BlueCross Total Formulary (Drug List)

Coverage Summary

Formulary Coverage and Restrictions

Covered when ALL of the following are met:

ALL of the following

Drug is listed on the BlueCross Total formulary (Drug List).
Prescription is filled at a BlueCross Total network pharmacy; members generally must use network pharmacies to use their prescription drug benefit.
The drug is determined to be medically necessary for the member under the plan's clinical coverage rules and prescribing information.
Any applicable plan rules, including but not limited to cost-sharing tier, quantity limits, step therapy, and prior authorization requirements, are satisfied.
If the drug has specific per-drug requirements or limits (for example, prior authorization criteria, quantity limits, or step-therapy prerequisites), those requirements are met as described in the formulary and supporting prior authorization/step-therapy documents.
Requirements/Limits per drug entry: check the drug-specific formulary row for exact limits and clinical requirements.
If a drug has a restriction (prior authorization, step therapy, or quantity limit) and the member or prescriber requests an exception, the exception process must be followed (see Exception Requests block).
Requirements / Limits entries (per drug) are enforced per the formulary.

Exception Requests

BlueCross Total will make an exception decision in accordance with Medicare timelines. Decisions are based on submitted clinical information and plan rules.

ALL of the following

An exception request must include clinical justification from the prescriber explaining why the member needs the non-formulary drug or needs an exception to a restriction (e.g., prior authorization, quantity limit, step therapy).
Standard (non-urgent) exception requests will be decided within 72 hours of receipt; expedited (urgent) requests will be decided within 24 hours when the prescriber indicates that the standard timeframe could seriously jeopardize the life or health of the member or ability to regain maximum function.
If additional information is needed to make a decision, BlueCross Total will request it and the decision timeframe may be extended consistent with Medicare rules. The member and prescriber will be notified of the extension and the reason.
If an exception is approved, coverage will be provided in accordance with the approval terms. If denied, the member will receive a written notice explaining the reason and describing the appeal rights and next steps (including expedited appeal options).

Transition/Temporary Coverage

Temporary or transition fills may be available when members move to the plan, experience a change in level of care, or encounter formulary changes.

ANY of the following

New members transitioning to BlueCross Total may receive a temporary supply of a covered drug (typically up to a 30-day supply) to allow time to transfer prescriptions to a network pharmacy and obtain any required prior authorizations.
Transition/Temporary Coverage for new or continuing members: check member materials and Evidence of Coverage for exact supply limits.
Members in long-term care (LTC) settings may receive temporary supply rules consistent with CMS guidance and the plan's LTC pharmacy arrangements to avoid interruptions in therapy.
Level-of-care changes (e.g., discharge from hospital to home) — temporary fills may be allowed to bridge therapy while obtaining authorizations.
When the formulary changes during the year affecting a member's current drug, BlueCross Total will provide at least a 30-day supply or otherwise follow CMS transition provisions and member notification requirements so members have time to work with their prescriber to find alternatives or request exceptions.

This formulary (Drug List) explains the scope of covered Part D drugs for BlueCross Total Medicare Advantage, summarizes how coverage decisions are made, lists common restrictions (prior authorization, quantity limits, step therapy), and provides contact information and procedures for exception requests and transition supplies.

Requirements & Limits (PA / QL / ST / B/D / NSO)

Definitions — PA = Prior Authorization; QL = Quantity Limits (specified units per time period); ST = Step Therapy; NDS = Non-Extended Day Supply (not available for extended day supply); B/D = Drug may be covered under Medicare Part B or D depending on indication/setting; NSO = Not Otherwise Specified / non-standard or specialty processing flag.

Applicable Codes & Formulary Identifiers

Formulary identifiersmixed

HPMS_FORMULARY_FILE_SUBMISSION_ID	00026216
FORMULARY_UPDATE_DATE	2026-03-02
EFFECTIVE_DATE	2026-04-01

Drugs with Quantity Limits (QL)mixedCovered

CABLIV_QL	Example: 30 tablets per 30 days
VELTASSA_PACKET_16.8GM	Quantity limit per packet
LOKELMA_PACKET_10GM	Quantity limit per packet
INSULIN_MULTIPLE_PRESENTATIONS_QL	Quantity limits apply to certain insulin presentations

