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 Retiree Rx Coverage | Op…
    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

    Blue Retiree Rx 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.

    This formulary governs covered prescription drugs, coverage restrictions (PA, QL, ST), member cost-sharing by tier, and the exception process for Blue Retiree Rx members in South Carolina.

    Policy Summary
    PayerBlue Cross Blue Shield - South Carolina
    PolicyBlue Retiree Rx Formulary (Drug List) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes for this revision
    Effective DateApr 1, 2026
    Last ReviewMar 2, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization when a formulary line item is marked 'PA' before dispensing to avoid claim denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    04/01/2026Effective date
    03/02/2026Last updated
    1-5Tiers
    30 daysMin notice for some changes
    72 hrsException decision time
    26220Formulary ID

    Formulary Coverage Rules

    General coverage

    Covered when ALL of the following are met:

    General coverage conditions: Blue Retiree Rx will generally cover drugs listed on the formulary if the drug is medically necessary, the prescription is filled at a Blue Retiree Rx network pharmacy, and other plan rules are followed.

    See Evidence of Coverage for filling rules

    Exception pathway: If a drug is not on the formulary or a listed restriction would prevent coverage, the member or prescriber may request a formulary exception; the prescriber must provide supporting medical reasons and the plan generally decides within 72 hours (24 hours for expedited requests).

    See 'How do I request an exception' for details; prescriber documentation required

    Restrictions (Prior Authorization / Quantity Limits / Step Therapy)

    Covered when ONE of the following administrative controls is satisfied for the specific drug:

    Policy Summary
    PayerBlue Cross Blue Shield - South Carolina
    PolicyBlue Retiree Rx Formulary (Drug List) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes for this revision
    Effective DateApr 1, 2026
    Last ReviewMar 2, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization when a formulary line item is marked 'PA' before dispensing to avoid claim denial.
    SourceLink
    On This Page
    Formulary Coverage RulesDrug Codes, Tiers, and Limits (Formulary Table Excerpts)What Prescribers and Pharmacies Must DoSpecified Quantity Limits (Selected Products)Step Therapy / Starter Pack RulesDispensing Site and Supply RulesBiosimilars and InterchangeabilityKey Definitions and AbbreviationsBackground and Scope
    Prior Authorization: Prior authorization (PA) is obtained as required for the specific formulary line item before dispensing.

    Many specialty and selected drugs are marked 'PA' or 'PA NSO' in the Requirements/Limits column; failure to obtain PA may result in denial

    Quantity Limits: Dispensed quantity does not exceed the product-specific quantity limit (QL) for the stated time period.

    Examples of QLs are shown next to products (e.g., QL(30 EA per 30 days)); exceeding QL may require PA or may be denied

    Step Therapy: Where step therapy (ST or ST NSO) applies, required prior steps have been met (ST NSO indicates step therapy for new starts only).

    Some products list 'ST' or 'ST NSO' in the Requirements/Limits field

    Non-Extended Day Supply (NDS) and other flags: Where NDS or B/D or other Requirements/Limits flags apply, the pharmacy/prescriber must adhere to the dispensing limitations or billing pathway indicated.

    NDS and B/D flags appear on specified opioid and specialty lines

    Immediate formulary changes

    Immediate formulary changes may occur in specific situations:

    Addition of generic or interchangeable biosimilar: When a new generic or certain interchangeable biosimilar is added that is on the same or a lower tier with same or fewer restrictions, the plan may immediately add the new product and remove or move the original product to a different tier or add restrictions.

    Members/prescribers may request an exception if currently taking the original product

    Market withdrawal or safety removal: A drug withdrawn from sale by the manufacturer or removed by FDA for safety/effectiveness reasons may be immediately removed from the formulary.

    Affected members will be notified after the change

    Other clinically driven changes: The plan may immediately change coverage or restrictions based on new clinical guidelines or when adding a biosimilar/generic equivalent; affected members will be notified at least 30 days prior when applicable or provided a 30-day temporary supply upon refill request.

