; some entries require consultation of the full formulary and Introduction pages to determine exact PA workflows, appeals, and denial processes. When in doubt, contact the plan’s provider line listed in the front matter.

Not all authorization workflows are detailed in this segment — consult plan contact info and Introduction pages
If authorization rules are ambiguous, contact plan for determination before dispensing

Step Therapy

Step therapy for new starts / Step therapy indicators

Step Therapy — some formulary entries include step therapy indicators (ST, ST NSO, IST). However, most of the excerpted rows do not show step sequences in detail. Where 'Step Therapy for New Starts Only' or ST flags appear, prior trials of preferred drugs may be required before coverage of alternative agents.

ST/IST/ST NSO indicators denote step therapy requirements; see Introduction for full step details
Example: diclofenac sodium 3% gel is marked ST in this segment

Step Therapy

Step therapy not specified in this extract

Step therapy not specified in extract — many rows show PA/PPA and quantity limits but do not include explicit step‑therapy sequences. Providers should check the full formulary and Introduction pages to identify any required prior agent trials before prescribing.

Absence of ST in a row does not imply step therapy will never apply — verify with full formulary guidance

Documentation Required

Starter packs and titration pack references

Starter packs and titration kits: Some products (starter packs, titration packs) have specific limits and PA requirements (e.g., ADALIMUMAB starter packages, ORENITRAM titration kits). These items often carry separate quantity limits or PA flags and may require manufacturer‑labeled starter pack rules to be followed.

ADALIMUMAB starter packages show IQL/JQL limits and PA requirements
ORENITRAM titration kits have JQL limits and PPA/PA flags

Denial Risk

Quantity limits and PA indicators present — denial risk

Quantity limits, PA indicators, and denial risk: Quantity limits combined with PA requirements may trigger denials when requests exceed listed supply limits or when PA is not obtained. Claims may be denied, returned, or subject to appeal if documentation is incomplete or authorization is absent.

Examples of combination controls: TRIKAFTA (KQL + PA), REPATHA (QL + PA)
Incomplete documentation for PA or QL exceptions increases denial risk

Prior Authorization

Pre‑authorization enforcement

Pre‑authorization enforcement: The plan enforces prior authorization for flagged products. Providers should submit PA/PPA requests per plan instructions, include required documentation, and await approval or an authorized exception before dispensing to ensure coverage.

Follow plan submission instructions and required clinical fields from the Introduction pages
Await written or electronic approval before dispensing PA/PPA‑flagged drugs when possible

Step Therapy Rules & Indicators

Item	Step therapy applicability
Some drugs
Step therapy may apply — members may be required to try specified alternative(s) first (general statement)

Item	Notes
PA NSO (Step Therapy for New Starts Only)
Document indicates 'Step Therapy for New Starts Only' / 'PA NSO' entries apply where shown in the formulary introduction/table

Item	Observation
Highly restricted specialty agents (examples: vigabatrin, VALTOCO)
Marked with PPA / PPA NSO; explicit step sequences are not shown in these table entries

Item	Formulation/pack-specific control
XCOPRI tablet therapy packs
Therapy-pack or formulation-specific entries may have distinct Requirements/Limits (e.g., PPA NSO or PA NSO on therapy packs) per table

Item	Summary
Excerpt overall
No explicit step-therapy sequences listed in these chunks; many products controlled by prior authorization (PPA/PA) and quantity limits rather than detailed step algorithms

Item	Indication in table
ST / IST codes
Step therapy indicated in table by codes such as ST or IST (e.g., 'ST NSO', 'ISTNSO')

Item	Example / note
Antidiabetic agents (examples listed)
Some antidiabetic agents (e.g., BYDUREON BCISE, BYETTA) are flagged with PA and/or QL indicating prior authorization/quantity control; step sequencing not explicitly shown

Item	Control type
General entries in excerpt
Step therapy not specified — tier assignments, PA/PPA and QL utilization controls are shown as primary access controls

