CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A
BlueCross Total 2025 Formulary (Drug List) — Coverage Criteria
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Defines the plan's covered prescription drugs, formulary structure, member cost-sharing tiers, and administrative rules (prior authorization, step therapy, quantity limits, exceptions) for BlueCross Total members under BlueCross BlueShield of South Carolina.
Policy Summary
PayerBlue Cross Blue Shield - South Carolina
PolicyBlueCross Total 2025 Formulary (Drug List) — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date10/01/2025
Last ReviewOct 1, 2025
Next Review DateN/A
Key ActionObtain prior authorization when 'PA' is indicated on the Drug List before prescribing to ensure coverage.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
MonthlyFormulary update frequency
30 daysAdvance notice for most changes
72 hrsStandard exception timeframe
24 hrsExpedited exception timeframe
10/01/2025Formulary effective as of
5Cost-sharing tiers
Coverage Criteria and Transition Rules
General Formulary Coverage
Covered when ALL of the following are met
Formulary Coverage General Conditions: Drug is listed on the BlueCross Total formulary; drug is medically necessary; prescription is filled at a BlueCross Total network pharmacy; and applicable plan requirements (such as prior authorization, quantity limits, and step therapy) are followed.
From formulary overview and usage instructions.
Transition and Emergency Coverage
Temporary coverage allowances
Transition and Emergency Supplies: For drugs not on the formulary or drugs with restrictions, BlueCross Total will cover a temporary 30-day supply for new or continuing members (refills may be allowed up to a 30-day maximum); long‑term care residents may receive a 31-day emergency supply when eligible; and during discharge or level-of-care changes an outpatient supply may be provided to prevent gaps in therapy.30 days / 31 days
See transition and discharge provisions.
Drugs may be removed from the formulary when they are withdrawn from sale by the manufacturer or if the FDA withdraws them for safety or effectiveness reasons. In those cases BlueCross may immediately remove the drug from the formulary and it will no longer be covered; the plan may subsequently notify affected members. For other formulary changes (for example adding a generic or biosimilar, moving a drug to a different tier, or adding utilization controls), BlueCross will provide notice at least 30 days before the change becomes effective or provide a 30‑day supply at the time a member requests a refill and include notice of the change. Members or prescribers may request an exception to continue coverage when a change affects a member currently taking a drug.
The formulary includes explicit entries that are designated Not Covered in the table (several Tier 5 and Mail Order/LTC rows show "Not Covered" for specific specialty or mail‑order categories). Where a drug row indicates "Not Covered," claims for that product are not payable under the pharmacy benefit unless an approved exception is obtained.
The sample formulary excerpts in this document primarily present administrative controls (tier assignment, PA and QL markers) and product‑level quantity limits. The extract does not include standalone clinical‑necessity narrative criteria tied to specific diagnoses; coverage is determined by whether the drug is on the formulary and whether the listed administrative requirements (e.g., prior authorization, quantity limits) are met.
Within the provided table excerpts there are no explicit clinical exclusion rules stated (for example, lists of diagnoses or clinical conditions that automatically exclude coverage). Entries in these chunks are limited to formulary tiering and utilization controls such as PA and QL, which are enforced administratively rather than by a separate clinical exclusion statement.
Utilization Flags, Quantity Limits and Example Codes
Formulary utilization flags and example quantity limitsmixed
| QL(148 EA per 365 days) | Quantity limit example for ELIQUIS STARTER PACK |
| QL(84 EA per 28 days) | Quantity limit example for ELIQUIS CAPSULE SPRINKLE |
| QL(140 EA per 28 days) | Quantity limit example for ELIQUIS TABLET SOLUBLE 0.5MG |
| PA | Prior authorization required (used for multiple specialty agents listed) |
| QL(102 EA per 365 days) | Quantity limit example for XARELTO STARTER PACK |
| QL(30 EA per 30 days) | Quantity limit example for XARELTO 10/20mg |
| QL(60 EA per 30 days) | Quantity limit example for XARELTO 15mg |
| QL(240 EA per 30 days) | Quantity limit example for ENTRESTO CAPSULE SPRINKLE |
| QL(60 EA per 30 days) | Quantity limit example for sacubitril/valsartan |
| QL(120 EA per 30 days) | Quantity limit example for XOLREMDI |
inv-08: Quantity limits examples
Common QL examplesQL(30 EA per 30 days); QL(60 EA per 30 days); QL(90 EA per 30 days); QL(120 EA per 30 days); QL(180 EA per 30 days); QL(336 EA per 365 days); QL(540 ML per 30 days)
Formatting noteQuantity limits use the format QL(## <unit> per ## days) as shown in the table
Provider actionDispensed quantity must not exceed the listed QL without prior authorization or exception request
inv-09: Example quantity limits
Quarterly/interval QL examplesQL(91 EA per 91 days); QL(0.65 ML per 90 days); QL(1 EA per 28 days); QL(10 ML per 28 days)
Contraceptive pack exampleQL(91 EA per 91 days) used for several contraceptive brands
Injectable/vial exampleQL(0.65 ML per 90 days) for DEPO-SUBQ PROVERA 104
inv-10: Quantity limits shown
Additional QL examplesQL(30 EA per 30 days); QL(60 EA per 30 days); QL(270 ML per 30 days); QL(540 ML per 30 days)
Sleep/wa kefulness agentsQL(30 EA per 30 days) examples for zolpidem and modafinil; sodium oxybate shown as QL(540 ML per 30 days)
Inhaled/respiratory examplesQL(270 ML per 30 days) used for multiple respiratory products (TRELEGY, wixela, others)
Prior Authorization, Step Therapy, Documentation, and Denial Risk
Prior Authorization
Prior Authorization Required
Some covered drugs require prior authorization (PA) before the plan will approve payment. When an entry in the formulary is annotated with PA, PA NSO (prior authorization for new starts only), or PA/PA NSO, the prescriber must obtain approval from the plan prior to dispensing. Failure to obtain required prior authorization may result in the drug not being covered.
