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CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

BlueCross Rx Essential Formulary (Medicare Part D) — Coverage Criteria

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Describes the prescription drug formulary for BlueCross Rx Essential (Medicare Part D) members, including coverage rules, tiers, restrictions (prior authorization, quantity limits, step therapy), exception processes, and contact information for members and prescribers.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyBlueCross Rx Essential Formulary (Medicare Part D) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date08/01/2024 (effective 09/01/2024)

Last ReviewAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization when a drug's Requirements/Limits column lists 'PA' or 'PA NSO' to obtain coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

09/01/2024effective date

08/01/2024formulary current as of

1-888-645-6025customer service

30 daystemporary supply

5tiers

Coverage Criteria & Formulary Rules

General coverage conditions

Covered when plan rules and requirements are met

Formulary listing and medical necessity: Drug is listed on the BlueCross Rx Essential formulary and is medically necessary for the member

Prescription must be filled at a BlueCross Rx Essential network pharmacy and other plan rules (tier, QL, PA, ST) must be followed

Plan rules followed: Coverage is subject to the plan's cost-sharing tier and any utilization controls shown in the formulary (Quantity Limits, Prior Authorization, Step Therapy, Non‑Extended Day Supply).

Higher tiers generally have higher member cost share (see tier copays/coinsurance).

Formulary exception and transition rules

Exceptions and transitional supplies

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyBlueCross Rx Essential Formulary (Medicare Part D) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date08/01/2024 (effective 09/01/2024)

Last ReviewAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization when a drug's Requirements/Limits column lists 'PA' or 'PA NSO' to obtain coverage.

SourceLink

On This Page

Temporary coverage for new/transitioning members:

For drugs not on the formulary or with limits, the plan will provide a temporary supply while the member and prescriber pursue a formulary change or exception request

30 days (standard); 31 days for LTC emergency supply

Temporary 30‑day supply available during the first 90 days of membership; LTC residents past 90 days may receive a 31‑day emergency supply; discharge/level‑of‑care transitions may permit an outpatient supply to avoid gaps

Exception request process and timelines: Member or prescriber must submit a formulary or utilization restriction exception request with a supporting statement from the prescriber72 hours standard decision; 24 hours expedited if granted

Expedited requests require prescriber statement; exceptions are approved only if alternatives are not as effective or would cause harm

Tier-based coverage with utilization management

Covered drugs are placed into tiers with associated utilization controls; coverage is subject to the listed requirements/limits where specified.

Tier assignment: Each drug is assigned to one of five cost‑sharing tiers (Tier 1–Tier 5); tier determines member cost‑sharing and may influence preferred alternatives

Tier descriptions: Tier 1 preferred generic through Tier 5 specialty — higher tiers typically have higher cost share

Utilization controls apply per tier and drug: Drugs may have Quantity Limits (QL), Prior Authorization (PA), Step Therapy (ST), Non‑Extended Day Supply (NDS) or Limited Access (LA) as noted in the formulary entries

Refer to specific formulary rows for QL values and PA/ST flags

Formulary tiering, prior authorization, and quantity limits

Formulary coverage/tiering and any specific requirement or limit as presented in the table rows

Tier assignments reflected per line‑item: Individual drugs are assigned tiers as listed in the formulary table; tier determines coverage placement and expected member cost share

See table entries for the drug's tier

PA NSO designation: Products listed with 'PA NSO' require prior authorization per the formulary (examples include BRIVIACT, EPIDIOLEX, FINTEPLA, DIACOMIT), and requests must include supporting clinical documentation

PA NSO flagged items are subject to prior authorization without standard override

Quantity limits (QL) shown inline: Where QL(...) appears after a product, the specified maximum quantity per time period applies to coverage (examples include NAYZILAM QL(10 EA per 30 days), gabapentin QLs)Exact QL values as printed in table

Prescribers must provide justification/documentation for quantities exceeding QL

Coverage conditional on plan flags

Coverage and restrictions are indicated per drug line-item by Tier, with QL, PA, and ST flags where shown. Coverage requires meeting any stated QL/PA/ST rules.

