BlueCross Total Value 2026 Formulary — Drug List and Requirements/Limits
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Governs the BlueCross Total Value 2026 prescription drug formulary and rules for coverage, prior authorization, quantity limits, step therapy, and exceptions for plan members and prescribers.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage criteria
Covered when ALL of the following conditions are met:
Based on formulary definition and coverage restrictions
See Requirements/Limits flags (PA, QL, ST, NDS) in formulary; failure to obtain PA or exceed QL may result in denial.
Members may request formulary or restriction exceptions; decisions: standard 72 hours, expedited 24 hours.
Per-drug coverage flags and limits
Coverage status and any utilization controls are displayed for each product in the formulary table; a listed product may be covered subject to the specific flags shown.
Follow the specified flags for coverage and required documentation.
Formulary listing with requirements/limits
Formulary listing entries include tiering and utilization controls; follow the Requirements/Limits column for coverage details.
Examples in the formulary: GENOTROPIN products listed with PA; ISTURISA formulations listed with QL and PA.
Drugs that are withdrawn from sale by the manufacturer or that the FDA withdraws for safety or effectiveness reasons may be immediately removed from the formulary and not covered. When other changes (for example, adding a generic or biosimilar, applying new restrictions, or moving a drug to a different cost-sharing tier) are made, the plan will generally provide at least 30 days notice to affected members or supply a one-time 30-day refill with notice when a member requests a refill. Members or prescribers may request an exception to continue coverage where medically justified.
The provided extract is a formulary table showing drug entries with tier assignments and Requirements/Limits annotations (e.g., QL, PA, ST, NSO). There are no explicit clinical exclusion statements or standalone 'not covered' listings in these chunks; exclusions are represented indirectly through requirement flags rather than clinical exclusion text.
Within the excerpt, coverage is expressed via formulary table entries and Requirements/Limits flags (such as QL and PA). The text does not contain explicit statements that any listed product is categorically not covered; instead, restrictions are implemented through the table flags and quantity limits.
This extract consists of drug list table rows with tiering and Requirements/Limits annotations. It does not include explicit exclusion language that would remove coverage for specific patient populations or indications; any limitations are indicated by table flags (e.g., PA, QL) rather than standalone exclusion statements.
Some formulary entries are restricted to a specific manufacturer's labeled products (for example, listings that state 'Boehringer Ingelheim labeled products only' or 'AbbVie labeled products only'). These annotations limit coverage to the named manufacturer's labeled presentations and exclude other manufacturers' versions for that listing.
The excerpted table uses Requirements/Limits annotations to indicate utilization controls but does not include any explicit determinations that items are not medically necessary. No 'not medically necessary' rulings are present in these chunks.
In this portion of the formulary excerpt, coverage status is shown via tier assignments and requirement flags. There are no statements in this excerpt identifying items as not medically necessary or otherwise excluding coverage on that clinical basis.
The extract lists drug names, tiers, and Requirements/Limits flags (e.g., PA for GENOTROPIN) but does not include any explicit text designating products as not medically necessary. No items in this chunk are labeled with that determination.