- PA markers appear throughout the formulary (e.g., ".PA", "PA NSO", "PA;" annotations).
- PA applies to many specialty and biologic agents (examples: Dupixent, Otezla, Humira, many oncology agents marked PA NSO).
- Some antiviral and acute-use products are PA'd (examples: PAXLOVID entries show .PA).
Prior Authorization
When Prior Authorization Applies
Prior authorization is required for listed products when shown in the formulary’s Requirements/Limits column. Examples of PA and PA NSO designations in the formulary include: PA for biologics and injectables (e.g., ORENCIA, RINVOQ, SKYRIZI), PA NSO for many oncology agents and specialty products (e.g., multiple items in Tier 5 flagged PA NSO).
- Specialty oncology and targeted therapies frequently carry PA NSO.
- Many monoclonal antibodies and immunological agents are listed with PA and quantity limits.
- Starter packages and manufacturer-labeled starter kits may have PA plus manufacturer-specific restrictions noted (see adalimumab starter package entries).
Prior Authorization
Prior Authorization Noted for Specific Products
The formulary lists specific products and the corresponding PA, QL, ST, and other flags. Providers should consult the formulary row for the drug to see the exact requirement(s) and any quantity limits or starter-package notes.
- Topical and oral products may have combined QL+PA entries (e.g., lidocaine topical entries show QL and PA).
- Anticonvulsants and specialized neurologic therapies show PA NSO or PA for certain formulations (e.g., BRIVIACT = PA NSO; EPIDIOLEX = PA NSO).
- Starter/package designations and manufacturer-specific restrictions are called out on some biologic starter packs (e.g., Boehringer Ingelheim, AbbVie labeled products).
Prior Authorization
PA for Specialty Drugs
Many specialty, injectable, biologic, enzyme-replacement, gene/rare-disease, and oncology agents require prior authorization. When a specialty product is flagged PA or PA NSO, the prior authorization requirement must be met before the plan will cover the product.
- Oncology agents in Tier 5 often show PA NSO (e.g., multiple chemotherapy and targeted therapy listings).
- Immunologic and biologic drugs (Dupixent, Cosentyx, Ocrevus-like entries) show PA and often QL limits.
- Enzyme replacement, genetic disorder, and cystic fibrosis agents are PA’d (examples: Fabrazyme, Evrysdi, Trikafta).
Prior Authorization
Quantity Limits, Step Therapy, and PA
Quantity limits (QL) and step-therapy (ST/ST NSO) indicators often accompany PA requirements. When QL or ST is present with PA, documentation must support medical necessity for overrides or exceptions.
- Examples: lidocaine topical products list QL and PA.
- CGRP migraine injectables show QL and PA (e.g., Aimovig, Emgality).
- Some agents use ST NSO or ST for new starts only; other PA entries may imply step edits.
Documentation Required
Exception Request and Documentation Requirements
Documentation: when requesting an exception, prior authorization, or step-therapy override, the prescriber must provide a supporting clinical statement explaining the medical necessity. The plan generally must decide within 72 hours of receiving the prescriber's supporting statement; expedited (24-hour) review is available when waiting could seriously harm the patient.
- Prescriber supporting statement required for exception and PA requests.
- Expedited (fast) requests available — decision within 24 hours if criteria met; standard decisions within 72 hours.
- Refer to the formulary introduction pages for definitions of PA, QL, NDS, ST, ST NSO and for submission instructions.
Denial Risk
Follow Formulary Flags and Avoid Denials
Use the formulary requirement flags (PA, PA NSO, QL, ST, ST NSO) shown in each drug row when submitting prior authorization and claims. Claims may be denied if the required PA is not obtained or if quantity limits are exceeded.
- Follow the exact PA/QL/ST markers on the formulary row when requesting approvals.
- Exceeding a listed QL may require an override and can lead to denial if not supported.
- Missing PA or unmet ST requirements are common triggers for claim denials.
Denial Risk
Prior Authorization Denial Risk
Denial risk: failure to obtain prior authorization, to meet step-therapy requirements, or to adhere to quantity limits may result in non-coverage. Providers should confirm PA and QL status before dispensing specialty or high-cost medications.
