BlueCross Total Medicare Part D Formulary — Coverage Criteria
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This document is the BlueCross Total (BlueCross BlueShield of South Carolina) Medicare Part D formulary describing covered drugs, coverage rules, restrictions (prior authorization, step therapy, quantity limits), and how members can request exceptions. It affects plan members, prescribers, and network pharmacies using BlueCross Total prescription drug benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria & Rules
General coverage conditions
Covered when ALL of the following general conditions are met
See formulary chart for drug-specific requirements (prior authorization, quantity limits, step therapy).
Temporary transition coverage
Covered temporarily under limited circumstances
Outpatient discharge supplies may be provided to prevent a gap in care; refill rules apply to limit the temporary supply to a maximum 30 days for new members.
Coverage flags and administrative requirements
Products listed are assigned drug tiers and may have one or more of the following requirements/limits:
This excerpt does not provide the clinical entry criteria to meet PA or NDS; refer to the formulary introduction or specific PA policies for required documentation and clinical criteria.
Coverage indicators (Tier / PA / QL)
Drugs are listed with Tier and any Requirements/Limits; PA and QL annotations indicate additional authorization or quantity controls.
This segment does not include clinical entry criteria beyond PA/QL annotations.
If a medication is not listed on the BlueCross Total formulary, coverage will not be provided unless an exception is approved. Members or prescribers should first contact Customer Service to confirm whether an alternative covered drug exists. If a covered therapeutic alternative is available, prescribers are encouraged to consider switching to that product to obtain coverage under the plan. If no suitable alternative is acceptable, the prescriber or member may request a formulary exception for the non‑formulary drug; instructions for how to request an exception are provided in the formulary (see exception request guidance).
Provider Actions, Prior Authorization & Process
Prior authorization required for some drugs
Certain drugs listed on the formulary require prior authorization from BlueCross Total before the prescription is filled; check the Requirements/Limits column on the formulary for PA indicators to determine if authorization is required for a given product. Failure to obtain required prior authorization may result in non-coverage of the drug.
- PA indicator shown in Requirements/Limits column denotes prior authorization is required.
- Prescribers must submit PA per the plan's PA process before dispensing when 'PA' or 'PA NSO' is present.
Prior Authorization requirement
Prior authorization (PA) is required for drugs marked 'PA' in the Requirements/Limits Key and for individual drug entries that list PA; examples in the formulary include diclofenac sodium external solution 1.5% and other line items annotated 'PA'.
- Refer to the Requirements/Limits Key: 'PA = Prior Authorization'.
- Individual drug rows showing 'PA' (Requirements/Limits) require prescriber submission of PA.
Prior authorization required for some listed products
Some specific products in the extract display PA in their Requirements/Limits column (for example, fentanyl oral transmucosal lozenges and ARIKAYCE); providers must obtain PA prior to dispensing those products.
- Fentanyl oral transmucosal lozenge entries show 'Requirements/Limits = PA; NDS'.
- ARIKAYCE SUSPENSION 590MG/8.4ML is listed with 'Requirements/Limits = PA'.
Prior authorization required for flagged products
Certain specialty or brand products are flagged 'PA NSO' in the formulary; when 'PA NSO' appears next to a product, prior authorization must be obtained before coverage will be approved.
- 'PA NSO' entries (e.g., BRIVIACT formulations, EPIDIOLEX, SPRAVATO) indicate prior authorization is required.
- Providers must follow the plan's PA process for PA NSO products before dispensing.
Prior authorization required for specified drugs
Multiple listed products are designated 'PA' or 'PA NSO' in their Requirements/Limits field, indicating prior authorization must be obtained before coverage is approved for those specific drugs.
- Examples include SPRAVATO therapy packs and numerous specialty agents annotated with PA NSO or PA.
- Check each product row for the 'PA' or 'PA NSO' annotation to determine PA requirement.
Prior authorization (PA NSO) required for many listed drugs
Many specialty and oncology drugs in this formulary excerpt are marked 'PA NSO', meaning prior authorization (with NSO modifier) is required and providers must obtain authorization per the plan's PA process.
- Examples: POMALYST, THALOMID, INLURIYO, and other oncology agents are listed with 'PA NSO'.
- PA NSO entries require prescriber submission of prior authorization prior to dispensation.