Coverage conditional on requirements/limits: Drugs listed are covered only when the formulary tier and any associated Quantity Limits (QL), Prior Authorization (PA), or Step Therapy (ST) requirements are satisfied

Claims may be denied if PA is not obtained or QL is exceeded (examples: MOUNJARO QL(2 mL per 28 days); PA).

Formulary tiering and PA/QL rules

Formulary coverage is expressed by drug tier, and for some products by quantity limits (QL) and prior authorization (PA).

Tier determines cost share and placement: Each drug's tier designation in the formulary determines member cost‑sharing and formulary placement (Tier 1 through Tier 5)

Examples in the formulary show a range of tiers for cardiovascular and other agents

When QL or PA appear they govern coverage: If a product line‑item lists QL(...) and/or 'PA', those quantity limits and prior authorization requirements apply to coverage for that specific formulation/strengthQL values as printed per product

Examples: CORLANOR QL(60 EA per 30 days); ENTRESTO QL values by strength; VYNDAMAX QL(30 EA per 30 days) with PA

If a drug is removed from the market or the Food and Drug Administration deems it unsafe, the plan will immediately remove that drug from the formulary and notify affected members. Changes to the formulary during the year (including removals, tier moves, or added restrictions) are made in accordance with Medicare rules and may take effect before the next benefit year; members will be notified as required by those rules.

Formulary table entries use inline symbols and the Requirements/Limits column to indicate utilization controls (for example, PA = Prior Authorization, QL(...) = Quantity Limit, ST = Step Therapy, and NDS = Non-Extended Day Supply). The legend for these symbols and abbreviations appears on the introduction pages of the document; refer to those pages when interpreting the table rows.

No explicit product-level exclusions are listed in the cited formulary excerpts. The table rows direct readers to the introduction pages for symbol meanings and any exclusion language; where entries show no QL/PA/ST, those products are treated per standard formulary coverage within their assigned tier.

In the provided excerpts there are no statements declaring any product as 'not medically necessary.' Coverage stance for listed products is expressed by tier assignment and any accompanying QL, PA, or ST flags rather than explicit 'not medically necessary' language in these chunks.

Formulary Entries, Tiers, and Coding Tables

Provider Requirements, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Certain drugs require prior authorization (PA) before Blue Cross Blue Shield - South Carolina will cover them. Claims submitted without a required PA may be denied. Providers must obtain PA for listed fentanyl lozenges and other drugs flagged with PA, PA NSO, or PA for new starts in the formulary.

Prior authorization required for selected fentanyl citrate oral transmucosal lozenges on a handle (all strengths listed) — Requirements/Limits = PA; NDS.
PA and/or PA NSO flags appear throughout the formulary for many specialty, oncology, injectable diabetes, and high‑tier drugs (examples: REVLIMID, THALOMID, many oncology agents).
PA NSO indicates prior authorization required and not subject to standard overrides; obtain authorization prior to dispensing.
PA required for select fentanyl lozenges specifically flagged in the formulary (see fentanyl citrate entries).

Prior Authorization

Prior Authorization and Quantity Limits

Some drugs have both prior authorization and quantity limits (QL). If the requested quantity exceeds the QL, the claim may be denied or require supporting documentation demonstrating medical necessity. Obtain PA when both PA and QL are listed.

Lidocaine topical products: QL and PA flagged (e.g., lidocaine/prilocaine cream QL(30 GM per 30 days); PA).
Migraine biologics and other injectables (AIMOVIG, EMGALITY, NURTEC) — QL per 28 days plus PA.
GLP‑1 and other injectable diabetes agents (MOUNJARO, OZEMPIC, TRULICITY, VICTOZA) show QL and PA entries — verify both before dispensing.
Specialty biologics (REPATHA, many oncology agents) frequently have QL and PA; follow in‑line QL and PA entries in the formulary.

Documentation Required

Requirements, Limits & Enforcement

PA/QL/PA NSO/QL enforcement: providers must follow the formulary 'Requirements/Limits' keys. Submissions outside those limits risk denial. When a drug shows 'PA NSO' or 'PA', obtain prior authorization; when 'QL' appears, ensure the dispensed amount does not exceed the listed quantity without supporting documentation.