Coding and Requirements/Limits Codes
| PA | Prior Authorization |
| QL | Quantity Limits |
| NDS | Non-Extended Day Supply |
| ST | Step Therapy |
| B/D | Drug that may be covered under Medicare Part B or Medicare Part D, depending on the indication, where and how the drug was administered and by whom. The plan must first conduct a review to determine the correct coverage (B or D). |
| N/A | No CPT/HCPCS/ICD-10 or NDC codes listed in these chunks; only drug names, strengths, tiers and requirement annotations are present. |
| QL(60 EA per 30 days) | Quantity limit example (multiple products listed with this QL) |
| QL(148 EA per 365 days) | Quantity limit example for ELIQUIS STARTER PACK (listed as 148 EA per 365 days in brief) |
| QL(84 EA per 28 days) | Quantity limit example for ELIQUIS CAPSULE SPRINKLE 0.15MG (example QL) |
| QL(140 EA per 28 days) | Quantity limit example (pack variants) |
| QL(420 EA per 28 days) | Quantity limit example (pack variants) |
| QL(560 EA per 28 days) | Quantity limit example (ELIQUIS tablet soluble pack example) |
| QL(60 EA per 30 days) | Quantity limit example for ELIQUIS TABLET 2.5MG / other products |
| QL(90 EA per 30 days) | Quantity limit example for ELIQUIS TABLET 5MG / other products |
| QL(102 EA per 365 days) | Quantity limit example for XARELTO STARTER PACK (example in brief) |
| QL(600 ML per 30 days) | Quantity limit example for XARELTO SUSPENSION RECONSTITUTED 1MG/ML |
| QL(60 EA per 30 days) | Quantity limit of 60 each per 30 days for atomoxetine hydrochloride capsule 10mg |
| QL(30 EA per 30 days) | Quantity limit of 30 each per 30 days for atomoxetine capsule various strengths |
| QL(90 EA per 30 days) | Quantity limit of 90 each per 30 days for methylphenidate hydrochloride tablet (various strengths) |
| PA | Prior authorization required (flag shown for multiple products) |
| QL(56 EA per 365 days) | Quantity limit example for therapy pack (AUSTEDO XR patient titration kit) |
| QL(30 EA per 30 days) | Quantity limit example for AUSTEDO XR extended release tablet |
| QL(120 EA per 30 days) | Quantity limit example for immediate-release AUSTEDO |
| B/D | Benefit/Distribution flag shown for some injectable nutrition products (indicates may be covered under Medicare Part B or Part D depending on indication/administration) |
| ST | Step therapy flag (example: diclofenac sodium gel 3% marked with ST) |
| Formulary ID: 26218 | Formulary identifier |
Provider Actions, Prior Authorization & Step Therapy
Obtain prior authorization before dispensing PA‑listed drugs
Prescribers must obtain prior authorization (PA) from BlueCross Total Value before filling prescriptions for drugs annotated with PA or PA NSO in the formulary; without prior approval the plan may not cover the drug.
- PA is required for coverage of products marked 'PA' or 'PA NSO'.
- Examples include GENOTROPIN, INCRELEX, ISTURISA and many specialty biologics.
Follow Requirements/Limits key (PA, QL, NDS, ST) on submissions
Follow the Requirements/Limits key when submitting requests: identify PA, QL, NDS and ST flags on the formulary entry and ensure supporting documentation addresses those specific requirements.
- Use the Requirements/Limits key (PA, QL, NDS, ST, B/D) to determine required controls for each drug.
- Supply documentation consistent with the flagged requirements when submitting PA or exception requests.
Submit PA for specialty/anticonvulsant products marked PA NSO
Prior authorization is required for numerous specialty and anticonvulsant products designated 'PA NSO' — submit PA requests for those formulations per the formulary.
- Examples of PA NSO products: BRIVIACT (solution and tablets), EPIDIOLEX (solution), DIACOMIT (capsule/packet), VIGAFYDE, ZTALMY.
- PA NSO denotes prior authorization is required as indicated in the formulary introduction.
Request PA for selected high‑tier and specialty drugs
Many high‑tier and specialty agents are marked 'PA' with quantity limits; prescribers must request prior authorization and document medical necessity for coverage.
- Examples include AIMOVIG, EMGALITY, QULIPTA, NURTEC and select oncology/specialty agents.
- Check respective QL entries (e.g., AIMOVIG QL per 28 days) when preparing PA submissions.
PA required for many specialty and oncology agents
Numerous specialty and oncology agents require prior authorization (PA NSO); providers must submit PA requests following the plan’s PA process and refer to introduction pages for details.
- PA NSO appears on many oncology and specialty entries — absence of PA may lead to denial.
- Refer to formulary introduction pages for PA submission instructions and symbol definitions.
Submit PA for flagged formulations (PA / PA NSO)
If a product is labeled 'PA' or 'PA NSO' for a specific formulation, providers must submit prior authorization for that formulation to obtain coverage.
- Several listed formulations include the 'PA' annotation — submission must reference the exact formulation shown in the formulary.