- Many Tier 4–5 and specialty drugs carry PA/PA NSO flags — high denial risk if PA is missing.
- Antivirals and acute-course products (e.g., PAXLOVID) include PA and QL entries — confirm before dispensing.
- Pharmacy claims processing enforces QL and PA — prescribers should submit necessary documentation proactively.
Documentation Required
Operational Steps for Providers
Operational notes: observe quantity limits at dispensing and include PA documentation with the prescription when required. For starter packs, labeled products, or manufacturer-specific kits, note any product-specific restrictions called out in the formulary (e.g., Boehringer Ingelheim or AbbVie labeled starter product restrictions).
- Starter/package designations may list QL and PA plus manufacturer-specific limits.
- Prescriptions should match the formulary QL and PA requirements to avoid reimbursement issues.
- Refer to the formulary introduction for submission instructions and contact information for PA requests.
Step Therapy Listings and Applicability
| Requirement | Description |
|---|---|
| Member must try specified alternative drug(s) before the plan will cover the requested drug. | |
| If first-line agent(s) do not work or are not tolerated, the plan may cover the requested drug after documentation of trial/failure as required by BlueCross Total. |
| Indicator | Applies When |
|---|---|
| ST | |
| Applies where the Drug List row shows 'ST' (step therapy). | |
| ST NSO | |
| Applies where the Drug List row shows 'ST NSO' (Step Therapy for New Starts Only; may include NSO handling). |
| Control | Implication |
|---|---|
| Tier assignments | |
| Indicate member cost-sharing level and can be associated with utilization controls (PA, QL) that may trigger step edits at point of sale. | |
| Requirements/Limits keys (PA, QL, NDS) | |
| Show utilization management applied to the product (e.g., prior authorization required, quantity limits) and signal where step therapy may be enforced. |
| Drug | Step Therapy Flag |
|---|---|
| NAMZARIC CAPSULE EXTENDED RELEASE 24 HOUR | |
| Marked 'ST' indicating step therapy applies prior to coverage (QL(30 EA per 30 days); ST). |
| Drug | Step Therapy / Limit |
|---|---|
| EXXUA | |
| Marked 'ST NSO' with QL(30 EA per 30 days); indicates Step Therapy for New Starts Only and NSO handling. | |
| EXXUA TITRATION PACK | |
| Marked 'ST NSO' with QL(30 EA per 30 days); step therapy applicable for new starts (NSO). |
| Observation | Notes |
|---|---|
| No explicit step therapy sequences listed | |
| The document excerpt often shows only PA and QL markers without detailed step-by-step (fail-first) algorithms for most products. | |
| Utilization flags present | |
| Many entries are controlled by PA or QL indicators; where 'ST' or 'ST NSO' appear they indicate step therapy but specifics are not provided in these chunks. |
| Drug / Example | Step Therapy Flag |
|---|---|
| RYTARY | |
| Listed with 'ST' (step therapy) in the formulary excerpt, indicating a step requirement before coverage. |
| Product Group | Utilization Flag |
|---|---|
| GLP-1 and other antidiabetic injectables (examples: MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) | |
| Marked with PA and QL in the table (e.g., OZEMPIC QL; RYBELSUS QL; PA noted) indicating prior authorization and potential step edits though explicit step sequences are not listed. |
| Agent Type | Management |
|---|---|
| Specialty / hematopoietic agents (examples: NEULASTA, PROCRIT, PROMACTA, RETACRIT) | |
| Marked 'PA' (prior authorization) or QL in the table; many require PA but explicit multi-step sequences are not provided in the excerpt. |
| Product Category | Quantity Limit Example |
|---|---|
| ADHD stimulant and related products (amphetamine/dextroamphetamine, methylphenidate, atomoxetine) | |
| Quantity limits applied (examples: QL(60 EA per 30 days), QL(90–180 EA per 30 days) depending on product) as shown in the table. |
| Product Type | Utilization Controls |
|---|---|
| Diclofenac gel 3%; RELISTOR formulations; XERMELO | |
| These products are shown with 'ST' in the Requirements/Limits column (diclofenac sodium gel 3% QL(300 GM per 30 days); RELISTOR entries QL and ST), indicating step therapy applies to select agents. | |
| Other examples (diclofenac gel; RELISTOR; XERMELO) | |
| Marked 'ST' in the table demonstrating instances where step therapy is used for selected agents. |
| Observation | Detail |
|---|---|
| No explicit multi-step sequences in many segments | |