Requirements/Limits key definitions: PA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy; NDS = Non‑Extended Day Supply; PA NSO = Prior Authorization (Not Subject to Override).
PA NSO examples: BRIVIACT, EPIDIOLEX, FINTEPLA, REVLIMID, THALOMID, many oncology agents — PA must be obtained before dispensing.
Quantity limits listed as QL(...) are enforced per the formulary (e.g., QL(2 ML per 28 days); QL(30 EA per 30 days)).

Prior Authorization

Opioid Dependence Agents — PA/QL

Opioid dependence agents and related products have specific QL and PA entries. Some formulations of buprenorphine/naloxone and films/tablets are quantity‑limited; naloxone and other reversal agents may be exempt from limits. Verify the formulary entry for each product.

Buprenorphine/naloxone sublingual tablets and films show QL entries (e.g., QL(360 EA per 30 days), QL(90 EA per 30 days), QL(60 EA per 30 days)).
Opioid dependence class header indicates requirements apply — check specific strength/formulation for QL or PA.
Opioid reversal agents (naloxone) are listed with no QL in many entries — follow formulary details for coverage.

Step Therapy

Step Therapy Requirements

Step therapy (ST) may apply to certain products. When ST or ST NSO appears, providers must follow step‑therapy rules for new starts or therapy packs before alternative agents will be covered.

ST = Step Therapy. ST NSO indicates Step Therapy for New Starts Only (e.g., FETZIMA entries show ST NSO).
NAMZARIC and certain CNS agents include QL plus ST flags — ensure prior trials are documented for new starts.
If step therapy applies, documentation of failure/intolerance to required first‑line agents will be needed for an exception.

Documentation Required

Documentation & Submission Requirements

Documentation required for PA/QL requests: a prescriber's supporting statement describing diagnosis, prior therapies tried (if step therapy applies), dosage, expected length of therapy, and rationale for exceeding QL or requesting an exception. Quantity‑limit exceedances and PA requests must be justified with clinical evidence of necessity.

When requesting an exception or PA decision, submit the prescriber's statement; standard turnaround is 72 hours for routine requests and 24 hours for expedited requests when clinically necessary.
For QL exceedance requests, include documentation supporting medical necessity and the duration/amount required.
Follow the formulary 'Requirements/Limits' column and provide all requested clinical information to avoid delays or denials.

Denial Risk

Denial Risk & Triggers

Denial triggers: claims may be denied if no PA is on file for drugs that require it, if dispensed quantity exceeds QL without approval, or if step‑therapy requirements are unmet. Providers should verify PA/QL/ST flags before dispensing to reduce denial risk.

Common denial triggers: missing PA for PA/PA NSO items; exceeding QL without an approved exception; not completing step therapy requirements when ST is present.
Selected fentanyl lozenges are PA; dispensing without PA may result in denial.
Many specialty/high‑tier injectables and oncology agents list PA NSO — denial is likely without prior approval.

Note

Provider Operational Actions

Operational reminder: follow the in‑line Requirements/Limits entries in the formulary for each product. Submit a prior authorization when indicated and include required documentation to support clinical necessity. Contact plan Customer Service for questions or to request exceptions.

Submit PA for items flagged PA, PA NSO, or PA for new starts (PA NSO requires authorization before dispensing).
Follow in‑line QL and PA entries — e.g., REPATHA, MOUNJARO, OZEMPIC, many oncology and specialty drugs require PA and have quantity limits.
For exceptions/expedited requests, provide prescriber rationale and supporting clinical records; routine decision time is 72 hours, expedited is 24 hours when criteria met.

Initial Authorization Examples

Initial authorization examples

Examples of initial authorization constraints for specific products as listed:

MOUNJARO injections (all listed strengths) require prior authorization and have a quantity limit of QL(2 ML per 28 days).QL 2 mL per 28 days

PA flag present on listed MOUNJARO strengths

OZEMPIC injections are listed with quantity limits (QL 1.5 mL or 3 mL per 28 days depending on presentation) and require prior authorization where indicated.QL 1.5–3 mL per 28 days

PA flag present on listed OZEMPIC presentations

TRULICITY and RYBELSUS examples: TRULICITY injections have QL(2 ML per 28 days) and PA; RYBELSUS tablets have QL(30 EA per 30 days) and PA for some strengths—prior authorization required as noted.QL 2 mL per 28 days; QL 30 EA per 30 days

PA annotation present on these GLP‑1 agents in the formulary

Step Therapy Requirements

Requirement	Summary
Step therapy (ST)
Members must try specified preferred agent(s) first before the plan will cover the requested drug; coverage is subject to meeting step therapy rules as listed in the formulary Requirements/Limits column.