- Check the Requirements/Limits field on the drug row to identify PA applicability for the specific NDC/formulation.
Check formulary rows for PA annotations and request authorization
Prior authorization is applied to many listed products; verify the formulary row for PA annotation and submit authorization requests before dispensing.
- Examples of PA annotations include VYJUVEK GEL and diabetes specialty products (MOUNJARO, OZEMPIC).
- Follow PA and QL guidance shown on the formulary for those products.
Obtain PA for listed PA‑designated supportive care and injection products
Drugs designated 'PA' in the Requirements/Limits column (for example eltrombopag, NEULASTA, PROCRIT, RETACRIT, UDENYCA) require prior authorization prior to coverage.
- Submit PA for colony‑stimulating factors, ESAs and related high‑cost supportive care injections listed as PA.
- Claims submitted without required PA for these products may be denied.
Provide PA and QL justification for selected specialty/restricted drugs
Certain specialty or restricted drugs are subject to prior authorization and quantity limits; prescribers must supply PA documentation referencing applicable QL values.
- Examples: metyrosine = PA; PRALUENT and REPATHA have QL and PA requirements.
- Include clinical justification and requested quantity relative to the stated QL when submitting PA.
Request PA for selected high‑tier agents and address ST where shown
Multiple high‑tier products (e.g., AUSTEDO XR, INGREZZA, OTEZLA and many MS agents) carry PA flags; prescribers must request authorization and document indication and prior therapies where relevant.
- Therapies flagged PA often also have QLs — include dose and duration details in PA requests.
- For products with ST flags, ensure step‑therapy requirements are addressed or an exception is requested.
Obtain PA for multiple PA‑designated products to ensure coverage
Several products across the formulary are designated 'PA' — providers must obtain prior authorization before dispensing to avoid claim denial.
- Examples include deferasirox formulations, JYNARQUE (tolvaptan), RELISTOR, LIVMARLI and EVRYSDI.
- Verify QL values and include them in the PA request as applicable.
Submit PA (and document QL) for growth hormone and related agents
Growth hormone products and related agents (GENOTROPIN, INCRELEX, ISTURISA) are listed with PA (and QL for ISTURISA) — prescribers must submit a PA request that documents indication and quantity.
- ISTURISA has explicit QLs (240 EA per 30 days for 1mg; 360 EA per 30 days for 5mg) and requires PA.
- GENOTROPIN and INCRELEX are marked PA — include clinical rationale in the PA submission.
Follow PA process for PA and PA NSO‑flagged biologic/specialty drugs
Many listed drugs are subject to prior authorization (PA) and PA NSO annotations; providers must follow the PA process for these products to secure coverage.
- Biologic agents such as ENBREL, HUMIRA formulations and infliximab are examples requiring PA.
- Check for manufacturer‑labeled or starter‑pack restrictions shown with PA entries.
Submit PA and follow manufacturer/label restrictions for biologics
Many biologic and other specialty biologic agents (ENBREL, HUMIRA, infliximab and others) require prior authorization; submit PA requests and respect any manufacturer‑label or starter pack restrictions.
- HUMIRA listings may be limited to AbbVie labeled products only — include product specificity in PA requests.
- Starter pack QLs and PA requirements must be honored to avoid denials.
Document trial and failure of first‑line therapy for Step Therapy
Step therapy requires trying specified alternative drugs first; if the initial drug fails, document failure and submit for coverage of the subsequent agent.
- Step Therapy may require trial of preferred drugs before covering alternatives.
- If requesting an exception to ST, prescribers must explain medical reasons supporting the exception.
Apply 'Step Therapy for New Starts Only' when ST is indicated
Step Therapy applies to some drugs and is noted as 'Step Therapy for New Starts Only' in the key; for new starts follow the ST designation or request an exception if clinically justified.
- ST flags in the table indicate step‑edit requirements for new starts.
- Providers should consult the introduction pages for step‑therapy definitions and processes.
Comply with 'ST NSO' step therapy requirements or request exception
Products designated 'ST NSO' require step therapy as noted; prescribers must follow the step requirements or submit documentation explaining why the step cannot be met.