| Across several chunks the formulary lists PA and QL markers primarily; detailed step-by-step (fail-first) algorithms are not provided in these excerpts. |
| Designation | Note |
|---|---|
| Starter / Starter Package entries | |
| Some biologic starter packages are shown with QL and PA plus manufacturer-specific notes (e.g., Boehringer Ingelheim labeled products only), implying starter-package controls. |
| Observation | Examples |
|---|---|
| PA required for many biologic products | |
| Numerous biologic and specialty products (HUMIRA variants, INFLECTRA, INFLIXIMAB, DUPIXENT, COSENTYX, etc.) are marked with PA and QL; step therapy specifics are not listed in the excerpt. |
| Observation | Note |
|---|---|
| PA and QL controls present | |
| Many entries in the respiratory and specialty sections show PA and QL values (examples: cystic fibrosis agents, inhaled products) but do not provide explicit step therapy algorithms in this excerpt. |
| Drug(s) | Requirement |
|---|---|
| armodafinil, modafinil, sodium oxybate | |
| Marked with 'PA' in the Requirements/Limits column; prior authorization is required for these wakefulness-promoting agents (examples shown with QL values and PA). |
Product-Specific Quantity Limits
inv-122: Cablivi — quantity example
Cablivi quantity limit30 tablets per 30 days (example shown in formulary overview)
ContextProvided as an illustrative QL in the formulary overview describing quantity limits
inv-123: Multiple small-molecule examples
CelecoxibQL(60 EA per 30 days)
Diclofenac sodium gel 1%QL(1000 GM per 30 days)
Ketorolac tabletQL(20 EA per 30 days)
Buprenorphine (formulations)QL(4 EA per 28 days) noted for some buprenorphine entries
Lidocaine productsLidocaine-prilocaine cream QL(30 GM per 30 days); lidocaine ointment QL(150 GM per 30 days)
inv-124: lidocaine-prilocaine cream — QL 30
Lidocaine-prilocaine creamQL(30 GM per 30 days)
AnnotationAlso listed with PA in Requirements/Limits for specific product rows
inv-126: lidocaine ointment 5% — QL 150
Lidocaine ointment 5%QL(150 GM per 30 days)
NoteListed with PA in the Requirements/Limits column for product rows
inv-127: NAYZILAM — QL 10
NAYZILAMQL(10 EA per 30 days)
Formulary tierListed at Tier 4 in the table entries
inv-128: linezolid tablet — QL 56
Linezolid tabletQL(56 EA per 28 days)
Linezolid suspension (reconstituted)QL(1800 ML per 28 days) — separate entry
inv-129: linezolid suspension reconstituted — QL 1800
Linezolid suspension (reconstituted)QL(1800 ML per 28 days)
NotesListed as a distinct formulary entry with its own QL
inv-130: vancomycin capsule 125mg — QL 120
Vancomycin capsule 125mgQL(120 EA per 30 days)
Vancomycin capsule 250mgQL(240 EA per 30 days)
Dispensing noteSeparate QLs provided per strength in the formulary table
inv-131: vancomycin capsule 250mg — QL 240
Vancomycin capsule 250mgQL(240 EA per 30 days)
Strength-specific QL250mg strength has a larger monthly QL than 125mg
inv-132: bupropion er 150mg — QL 60
Bupropion HCl ER 150mgQL(60 EA per 30 days)
TierListed at Tier 2 in the table
inv-133: NICOTROL NS — QL 360
NICOTROL NS (nicotine nasal spray)QL(360 ML per 365 days)
Usage periodQL expressed over 365 days for nicotine replacement product
inv-134: TYRVAYA — QL 8.4
TYRVAYA (nasal formulation)QL(8.4 ML per 30 days)
NotesListed in Requirements/Limits with QL per 30 days
inv-135: varenicline starter/tartrate — QL 504
Varenicline (starter / tartrate)QL(504 EA per 365 days)
Annual QLQuantity limit expressed over 365 days for varenicline starter/tartrate
inv-136: BRIVIACT SOLUTION/TABLET — QL noted (chunk references)
BRIVIACT (solution/tablet)Formulary lists BRIVIACT solution and tablet entries; QL values shown on product rows in the formulary (see corresponding table rows)
Management flagSome anticonvulsant specialty products carry PA NSO or other management flags in the table
inv-138: gabapentin capsule 400mg — QL 270
Gabapentin capsule 400mgQL(270 EA per 30 days)
Capsule strengths noteOther gabapentin strengths have different QLs (e.g., 100mg/300mg shown separately)
inv-139: gabapentin 100mg/300mg — QL 360
Gabapentin 100mg / 300mg capsulesQL(360 EA per 30 days)
Formulation-specific QLLower-strength capsules have higher numeric QL in table entries
inv-140: pregabalin capsules — QL 90
Pregabalin capsules (various strengths)QL(90 EA per 30 days)
Pregabalin solutionQL(900 ML per 30 days) for solution formulation
inv-141: pregabalin solution — QL 900
Pregabalin solutionQL(900 ML per 30 days)
Formulation noteSolution formulation has ML-based QL separate from capsule EA limits