Indicator	Meaning / Scope
ST NSO
Step Therapy for New Starts Only — applies to new therapy starts as designated in the dosage/abbreviation key; step therapy requirement is limited to new starts per the formulary key.

Interplay	Implication
Higher-tier agents vs lower-tier preferred agents
Higher-tier products frequently carry additional controls (prior authorization or quantity limits) — step therapy requires trial of preferred/lower-tier agents first; higher-tier coverage may still require PA or adherence to QL values before approval.

Observation	Policy note
No explicit multi-step sequences provided in excerpt
Where step sequences are not specified, prior authorization (PA) and quantity limits (QL) are the primary utilization controls noted in the Requirements/Limits column and must be followed per formulary rules.

Drug(s)	ST Marker
NAMZARIC (various ER strengths)
Marked with 'ST' and QL(30 EA per 30 days) — step therapy applies per formulary entry.
FETZIMA (titration pack and ER strengths)
Multiple FETZIMA entries show 'ST NSO' (step therapy for new starts) and have QL values (e.g., QL(30 EA per 30 days); titration pack QL(56 EA per 365 days)).

Product	ST designation
FETZIMA titration pack and ER strengths (20/40/80/120 mg)
Flagged 'ST NSO' (Step Therapy for New Starts Only) in the formulary; specific step requirements are not detailed in this section.

Flag	Note
PA NSO on specialty/oncology drugs
Some specialty and oncology agents are annotated 'PA NSO' (prior authorization with plan-specific handling); step therapy details are not provided in the excerpt — PA is the primary control indicated.

Product group	Step therapy flag
FANAPT formulations (titration pack and strengths)
All FANAPT entries are annotated 'ST NSO' indicating step therapy applies (per formulary Requirements/Limits).

Product	Requirement
INVEGA HAFYERA injections (1092 mg/3.5 mL; 1560 mg/5 mL)
Marked 'ST NSO' in the formulary — step therapy for new starts applies to these injectable antipsychotic presentations.

Indicator	Implication
ST or ST NSO flags
Drugs marked 'ST' or 'ST NSO' in the Requirements/Limits column require step therapy (trial of preferred agents first) before the plan will cover the listed product; claims may be denied if step therapy requirements are not met.

Category	Notes
Injectable diabetes therapies (GLP-1 and others)
Several injectable diabetes agents list PA and QL (e.g., MOUNJARO injections QL(2 ML per 28 days); PA) — step therapy is not numerically specified in this section, but PA/QL are enforced for coverage.

Product	ST
BASAGLAR KWIKPEN (100 unit/mL)
Designated 'ST' in the formulary Requirements/Limits — step therapy requirement must be satisfied before coverage per plan rules.

Step	Description
Step 1
Member must try preferred/formulary-preferred agent(s) first; if the preferred agent is ineffective or inappropriate, the plan may cover the requested agent per the formulary's step therapy rules.

Products	Authorization requirement
CORLANOR tablets (5 mg, 7.5 mg)
Annotated with 'PA' and QL(60 EA per 30 days) — prior authorization is required before coverage per the formulary entry.

Annotation	Implication
'PA' flags on specialty agents
Many listed specialty agents are labeled 'PA' (prior authorization) and/or have QL values; providers must submit prior authorization requests where indicated before coverage will be approved.

Quantity Limit Examples by Product

inv-139: CABLIVI — 30 tablets per 30 days

CABLIVI30 tablets per 30 days

inv-140: celecoxib capsule (50mg-400mg) — QL(60 EA per 30 days)

celecoxib capsules (50 mg, 100 mg, 200 mg, 400 mg)QL(60 EA per 30 days)

inv-141: diclofenac sodium gel 1% — QL(1000 GM per 30 days)

diclofenac sodium gel 1%QL(1000 GM per 30 days)

inv-142: buprenorphine patch weekly (5-20mcg/hr) — QL(4 EA per 28 days)