- Examples of ST NSO entries include ZONISADE suspension and certain EXXUA/EXXUA packs.
- If seeking an exception, provide clinical justification for bypassing step therapy.
Refer to introduction/PA criteria for full Step Therapy rules
Step therapy flags ('ST' shorthand) appear for select items but full step sequences are not detailed in this extract; providers must refer to the formulary introduction or PA criteria for specific step requirements.
- FETZIMA is an example with QL and ST NSO entries.
- Introduction pages contain definitions and processes for ST flags.
Satisfy ST or request exception for products flagged ST / ST NSO
Products marked 'ST' or 'ST NSO' (for example RYTARY, FANAPT titration packs) require step therapy per the formulary; providers must ensure step requirements are satisfied or request an exception.
- FANAPT titration packs are marked ST NSO with specific QLs.
- RYTARY is listed with ST — document prior therapies when submitting PA or exception requests.
No explicit step‑therapy sequences in extract — consult detailed criteria
This extract does not include explicit step‑therapy sequences (fail‑first chains); when ST is indicated, consult the plan’s detailed criteria or introduction pages for exact prior therapy requirements.
- No complete fail‑first sequences are shown in these chunks.
- Use the plan’s online documents or PA criteria for step sequence details.
Address ST for diclofenac sodium gel 3% or request exception
Some formulary entries (e.g., diclofenac sodium gel 3%) are flagged 'ST'; providers must meet the step‑therapy condition or submit clinical justification to override it.
- Diclofenac sodium gel 3% has QL(300 GM per 30 days) and ST.
- Document prior use of required agents or request an exception with supporting rationale.
Satisfy ST or document exception for RELISTOR (ST‑flagged agents)
RELISTOR INJECTION and certain other agents are marked 'ST'; ensure step‑therapy requirements are satisfied or include rationale for exceptions in the PA request.
- RELISTOR INJECTION 8MG/0.4ML has QL(12 ML per 30 days) and ST.
- Specify prior therapies and clinical response when requesting coverage beyond the step.
Consult plan resources for full Step Therapy details when ST is shown
No complete step‑therapy requirements are specified in this extract; when ST appears on a drug row, consult the formulary intro or the payer’s PA/step‑therapy documentation for details.
- The extract shows ST flags but not full step sequences.
- Contact the plan or refer to online PA/ST documents for exact requirements.
Adhere to manufacturer‑labeled product limitations or request exception
Some products are limited to specific manufacturer‑labeled items (e.g., 'Boehringer Ingelheim labeled products only'); when present, prescribe and document the exact labeled product or request an exception.
- Entries may restrict coverage to manufacturer‑labeled starter packs or branded labeled products.
- Examples include Boehringer Ingelheim labeled listings and AbbVie/HUMIRA labeled products.
Provide medical justification for exception requests (72h standard; 24h expedited)
When requesting an exception to PA, QL, or ST, the prescriber must explain the medical reasons supporting the exception; standard decisions are made within 72 hours and expedited decisions within 24 hours when appropriate.
- Prescribers must provide clinical justification for exceptions.
- Decision timelines: standard 72 hours; expedited 24 hours if request qualifies.
Include required documentation for PA, QL, NDS and ST per Requirements/Limits
Prescriptions subject to PA, QL, NDS, or ST must include documentation required by the Requirements/Limits field; include indication, prior therapies, and requested quantity/timeframe to support the request.
- The Requirements/Limits field (PA, QL, ST, NDS) documents needed controls and supporting evidence.
- Provide dose, duration, prior treatment history and rationale in PA or exception submissions.
Adhere to Quantity Limits or document justification in PA/exception requests
When a drug has a quantity limit (QL), prescribers/pharmacies must adhere to the stated QL or include documentation supporting the need for a larger quantity when requesting PA or an exception.
- Examples of QLs: clonazepam ODT QL(300 EA per 30 days); ELIQUIS SOLUBLE QL(560 EA per 28 days); many specialty injectables list ML or EA limits.
- Exceeding QL without an approved exception may result in denial.