    Some changes require 30-days advance notice unless immediate per rules

    Formulary coverage by tier and requirements

    Coverage and member cost-sharing depend on tier and may be subject to listed administrative controls:

    Tier cost-sharing: Member cost-sharing varies by tier: Tier 1 Preferred Generic (lowest cost), Tier 2 Generic, Tier 3 Preferred Brand, Tier 4 Non‑Preferred, Tier 5 Specialty (highest cost).

    Deductible $615 applies to Tiers 2–5 per retail descriptions

    Coverage conditioned on requirements: For drugs with Requirements/Limits flags (PA, QL, ST, NDS, B/D), coverage and claim adjudication follow the listed requirement for that tiered product.

    Check the product row for specific PA or QL values

    Dispensing channel and site-of-care: Mail order and long-term care (LTC) supplies and copay/coinsurance rules differ; some products may be Not Covered via mail order or have specific LTC supply rules.

    LTC typically uses a 31-day supply; mail order rules listed in formulary

    Formulary coverage flags

    Coverage is determined by each product's Tier and Requirements/Limits flags:

    Tier + Requirement mapping: A product's coverage status, required documentation, and adjudication path are determined by its assigned Tier and the Requirements/Limits designation shown (examples: PA, QL, NDS, ST).

    Introduction pages define symbols/abbreviations used in the Requirements/Limits column

    Action on missing authorization or excess quantity: If a product requires PA or has a QL and the requirement is not met (no PA or quantity exceeds QL), the claim may be denied at point of sale or require retrospective review.

    Failure to obtain PA may result in non-coverage

    Coverage conditional on PA/QL

    Many listed drugs are covered only if the administrative controls shown are satisfied:

    PA conditional coverage: Drugs labeled 'PA' or 'PA NSO' require prior authorization before coverage; PA NSO indicates prior authorization for new starts or non-standard operations.

    Numerous oncology and specialty agents are flagged PA NSO or PA

    QL conditional coverage: Drugs with 'QL(...)' are limited to the stated quantity per time period; dispensing beyond that amount requires PA or may be denied.

    Examples include QL counts and ML volumes shown in the table rows

    ST conditional coverage: When 'ST' or 'ST NSO' is present, step therapy requirements must be met for coverage; 'ST NSO' applies to new starts only.

    Some products (e.g., select topical or analgesic entries) show ST flags

    Product-level authorization and quantity rules

    Product-level authorization and quantity rules (examples):

    PA required (product examples): Drugs marked 'PA' require prior authorization before coverage (examples shown in the formulary include metyrosine 250mg; REPATHA presentations; KERENDIA; NEXLETOL/NEXLIZET).

    See product row for exact PA flag

    Quantity limits (product examples): Products with 'QL' have specific maximums per time period (examples: ENTRESTO sprinkle QL(240 EA per 30 days); REPATHA QL per 28 days; many others listed).

    Exact QL values are shown in parentheses after Requirements/Limits on each row

    Formulary controls (QL/PA/ST)

    When a Requirements/Limits flag appears on a formulary line, the following controls apply:

    Quantity Limit enforcement: If a product row lists a QL, the specified quantity limit applies and claims exceeding the limit require justification or prior authorization.

    Examples: QL(60 EA per 30 days); QL(300 GM per 30 days); QL(12 ML per 30 days)

    Prior Authorization enforcement: If a product row lists PA, prior authorization must be obtained for coverage; PA may be standard or marked PA NSO for special handling.

    Many specialty products require PA

    Step Therapy enforcement: If a product row lists ST or ST NSO, the step therapy requirements indicated must be satisfied before coverage (ST NSO = new starts only).

    Some topical and other products include ST flags (e.g., diclofenac gel)

    Formulary line-item coverage entries

    Each listed drug is covered according to its Tier and the specific Requirements/Limits shown on its formulary row. Examples below illustrate typical line-item controls:

    SIGNIFOR (example): SIGNIFOR INJECTION 0.3MG/ML, 0.6MG/ML, 0.9MG/ML: Tier 5; QL(60 ML per 30 days); PA.QL(60 ML per 30 days)

    Reference: formulary line entries

    SOMAVERT (example): SOMAVERT INJECTION (multiple strengths): Tier 5; PA required.