buprenorphine patch weekly (5–20 mcg/hr)QL(4 EA per 28 days)

inv-143: buprenorphine/naloxone sublingual 2mg/0.5mg — QL(360 EA per 30 days)

buprenorphine/naloxone sublingual tablet 2 mg/0.5 mgQL(360 EA per 30 days)

buprenorphine/naloxone film formulations (various strengths)examples include QL(90 EA per 30 days) and QL(60 EA per 30 days) depending on strength/formulation

inv-144: fentanyl oral transmucosal lozenge (selected strengths) — PA; NDS noted

fentanyl citrate oral transmucosal lozenge on a handle (selected strengths)PA; NDS noted for multiple strengths

inv-145: lidocaine/prilocaine cream 2.5%/2.5% — 30 GM per 30 days

lidocaine/prilocaine cream 2.5%/2.5%QL(30 GM per 30 days)

lidocaine ointment 5% / premium lidocaine ointment 5%QL(150 GM per 30 days)

lidocaine patch 5%PA (per table)

inv-147: buprenorphine/naloxone sublingual 2mg/0.5mg — QL(360 EA per 30 days)

buprenorphine/naloxone sublingual 2 mg/0.5 mgQL(360 EA per 30 days)

buprenorphine/naloxone sublingual 8 mg/2 mgQL(90 EA per 30 days)

buprenorphine films (12 mg/3 mg)QL examples include QL(60 EA per 30 days)

inv-148: buprenorphine/naloxone sublingual 2mg/0.5mg — QL(360 EA per 30 days)

buprenorphine/naloxone sublingual 2 mg/0.5 mgQL(360 EA per 30 days)

inv-149: buprenorphine/naloxone sublingual 8mg/2mg — QL(90 EA per 30 days)

buprenorphine/naloxone sublingual 8 mg/2 mgQL(90 EA per 30 days)

inv-150: linezolid suspension reconstituted 100mg/5ml — QL(1800 ML per 28 days)

linezolid suspension reconstituted 100 mg/5 mLQL(1800 ML per 28 days)

inv-151: vancomycin capsule 125mg — QL(120 EA per 30 days)

vancomycin hydrochloride capsule 125 mgQL(120 EA per 30 days)

inv-152: NAYZILAM SOLUTION 5MG/0.1ML — QL 10 EA

NAYZILAM solution 5 mg/0.1 mLQL(10 EA per 30 days)

inv-153: clonazepam various ODT/tablet strengths — QL 90 EA or 300 EA

clonazepam (various ODT/tablet strengths)QL(90 EA per 30 days) or QL(300 EA per 30 days) depending on strength

inv-154: gabapentin various strengths/forms — examples (360/270/180/150 EA; 2160 ML)

gabapentin (various strengths/forms)examples include QL(360 EA), QL(270 EA), QL(180 EA), QL(150 EA per 30 days); solution QL(2160 ML per 30 days)

inv-155: LIBERVANT FILM (multiple strengths) — QL 10 EA

LIBERVANT film (multiple strengths)QL(10 EA per 30 days)

inv-156: VALTOCO dose liquids — QL(10 EA per 30 days)

VALTOCO dose liquids (5/10/20 mg)QL(10 EA per 30 days)

inv-157: NAMZARIC, memantine ER, AUVELITY, FETZIMA — QL examples

NAMZARIC / memantine ER / AUVELITY / FETZIMAQL examples include QL(30 EA per 30 days), QL(60 EA per 30 days), FETZIMA titration pack QL(56 EA per 365 days)

inv-158: ZURZUVAE — QL(28 EA per 14 days) or QL(14 EA per 14 days)

ZURZUVAE (various strengths)QL(28 EA per 14 days) or QL(14 EA per 14 days) depending on strength

inv-159: FETZIMA titration pack — 56; FETZIMA ER — 30

FETZIMA titration pack (ER therapy pack)QL(56 EA per 365 days)