Submit PA referencing the exact formulation and Requirements/Limits
PA flags in the table imply that prior authorization is required and that prescribers must submit authorization requests referencing the specific formulation and QL shown.
- Many entries show 'PA' or 'PA NSO' next to exact formulations — PA must reference those formulations.
- Check the Requirements/Limits field for any QL values to include in the request.
Provide PA/QL documentation per the formulary flags and introduction
Table flags such as 'PA NSO' and explicit QL(...) indicate documentation and authorization requirements; providers should follow the payer’s prior authorization process and include supporting clinical information.
- PA NSO denotes PA required as indicated; QL entries specify allowed units per time period.
- Introduction pages explain the symbols and the PA submission process.
Submit PA documentation for PA‑marked drugs (examples: GENOTROPIN, INCRELEX, ISTURISA)
Prescribers must supply prior authorization documentation for drugs marked 'PA' (for example GENOTROPIN, INCRELEX, ISTURISA) to the plan’s PA process to obtain coverage.
- ISTURISA requires QL(240 EA per 30 days for 1mg; 360 EA per 30 days for 5mg) plus PA.
- Include indication, dosing schedule and clinical rationale with PA submission.
Denial risk if PA/QL/NDS/ST requirements are not met
Failure to obtain required prior authorization, exceeding stated quantity limits, or ignoring NDS/ST flags may result in claim denial — verify flags on the formulary entry before dispensing.
- Denial triggers include lack of PA, exceeding QL, or attempting NDS when extended supply rules apply.
- Claims for PA‑marked products may be denied without approved authorization.
Avoid denials by securing PA for PA/PA NSO drugs and adhering to QLs
Lack of required PA or exceeding QL are primary denial triggers; when a drug is labeled 'PA NSO' or 'PA' ensure PA is obtained to minimize denial risk.
- PA NSO and PA flags indicate authorization is required; claims may be denied without it.
- Exceeding quantity limits listed in QL(...) can also trigger denials.
High denial risk for specialty/biologic injectables without PA
Claims for many specialty products (including biologics and high‑cost injectables) may be denied if prior authorization is not obtained; check each product’s Requirements/Limits before prescribing.
- High‑cost injections such as ORENCIA 250mg, FORTEO and teriparatide are listed with PA.
- Biologics like ENBREL and HUMIRA require PA and often have QLs or manufacturer‑label restrictions.
Refer to introduction pages for symbol definitions and PA/ST instructions
Providers should reference the formulary introduction pages for definitions of symbols/abbreviations (PA, QL, ST, NDS, B/D) and for instructions on PA and step‑therapy processes.
- Introduction pages provide symbol meanings and where to find PA/ST documentation.
- Formulary ID and version (Formulary ID: 26218, Version: 12) are listed on the introduction pages.
Initial Therapy Criteria / Selected Agents
Migraine/CGRP agents (formulary flags)
Migraine/CGRP and acute migraine agents are covered subject to the following utilization controls as shown in the formulary:
Per formulary Requirements/Limits: AIMOVIG entries include both QL and PA.
Per formulary Requirements/Limits entries for EMGALITY.
Per formulary Requirements/Limits: NURTEC shown with QL and PA; QULIPTA entry present in the migraine section.