inv-142: FETZIMA TITRATION PACK — QL 56
FETZIMA titration packQL(56 EA per 365 days)
Step therapy flagListed with ST NSO in the table for titration pack
inv-143: terbinafine tablet — QL 84
Terbinafine HCl tabletQL(84 EA per 180 days)
Dosing intervalQL provided over 180-day interval for terbinafine tablets
inv-144: clotrimazole cream — QL(90 GM per 30 days)
Clotrimazole creamQL(90 GM per 30 days)
Topical QL formatTopical products commonly list grams (GM) per 30 days in QL entries
inv-146: AIMOVIG injection — QL(1 ML per 28 days)
AIMOVIG injection 140mg/mlQL(1 ML per 28 days)
Alternate strengthAIMOVIG 70mg/ml listed with QL(2 ML per 28 days) for that strength
inv-147: EMGALITY injection — QL(2 ML per 28 days)
EMGALITY injection 120mg/mlQL(2 ML per 28 days)
Other strengthsEMGALITY 100mg/ml listed with QL(3 ML per 28 days)
inv-148: ALUNBRIG tablet 30mg — QL(120 EA per 30 days)
ALUNBRIG tablet 30mgQL(120 EA per 30 days)
PA NSOALUNBRIG entries also marked PA NSO in table
inv-149: RETEVMO tablet 40mg — QL(90 EA per 30 days)
RETEVMO tablet 40mgQL(90 EA per 30 days)
PA NSO flagRETEVMO entries include PA NSO in the formulary rows
inv-150: TAGRISSO tablet 40mg — QL(30 EA per 30 days)
TAGRISSO tablet 40mgQL(30 EA per 30 days)
PA NSOTAGRISSO entries are marked PA NSO in the table
inv-151: VENCLEXTA tablet 10mg — PA noted; tier 4
VENCLEXTA tablet 10mgPA noted; listed on Tier 4 (PA requirement) — see Requirements/Limits
Coverage actionPrior authorization is required for VENCLEXTA starting pack and some tablet strengths
inv-152: aripiprazole ODT 15/10mg — QL(60 EA per 30 days)
Aripiprazole ODT 15mg/10mgQL(60 EA per 30 days)
Psychotropic QLsODT and tablet forms commonly have 30-day EA limits listed
inv-153: clozapine ODT 100mg/25mg — QL(270 EA per 30 days)
Clozapine ODT 100mg/25mgQL(270 EA per 30 days)
Formulation-specificClozapine strengths/formulations carry distinct QLs in the table
inv-154: MAVYRET tablet — QL(336 EA per 365 days)
MAVYRET tabletQL(336 EA per 365 days)
Hepatitis C therapy packAnnual QL shown (336 EA per 365 days) consistent with course-based therapy
inv-155: BARACLUDE solution — QL(600 ML per 30 days)
BARACLUDE solutionQL(600 ML per 30 days)
Antiviral liquid formulationSolution QL expressed in mL per 30 days
inv-156: COMPLERA — QL 30
COMPLERAQL(30 EA per 30 days)
DELSTRIGO / EDURANTDELSTRIGO QL(30 EA per 30 days); EDURANT QL(30 EA per 30 days); EDURANT PED QL(180 EA per 30 days)
inv-157: DELSTRIGO — QL 30
DELSTRIGOQL(30 EA per 30 days)
EDURANT PEDQL(180 EA per 30 days) for pediatric formulation
inv-158: EDURANT — QL 30
EDURANT (adult)QL(30 EA per 30 days)
EDURANT PEDQL(180 EA per 30 days) for pediatric strength
inv-159: EDURANT PED — QL 180
Edurant pediatricQL(180 EA per 30 days)
Separate pediatric QLPediatric formulations have distinct monthly QLs
inv-160: etravirine 100mg — QL 60
Etravirine 100mgQL(60 EA per 30 days)
Other strengths200mg strength also listed with QL(60 EA per 30 days)
inv-161: INTELENCE 25mg — QL 120
INTELENCE 25mgQL(120 EA per 30 days)
Antiretroviral QLHigher EA limits shown for some HIV agents (INTELENCE example)
Additional Product-Specific Quantity Limits (continued)
inv-162: nevirapine er 400mg — QL 30
Nevirapine ER 400mgQL(30 EA per 30 days)
Nevirapine ER 100mgQL(60 EA per 30 days) — lower strength has higher numeric QL
inv-163: nevirapine er 100mg — QL 60
Nevirapine ER 100mgQL(60 EA per 30 days)
Formulation noteExtended-release tablet strengths have separate QLs listed
inv-164: nevirapine suspension — QL 1200
Nevirapine suspensionQL(1200 ML per 30 days)
Liquid antiviral QLLarge-volume ML QL shown for suspension formulations
inv-165: abacavir tablet — QL 60
Abacavir tabletQL(60 EA per 30 days)
Abacavir-containing combosAbacavir combination products listed with varying QLs (30–60 EA per 30 days)
inv-166: EMTRIVA solution — QL 850
EMTRIVA solutionQL(850 ML per 30 days) (also appears as 960 mL in other rows)
Liquid antiretroviral QLEMTRIVA solution listed with a high mL-per-month QL
inv-167: TRIZIVIR — QL 60
TRIZIVIRQL(60 EA per 30 days)
Combination NRTI QLStandard 30–60 EA per 30 days limits used for many combination HIV tablets
inv-168: VIREAD powder — QL 240
VIREAD powderQL(240 GM per 30 days)
VIREAD tabletsVIREAD tablets (150/200/250mg) QL(30 EA per 30 days)
inv-169: VIREAD tablet (various strengths) — QL 30
VIREAD tablets (various strengths)QL(30 EA per 30 days)
Strength noteListed QL applies across multiple tablet strengths per table rows
inv-170: acyclovir capsule 200mg — QL (chunk referenced)