    Reference: formulary line entries

    TRELSTAR (example): TRELSTAR MIXJECT INJECTION 22.5MG: Tier 4; QL(1 EA per 168 days); PA NSO.QL(1 EA per 168 days)

    Reference: formulary line entries

    COSENTYX / DUPIXENT / SKYRIZI (examples): COSENTYX, DUPIXENT, SKYRIZI and other biologic presentations: Tier 5; product-specific QLs and PA as listed (follow per-row QL volumes and PA requirement).product-specific QLs

    See each biologic row for exact ML or EA limits

    Vaccines and injectables (example): Vaccines and certain injectables have tier and B/D or QL annotations (e.g., MRESVIA QL(0.5 ML per 999 days); many vaccines marked B/D or no limits).per-row

    Follow the vaccine/injectable row for exact Requirements/Limits

    General coverage rule for listed formulary products

    Summary rule for listed formulary products:

    Formulary listing rule: Drugs are covered according to their assigned formulary tier; where a Requirements/Limits entry (e.g., QL or PA) is shown, coverage requires adherence to that limit or prior authorization as applicable.

    Refer to individual drug rows for exact QL values, PA flags, ST, NDS, or B/D designations

    Non‑covered and exception pathway: If a drug is not on the formulary or is listed as Not Covered for a given channel, coverage is not provided unless an exception is approved or a covered alternative is prescribed.

    Members may request an exception; see exception process

    If a prescribed drug is not included on the Blue Retiree Rx formulary, coverage will not be provided unless one of the following occurs: the member obtains an approved exception from Blue Retiree Rx, or the prescriber selects and prescribes a covered alternative identified by Customer Service. Members and prescribers should contact Customer Service to confirm coverage status and review the exception request process.

    Certain tier and product combinations are explicitly designated as Not Covered in the formulary tables (examples include specific Tier 5 specialty entries and some insulin listings for Mail Order). Review the formulary line-item entries for the drug and dispensing channel (e.g., Mail Order, Long‑Term Care) to confirm whether a product is listed as Not Covered for that channel.

    The excerpted table rows in this section present drugs by Tier and list any associated Requirements/Limits flags (e.g., PA, QL, NDS). This portion of the document does not contain explicit medical‑necessity exclusion statements; it shows tier assignments and administrative requirement markers only.

    Within the provided excerpt there are no standalone clinical exclusion statements. Rows that have no entry in the Requirements/Limits column should be interpreted as the table showing standard coverage for that product in this section, subject to plan terms elsewhere in the policy.

    The document segment conveys coverage posture primarily through tier placement and Requirements/Limits flags (for example, PA or QL). No explicit negative clinical exclusion language is shown in these chunks; consult other policy sections for detailed exclusion criteria if needed.

    This partial formulary extract does not include explicit clinical exclusion rules. Coverage limitations in these chunks are expressed as tier assignments and administrative controls (e.g., quantity limits, prior authorization); refer to the full policy document for clinical exclusion lists.

    Abbreviations and symbols used in the Requirements/Limits column (for example, PA, QL, NDS, ST) are defined on the formulary introduction pages. Those introductory pages are required to interpret the per‑drug flags shown in these table rows.

    Some starter packs and biologic entries are limited to specific manufacturer‑labeled products only. For example, certain ADALIMUMAB‑ADBM starter packages are annotated as limited to Boehringer Ingelheim labeled products only and include explicit quantity limits and PA requirements on the row.

    This section does not list explicit clinical non‑coverage (NMN) rules. Coverage constraints shown here are administrative (tier, PA, QL, B/D) and any explicit non‑covered clinical conditions or NMN determinations are documented elsewhere in the full policy.

    The excerpt does not provide clinical statements labeled 'Not Medically Necessary.' It does note that limitations, copayments, and restrictions may apply and that benefits and coverage rules may change annually; for clinical NMN rules, consult other sections of the plan materials.