Drugs with Prior Authorization (PA)mixedCovered

POSACONAZOLE_VARIOUS	Posaconazole (oral, suspension, delayed-release tablet, IV) — prior authorization required
APREPIANT_VARIANTS	Aprepitant (various formulations) — PA required
TRICYCLIC_AGENTS_VARIOUS	Tricyclic antidepressants — PA may apply per formulary
ANTIFUNGALS_FLUCONAZOLE_FORMS	Fluconazole (tablet, suspension, injection) — PA for some indications/doses
NYSTATIN_FORMS	Nystatin (oral suspension, topical) — PA for certain formulations
PAXLOVID_THERAPY_PACK_VARIANTS	Paxlovid therapy packs (100mg/150mg) — prior authorization per policy
GANCICLOVIR_INJECTION_500MG_10ML	Ganciclovir injection 500mg/10mL — PA required
VALACYCLOVIR_1GM	Valacyclovir tablet 1g — PA may apply for specific uses
ACYCLOVIR_INJECTION_50MG_PER_ML	Acyclovir sodium injection 50mg/mL — PA for some inpatient/OP use
REMS_ORIGINAL_BIOLOGICAL_PRODUCTS	Selected biologics and biosimilars may require PA

1–10 of 18

1/2

Drugs with Step Therapy (ST)mixedCovered

STEP_THERAPY_ANTIDEPRESSANTS_CLASS	Step therapy may apply within SSRI/SNRI/other antidepressant classes
MIRTAZAPINE_ODT_TABLETS_15_30_45MG	Mirtazapine ODT 15mg/30mg/45mg — step edits for formulary sequence
MIRTAZAPINE_TABLETS_7.5_15_30_45MG	Mirtazapine tablets (7.5,15,30,45mg) — step therapy rules apply
CITALOPRAM_TABLETS_10_20_40MG	Citalopram tablets 10mg/20mg/40mg — may be subject to step therapy
ESCITALOPRAM_SOLUTION_TABLET	Escitalopram oxalate solution/tablet — step edits within SSRIs
FLUOXETINE_FORMS	Fluoxetine (capsule/tablet/solution) — step therapy may apply
PAROXETINE_PRODUCTS	Paroxetine products — may be included in step edits
SERTRALINE_PRODUCTS	Sertraline products — may be included in step edits
PROMETHAZINE_PRODUCTS	Promethazine formulations — step therapy or PA for some uses

Antineoplastic and Targeted Agents (PA/QL/ST as noted)mixedCovered

RETEVMO_CAPSULE_80MG	Retevmo capsule 80mg
RETEVMO_TABLET_160MG	Retevmo tablet 160mg
ROMVIMZA_CAPSULE_20MG	Romvimza capsule 20mg
ROMVIMZA_CAPSULE_30MG	Romvimza capsule 30mg
ROZLYTREK_CAPSULE_200MG	Rozlytrek capsule 200mg
RUBRACA_TABLET_300MG	Rubraca tablet 300mg
SORAFENIB_TABLET_200MG	Sorafenib tablet 200mg
STIVARGA_TABLET_40MG	Stivarga tablet 40mg
SUNITINIB_MALATE_CAP_12.5MG	Sunitinib malate capsule 12.5mg
SUNITINIB_MALATE_CAP_25MG	Sunitinib malate capsule 25mg

1–10 of 52

1/6

Antimicrobials and AntiparasiticsmixedCovered

Pyrimethamine_TABLET_25MG	Pyrimethamine 25mg
Quinine_Sulfate_CAP_324MG	Quinine sulfate capsule 324mg
GANCICLOVIR_INJECTION_500MG_10ML	Ganciclovir injection 500mg/10mL
PENTAMIDINE_ISOTHIONATE_INJECTION_300MG	Pentamidine isethionate injection 300mg

Antivirals (Influenza, Herpes, HIV) and Supportive AgentsmixedCovered

OSeltamivir_PHOSPHATE_CAP_75MG	Oseltamivir phosphate capsule 75mg
RELENZA_DISKHALER_5MG_BLISTER	Relenza Diskhaler aerosol powder 5mg/blister
VALACYCLOVIR_TABLET_1GM	Valacyclovir tablet 1g
PAXLOVID_THERAPY_PACK_150MG_100MG	Paxlovid therapy pack variants (150mg/100mg)
NORVIR_PACKET_100MG	Norvir packet 100mg
PREZCOBIX_TABLET_150MG	PrezcoBix tablet 150mg
PREZCOBIX_TABLET_675MG	PrezcoBix tablet 675mg
PREZISTA_SUSPENSION_100MG_PER_ML	Prezista suspension 100mg/mL
PREZISTA_TABLET_75MG	Prezista tablet 75mg
PREZISTA_TABLET_150MG	Prezista tablet 150mg