Prior authorization required for many Tier 5 drugs
Numerous Tier 5 and other high-cost drugs are annotated with 'PA' or 'PA NSO' in the Requirements/Limits column; providers must obtain PA before dispensing when indicated to avoid denial.
- Many Tier 5 entries (e.g., oncology and specialty agents) show PA NSO or PA in their rows.
- Prescribers should submit PA documentation per plan requirements for Tier 5 drugs when PA is indicated.
Prior authorization required for specified products
Certain high-tier or specialty products are specifically designated 'PA' in the Requirements/Limits column (examples include MAVYRET, sofosbuvir/velpatasvir, VOSEVI, MOUNJARO, OZEMPIC); obtain PA before coverage is approved for those products.
- MAVYRET and sofosbuvir/velpatasvir entries show QL and PA annotations.
- MOUNJARO and OZEMPIC rows include QL and PA indicators — submit PA per formulary guidance.
PA required for annotated products
Drugs annotated 'PA' in the Requirements/Limits column require prior authorization; review the product row annotations and submit PA per the plan's process for any 'PA' entries.
- Examples in this segment: MOUNJARO, OZEMPIC, TRULICITY, RYBELSUS are annotated with PA.
- PA annotation in the product row is actionable—providers must request authorization before dispensing.
Prior authorization / quantity limits required
Selected branded and specialty products require prior authorization and/or have quantity limits as annotated in the Requirements/Limits column; providers must both obtain PA where shown and ensure dispensed quantities do not exceed listed QLs.
- Examples: metyrosine capsule 250mg (PA); ENTRESTO CAPSULE SPRINKLE QL(240 EA per 30 days); PRALUENT QL(2 ML per 28 days) with PA.
- Claims exceeding QL may require PA or be denied—confirm QL on the product row before adjudication.
Prior Authorization required for listed PA drugs
Several specialty and high-cost products listed with 'PA' require prior authorization; check each product row for PA indications and submit required documentation before dispensing to avoid claim denial.
- REPATHA and PRALUENT entries include QL and PA annotations.
- SPEVIGO and other specialty injectables show both QL and PA requirements.
PA for specialty agents
Multiple specialty agents used in conditions like multiple sclerosis and dermatology are listed with PA indicators (e.g., AVONEX, BETASERON, glatiramer acetate, KESIMPTA, VUMERITY); prescribers must request PA per the formulary row when PA is present.
- Glatiramer acetate injections and KESIMPTA include QL and PA in their rows.
- Submit PA according to the plan's PA process for these specialty agents before dispensing.
Prior authorization required for specific drugs
Some specific high-tier products (for example SPEVIGO INJECTION) list 'PA' in their Requirements/Limits and will require prior authorization documentation to be submitted before coverage is approved.
- SPEVIGO INJECTION 150MG/ML, 300MG/2ML shows QL(4 ML per 28 days); PA.
- OTEZLA, JYNARQUE, LIVMARLI and other high-tier products are annotated with PA—submit supporting documentation with PA request.
Prior authorization required where 'PA' indicated
When a product row lists 'PA' next to Requirements/Limits (e.g., LIVMARLI formulations), prior authorization is required for coverage; providers must submit PA per the plan's process prior to dispensing.
- LIVMARLI solutions and tablets include QL and PA annotations (e.g., QL(60 ML per 30 days); PA).
- Check product row annotations for PA and corresponding QL before submitting claims.
Prior authorization required for selected injectable/specialty agents
Several injectable hormonal agents and other specialty injectables are marked with PA or PA NSO and/or quantity limits (e.g., FIRMAGON, LUPRON DEPOT, ORGOVYX, SIGNIFOR); obtain PA according to the Requirements/Limits annotation before dispensing.
- FIRMAGON Injection entries include QL and PA NSO annotations.
- LUPRON DEPOT entries show QL and PA NSO across multiple dose intervals—submit PA for these injectable products as indicated.
Prior authorization required for many products
Numerous products across the formulary require prior authorization as indicated next to product rows; prescribers must obtain PA prior to dispensing to avoid claim denial for those items.
- Multiple entries across the formulary include PA or PA NSO markers—review each product row for PA requirements.
- PA must be obtained according to the plan's PA process before dispensing PA-marked drugs.
Step therapy requirements
Step therapy may require that prescribers document and demonstrate prior use of specified first-line drugs before the plan will cover alternative agents; check product rows and the Requirements/Limits Key for ST or ST NSO indicators.
