Essential Plus Formulary Guide (May 2026) - Part 1

Coverage Summary & Scope

This is a partial/indexed fragment of the Essential Plus Formulary Guide (May 2026) for BlueCross BlueShield of Tennessee covering the Essential Plus plan family. The fragment represents Part 1 of the guide (a partial/indexed extract) and summarizes formulary listings, tiers, and pharmacy benefit programs. Programs referenced in this part include Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Maintenance Matters (MT), Limited Distribution (LD), and the MME opioid program. Effective date: 2026-05-01.

Key thresholds and representative QLs

MME prior authorization threshold> 120 mg morphine equivalents/day

JANUVIA (sitagliptin) QL30 tabs every 30 days

MOUNJARO (tirzepatide) QL4 pens every 28 days

OZEMPIC (semaglutide) QL1 pen every 28 days

Insulin/pen example — FIASP90 mL every 30 days (FIASP solution) / 60 mL penfill/pumpcart

Naloxone QL2 sprays every 30 days (naloxone nasal) / 2 injections every 30 days for injectables

TARPEYO QL120 caps every 30 days

Provider actions, prior authorization, appeals and dispensing rules

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Many specialty, oncology, immune therapy and other select agents require prior authorization before coverage will be approved. Provider must request a coverage review digitally through CoverMyMeds, by phone at 1-800-924-7141, or by fax at 1-888-343-4232.

Examples of products that require prior authorization include specialty and oncology SKUs listed on the formulary (see PA and specialty drug notes).
Specialty agents and many immune therapies are commonly PA-required and are limited to specialty pharmacies and typically a 30-day supply.

Documentation Required

Reconsideration Submission Requirements

Reconsideration / Documentation: For reconsideration or appeals of denials, provide complete written documentation to Pharmacy Management Reconsiderations. Fax supporting materials to 1-888-343-4232 or mail to Pharmacy Management Reconsiderations, BlueCross BlueShield of Tennessee, 1 Cameron Hill Circle, Chattanooga, TN 37402-2555. Include the following with any request: patient name and cardholder ID number, physician name and phone number, drug name and dosage, and diagnosis / clinical rationale.

General Prior Authorization and Program Requirements

Coverage and access to certain drugs are subject to PA, QL, ST, MT, LD, ACA, OTC, and MME program rules as defined below.

Prior Authorization (PA) may be required for certain drugs
Provider must request coverage review via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232
Quantity Limit (QL) applies to specified drugs
Limits specified per drug as e.g. '60 caps every 30 days'
Step Therapy (ST) may be required for specified drugs
Provider must request coverage review as above
Limited Distribution (LD) indicates limited pharmacy availability

Formulary tiers and selected drug groups

Unsupported block type: mixed

Selected therapeutic classes with requirements

Amphetamines and ADHD agents (selected entries with requirements)mixed

amphetamine-dextroamphetamine 3-bead cap er 24hr 12.5 mg	PA, QL (60 caps every 30 days) for some strengths; others listed without explicit QL
amphetamine-dextroamphetamine 3-bead cap er 24hr 25 mg	PA, QL (30-60 caps every 30 days depending on strength)
amphetamine-dextroamphetamine cap er 24hr 5 mg	PA, QL (90 caps every 30 days) for some strengths
amphetamine-dextroamphetamine tab 5 mg	PA, QL (90 tabs every 30 days) for some strengths
dextroamphetamine sulfate cp24 5mg,10mg	PA, QL (120 caps every 30 days) for some strengths
lisdexamfetamine dimesylate caps 10-30 mg	PA, QL (60 caps every 30 days)
lisdexamfetamine dimesylate caps 40-70 mg	PA, QL (30 caps every 30 days)

Stimulants / Analepticsmixed

atomoxetine hcl caps 10-25 mg	QL (120 caps every 30 days)
armodafinil tabs 50 mg	PA, QL (60 tabs every 30 days)
dexmethylphenidate hcl various	PA, QL (30-120 caps/tabs every 30 days depending on strength/form)
methylphenidate (patch/chew/soln/tabs) various	PA, QL with limits per formulation (patch 30 per 30d, chew/tabs up to 180 per 30d, soln up to 1800 mL per 30d etc.)
modafinil tabs 100-200 mg	PA, QL (60 tabs every 30 days)
Quillivant XR/Quillichew	PA, QL with specified limits (e.g. 360 mL every 30 days)

Anti-TNF-alpha and immunomodulatorsmixed

adalimumab (multiple presentations)	PA, QL (ranges: 2-4 syringes/injections every 28 days depending on presentation/strength)
ENBREL (various presentations)	PA, QL (4 vials/4-8 syringes/4 pens every 28 days depending on presentation)
ARCALYST, ILARIS	PA; LD

Opioid agonists and combinations (MME program applies)mixed

codeine sulfate tabs 30 mg	PA; MME program applies
fentanyl patch and lollipop presentations	PA; MME applies
BELBUCA film	PA, QL (60 films every 30 days); MME
buprenorphine patches	PA, QL (4 patches every 28 days); MME
ZUBSOLV sublingual tablets various strengths	QL (60-90 tabs every 30 days depending on strength)

Anti-infectives and related (selected)mixed

CAYSTON soln 75 mg	PA, QL (90 vials every 30 days); LD
XIFAXAN tabs 200 mg	PA, QL (9 tabs every 30 days)
vancomycin HCl caps 125/250 mg	QL (120 caps every 30 days)
linezolid (susp, tabs 600 mg)	QL (14 days supply every 30 days)

Specialty injectables with QL/PAproprietaryCovered

NUCALA (all presentations)	PA, QL (varies by presentation), LD
MOUNJARO SOAJ	PA, QL (4 pens every 28 days)
OZEMPIC SOPN	PA, QL (1 pen every 28 days)
TRULICITY SOAJ	PA, QL (4 pens every 28 days)

Quantity Limits (QL) — examples and enforcement

Many individual SKUs in this part have explicit Quantity Limits (QL) stated per fill period (examples include caps/tabs per 30 days, inhalers per 30 days, mL per 30 days). Pharmacies and providers must dispense within the listed QL or obtain Prior Authorization (PA) as required by the plan.