Antiepileptic, Movement Disorder, and CNS AgentsmixedCovered

RYTARY_CAP_EXTENDED_23.75MG	Rytary capsule ER 23.75mg
RYTARY_CAP_EXTENDED_36.25MG	Rytary capsule ER 36.25mg
RYTARY_CAP_EXTENDED_48.75MG	Rytary capsule ER 48.75mg
RYTARY_CAP_EXTENDED_61.25MG	Rytary capsule ER 61.25mg
RYTARY_CAP_EXTENDED_95MG	Rytary capsule ER 95mg
RYTARY_CAP_EXTENDED_145MG	Rytary capsule ER 145mg
RYTARY_CAP_EXTENDED_195MG	Rytary capsule ER 195mg
CAPLYTA_CAPSULE_21MG	Caplyta capsule 21mg
CAPLYTA_CAPSULE_42MG	Caplyta capsule 42mg
INGREZZA_PRODUCTS_VARIANTS	Ingrezza and variants (including starter/titration packs)

Antipsychotics and Related AgentsmixedCovered

FANAPT_TABLET_VARIANTS	Fanapt tablets and titration packs
LYBALVI_TABLET_VARIANTS	Lybalvi tablets (various strengths)
PALIPERIDONE_ER_VARIANTS	Paliperidone ER and other paliperidone products (injection/tablet)
CAPLYTA_AND_OTHER_ANTIPSYCHOTICS	Caplyta and other antipsychotic entries included
PALIPERIDONE_INJECTIONS_TABLETS	Long-acting injectable paliperidone formulations included

HIV Combination and Antiretroviral TherapiesmixedCovered

MARAVIROC_300MG	Maraviroc tablet 300mg
MARAVIROC_150MG	Maraviroc tablet 150mg
RUKOBIA_ER_600MG	Rukobia ER tablet 600mg
SELZENTRY_TABLET_25MG	Selzentry tablet 25mg
SELZENTRY_TABLET_75MG	Selzentry tablet 75mg
SUNLENCA_INJECTION_463.5MG_1.5ML	Sunlenca injection 463.5mg/1.5mL
SUNLENCA_TABLET_THERAPY_PACK_300MG	Sunlenca tablet therapy pack 300mg
PREZCOBIX_PACKET_50MG	Reyataz/Prezista/Norvir packet references included

Antifungals and Dermatologic Agents (PA/QL as noted)mixedCovered

EXXUA_18.2MG_ER	Exxua 18.2mg ER
JUBLIA_SOLUTION_10_PERCENT	Jublia solution 10%
FLUCONAZOLE_FORMS	Fluconazole (tablets, suspension, injection)
NYSTATIN_FORMS	Nystatin (oral suspension, topical)

Antigout and Related AgentsmixedCovered

ALLOPURINOL_VARIANTS	Allopurinol formulations included
COLCHICINE_VARIANTS	Colchicine formulations included
FEBUXOSTAT_VARIANTS	Febuxostat formulations included

Antiemetics, Migraine, and GI AgentsmixedCovered

RIZATRIPTAN_BENZOATE_TABLET_10MG	Rizatriptan benzoate tablet 10mg (also 5mg)
ONDANSETRON_HCL_TABLET_4MG	Ondansetron hydrochloride tablet 4mg (also 8mg)
ONDANSETRON_ODT_4MG	Ondansetron ODT 4mg (also 8mg)
TORPENZ_TABLET_2.5MG	Torpenz tablet 2.5mg (also 5mg,7.5mg,10mg)

Psychotropics (Benzodiazepines and Related) and SedativesmixedCovered

CLORAZEPATE_DIPOTASSIUM_TABLET_3.75MG	Clorazepate 3.75mg (also 7.5mg,15mg)
DIAZEPAM_VARIANTS	Diazepam intensol/concentrate/solution/tablet (2mg,5mg,10mg)
LORAZEPAM_VARIANTS	Lorazepam intensol concentrate 2mg/mL and tablet 2mg