- ST and ST NSO symbols in the Requirements/Limits Key denote step therapy requirements.
- If a drug is marked with ST or ST NSO, prior therapeutic steps must be documented to support coverage.
Step therapy indicators
Step therapy abbreviations (e.g., ST NSO) appear in the Requirements/Limits Key and product rows; ST NSO indicates 'Step Therapy for New Starts Only' and may limit PA applicability to new starts.
- Reference the Dosage/Requirements Abbreviation Key for the meaning of ST NSO and related symbols.
- Providers should consult the introduction pages for exact interpretation of ST and ST NSO indicators.
Step therapy not specified in this excerpt
This extract does not provide explicit step-therapy sequences or detailed fail-first rules for most products; where step therapy is applicable the product row will show ST or ST NSO and providers should consult the formulary introduction or related PA/ST policy pages for the required sequence.
- No explicit step sequences are listed in these chunks for most products.
- Consult the formulary introduction or the plan's PA/step therapy policies for specific step requirements.
Step therapy examples
Examples in the formulary show 'ST NSO' markers on certain products (e.g., ZONISADE suspension, AUVELITY, EXXUA, FETZIMA) indicating step therapy applies for new starts; providers must document prior steps per the Requirements/Limits annotation when submitting for coverage.
- ZONISADE SUSPENSION 100MG/5ML is listed with 'ST NSO'.
- FETZIMA entries include ST NSO and QL annotations—follow Requirements/Limits when requesting coverage.
Step therapy indicated for some products
Some products are marked 'ST' or 'ST NSO' (for example FETZIMA and diclofenac sodium gel 3%), indicating step therapy requirements exist; providers must document prior steps when requesting coverage under these markers.
- diclofenac sodium gel 3% is annotated 'ST' in the product row.
- For products with 'ST' or 'ST NSO' the plan expects documentation of prior therapy per the formulary rules.
Product-specific labeling restrictions
Certain product-specific labeling restrictions and starter-pack limits are called out (for example, Boehringer Ingelheim labeled ADALIMUMAB-ADBM starter packages), which may impose PA and QL conditions; providers should follow the formulary's Requirements/Limits and labeled-product notes when submitting authorization requests.
- ADALIMUMAB-ADBM starter packages include QL and PA with 'Boehringer Ingelheim labeled products only' notation.
- Product-specific labeling or starter-pack restrictions must be observed when requesting PA or processing claims.
Prescriber's supporting statement and decision timelines
When requesting an exception, the prescriber must provide a supporting statement explaining medical necessity; the plan generally must decide within 72 hours of receiving the prescriber's statement (24 hours for expedited requests).
- Standard decision timeline: 72 hours after receipt of prescriber's supporting statement.
- Expedited decision timeline (when agreed): 24 hours after receipt of prescriber's supporting statement.
Site-specific coverage documentation (LTC/mail order guidance)
For Long-Term Care (LTC) and mail-order claims, site-specific supply and copay/coinsurance rules apply (e.g., LTC = 31-day supply); providers should use the formulary's site-of-care guidance for correct benefit application.
- Long-Term Care (LTC) supply is defined as a 31-day supply in the formulary.
- Mail order and LTC copay/coinsurance differ from retail—use site-of-care rules when adjudicating claims.
Formulary reference (ID/version)
Reference the formulary identifier and version (Formulary ID: 26216, Version: 10, Effective Date: 03/01/2026; Last Updated: 02/02/2026) when submitting or verifying authorizations and coverage determinations.
- Formulary ID: 26216, Version: 10; Effective Date: 03/01/2026; Last Updated: 02/02/2026.
- Include this formulary/version information as needed when filing authorizations or appeals.
Quantity limit examples
Quantity limits (QL) shown on product rows must be observed; examples in the formulary include NAYZILAM QL(10 EA per 30 days) and memantine/donepezil QL(30 EA per 30 days).
- Check the product row for QL(...) notation and ensure dispensed quantity does not exceed the listed limit without prior authorization.
- Exceeding QL may require PA or may be denied at claim adjudication.
Reference to introduction pages for symbols/abbreviations
The formulary introduction pages define the symbols and abbreviations used in product rows (e.g., PA, QL, ST, NDS, PA NSO); providers should consult those introduction pages for precise meanings and documentation expectations.