Acyclovir capsule 200mgQL shown in antiviral sections (see acyclovir entries) — formulary lists capsule entry (QL referenced in table)
ValacyclovirQL(120 EA per 30 days)
inv-171: valacyclovir hydrochloride — QL 120
Valacyclovir HClQL(120 EA per 30 days)
Antiviral QLCommon 30-day EA limits used for oral antiherpetic agents
inv-172: PAXLOVID therapy pack — QL 11
PAXLOVID therapy pack (standard)QL(11 EA per 5 days); PA
Alternative pack sizesAlternative PAXLOVID pack entries show QL(20 EA per 5 days) and QL(30 EA per 5 days)
inv-173: PAXLOVID alternative pack — QL 20
PAXLOVID alternative pack (20)QL(20 EA per 5 days)
PA annotationPAXLOVID entries include .PA in Requirements/Limits indicating PA requirement
inv-174: PAXLOVID alternative pack — QL 30
PAXLOVID alternative pack (30)QL(30 EA per 5 days)
Therapy-pack formatPack QLs are expressed per 5-day therapy course in the formulary
inv-175: alprazolam 0.25-1mg — QL 120
Alprazolam 0.25–1mgQL(120 EA per 30 days)
Alprazolam 2mgQL(150 EA per 30 days)
PA flagMany benzodiazepine entries include PA with associated QLs
inv-176: alprazolam 2mg — QL 150
Alprazolam 2mgQL(150 EA per 30 days)
Higher-strength limit2mg tablet has a higher monthly EA QL than lower strengths
inv-177: BYDUREON BCISE — QL 3.4
BYDUREON BCISEQL(3.4 ML per 28 days)
Injectable diabetic agentQL expressed in mL per 28 days for injectables
inv-178: BYETTA 10MCG — QL 2.4
BYETTA 10mcgQL(2.4 ML per 28 days)
BYETTA 5mcgQL(4.8 ML per 28 days)
inv-179: BYETTA 5MCG — QL 4.8
BYETTA 5mcgQL(4.8 ML per 28 days)
PA notedEntries indicate PA alongside QL for these injectable agents
inv-180: EMTRIVA SOLUTION — QL 960
EMTRIVA solution (alternate row)QL(960 ML per 30 days) appears in other table rows; EMTRIVA also listed as 850 mL in adjacent entries
Document varianceSome solution QLs appear with slightly different numeric values across sections (850 vs 960 mL) — see product rows
inv-181: MOUNJARO — QL 2
MOUNJARO (GLP-1)QL(2 ML per 28 days)
Injectable GLP-1 examplesOZEMPIC, MOUNJARO and TRULICITY entries show mL-based QLs per 28 days
inv-182: OZEMPIC 2MG/1.5ML — QL 1.5
OZEMPIC 2mg/1.5mlQL(1.5 ML per 28 days)
Other OZEMPIC strengthsOther OZEMPIC strengths listed with QL(3 ML per 28 days)
inv-183: OZEMPIC other strengths — QL 3
OZEMPIC other strengthsQL(3 ML per 28 days)
Strength-differentiated QLDifferent presentations of same product have distinct mL QLs
inv-184: RYBELSUS 14/4/7/9mg — QL 30
RYBELSUS (14/4/7/9mg)QL(30 EA per 30 days)
RYBELSUS (1.5/3mg)QL(60 EA per 365 days)
inv-185: RYBELSUS 1.5/3mg — QL 60
RYBELSUS 1.5/3mgQL(60 EA per 365 days)
Lower-dose annual QL1.5/3mg strengths expressed with annual QL in formulary
Remaining Quantity Limit Entries
inv-186: TRULICITY — QL 2
TRULICITYQL(2 ML per 28 days)
Injectable GLP-1 noteTRULICITY listed with 2 mL per 28 days QL and PA annotation
inv-187: ELIQUIS starter pack — QL 148 EA
ELIQUIS starter packQL(148 EA per 365 days)
ELIQUIS sprinkle / soluble examplesELIQUIS capsule sprinkle QL(84 EA per 28 days); soluble 0.5mg QL examples include 140/420/560 EA per 28/365 days
inv-188: ELIQUIS capsule sprinkle — QL 84 EA
ELIQUIS capsule sprinkleQL(84 EA per 28 days)
Soluble tablet QLsSoluble 0.5mg shown with multiple QL examples (140/420/560 EA) in table rows
inv-189: ELIQUIS soluble 0.5mg — QL examples (140/420/560 EA)
ELIQUIS soluble 0.5mgExamples include QL(140 EA per 28 days), QL(420 EA per 28 days), QL(560 EA per 28 days)
Multiple QLsTable displays alternative QL examples for soluble formulation
inv-190: XARELTO starter pack — QL 102 EA
XARELTO starter packQL(102 EA per 365 days)
XARELTO tablet QLsXARELTO 10/20mg QL(30 EA per 30 days); 15mg QL(60 EA per 30 days)
inv-191: ENTRESTO capsule sprinkle — QL 240 EA
ENTRESTO capsule sprinkleQL(240 EA per 30 days)
Sacubitril/valsartanAlso listed with QL(60 EA per 30 days) for certain strengths
inv-192: sacubitril/valsartan — QL 60 EA
Sacubitril/valsartanQL(60 EA per 30 days)
Cardiovascular QL examplesMultiple CV agents show 30-day EA limits in the formulary rows
inv-193: XOLREMDI — QL 120 EA
XOLREMDIQL(120 EA per 30 days)
Hematology agent noteListed with PA in many specialty sections; QL shown per 30 days
inv-194: NEXLETOL — QL 30
NEXLETOLQL(30 EA per 30 days)
NEXLIZETQL(30 EA per 30 days)
inv-195: NEXLIZET — QL 30
NEXLIZETQL(30 EA per 30 days)
PABoth NEXLETOL and NEXLIZET rows include PA in Requirements/Limits
inv-196: PRALUENT — QL 2
PRALUENTQL(2 ML per 28 days)
PAPRALUENT entries include PA alongside QL
inv-197: REPATHA — QL 3