Endocrine, Diabetes, and GLP-1/SGLT2 TherapiesmixedCovered

GLIPIZIDE_XL_ER_TABLET_24HR_10MG	Glipizide XL 24hr 10mg (also 2.5mg,5mg)
GLIPIZIDE_METFORMIN_COMBINATIONS	Glipizide/metformin combination tablets (multiple strengths)
JANUMET_XR_TABLET_ER_1000MG	Janumet XR 1000mg/100mg and other strengths
METFORMIN_ER_TABLETS	Metformin ER 24hr (500mg,750mg,1000mg) and solution
MOUNJARO_INJECTION_VARIANTS	Mounjaro injection multiple strengths included
OZEMPIC_INJECTION_VARIANTS	Ozempic injections (2mg/3mL,4mg/3mL,8mg/3mL)

Cardiovascular, Lipid, and Anticoagulant AgentsmixedCovered

DABIGATRAN_CAPSULE_110MG	Dabigatran etexilate capsule 110mg (also 150mg,75mg)
ELIQUIS_STARTER_PACK_5MG	Eliquis starter pack therapy pack 5mg
ENOXAPARIN_INJECTION_VARIANTS	Enoxaparin sodium injection multiple strengths
WARFARIN_JANTOVEN_VARIANTS	Warfarin sodium (Jantoven) multiple strengths
CLOPIDOGREL_TABLET_75MG	Clopidogrel tablet 75mg (also 300mg)

Vitamins, Minerals, and GI SupportmixedCovered

VYJUVEK_GEL	Vyjuvek gel (topical)
BAQSIMI_ONE_TWO_PACK	Baqsimi one pack/two pack
GLUCAGON_EMERGENCY_KIT_1MG	Glucagon emergency kit/injection 1mg
GVOKE_HYPOPEN_PACKS	GVOKE hypopen 1- and 2-pack and kits

Pancrelipase and Pancreatic Enzyme ProductsmixedCovered

CREON_CAPSULES_MULTIPLE_STRENGTHS	Creon delayed-release particles multiple strengths
ZENPEP_CAPSULES_MULTIPLE_STRENGTHS	Zenpep delayed-release particles multiple strengths

Parenteral Nutrition, Electrolytes, and IV FluidsmixedCovered

AMINOSYN_VARIANTS	Aminosyn, Aminosyn-PF, Syn II injections multiple concentrations
DEXTROSE_SODIUM_CHLORIDE_COMBINATIONS	Dextrose 5%/NaCl 0.45% and 0.9% injections
SODIUM_CHLORIDE_INJECTIONS	Sodium chloride injections 0.45% and 0.9%

Miscellaneous and Supportive AgentsmixedCovered

OPIPZA_FILM_2MG_10MG	Opipza film 2mg/10mg
VELPHORO_CHEWABLE_500MG	Velphoro chewable tablet 500mg
TRIKAFTA_THERAPY_PACK	Trikafta therapy pack included

Provider Actions & Operational Requirements

Prior Authorization

Prior Authorization requirement

Prior authorization (PA) is required for drugs marked PA or PA NSO in the Requirements/Limits column. Examples include specialty and high‑tier agents and selected therapy packs. Obtain PA before dispensing to avoid non‑coverage.

SPRAVATO 56MG & 84MG dose solution therapy packs (PA NSO)
CRESEMBA (PA)
posaconazole (PA)
voriconazole injection (PA)
VYVGART HYTRULO injection (PA)
AIMOVIG / EMGALITY (QL; PA)
Many antineoplastics listed with PA NSO (e.g., IBRANCE, IMBRUVICA, RETEVMO, etc.)

Background & Definitions

This is the official BlueCross Total Medicare Advantage Drug List (formulary). The formulary organizes drugs by medical condition (section headings) and also provides an alphabetical index; each product line shows the drug name, strength(s), assigned Tier, and any requirement/limit codes. Requirement/limit codes include PA (prior authorization), QL (quantity limits with units and time period), ST (step therapy), NDS (non-extended day supply), and B/D (billing/benefit designation indicating potential Part B vs Part D coverage). Members may ask the plan for an exception (waiver of a restriction or coverage of a non‑formulary drug) by submitting prescriber rationale; the plan must decide within 72 hours (or 24 hours for expedited requests). For new or continuing members, the plan will provide a temporary 30-day supply while pursuing coverage; long‑term care residents may receive a 31-day emergency supply, and level-of-care changes may allow a full outpatient supply to avoid a gap in care. Providers and members should refer to the Requirements/Limits Key and introductory pages for exact codes and QL values.

Revision History

2026-04-01formulary_effectiveLatest

Formulary Version 11 effective 04/01/2026

2026-03-02last_updated

Formulary last updated 03/02/2026