- Introduction explains Requirements/Limits Key and dosage/abbreviation symbols.
- Interpretation of ST NSO, PA NSO and other markers requires reference to the introduction.
PA NSO requires prior authorization (documentation specifics not included)
When a drug line lists 'PA NSO' the plan requires prior authorization (PA NSO = Prior Authorization — Non-State Only); this excerpt does not include the specific documentation elements required for PA NSO requests, so providers must follow the plan's PA submission guidance.
- 'PA NSO' entries indicate PA is required (examples: POMALYST, BRIVIACT, EPIDIOLEX).
- Specific documentation requirements for PA NSO are not detailed in this extract—refer to the plan's PA instructions.
PA submission (providers must submit per PA process)
Prescribers must submit prior authorization requests for drugs marked 'PA' and support those requests consistent with the plan's PA process and the introduction pages referenced in the formulary.
- Submit PA according to the plan's PA process when 'PA' is indicated on the product row.
- Include clinical justification and any requested supporting documents per PA instructions.
Failure to obtain required prior authorization may result in non-coverage
Failure to obtain required prior authorization may result in the plan not covering the drug; providers should obtain PA before dispensing PA-marked drugs to avoid claim denials.
- If prior authorization is required but not obtained, the plan may deny coverage for the drug.
- Confirm PA status on the product row and obtain authorization prior to dispensing when indicated.
Prior authorization triggers
Prior authorization is triggered by PA markers in the Requirements/Limits Key and by PA annotations in individual drug entries (e.g., diclofenac sodium external solution 1.5% is listed with 'PA'); providers should check these markers to identify PA triggers.
- 'PA' in the Requirements/Limits Key signals a PA trigger.
- Individual product rows annotated with 'PA' or 'PA NSO' trigger PA submission requirements.
PA/NDS required for some opioid products
Some opioid products (e.g., fentanyl transmucosal lozenges) include PA and NDS annotations ('PA; NDS'); claims for these items may require PA or special handling and could be denied without required authorizations.
- Fentanyl citrate oral transmucosal lozenge entries show 'PA; NDS'.
- Claims for opioid products annotated with PA/NDS may be denied or require PA/override handling if authorization is not obtained.
PA for ARIKAYCE
ARIKAYCE SUSPENSION 590MG/8.4ML is listed with 'Requirements/Limits = PA' and may be denied without PA documentation; obtain and submit prior authorization before dispensing ARIKAYCE.
- ARIKAYCE row explicitly indicates 'PA' in Requirements/Limits.
- PA documentation must be submitted prior to dispensing to avoid denial.
Prior authorization risk examples
Products labeled 'PA NSO' (examples: BRIVIACT formulations, EPIDIOLEX, DIACOMIT, vigabatrin products, XCOPRI packs) indicate prior authorization is required and may lead to denial if PA is not obtained.
- BRIVIACT and EPIDIOLEX entries are annotated 'PA NSO'.
- XCOPRI therapy packs are listed with 'PA NSO'—submit PA accordingly.
Prior authorization required for PA/PA NSO entries
Claims for drugs listed with 'PA' or 'PA NSO' will require prior authorization; lack of authorization may trigger claim denial—providers must obtain PA before dispensing when these annotations are present.
- PA/PA NSO in product rows indicates authorization requirement.
- Confirm PA status and secure authorization to prevent claim denials.
Quantity limit exceedance may result in denial or need for PA
Exceeding a product's specified quantity limit (QL) may result in claim denial or require prior authorization; providers should verify QL values on the product row before dispensing larger quantities.
- PAXLOVID QL is specified per 5-day therapy packs—exceeding listed QL could trigger denial or review.
- Many products list explicit QL(...) values—ensure dispensed quantities comply or obtain PA to exceed limits.
Prior authorization required where PA NSO indicated
Where product rows list 'PA NSO', prior authorization is required and claims may be denied or require special handling if PA NSO is not obtained (examples across oncology and specialty drug listings).
- PA NSO entries (e.g., many oncology agents) require PA prior to dispensing.
- Providers should follow PA submission instructions for PA NSO products to avoid denial.
Claims or dispensings for listed drugs may be denied if PA/NSO conditions are not met
Claims or dispensings for listed drugs may be denied if prior authorization (PA) requirements or non-standard override (NSO) conditions are not met; providers must confirm PA/NSO annotations and obtain approvals as required.