Step Therapy Rules
| Summary | Source evidence |
|---|---|
| Members may be required to try preferred drugs first (step therapy) before the plan will cover an alternative drug for the same condition. | |
| Formulary introduction explains step therapy may require trying specified alternative drugs first; see 'Are there any restrictions on my coverage?' and the Requirements/Limits Key defining ST. |
| Rule | Source evidence |
|---|---|
| Step Therapy for New Starts Only applies where ST is indicated on the drug list. | |
| Legend entries include 'Step Therapy for New Starts Only' in the introduction/key indicating the ST designation applies to new starts as noted in the Requirements/Limits Key. |
| Example product(s) marked ST NSO | Source evidence |
|---|---|
| ZONISADE suspension 100 mg/5 mL — Requirements/Limits = ST NSO. | |
| Multiple antidepressant/titration pack examples (e.g., EXXUA, FANAPT titration packs) show ST NSO or ST alongside quantity limits in the Requirements/Limits Key. |
| Observation | Source evidence |
|---|---|
| Some entries include the shorthand 'ST' or 'ST NSO' (e.g., FETZIMA shows 'ST NSO') but the full step-therapy sequencing rules are not provided in this extract. | |
| Formulary pages instruct providers to consult introduction pages for symbol definitions and detailed program rules; full step-edit rules are in the introduction rather than the excerpted table. |
| Finding | Source evidence |
|---|---|
| No explicit step therapy sequences are listed in the extracted tables; many agents are annotated with 'PA NSO' or other flags instead. | |
| The extract contains numerous PA NSO annotations and quantity limits but does not contain detailed step-therapy failure/step sequencing criteria. |
| Implication | Source evidence |
|---|---|
| Products flagged 'ST' or 'ST NSO' require step therapy per the formulary table; specific step details must be referenced in the plan's introduction or prior authorization criteria. | |
| Examples in the Requirements/Limits Key show multiple products annotated with ST or ST NSO indicating step-edit applies and must be met prior to coverage. |
| Products with PA flags (diabetes/specialty) | Source evidence |
|---|---|
| MOUNJARO injection (various strengths) — Requirements/Limits = QL(2 ML per 28 days); PA. | |
| OZEMPIC injection (various sizes) and RYBELSUS tablet — listed with quantity limits and PA in the Requirements/Limits Key. |
| Products requiring PA | Source evidence |
|---|---|
| Multiple high-tier specialty injectables and supportive oncology/hematology agents are listed with 'PA' (examples: NEULASTA, PROCRIT/RETACRIT, eltrombopag, ENBREL entries). | |
| Requirements/Limits Key entries show PA required for many listed specialty products and injections; absence of PA may result in denial. |
| Summary | Source evidence |
|---|---|
| Some specialty injectables and oral specialty drugs are subject to prior authorization (PA) and quantity limits (QL); the extract does not provide an explicit step sequence for these agents. | |
| Examples (PRALUENT, REPATHA, AUSTEDO XR, COBENFY starter packs) list QLs and PA in the Requirements/Limits Key but no step-therapy order is shown in the excerpt. |
| Product | Source evidence |
|---|---|
| diclofenac sodium gel 3% — Requirements/Limits = QL(300 GM per 30 days); ST. |
| Product | Source evidence |
|---|---|
| RELISTOR tablet 150 mg — Requirements/Limits = QL(90 EA per 30 days); ST. |
| Products | Source evidence |
|---|---|
| GENOTROPIN Miniquick and GENOTROPIN injection formulations — Requirements/Limits = PA. | |
| ISTURISA tablets (1 mg and 5 mg) — Requirements/Limits = QL(240 EA per 30 days) / QL(360 EA per 30 days); PA. |
| Adalimumab / biologic listing notes | Source evidence |
|---|---|
| Multiple adalimumab (HUMIRA) starter packs and pens are listed with quantity limits and PA; some starter/pack entries reference manufacturer-labeled products only. | |
| Formulary entries for HUMIRA include QL values and PA; select HUMIRA entries note 'Abbvie labeled products only'. |
| AbbVie-labeled restriction examples | Source evidence |
|---|---|
| HUMIRA pen and injection entries include 'Abbvie labeled products only' on certain formulations (e.g., HUMIRA PEN INJECTION 80 mg/0.8 mL and 40 mg/0.8 mL entries). | |
| Other biologic listings may include manufacturer-labeled restrictions (e.g., Boehringer Ingelheim labeled products only noted elsewhere in the table). |
Quantity Limits (QL) — Per-Product Examples
Site of Care / Dispensing Rules
Definitions and Abbreviations
Background
This document is the BlueCross Total Value Medicare Part D formulary (Drug List). It identifies covered drugs, their assigned drug tiers, and utilization controls such as Prior Authorization (PA), Quantity Limits (QL), and Step Therapy (ST). For interpretive guidance (symbols/abbreviations) and fallback references relevant to Medicare Part D, providers should consult the formulary introduction pages referenced in the document.
Biosimilar Substitution
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