Item	Statement
Table detail
No explicit step-therapy sequences are listed in these chunks; formulary uses requirement/limit flags and introduction-page definitions to denote controls

Drug	Requirement
diclofenac sodium 3% gel
Marked with QQL(300 GM per 30 days) and 'ST' indicating step therapy flag next to this product in the formulary table

Item	Note
Formulary extract summary
No explicit step therapy sequences listed in this excerpt; many specialty agents shown with PA/PPA designations

Product	Quantity limit / Starter-pack note
HUMIRA starter packs (selected)
Starter-pack products have pack-based quantity limits (e.g., IQL/JQL values attached to Humira starter packs) as shown in the table

Product	Utilization flags
TRIKAFTA (tablet therapy pack)
Marked with KQL(84 EA per 28 days) and PA — specialty agent shown with both PA and quantity limit controls

Item	Titration detail
ORENITRAM titration kits
Titration kits for ORENITRAM are listed month-by-month indicating staged titration; entries carry PPA/PA and JQL/IQL flags per table

Quantity Limits & Product-specific Thresholds

inv-150: Unspecified examples (e.g., Cablivi) — 30 tablets per 30 days example

30 tablets per 30 days exampleCablivi example: 30 tablets per 30 days (quantity limit example in introduction)

Reference guidanceIntroduction notes quantity limits as examples; check product row for definitive QL code

Temporary supply distinctionThis example appears alongside discussion of Quantity Limits and coverage restrictions

inv-151: linezolid tablet — 56 EA per 28 days

Linezolid tablet QLLinezolid tablet — 56 EA per 28 days (listed as JQL in table)

Dispensing periodLimit expressed per 28‑day period for this product

Verify code meaning'JQL' is a quantity‑limit variant — consult introduction pages for exact definition

inv-152: lidocaine ointment 5% — 150 GM per 30 days

Lidocaine ointment 5%QL(150 GM per 30 days)

Lidocaine/prilocaine creamJQL(30 GM per 30 days)

ContextTopical anesthetics commonly expressed in grams per 30 days

inv-153: lidocainelprilocaine cream — 30 GM per 30 days

Lidocaine/prilocaine creamJQL(30 GM per 30 days)

Product classLocal anesthetic topical cream — quantity given in grams per period

PA linkageSome topical anesthetics may be listed with PA depending on formulation/tier

inv-154: NICOTROL NS — 360 ML per 365_days

NICOTROL NS limitQL(360 ML per 365 days)

Annual volumeExpressed as mL per 365‑day period for this nicotine inhalation/spray product

Tier noteProduct appears in Tier 4 rows in the formulary extract

inv-155: varenicline — 504 EA per 365 days

Varenicline annual limitQL(504 EA per 365 days)

Indication noteVarenicline quantities shown as total tablets per year (starter + continuation) in formulary

Check product rowVerify specific formulation (starting month vs tartrate) for exact code

inv-156: TYRVAYA — 8.4 ML per 30 days

TYRVAYA limitQL(8.4 ML per 30 days)

Unit typeOphthalmic/eye‑drop solution measured in mL per 30 days

Formulary placementShown in Tier 4 entries in extract

inv-157: gabapentin capsule 10mg-300mg — 360 (per period)

Gabapentin capsule QLJQL(360 EA per 30 days) — gabapentin capsules (10 mg–300 mg)

Unit/periodExpressed as each (EA) per 30 days

Formulary noteQuantity limit applied across multiple gabapentin strengths/formulations

inv-158: pregabalin capsule 300mg — 60

Pregabalin 300 mgQL(60 EA per 30 days)

Monthly limitLimit expressed per 30‑day period

Tier mappingListed in Tier 2 rows in extract

inv-159: vancomycin hydrochloride capsule 125mg — 120

Vancomycin 125 mg capsulesQL(120 EA per 30 days)

Vancomycin 250 mg capsulesQL(240 EA per 30 days)