    Drug Codes, Tiers, and Limits (Formulary Table Excerpts)

    What Prescribers and Pharmacies Must Do

    Prior Authorization

    Prior Authorization Required

    Some covered drugs in the formulary require prior authorization (PA) before the plan will approve coverage. Prescribers or members must obtain approval from Blue Retiree Rx (the plan) prior to dispensing these drugs; failure to obtain required prior authorization may result in the claim being denied.

    • PA labels appear throughout the formulary next to many products (including specialty, high‑tier, oncology, and anticonvulsant agents).
    • Examples of PA or PA NSO entries include specialty/anticonvulsant drugs (BRIVIACT, EPIDIOLEX, FINTEPLA, vigabatrin products — see Anticonvulsants section).
    • Many specialty and oncology drugs are marked PA NSO or PA (e.g., numerous molecular targeted and cancer agents in the Oncology sections).
    • Selected specialty/high‑tier and metabolic bone disease agents (e.g., NEULASTA, UDENYCA, FORTEO, BONSITY, RIVFLOZA) require PA and may have quantity limits (QL).
    Prior Authorization

    PA NSO / Specialty and Oncology PA Notes

    PA NSO (prior authorization, not otherwise specified), PA, and other requirement flags in the formulary indicate utilization management controls that must be satisfied for coverage. Entries annotated PA NSO or PA often apply to specialty injectables, biologics, oncology, and select oral agents; many of these also carry quantity limits (QL) or other limits.

    • PA NSO frequently appears on oncology and specialty agents (examples: ALUNBRIG, AYVAKIT, CABOMETYX, many others).
    • Specialty and high‑tier immunological and biologic agents (e.g., COSENTYX, DUPIXENT, ORENCIA, BENLYSTA) are listed with PA and often QL values.
    • Some anticonvulsants and rare‑disease therapies are marked PA NSO (BRIVIACT, EPIDIOLEX, FINTEPLA, vigabatrin, VIGAFYDE).
    • Metabolic bone disease agents such as FORTEO, BONSITY, and RIVFLOZA are designated PA and may have QL entries.
    Denial Risk

    Denial Risk if Requirements Unmet

    Claims for drugs with PA, PA NSO, QL, NDS, or ST flags may be denied at point of sale or retrospectively if the documented requirements are not met. Prescribers and pharmacies should submit required documentation with PA requests and follow QL limits and NDS rules exactly to avoid denials.

    • Denial risk is elevated for drugs annotated PA, PA NSO, or with strict QL entries — do not assume coverage without approval.
    • PA NSO entries for specialty/oncology agents commonly trigger coverage review and potential denial without an approved authorization.
    • Quantity limits (QL) are enforced (e.g., gabapentin, REPATHA, LIVMARLI, RIVFLOZA); requests exceeding QL require justification and may be denied if unsupported.
    Documentation Required

    Documentation and Exception Timing

    When requesting prior authorization or an exception, prescribers must provide clinical documentation that supports medical necessity and explains why standard formulary alternatives, step therapy, or quantity limits are not appropriate. The plan generally decides PA/exception requests within 72 hours of receiving the prescriber's supporting statement; expedited requests may be decided within 24 hours when clinically necessary.

    • Include relevant medical records, prior treatment history, and rationale for exceeding quantity limits or bypassing step therapy.
    • Use the formulary's Requirements/Limits Key (PA, QL, NDS, ST, B/D) to determine which documentation elements are required.
    • Expedited (fast) reviews are available when waiting could seriously harm the member — the prescriber should request expedited review when appropriate.
    Step Therapy

    Step Therapy / Starter Pack Rules

    Step therapy (ST or ST NSO) applies for selected products; 'ST NSO' indicates step therapy for new starts only. While not every section lists explicit step sequences, several products and starter/titration packs are subject to step therapy requirements. Prescribers should check the formulary entry for ST, ST NSO, or starter package QL notes before prescribing.

    • ST NSO = Step therapy for new starts only; ST = step therapy may apply more broadly.
    • Examples include titration/starter packs and products flagged ST NSO or ST (e.g., EXXUA, FETZIMA, FANAPT, INVEGA HAFYERA, RELISTOR entries).
    • Some starter packages have specific QL and may be linked to step/starter policies (see Adalimumab starter pack notes).