REPATHAQL(3 ML per 28 days)
REPATHA PUSHTRONEXQL(7 ML per 28 days)
inv-198: REPATHA PUSHTRONEX — QL 7
REPATHA PUSHTRONEX systemQL(7 ML per 28 days)
Administered device QLPushtroNex system has a distinct QL compared with other presentations
Remaining Quantity Limit Entries (continued)
Final Quantity Limit Entries
Billing and Site-of-Care Notes
Note
Biosimilar and Interchangeable Biosimilar Policy
Note
Formulary Definitions and Abbreviations
inv-75: Formulary / Drug List definition
Cablivi (summary)30 tablets per 30 days (illustrative QL in formulary overview)
ReferenceOverview mentions Cablivi as an example of a 30-tablet-per-month QL
inv-76: Biosimilar / Interchangeable biosimilar definition
Biosimilar definitionBiosimilars are alternatives to original biological products; interchangeable biosimilars may be substituted per state law
Substitution ruleInterchangeable biosimilars may be substituted without a new prescription depending on state law
inv-77: PA definition — Prior Authorization
PA (Prior Authorization)PA = Prior Authorization: payer approval required before coverage; absence of PA may result in non-coverage
Where usedDrugs listed with 'PA' or '.PA' in Requirements/Limits require prior authorization per formulary rows
inv-78: QL definition — Quantity Limits
QL (Quantity Limits)QL = Quantity Limits; specifies the maximum allowed quantity within a stated time period (format: QL(## <unit> per ## days))
Example formatsEA per 30 days, ML per 30 days, GM per 30 days, EA per 365 days are all used in table examples
inv-79: NDS definition — Non-Extended Day Supply
NDS definitionNDS = Non-Extended Day Supply — item is not available for extended days' supply
Use in tableNDS appears next to certain opioid products indicating dispensing restriction
inv-80: ST / ST NSO definitions
ST / ST NSOST = Step Therapy; ST NSO = Step Therapy for New Starts Only
ApplicationApply where Drug List denotes ST or ST NSO in Requirements/Limits
inv-81: PA NSO definition
PA NSOPA NSO = Prior Authorization with non-standard office or specialty handling designation (see formulary introduction for full definition)
ImplicationPA NSO flags indicate specialized prior authorization workflows for some specialty agents
inv-82: QL exact format
QL exact formatQL entries give exact allowed quantity and time period (e.g., QL(10 EA per 30 days))
Units usedEA (each), ML (milliliters), GM (grams) are common units in QL entries
inv-83: PA NSO table flag — reference to intro pages
Intro/table flags referenceThe formulary introduction pages define symbols and abbreviations (PA, QL, ST, NSO, B/D) used in Requirements/Limits
Provider actionProviders should consult the introduction pages for exact documentation/submission requirements when flags appear
inv-84: QL format examples
QL example formatsCommon example formats include QL(## EA per 30 days) and QL(## EA per 365 days) and ML/GM per 30 days (e.g., QL(270 ML per 30 days))
Topical exampleTopicals often show GM per 30 days (e.g., QL(120 GM per 30 days))
inv-85: QL explanatory note
Explanatory note on QLQuantity limits listed per drug must be followed at dispensing; exceeding a QL may require prior authorization or an exception request
EnforcementFormulary indicates QL enforcement and that providers should align dispense quantity and days' supply with QL entries
inv-86: .PA annotation definition
.PA annotation'.PA' in the Requirements/Limits field indicates prior authorization is required for that product entry
ExamplePAXLOVID entries include .PA and QL values in the formulary rows
inv-87: Tier definition
Tier definitionTier = formulary tier level indicating member cost-sharing or coverage category
Use in tableEach drug row lists a Tier value alongside Requirements/Limits (PA/QL) in the formulary
inv-88: Quantity Limit brief definition
Quantity Limit (brief)QL = maximum units allowed in the specified time frame as listed in the table
Documentation requirementProviders must ensure dispensed quantity matches QL or obtain PA/exception if exceeding QL
inv-89: Prior Authorization brief definition
Prior Authorization (brief)PA = Prior Authorization; coverage requires payer pre-approval per formulary row
ImpactLack of PA may result in claims denial as noted in denial-risk sections
inv-90: QL definition with example formats
QL — time period examplesQL commonly expressed per 30 days, 28 days, 365 days, or other interval depending on product (e.g., QL(120 GM per 30 days))
Topical and solution unitsTopicals use GM per 30 days; solutions use ML per 30 days in QL entries