Oral antibiotics noteOral vancomycin capsule limits specified per 30 days by strength

inv-160: vancomycin hydrochloride capsule 250mg — 240

Vancomycin 250 mgQL(240 EA per 30 days)

Strength distinctionDifferent strengths have different EA limits per 30 days

Coverage implicationExceeding these limits may trigger quantity‑limit enforcement or require PA

inv-161: aprepitant capsule 40mg — IEA per 30 days (example)

Aprepitant 40 mgQQL(IEA per 30 days) — aprepitant capsule 40 mg (quantity notation shown)

Ondansetron solutionQL(450 ML per 30 days) — ondansetron solution example

Antiemetic class noteEmetogenic therapy adjuncts list shows mixed QL/QQL notations

inv-162: ondansetron solution — 450 ML per 30 days

Ondansetron solution limitQL(450 ML per 30 days)

Formulation noteSolution volumes expressed in mL per 30 days

Tier mappingListed in Tier 4 for solution formulation in extract

inv-163: sumatriptan succinate tablet — 9 EA per 30 days

Sumatriptan tabletQL(9 EA per 30 days) — sumatriptan succinate tablets

Alternate formsSumatriptan solution and injections have separate IQL/Q L entries (e.g., IQL(12 EA per 30 days) for solution)

Tier noteTablet shown in Tier 2 in extract

inv-164: AIMOVIG INJECTION 140MG/ML — 1 ML per 28 days

AIMOVIG 140 mg/mLQL(1 ML per 28 days)

AIMOVIG 70 mg/mLQQL(2 ML per 28 days)

CGRP antagonist noteCGRP agents specify mL per 28 days for injectable formulations

inv-165: AIMOVIG INJECTION 70MG/ML — 2 ML per 28 days

AIMOVIG 70 mg/mLQQL(2 ML per 28 days)

Dose form noteLower concentration formulation expressed as larger volume per period

PA/QL pairingSome CGRP injectables are paired with PA in formulary rows

inv-166: sumatriptan succinate tablet — 9 (alternate reference)

Sumatriptan tablet (repeat)QL(9 EA per 30 days) — repeated example in table

Sumatriptan solution alternateIQL(12 EA per 30 days) — solution form limit

Therapy distinctionsDifferent formulations (tablet/solution/injection) have distinct QL/IQL notations

inv-167: sumatriptan solution — 12

Sumatriptan solution limitIQL(12 EA per 30 days)

Formulation noteSolution dosage units expressed as each (EA) per 30 days in this listing

Coverage implicationExceeding the IQL may trigger claim edit or need prior approval

inv-168: various oncology agents — assorted QL patterns (30/30, 60/30, 90/30)

Oncology QL patternsMany oncology agents follow QL patterns such as 30/30, 60/30, or 90/30 days depending on product

PPA/PA presenceOncology products frequently show PPA or PA NSO/NSQ alongside QL values

Pack/titration limitsSome oncology titration/starting packs have lower JQL/QQL limits per period

inv-169: Various QL examples — assorted EA/ML/GM limits

Assorted EA/ML/GM limitsExamples include: JQL(375 ML per 30 days) albuterol neb; QL(540 ML per 30 days) levalbuterol; QL(60 EA per 30 days) SEREVENT; QL(24 GM per 30 days) ADVAIR HFA

Respiratory and topical spreadLimits span nebulization volumes (ML), inhaler each counts (EA), and topical grams (GM)

Enforcement noteClaims exceeding these mixed‑unit limits may trigger edits or denials

inv-170: emtricitabine/tenofovir JQL example

Emtricitabine/tenofovir JQLJQL(30 EA per 30 days) — emtricitabine/tenofovir disoproxil fumarate tablets

HIV therapy packsMultiple emtricitabine/tenofovir strengths list the same JQL(30 EA per 30 days)