- Many Tier 5 drugs list PA NSO and will require PA/NSO handling before coverage.
- Failure to meet PA/NSO conditions may lead to claim denial at adjudication.
Prior authorization noted in table (examples MAVYRET, VOSEVI)
The formulary table includes numerous examples where PA is noted inline for specific products (for instance MAVYRET and VOSEVI show QL and PA); providers must consult those rows and obtain PA when shown.
- MAVYRET PACKET: QL(560 EA per 365 days); PA.
- sofosbuvir/velpatasvir and VOSEVI entries include QL and PA annotations—submit PA as required.
Quantity-limit enforcement (PAXLOVID example)
Quantity-limit enforcement is applied to certain products (PAXLOVID therapy packs include multiple QL variants per 5-day course); dispensing beyond the listed QL may trigger denial or require prior authorization.
- PAXLOVID entries show QL(11-30 EA per 5 days) depending on pack size—adhere to the listed QL.
- If a requested dispensing exceeds QL, obtain PA or expect claim review/denial.
Prior authorization required for marked products (GLP‑1 examples)
Coverage may be denied without prior authorization for products marked 'PA' such as MOUNJARO, OZEMPIC, TRULICITY, RYBELSUS and other GLP‑1 or injectable agents; obtain PA and adhere to the listed QLs prior to dispensing.
- MOUNJARO INJECTION 10MG/0.5ML = QL(2 ML per 28 days); PA.
- OZEMPIC INJECTION 2MG/3ML = QL(3 ML per 28 days); PA.
Quantity limits enforcement (GLP‑1 / tablet examples)
Exceeding quantity limits for products with QL annotations (for example QL(2 ML per 28 days) for MOUNJARO; QL(3 ML per 28 days) for OZEMPIC; QL(30 EA per 30 days) for certain tablets) may trigger claims denial or require prior authorization.
- Observe per-product QL entries when dispensing injectables and tablets.
- Requests above QL require PA or may be denied at claim adjudication.
Prior authorization triggers (selected cardiovascular and specialty agents)
Some drugs are listed with 'PA' in the Requirements/Limits column (e.g., metyrosine capsule 250mg; NEXLETOL/NEXLIZET; PRALUENT; REPATHA; VYNDAMAX; KERENDIA); these annotations trigger a PA requirement and possible denial if authorization is not obtained.
- metyrosine capsule 250mg = PA.
- NEXLETOL and NEXLIZET: QL(30 EA per 30 days); PA.
PA indicated for listed drugs (cardiology/lipid examples)
Coverage may be denied or subject to prior authorization for products listed with 'PA' such as NEXLETOL, NEXLIZET, PRALUENT, REPATHA products and VERQUVO; obtain PA and respect any stated quantity limits when submitting claims.
- PRALUENT injection lists QL(2 ML per 28 days); PA.
- REPATHA entries include QL and PA—submit PA with required documentation.
Authorization/denial triggers (PA/ST/QL)
Products listed with 'PA' or with utilization flags such as 'ST' or 'QL' may be denied if prior authorization, step-therapy criteria, or quantity limits are not met; providers must document compliance with the applicable Requirements/Limits to avoid denials.
- SPEVIGO INJECTION: QL(4 ML per 28 days); PA — authorization required.
- RELISTOR entries show QL and ST annotations—ensure step or PA criteria are met.
Prior authorization required for specified products (LIVMARLI example)
Claims for listed products may be denied without prior authorization where PA is indicated (examples include LIVMARLI solutions/tablets and other specialty agents); confirm PA requirements and obtain authorization before dispensing.
- LIVMARLI solutions and tablets list QL and PA annotations (e.g., QL(60 ML per 30 days); PA).
- Specialty agents with PA annotations require prior approval to be covered.
Products marked with PA/PA NSO and QL are at risk for denial without PA
Products marked with PA or PA NSO and specific QL entries are at risk for denial if prior authorization is not obtained or QL is exceeded; providers should verify both PA and QL annotations on the formulary rows before dispensing.
- Examples: OSPHENA QL(30 EA per 30 days); PA and FIRMAGON with QL and PA NSO.
- When both PA and QL are present, ensure authorization covers the requested quantity.
Prior authorization required (general)
Coverage requests for drugs listed with 'PA' (Prior Authorization) may be denied if prior authorization is not obtained as indicated in the formulary rows; prescribers must request PA per the plan's process to secure coverage.