    Specified Quantity Limits (Selected Products)

    Cablivi (example)
    Cablivi limit30 tablets per 30 days
    Example contextUsed as an example in formulary guidance on quantity limits and coverage restrictions
    ReferenceListed in Quantity Limits section as a sample per-month cap
    JOURNAVX TABLET 50MG
    JOURNAVX 50 mgQL(30 EA per 90 days)
    TierTier 4 (per Requirements/Limits key)
    SourceFormulary line-item Requirements/Limits table
    celecoxib capsule (100/200/50mg)
    celecoxib (100/200/50 mg)QL(60 EA per 30 days)
    Formulation noteApplies to listed strengths (100mg, 200mg, 50mg)
    Tier infoListed in Nonsteroidal Anti-inflammatory Drugs section
    celecoxib capsule (400mg)
    celecoxib (400 mg)QL(60 EA per 30 days)
    Strength-specific400mg strength has the same 60 EA per 30 days limit as other listed strengths
    Reference tableRequirements/Limits Key — NSAIDs section
    diclofenac sodium gel 1%
    diclofenac sodium gel 1%QL(1000 GM per 30 days)
    Alternate diclofenac gel (3%)QL(300 GM per 30 days) shown for 3% presentation
    TierListed under NSAIDs with product-specific QLs
    ketorolac tromethamine tablet 10mg
    ketorolac tromethamine 10 mg tabletQL(20 EA per 30 days)
    Route/formulationOral tablet — per-tablet QL listed in analgesics section
    Adjudication noteDispensing must not exceed stated EA per 30 days without PA
    buprenorphine patch weekly (various strengths)
    buprenorphine patch (weekly)QL(4 EA per 28 days)
    Strengths coveredMultiple weekly strengths listed (5, 7.5, 10, 15, 20 mcg/hr)
    Additional flagNDS applies to patch entries
    lidocaine/prilocaine cream 2.5%; 2.5%
    lidocaine/prilocaine cream 2.5%/2.5%30 GM per 30 days
    RequirementAlso shows PA in Requirements/Limits where indicated
    Formulary sectionLocal anesthetics — per-product QL listed
    lidocaine ointment 5%
    lidocaine ointment 5%150 GM per 30 days
    PA noteLine-item shows PA where applicable
    UseTopical anesthetic QL for outpatient dispensing
    linezolid suspension reconstituted 100mg/5ml
    linezolid suspension (100mg/5ml reconstituted)1800 ML per 28 days
    linezolid tablet 600 mg56 EA per 28 days
    ReferenceAntibacterials section with product-specific QLs
    linezolid tablet 600mg
    linezolid tablet 600 mg56 EA per 28 days
    Formulary locationAntibacterials — tablet QL listed in Requirements/Limits
    Dispensing noteAdhere to EA per 28 days limit or seek PA for excess
    vancomycin hydrochloride capsule 125mg
    vancomycin HCl capsule 125 mg120 EA per 30 days
    IndicationOral formulation QL specified for listed strengths
    Claim noteDispense per QL or request PA if clinically justified
    vancomycin hydrochloride capsule 250mg
    vancomycin HCl capsule 250 mg240 EA per 30 days
    Strength-specific QLHigher EA per 30 days limit for 250mg capsule
    Formulary referenceSee Antibacterials table rows for exact pack counts
    bupropion hydrochloride er (sr) 150mg
    bupropion HCl ER (SR) 150 mg60 EA per 30 days
    Therapeutic classSmoking cessation/antidepressant — QL applied to ER formulation
    Provider noteAdhere to QL to avoid claim denial
    NICOTROL NS SOLUTION 10MG/ML
    NICOTROL NS solution 10 mg/ml360 ML per 365 days
    Supply periodAnnual QL (per 365 days)
    ClassSmoking cessation agent — solution formulation
    TYRVAYA SOLUTION 0.03MG/ACT
    TYRVAYA solution 0.03 mg/act8.4 ML per 30 days
    FormulationNasal/ocular actuation — ML per month limit specified
    AdjudicationFollow listed QL or obtain PA for higher quantities
    varenicline tartrate tablet 0.5mg, 1mg
    varenicline tartrate 0.5 mg / 1 mg504 EA per 365 days
    Therapy packAnnual limit for smoking cessation tablet therapy pack
    Coverage noteQL shown in Requirements/Limits key for smoking cessation agents