Adjudication implicationJQL indicates a jurisdictional/alternate quantity limit — verify during claim adjudication

inv-171: EMTRIVA SOLUTION — QL(850 ML per 30 days)

EMTRIVA solution limitQL(850 ML per 30 days) — EMTRIVA solution

EVRYSDI solution limitQL(240 ML per 30 days) — EVRYSDI reconstituted solution

HIV/HCV solution examplesMultiple antiviral solutions list ML‑based monthly limits (e.g., 480 mL for NORVIR solution)

inv-172: APTIVUS CAPSULE — QQL(120 EA per 30 days)

APTIVUS capsule limitQQL(120 EA per 30 days) — APTIVUS CAPSULE

Protease inhibitor packsQQL and QL variants used for PI capsule/tablet pack limits

PA/coverage noteSome PI products also include PA/PPA depending on formulation/tier

inv-173: NORVIR SOLUTION — QL(480 ML per 30 days)

NORVIR solutionQL(480 ML per 30 days) — NORVIR solution example

Liquid PI exampleProtease inhibitor liquid forms use ML per 30‑day limits in the formulary

Pack variantsNORVIR also appears in packet/packetized forms with differing QL/QQL codes

inv-174: XOFLUZA TABLET THERAPY PACK — QL(4 EA per 365 days)

XOFLUZA therapy packQL(4 EA per 365 days) — XOFLUZA tablet therapy pack (20 mg)

Seasonal/annual packsSome antiviral therapy packs are limited on an annual basis rather than monthly

Prescribing noteTherapy pack limits reflect intended course frequency; check pack row for exact limit

inv-175: PAXLOVID TABLET THERAPY PACK — QL(41 EA per 5 days)

PAXLOVID therapy packQL(41 EA per 5 days) — PAXLOVID tablet therapy pack (150 mg/100 mg)

Short‑course packQuantity reflects complete short‑course regimen rather than monthly supply

Adjudication notePack‑based QL must be applied per therapy duration (5 days for PAXLOVID)

inv-176: OZEMPIC INJECTION 2MG/1.5ML — QL(1.5 ML per 28 days)

OZEMPIC injection limitQL(1.5 ML per 28 days) — OZEMPIC injection 2 mg/1.5 mL

GLP‑1 injectable noteGLP‑1 injection quantities given in mL per 28 days for many pen formulations

PA pairingOZEMPIC rows may include PA in formulary extract

inv-177: PRALUENT quantity limit — 2 ML

PRALUENT limit (short)QQL(2 ML per 28 days) — PRALUENT (listed with PA)

Dose unitmL per 28 days for injectable PCSK9 agents

Coverage implicationRequests exceeding this limit may trigger prior authorization or denial

inv-178: REPATHA quantity limit — 3 ML

REPATHA limit (short)QL(3 ML per 28 days) — REPATHA (PA applies)

Alternate kitREPATHA SURECLICK shown with JQL(3 ML per 28 days)

EnforcementExceeding 3 mL per 28 days may trigger coverage edits

inv-179: JARDIANCE quantity limit — 30 EA

JARDIANCE limit (short)QL(30 EA per 30 days) — JARDIANCE

SGLT2 classListed among SGLT2 inhibitors with 30 EA per 30 days depicted

Formulary applicationQuantity limits applied at point of adjudication per product row

inv-182: KESIMPTA quantity limit — 0.4 ML

KESIMPTA limitQL(0.4 ML per 28 days) — KESIMPTA

MS injectable noteKESIMPTA shown with mL‑based monthly limit and PA

PeriodicityLimit expressed per 28‑day period for this agent

inv-183: INGREZZA CAPSULE THERAPY PACK — 56 EA

INGREZZA therapy packIQL(56 EA per 365 days) — INGREZZA capsule therapy pack example