- If a product row shows 'PA', submit PA prior to dispensing to avoid denial.
- Follow the plan's PA submission instructions and include required clinical documentation.
Drug Listings & Code Tables
| 200mcg | fentanyl citrate oral transmucosal lozenge on a handle 200mcg (Requirements/Limits = PA; NDS) |
| 400mcg | fentanyl citrate oral transmucosal lozenge on a handle 400mcg |
| 600mcg | fentanyl citrate oral transmucosal lozenge on a handle 600mcg |
| 800mcg | fentanyl citrate oral transmucosal lozenge on a handle 800mcg |
| 1200mcg | fentanyl citrate oral transmucosal lozenge on a handle 1200mcg |
| 1600mcg | fentanyl citrate oral transmucosal lozenge on a handle 1600mcg |
| ARIKAYCE SUSPENSION 590MG/8.4ML | ARIKAYCE SUSPENSION 590MG/8.4ML (Requirements/Limits = PA) |
| LINEZOLID SUSPENSION 100MG/5ML | linezolid suspension reconstituted 100mg/5ml (Requirements/Limits = QL(1800 ML per 28 days)) |
| LINEZOLID TABLET 600MG | linezolid tablet 600mg (Requirements/Limits = QL(56 EA per 28 days)) |
| VANCOMYCIN CAPSULE 125MG | vancomycin hydrochloride capsule 125mg (Requirements/Limits = QL(120 EA per 30 days)) |
| VANCOMYCIN CAPSULE 250MG | vancomycin hydrochloride capsule 250mg (Requirements/Limits = QL(240 EA per 30 days)) |
| Formulary ID: 26216 | Formulary identifier and version |
| POMALYST CAPSULE 3MG, 4MG | Tier = 5; Requirements/Limits = PA NSO |
| POMALYST CAPSULE 1MG, 2MG | Tier = 5; Requirements/Limits = QL(30 EA per 30 days); PA NSO |
| THALOMID CAPSULE 50MG,100MG,150MG,200MG | Tier = 5; Requirements/Limits = PA NSO |
| EMCYT CAPSULE 140MG | Tier = 5; Requirements/Limits = . |
| INLURIYO TABLET 200MG | Tier = 5; Requirements/Limits = PA NSO |
| PAXLOVID TABLET THERAPY PACK 150MG; 100MG | PAXLOVID tablet therapy pack (Requirements/Limits include QL variants per pack: QL(11 EA per 5 days); QL(20 EA per 5 days); QL(30 EA per 5 days)) |
| MOUNJARO INJECTION 10MG/0.5ML | MOUNJARO INJECTION 10MG/0.5ML (Requirements/Limits = QL(2 ML per 28 days); PA) |
| OZEMPIC INJECTION 2MG/3ML | OZEMPIC INJECTION 2MG/3ML (Requirements/Limits = QL(3 ML per 28 days); PA) |
| QL(30 EA per 30 days) | Quantity limit example for JANUVIA and RYBELSUS 14mg/7mg |
| QL(2 ML per 28 days) | Quantity limit example for MOUNJARO and TRULICITY |
| QL(3 ML per 28 days) | Quantity limit example for OZEMPIC |
| QL(60 EA per 365 days) | Quantity limit example for RYBELSUS 3mg |
| clobetasol propionate foam 0.05% | Drug Tier = 2 |
| clobetasol propionate gel 0.05% | Drug Tier = 3 |
| clobetasol propionate ointment 0.05% | Drug Tier = 2 |
| clobetasol propionate shampoo 0.05% | Drug Tier = 4 |
| desonide cream 0.05% | Drug Tier = 3 |
| desonide ointment 0.05% | Drug Tier = 2; QL(120 GM per 30 days) |
| desoximetasone cream 0.25% | Drug Tier = 3; QL(100 GM per 30 days) |
| EUCRISA OINTMENT 2% | Drug Tier = 4; PA |
| SPEVIGO INJECTION 150MG/ML, 300MG/2ML | Drug Tier = 5; QL(4 ML per 28 days); PA |
| triamcinolone acetonide cream 0.025%, 0.1%, 0.5% | Drug Tier = 1 |
| No codes listed |
Continuation & Transition Rules
Continuation Therapy
Continuation and transition rules
Immediate substitutions of new generics or biosimilars may occur; affected members may request exceptions. See formulary change notice requirements (30-day notice) and exception process.