FETZIMA ER capsules (20/40/80/120 mg)QL(30 EA per 30 days)

inv-160: FETZIMA ER capsules — 30

FETZIMA extended‑release capsules (20/40/80/120 mg)QL(30 EA per 30 days)

inv-161: JUBLIA SOLUTION 10% — 90

JUBLIA solution 10%QL(90 GM per 30 days)

inv-162: aprepitant capsule — varying limits by strength

aprepitant capsules (various strengths)QL varies by strength (examples: QL(1–8 EA per 30 days) depending on strength)

aprepitant 125 mgQL(2 EA per 30 days)

aprepitant 80 mgQL(8 EA per 30 days)

inv-163: ondansetron solution 4mg/5ml — 450

ondansetron HCl solution 4 mg/5 mLQL(450 ML per 30 days)

inv-164: AIMOVIG injections — 1 ML per 28 days or 2 ML per 28 days

AIMOVIG injectionsQL(1 ML per 28 days for 140 mg) or QL(2 ML per 28 days for 70 mg)

inv-165: EMGALITY injections — 2-3 ML per 28 days depending on strength

EMGALITY injectionsQL(2–3 ML per 28 days depending on strength)

inv-166: NURTEC/UBRELVY/QULIPTA — specific QL values (18/16/30 EA)

NURTEC (rimegepant)QL(18 EA per 30 days)

UBRELVY (ubrogepant)QL(16 EA per 30 days)

QULIPTA (atogepant)QL(30 EA per 30 days)

inv-167: sumatriptan injectable formulations — 5

sumatriptan injectable formulations (various) — e.g., 4 mg/0.5 mLQL(5 ML per 30 days)

inv-168: QULIPTA TABLET 60MG — 30

QULIPTA tablet 60 mgQL(30 EA per 30 days)

inv-169: UBRELVY TABLET 100MG — 16

UBRELVY tablet 100 mgQL(16 EA per 30 days)

inv-170: sumatriptan succinate injection 4mg/0.5ml — 5

sumatriptan succinate injection 4 mg/0.5 mLQL(5 ML per 30 days)

inv-171: TABRECTA TABLET 150MG — 120

TABRECTA tablet 150 mgQL(120 EA per 30 days)

inv-172: IDHIFA TABLET 100MG — 30

IDHIFA tablet 100 mgQL(30 EA per 30 days)

inv-173: ALUNBRIG — QL examples

ALUNBRIG tablet 30 mgQL(120 EA per 30 days)

ALUNBRIG tablet 90 mgQL(30 EA per 30 days)

inv-174: CAPRELSA TABLET 100MG — QL(60 EA per 30 days)

CAPRELSA tablet 100 mgQL(60 EA per 30 days)

inv-175: ICLUSIG TABLET (various strengths) — QL(30 EA per 30 days)

ICLUSIG tablets (some strengths)QL(30 EA per 30 days) for listed strengths

inv-176: NERLYNX TABLET 40MG — QL(180 EA per 30 days)

NERLYNX tablet 40 mgQL(180 EA per 30 days)

inv-177: TAGRISSO TABLET 40MG — QL(30 EA per 30 days)

TAGRISSO tablet 40 mgQL(30 EA per 30 days)

inv-178: ZEJULA TABLET 100MG — QL(30 EA per 30 days)

ZEJULA tablet 100 mgQL(30 EA per 30 days)

inv-179: ZEJULA TABLET 100MG — 30

ZEJULA tablet 100 mg (duplicate listing)30 EA per 30 days

inv-180: aripiprazole listings — 30 / 750

aripiprazole tablets (various strengths)QL(30 EA per 30 days)

aripiprazole solution 1 mg/mLQL(750 ML per 30 days)

inv-183: KYNMOBI film — 150

KYNMOBI film (multiple strengths)QL(150 EA per 30 days); PA

inv-184: CAPLYTA 42MG — 30 EA

CAPLYTA capsule 42 mgQL(30 EA per 30 days); PA NSO

inv-185: LATUDA 120MG — 30 EA

LATUDA tablet 120 mgQL(30 EA per 30 days)

inv-186: quetiapine fumarate examples — 60-90 EA

quetiapine fumarate tablets (100–300 mg examples)QL(60–90 EA per 30 days) depending on strength/formulation

inv-187: EPCLUSA / MAVYRET — 84 / 336-560

EPCLUSA tablets (400/100 mg)QL(84 EA per 365 days); PA

MAVYRET formulationsQL(336–560 EA per 365 days); PA

inv-189: VERSACLOZ SUSPENSION 50MG/ML — 540 ML

VERSACLOZ suspension 50 mg/mLQL(540 ML per 30 days)

inv-190: HIV agent QLs — 30/30/60

CIMDUO tablet 300 mgQL(30 EA per 30 days)