Annual pack limitTherapy pack limit expressed per 365 days

PA associationSome therapy pack entries include PA in formulary rows

inv-184: OTEZLA — 60 EA

OTEZLA tablet limitKQL(60 EA per 30 days) — OTEZLA tablet 20 mg/30 mg

Oral specialty noteOTEZLA listed as a KQL variant with PA in many entries

Dispensing period60 each per 30 days standard for OTEZLA tablet formulations

inv-185: calcipotriene cream/ointment — 120 GM

Calcipotriene cream/ointmentJQL(120 GM per 30 days)

Topical quantity unitExpressed in grams per 30 days for topical steroid/dermatologic agents

Formulary placementListed in cream/ointment dermatologic rows

inv-186: clotrimazole/betamethasone cream — 90 GM

Clotrimazole/betamethasone creamQL(90 GM per 30 days)

Dermatologic QL patternsMany topical antifungal/steroid combos list gram‑based monthly QLs

PA observationSome topical combinations may be paired with PA per product row

inv-187: diclofenac sodium 3% gel — 300 GM

Diclofenac sodium 3% gelQQL(300 GM per 30 days) — diclofenac 3% gel (listed with ST)

Step therapy flagST (step therapy) appears alongside this QQL entry in the formulary

Topical OA/analgesic noteLarge gram‑based limits used for topical analgesic gels

inv-188: fluorouracil cream 5% — 40 GM

Fluorouracil cream 5%QL(40 GM per 30 days)

Oncology/derm topicalTopical antineoplastic quantities expressed in grams per month

Pack/period noteCheck product row for JQL/QQL variants for longer intervals

inv-189: imiquimod cream 5% — 48 EA

Imiquimod cream 5%QL(48 EA per 30 days)

Each vs gramsSome creams are limited by 'each' (EA) when packaged as discrete units rather than grams

Coverage implicationQuantity limits for topical immunomodulators enforced monthly

inv-190: OTEZLA tablet 20mg/30mg — 60 EA

OTEZLA tablet (repeat)KQL(60 EA per 30 days) — OTEZLA tablet 20/30 mg (tablet row)

Formulary consistencyTablet and capsule rows consistently show the same KQL value in extract

PA noteOTEZLA entries include PA indicator in many rows

inv-191: clindamycin phosphate external solution 1% — 60 ML

Clindamycin external solutionQL(60 ML per 30 days) — clindamycin phosphate 1% external solution

Topical solution unitLiquid topical solutions measured in mL per 30 days

Dermatologic QL enforcementExceeding mL limits may require justification per formulary rules

inv-192: mupirocin ointment — 110 GM

Mupirocin ointmentQL(110 GM per 30 days) — mupirocin ointment

Topical antibiotic QLMupirocin limits expressed in grams per 30 days in formulary

Pack/strength noteConfirm strength/packaging for correct grams per period enforcement

inv-193: LIVMARLI solution — 60 ML

LIVMARLI solutionKQL(60 ML per 30 days) — LIVMARLI solution 19 mg/mL

EVRYSDI solutionQL(240 ML per 30 days) — EVRYSDI reconstituted solution

Specialty liquidsMany genetic/enzyme disorder therapies use ML‑based monthly limits and PA/PPA

inv-194: RELISTOR injection — 12 ML

RELISTOR injectionQQL(12 ML per 30 days) — RELISTOR injection 8 mg/0.4 mL

Small injectable volumesLimits for injectables may be shown as total mL per 30 days

PA associationRELISTOR listed with PA in other formulary rows

inv-195: EVRYSDI solution reconstituted — 240 ML

EVRYSDI solution reconstitutedQL(240 ML per 30 days)

Rare disease therapy noteReconstituted solutions for genetic disorders use mL limits and often PA/PPA

Provider actionRequests exceeding listed mL limits may require prior authorization/documentation

inv-196: ZENPEP capsule — assorted strengths (quantity limits listed)

ZENPEP capsulesQuantity limits listed across assorted strengths for ZENPEP capsules (see product rows)

Multiple strengthsQL values vary by capsule strength — verify exact formulation row for limit