Step Therapy Rules
| Coverage label | Description / rule |
|---|---|
| ST (Step therapy) | |
| Must try specified first-line drug(s) before coverage for second-line drug is authorized; if the first-line drug fails, the plan will then cover the alternate agent. |
| Coverage label | Description / rule |
|---|---|
| ST NSO | |
| ST NSO = Step Therapy for New Starts Only (indicator shown in Requirements/Limits Key on introduction pages) — step therapy applies only to new starts as defined by the formulary key. |
| Coverage label | Description / rule |
|---|---|
| No explicit sequences listed | |
| The extracted formulary rows in this excerpt show ST/ST NSO flags for certain drugs but do not provide explicit step-by-step (fail‑first) sequences or the clinical steps required to satisfy step therapy; providers must consult the introduction or related PA/step therapy policy for specific step details. |
| Product / marker | Formulary note |
|---|---|
| ZURZUVAE (capsules) - ST NSO | |
| SPRAVATO therapy packs - PA NSO and ST NSO flags shown (step therapy applies per Requirements/Limits Key) |
| Product | Requirements/Limits |
|---|---|
| FETZIMA TITRATION PACK | |
| Requirements/Limits include ST NSO for FETZIMA products (step therapy for new starts only) per the table entries. |
| Product | Notes |
|---|---|
| POMALYST capsules (1mg,2mg): QL(30 EA per 30 days); PA NSO | |
| MAVYRET / sofosbuvir-velpatasvir entries: QL and PA annotated; explicit step sequences not provided in this excerpt |
| Coverage label | Interpretation |
|---|---|
| ST or ST NSO markers present | |
| Some products are marked 'ST' or 'ST NSO' in the Requirements/Limits column indicating step therapy applies; specific step definitions and required prior steps are referenced on the document's introduction or separate step therapy policy pages. |
| Drug / class | Utilization management flags |
|---|---|
| MAVYRET, VOSEVI, sofosbuvir/velpatasvir (HCV agents) | |
| Designated with PA and QL annotations in the formulary (e.g., QL(336 EA per 365 days) for MAVYRET; QL(84 EA per 365 days) for sofosbuvir/velpatasvir) indicating utilization management controls. |
| Coverage label | What provider must do |
|---|---|
| PA (Prior Authorization) | |
| Prior authorization is required where 'PA' or 'PA NSO' is indicated next to a product; prescribers must obtain approval from BlueCross Total before dispensing to avoid claim denial. |
| Product group | Quantity / step notes |
|---|---|
| ADHD / stimulant products (various) - QLs present | |
| Multiple ADHD and stimulant formulations include quantity limits (examples: QL(60 EA per 30 days); QL(90 EA per 30 days); QL(120 EA per 30 days)); explicit step therapy requirements are not shown in this excerpt. |
| Product | Requirements/Limits |
|---|---|
| diclofenac sodium gel 3% | |
| Listed with Requirements/Limits = QL(300 GM per 30 days); ST — indicates step therapy applies to this topical diclofenac formulation. |
| Product / category | Management flags |
|---|---|
| LUPRON DEPOT; FIRMAGON; other specialty injectables | |
| Many specialty injectables include PA NSO and QL annotations (e.g., LUPRON DEPOT entries with QL and PA NSO; FIRMAGON QL and PA NSO) suggesting additional step/specialty criteria outside this extract. |
| Topic | Formulary note |
|---|---|
| Starter packs / labeled-product restrictions | |
| Some starter packages and product presentations are annotated with product-specific restrictions (e.g., Boehringer Ingelheim labeled products only for certain ADALIMUMAB-ADBM starter packages); see Requirements/Limits entries for details. |
Quantity Limits (per-product examples)
Mail Order & Long-Term Care (LTC) Guidance
Definitions & Requirements/Limits Key
Background & Scope
This formulary groups drugs by condition and shows the assigned tier and any Requirements/Limits for each product. If a listed product has utilization controls (for example, PA for prior authorization or QL(...) indicating a quantity limit) those flags appear in the Requirements/Limits column and must be followed. To request an exception when a drug is not covered or when a required authorization is needed, contact Customer Service and follow the plan’s exception/authorization process described in the formulary materials.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.