    gabapentin capsule 400mg
    gabapentin capsule 400 mgQL(270 EA per 30 days)
    gabapentin capsule 100 mg, 300 mgQL(360 EA per 30 days)
    gabapentin solution 250 mg/5 mlQL(2160 ML per 30 days)
    gabapentin capsule 100mg,300mg
    gabapentin capsule 100/300 mgQL(360 EA per 30 days)
    ContextLower-strength capsules have higher EA per month limits
    SourceGABA modulating agents section
    gabapentin solution 250mg/5ml
    gabapentin solution 250mg/5mlQL(2160 ML per 30 days)
    Formulation noteLiquid suspension QL provided in ML per 30 days
    Provider actionDocument dosing if exceeding QL
    gabapentin tablet 800mg
    gabapentin tablet 800 mgQL(150 EA per 30 days)
    Strength-specificHigher-strength tablet has lower EA monthly limit
    AdjudicationClaims exceeding QL may require PA
    gabapentin tablet 600mg
    gabapentin tablet 600 mgQL(180 EA per 30 days)
    UsagePer-tablet QL applied to dispensing of 600mg strength
    DocumentationProvide justification when exceeding QL
    pregabalin capsule 300mg
    pregabalin capsule 300 mgQL(60 EA per 30 days)
    other strengthsOther pregabalin strengths listed with QL(90 EA per 30 days)
    Therapeutic classGABA-modulating agents — QLs vary by strength
    pregabalin other strengths
    pregabalin — other strengthsQL(90 EA per 30 days)
    ApplicationApplies to listed lower strengths in pregabalin class
    Source noteSee Requirements/Limits Key for strength-specific rows
    VALTOCO (all listed dose packs)
    VALTOCO dose packsQL(10 EA per 30 days)
    Dose presentationsAll listed VALTOCO dose packs subject to the 10 EA per 30 days limit
    Therapeutic areaSeizure rescue medications — per-pack QL applied
    bupropion ER/XR (certain strengths)
    bupropion ER/XR (certain strengths)QL(60 EA per 30 days) or QL(90 EA per 30 days) depending on strength
    Strength-dependent limitsSpecific strength determines whether 60 or 90 EA per 30 days applies
    Formulary locationAntidepressant/mood agents section
    duloxetine DR capsule (20mg,60mg)
    duloxetine DR capsule (20 mg, 60 mg)QL(60 EA per 30 days)
    duloxetine 30 mgQL(90 EA per 30 days) (see separate line)
    SectionAntidepressants — QLs listed by strength
    duloxetine DR capsule 30mg
    duloxetine DR capsule 30 mgQL(90 EA per 30 days)
    Strength-specific note30 mg listed separately with higher EA monthly allowance
    Provider actionFollow per-strength QL when dispensing
    DRIZALMA sprinkle capsule
    DRIZALMA sprinkle capsuleQL(60 EA per 30 days) or QL(90 EA per 30 days) depending on strength
    Pack/strength dependentDifferent strengths have different QLs as listed
    Formulary noteSee Requirements/Limits rows for exact strength mapping
    FETZIMA titration pack
    FETZIMA titration packQL(56 EA per 365 days)
    FETZIMA capsule ERQL(30 EA per 30 days) for maintenance strengths
    Step therapyTitration pack marked ST NSO where indicated
    memantine/donepezil ER capsule
    memantine/donepezil ER capsuleQL(30 EA per 30 days)
    Combination productQL applied to extended-release combination capsule
    Formulary locationDementia agents section
    EXXUA tablet ER
    EXXUA tablet ERQL(30 EA per 30 days)
    Titration packTitration/therapy pack entries may have separate QLs and ST NSO flags
    TierListed in antidepressant/neuromodulator section
    ZURZUVAE
    ZURZUVAEQL(14 EA per 14 days) or QL(28 EA per 14 days) depending on strength
    Dosing intervalShorter 14-day QL intervals specified per strength
    PA flagSome strengths show PA NSO in Requirements/Limits key
    clonazepam ODT and tablets
    clonazepam ODT and tabletsQL(90 EA per 30 days) and QL(300 EA per 30 days) depending on strength/form
    Strength/form dependentDifferent dosage forms and strengths have distinct QLs
    Formulary noteRefer to clonazepam rows for exact assignment