inv-91: PA definition (repeated)
PA (short)PA indicates prior authorization required before coverage
Where seenPA flags appear across many specialty and high-cost drug entries
inv-92: QL example (120 GM per 30 days)
QL topical exampleQL(120 GM per 30 days) used for several topical creams (e.g., desonide, calcipotriene cream)
Dermatologic QLsMultiple dermatology products list grams per 30 days limits in the formulary
inv-93: PA definition (repeated)
PA (concise)Prior authorization required (plan approval before coverage)
ReferenceSee Requirements/Limits Key and product rows for PA indicators
inv-94: ST definition
ST (concise)ST = Step Therapy: prior trial of specified alternative(s) required before coverage of the requested drug
ST NSOST NSO indicates step therapy limited to new starts only
inv-95: prior authorization (short)
Prior authorization (short)PA — payer pre-approval required; may be annotated '.PA' in Requirements/Limits
ConsequenceClaims may be denied if PA is not obtained where indicated
inv-96: quantity limit (short)
Quantity limit (short)QL — maximum quantity allowed in the specified period (e.g., QL(30 EA per 30 days))
Dispensing implicationDispensed quantity should align with the QL to avoid denial or need for PA/exception
inv-97: QL — quantity limit definition
QL conciseQL entries specify numeric limits per time period using EA/ML/GM units
ExamplesForms include QL(60 EA per 30 days), QL(1 ML per 28 days), QL(336 EA per 365 days)
inv-98: PA / PA NSO definition
PA / PA NSOPA = Prior Authorization; PA NSO = Prior Authorization with non-standard office designation — both require authorization before coverage
Specialty examplesMany biologic and specialty products are marked PA or PA NSO in the Requirements/Limits column
inv-99: QL exact format
QL (format)QL(## EA per ## days) is the standard format shown in the document's Requirements/Limits column
Provider noteIntroduction pages define these formats and abbreviations used throughout the table
inv-100: PA (definition short)
PA (short) — definitionPrior Authorization: approval required before the product will be covered
Reference actionWhen PA appears in Requirements/Limits, providers must follow payer PA procedures
inv-101: Tier definition
Tier (definition)Tier = formulary cost-sharing category assigned to each drug row
UseTier appears alongside QL/PA flags and affects member cost-sharing
inv-102: Quantity Limit format QL(## per ## days)
Quantity Limit format (examples)QL(## EA per ## days) or QL(## ML per ## days) — used consistently across formulary product rows
Unit examplesEA, ML, GM commonly used units in QL expressions
inv-103: Prior Authorization (short)
Prior Authorization (short) — reminderPA = prior authorization required before coverage (see product row for .PA or PA flags)
Provider actionObtain PA per payer procedures when PA is listed
inv-104: Quantity Limit (QL) examples
Quantity Limit examples summaryExamples include QL(30 EA per 30 days), QL(60 EA per 30 days), QL(270 ML per 30 days), QL(540 ML per 30 days)
ApplicabilityThese QL examples appear across respiratory, sleep, and other therapeutic classes in the formulary
inv-105: Prior Authorization (PA) — final definition
PA final notePA indicates payer pre-approval required; see Requirements/Limits for '.PA' or PA annotations
ConsequenceFailure to obtain PA may lead to denial or non-coverage
Background and Scope
The formulary is a list of covered prescription drugs selected by BlueCross Total in consultation with providers to represent clinically appropriate therapies. Coverage generally requires that a drug be listed on the formulary, be medically necessary, and be dispensed at a BlueCross Total network pharmacy, subject to administrative rules such as Prior Authorization (PA), Step Therapy (ST), and Quantity Limits (QL). When a biosimilar is added to the formulary the plan may add the biosimilar and change coverage or tiering of the original biological product; interchangeable biosimilars may be substituted per applicable state law and the formulary introduction guidance.
Policy Summary
PayerBlue Cross Blue Shield - South Carolina
PolicyBlueCross Total 2025 Formulary (Drug List) — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date10/01/2025
Last ReviewOct 1, 2025
Next Review DateN/A
Key ActionObtain prior authorization when 'PA' is indicated on the Drug List before prescribing to ensure coverage.
SourceLink
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