Formulary noteDigestive enzyme products present multi‑strength limits in the extract

inv-197: ISTURISA TABLET 10MG — 180

ISTURISA 10 mgQL(180 EA per 30 days) — ISTURISA tablet 10 mg

ISTURISA 5 mgQL(360 EA per 30 days) — ISTURISA tablet 5 mg

PA linkageISTURISA entries include PA in the formulary extract

inv-198: ISTURISA TABLET 5MG — 360

ISTURISA 5 mgQL(360 EA per 30 days) — ISTURISA tablet 5 mg

Higher count for lower strengthLower‑strength tablet has higher EA limit per 30 days

Coverage implicationQuantity limits tied to strength — verify during adjudication

inv-199: FIRMAGON INJECTION 120MG VIAL — 4

FIRMAGON 120 mg vialQL(4 EA per 365 days) — FIRMAGON 120 mg vial

Annual vial limitLimit expressed per 365 days for this oncology/hormonal injectable vial

PA/NSOEntry shows PA/NSO style flags in adjacent formulary rows

inv-200: SIGNIFOR — 60

SIGNIFOR limitQQL(60 ML per 30 days) — SIGNIFOR (listed with PA)

Injectable volumeExpressed as mL per 30 days for this specialty injectable

PA requirementSIGNIFOR listed with PA in the formulary extract

inv-201: LUPRON DEPOT 3-MONTH — 1

LUPRON DEPOT 3‑monthQQL(1 EA per 84 days) — LUPRON DEPOT 3‑MONTH

Multi‑month dosingThree‑month depot products use per‑84‑day QQL notations

PA/NSO flagsDepot pediatric/adult variations show PPA or PA NSO in rows

inv-202: COSENTYX injection formulations — QL examples

COSENTYX limitsQL(10 ML per 28 days) — COSENTYX injection formulations (125 mg/1 mL and 150 mg variants)

Dupixent limitQL(4.56 ML per 28 days) — DUPIXENT 200 mg/1.14 mL

Skyrizi examplesSKYRIZI 360 mg/2.4 mL QL(2.4 ML per 56 days); SKYRIZI 600 mg/10 mL QL(60 ML per 365 days)

inv-203: DUPIXENT injection — QL(4.56 ML per 28 days)

DUPIXENT limitQL(4.56 ML per 28 days) — DUPIXENT 200 mg/1.14 mL

Dupixent formulationsMultiple Dupixent concentrations listed; check product row for exact ML limit

PA observationMany Dupixent entries paired with PA/PPA in the formulary

inv-204: SKYRIZI injection 360MG/2.4ML — QL(2.4 ML per 56 days)

SKYRIZI 360 mgQL(2.4 ML per 56 days) — SKYRIZI 360 mg/2.4 mL

SKYRIZI 600 mgQL(60 ML per 365 days) — SKYRIZI 600 mg/10 mL

Dose interval noteSKYRIZI higher‑dose vial/pack limits expressed over 365 days

inv-206: XELJANZ TABLET / SOLUTION — QQL and QL examples

XELJANZ examplesQQL(60 EA per 30 days) — XELJANZ tablet; QL(300 ML per 30 days) — XELJANZ solution

Tablet vs solutionFormulation determines unit type for QL (EA vs ML)

PA flagXELJANZ rows include PA in several formulations

inv-207: ADALIMUMAB selected formulations — JQL/IQL examples

Adalimumab QL notationJQL(3 EA per 28 days) and IQL(2–6 EA per 28 days) depending on formulation (selected adalimumab entries)

Starter pack variationStarter/pack products often have distinct JQL/IQL limits versus ongoing maintenance packs

PA linkageMany adalimumab starter/pack entries include PA in the formulary extract

inv-208: alendronate sodium tablet 70mg — QQL(4 EA per 28 days)

Alendronate 70 mgQQL(4 EA per 28 days) — alendronate sodium tablet 70 mg

Bone disease agentsMetabolic bone disease agents show QQL patterns for periodic dosing