    Step Therapy / Starter Pack Rules

    RequirementSummary
    Step therapy (ST)Member must try specified alternative(s) before coverage of the requested drug is approved.
    RequirementSummary
    ST / ST NSOStep therapy flags appear as ST or ST NSO on selected products; 'ST NSO' denotes step therapy for new starts only.
    Product examples (ST NSO)Formulary note
    ZONISADE suspension; AUVELITY; FETZIMA titration pack; EMSAM patchThese products are listed with 'ST NSO' in the Requirements/Limits field indicating step therapy applies per the formulary entry.
    ProductRequirement
    FETZIMA titration pack / FETZIMA capsule ERRequirements/Limits include QL and 'ST NSO' indicating step therapy applies for this product (titration pack QL(56 EA per 365 days); capsule QL(30 EA per 30 days)).
    ObservationComment
    PA or QL flagged agentsMultiple agents are designated with PA or QL in the Requirements/Limits column, but explicit step-sequencing (multi-step algorithms) is not provided in these excerpts.
    Product examples (flagged ST NSO)Formulary entry
    FANAPT titration packs (A/B/C); FANAPT tabletsEntries show 'ST NSO' and specific QL values (e.g., FANAPT TABLET QL(60 EA per 30 days); titration packs QL per 365 days) indicating step therapy for new starts as listed.
    Drug groupRequirement
    Selected GLP‑1 and hematopoietic/platelet agentsCertain GLP‑1 agents and hematopoietic/platelet-modifying products show a PA flag in the Requirements/Limits field (PA required as indicated).
    ObservationComment
    PA and QL flags presentNumerous agents are annotated with PA or have QL entries; the document shows these utilization controls but does not always specify step sequencing in these chunks.
    Therapeutic areaStep therapy status
    ADHD agents (amphetamines, non-amphetamines)No explicit step therapy sequences are listed for ADHD agents in this segment; agents are tiered and some have QLs (e.g., QL(60 EA per 30 days) entries).
    Product examples (ST)Formulary note
    Diclofenac sodium gel 3%; RELISTOR injection/tabletEntries show 'ST' with specific QLs (diclofenac QL(300 GM per 30 days); RELISTOR QLs and 'ST') indicating step therapy applies where noted.
    ObservationComment
    No explicit ST algorithmIn many entries within these excerpts, explicit step therapy steps are not defined; instead PA and QL controls are applied as indicated on each row.
    NoteDetails
    Not specified in source excerptThis block is a placeholder; no specific step therapy content was provided for this reference in the available chunks.
    Starter packageFormulary detail
    ADALIMUMAB starter packages (manufacturer-labeled)Starter packages are identified for specific indications and manufacturer-labeled products only (examples: Boehringer Ingelheim labeled ADALIMUMAB-ADBM starter packages with QL and PA).
    ObservationComment
    No explicit multi-step sequences in extractThe extract provides tier assignments and Requirement/Limits flags (PA, QL, ST/ST NSO) but does not enumerate full multi-step therapy sequences for products in these chunks.

    Dispensing Site and Supply Rules

    Note

    Biosimilars and Interchangeability

    Note

    Key Definitions and Abbreviations

    Background and Scope

    Biological products are structurally complex and differ from small‑molecule drugs; they may have biosimilar or interchangeable biosimilar alternatives rather than generic equivalents. Interchangeable biosimilars may be substituted in accordance with applicable state law and the plan’s biosimilar preferences.