DESCOVY tabletsQL(30 EA per 30 days)

lamivudine/zidovudine tablets (150/300 mg)QL(60 EA per 30 days)

inv-191: TRIUMEQ — 30; TRIUMEQ PD — 180

TRIUMEQ tablet 600/50/300 mgQL(30 EA per 30 days)

TRIUMEQ PD soluble tabletQL(180 EA per 30 days)

inv-195: oseltamivir / XOFLUZA — 168/84/110/1080

oseltamivir capsules 30/45/75 mgQL examples: 168 EA (30 mg per 365 days), 84 EA (45 mg per 365 days), 110 EA (75 mg per 365 days)

oseltamivir suspension 6 mg/mLQL(1080 ML per 365 days)

inv-199: MOUNJARO / JANUVIA — 2 / 30

MOUNJARO injections (all strengths listed)QL(2 ML per 28 days); PA

JANUVIA tabletsQL(30 EA per 30 days)

inv-202: Multiple (examples)

TRADJENTA / TRIJARDY / related agentsQL examples shown (e.g., QL(30 EA per 30 days) for some glycemic agents)

ELIQUIS starter packQL(148 EA per 365 days)

inv-203: ELIQUIS starter pack / strengths — 148 / 60 / 90

ELIQUIS starter packQL(148 EA per 365 days)

ELIQUIS 2.5 mgQL(60 EA per 30 days)

ELIQUIS 5 mgQL(90 EA per 30 days)

inv-206: XARELTO starter pack / tablets — 102 / 30

XARELTO starter packQL(102 EA per 365 days)

XARELTO 10 mg / 20 mgQL(30 EA per 30 days)

inv-209: PYRUKYND examples — 120 / 60

PYRUKYND tablet 50 mgQL(120 EA per 30 days)

PYRUKYND tablet 20 mgQL(60 EA per 30 days)

inv-211: OXBRYTA — 240

OXBRYTA tablet 300 mgQL(240 EA per 30 days)

inv-212: CORLANOR / ENTRESTO — 60 / 240

CORLANOR tablet 5 mg / 7.5 mgQL(60 EA per 30 days); PA

ENTRESTO capsule sprinkle strengthsQL(240 EA per 30 days)

inv-213: ENTRESTO tablets / VYNDAMAX — 60 / 30

ENTRESTO tablets (24/26, 49/51, 97/103 mg)QL(60 EA per 30 days)

VYNDAMAX capsule 61 mgQL(30 EA per 30 days)

inv-217: REPATHA QLs — 7 ML / 3 ML

REPATHA PUSHTRONEX 420 mg/3.5 mLQL(7 ML per 28 days); PA

REPATHA SureClick / REPATHA 140 mg/mLQL(3 ML per 28 days); PA

inv-219: VERQUVO — 30 EA per 30 days

VERQUVO tablets (2.5/5/10 mg)QL(30 EA per 30 days); PA

inv-220: COPAXONE / GILENYA — 12 ML / 30 EA

COPAXONE injection 40 mg/mLQL(12 ML per 28 days); PA

GILENYA capsule 0.5 mgQL(30 EA per 30 days); PA

Key Abbreviations and Symbols

inv-104: Formulary definition — Formulary described

QL = Quantity LimitsMaximum quantity allowed in the specified time period (e.g., QL(30 EA per 30 days)).

PA = Prior AuthorizationPrescriber must obtain approval before coverage; entries labeled 'PA' require PA per table.

NDS = Non‑Extended Day SupplyMedication is not available for an extended days' supply (NDS indicated in table rows).

Policy Background and Scope

This document is the BlueCross Rx Essential Medicare Part D formulary. It lists the plan’s covered drugs, assigns each drug to a tier (1–5), and documents utilization management controls such as Prior Authorization (PA), Quantity Limits (QL), and Step Therapy (ST). The formulary is current as of 08/01/2024 (effective 09/01/2024) and is intended to guide prescribers and pharmacies on coverage rules, member cost sharing, temporary supply provisions, and how to request exceptions.