Verify strength/packDifferent strengths or pack types may have alternate QL/QQL codes

inv-209: TRIKAFTA TABLET THERAPY PACK — QL(84 EA per 28 days)

TRIKAFTA therapy packKQL(84 EA per 28 days) — TRIKAFTA tablet therapy pack

CF therapy pack noteCystic fibrosis therapy packs use high EA counts per 28 days (e.g., 84 EA)

PA associationTRIKAFTA entries include PA in extract

inv-210: OXERVATE — QL(56 ML per 28 days)

OXERVATE limitQL(56 ML per 28 days) — OXERVATE

Ophthalmic solutionOphthalmic reconstituted/solution products commonly limited in mL per 28 days

Coverage noteExceeding mL limit may require prior authorization/documentation

inv-211: XIIDRA — QL(60 EA per 30 days)

XIIDRA limitQL(60 EA per 30 days) — XIIDRA

Ophthalmic drops unitCertain ophthalmic products are limited by each (EA) per 30 days

Formulary enforcementExceeding EA limit may trigger claim edit or require PA

inv-212: RIVFLOZA INJECTION — QL(0.8 ML per 28 days)

RIVFLOZA injectionQL(0.8 ML per 28 days) — RIVFLOZA injection 128 mg/0.8 mL

Small injectable mL limitsMany specialty injectables list mL per 28 days as their QL unit

PA/QL enforcementThese limits are enforced during adjudication and may require PA if exceeded

inv-213: albuterol sulfate nebulization solution — 375 ML

Albuterol nebulization solutionJQL(375 ML per 30 days) — albuterol nebulization solution example

Levalbuterol nebulization solutionQL(540 ML per 30 days) — levalbuterol nebulization solution

Nebulizer volumesNebulized bronchodilator solutions often limited in total mL per 30 days

inv-214: levalbuterol hydrochloride nebulization solution — 540 ML

Levalbuterol solution limitQL(540 ML per 30 days) — levalbuterol hydrochloride nebulization solution

Formulary noteLarge monthly ML limits used for chronic nebulized therapy

Adjudication implicationExceeding ML limit may require prior authorization/documentation

inv-215: TRIKAFTA TABLET THERAPY PACK — 84 EA

TRIKAFTA (repeat)KQL(84 EA per 28 days) — TRIKAFTA therapy pack (repeat listing)

ORKAMBI tablet limitJQL(412 EA per 28 days) — ORKAMBI tablet example

CF agents groupCF agents commonly show large EA limits per 28 days with PA indicated

inv-216: ORKAMBI TABLET — 412 EA

ORKAMBI limitJQL(412 EA per 28 days) — ORKAMBI tablet (example)

High EA countsCF combination therapies list very high EA counts per 28 days reflecting multi‑tablet daily dosing

PA noteMany CF agents include PA/PPA in formulary rows

inv-217: ADVAIR HFA — 24 GM

ADVAIR HFA limitQL(24 GM per 30 days) — ADVAIR HFA (example)

Inhaler weight unitsSome inhaler entries use grams per 30 days as the QL unit

Formulary placementADVAIR listed with QL in respiratory agents section

inv-218: NUCALA INJECTION 100MG — 3 EA

NUCALA injectionQL(3 EA per 28 days) — NUCALA injection 100 mg

Mepolizumab limitMany biologic asthma injectables use low EA counts per 28 days

PA associationNUCALA entries often include PA/PPA flags in the formulary extract

BlueCross Total Value Part D Formulary — Coverage Criteria

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Coverage Criteria & General Coverage Controls

Requirement Codes, Quantity Limits & Coding Examples

Actions, Prior Authorization & Documentation

Step Therapy Rules & Indicators

Quantity Limits & Product-specific Thresholds

Mail Order, Long-Term Care & Site-specific Rules

Symbol & Abbreviation Definitions

Background & Scope