Drugs with Quantity Limits (selected examples)proprietary|genericCovered

nitazoxanide tabs 500mg	QL (14 tabs every 30 days)
vancomycin hcl caps 125mg, 250mg	QL (120 caps every 30 days)
vancomycin hcl soln 25mg/ml	QL (900 mL every 30 days)
linezolid susr 100mg/5ml; tabs 600mg	QL (14 days supply every 30 days)
CAYSTON SOLR 75MG	QL (90 vials every 30 days)
ATROVENT HFA AERS 17MCG/ACT	QL (2 inhalers every 30 days)
SPIRIVA RESPIMAT AERS	QL (1 inhaler every 30 days)
ASMANEX HFA AERO 50/100/200MCG/ACT	QL (1 inhaler every 30 days)
albuterol sulfate aers 108mcg/act	QL (2 inhalers every 30 days)
gabapentin caps/soln/tabs	PA, QL (various: 180 caps every 30 days; 2160 mL every 30 days; 180 tabs every 30 days; 120 tabs every 30 days)

Compact QL examples

JANUVIA30 tabs / 30 days

MOUNJARO4 pens / 28 days

OZEMPIC1 pen / 28 days

TARPEYO120 caps / 30 days

Naloxone nasal (Narcan/KLOXXADO)2 sprays / 30 days

PAXLOVID (PAK/tab variants)

Prior Authorization (PA) — products and channels

Prior Authorization (PA) is a clinical review required for many specialty and other listed agents. Providers must request coverage review digitally via CoverMyMeds, by phone at 1-800-924-7141, or by fax at 1-888-343-4232 as described in the formulary definitions and provider instructions.

Drugs with PA requirementNDC|brandCovered

EPCLUSA family (EPCLUSA PAK/TAB variants)	PA
HARVONI family (packs/tabs)	PA
VOSEVI TAB	PA
CAMZYOS CAPS	PA
epoprostenol sodium soln	PA
ORENITRAM TBCR / tabs month 1-3	PA; LD
treprostinil soln	PA; LD
VENTAVIS SOLN	PA; LD
NUCALA products	PA

Drugs with Prior Authorization (PA)NDC|brandCovered

COSENTYX products	PA; QL (1-2 syringes/pens per dosing period); LD
DUPIXENT SOAJ/SOSY	PA, QL (4 pens every 28 days)
TREMFYA SOAJ/SOSY	PA, QL (1 injection every 28 days)
SKYRIZI SOSY/PEN	PA, QL (1 syringe/pen every 84 days)
SUCRAID SOLN 8500UNIT/ML	PA, QL (354 mL every 30 days); LD
BYLVAY products	PA; LD
LIVMARLI SOLN/TABS	PA; QL (30-60 tabs every 30 days); LD

Prior Authorization

Prior authorization required for many specialty and oncology agents

Prior authorization is required for many specialty, oncology, and biologic agents. Providers must request coverage review using CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232. Examples include hepatitis C and antiviral specialty products, biologics, and many oncology agents.

EPCLUSA (various PAK/TAB SKUs)
HARVONI family
NUCALA (multiple presentations)
CAYSTON SOLR 75MG
Many oncology agents (LENVIMA, TAGRISSO, IMBRUVICA, etc.)

Limited Distribution (LD) and Specialty channels

LD means Limited Distribution: certain drugs are available only through specified pharmacies or distributors. For LD products (examples in this part include CAYSTON, NUCALA, EPIDIOLEX), providers may need to use designated limited-distribution channels and follow payer documentation procedures when ordering or dispensing.

Drugs designated LD (Limited Distribution)mixedCovered

CAYSTON SOLR 75MG	LD
NUCALA products	LD
EPIDIOLEX SOLN 100MG/ML	LD
ZTALMY SUSP 50MG/ML	LD
ADEMPAS TABS	PA; LD
ORENITRAM TBCR / tabs	PA; LD
treprostinil soln	PA; LD
VENTAVIS SOLN	PA; LD
immune globulins (HYQVIA, GAMMAGARD, GAMUNEX-C, CUVITRU, CUTAQUIG)	PA; LD
many oncology and rare disease agents (e.g., LENVIMA, FRUZAQLA, IMBRUVICA, etc.)	PA, QL; many flagged LD

Documentation Required

Follow limited distribution pathways and include LD documentation in PA

When a product is limited distribution (LD), include LD documentation and follow the payer’s limited distribution/specialty pathways in your PA submission. For LD-designated products, the formulary notes the LD flag—providers must coordinate with the designated distributor and include LD-specific documentation in PA requests.

Include LD documentation in PA submissions for LD-marked products
Confirm and use designated limited distribution pharmacy or specialty channel
Examples of LD-marked products: CAYSTON SOLR 75MG; NUCALA presentations; EPIDIOLEX SOLN 100MG/ML; ZTALMY SUSP 50MG/ML

Definitions and program flags

Glossary — key terms used in this part:

PA — Prior Authorization: clinical approval required before coverage; provider must request via CoverMyMeds, phone, or fax.

QL — Quantity Limit: plan limits the quantity covered in a specified time period (e.g., 60 caps every 30 days shown on entries).

ST — Step Therapy: requires trying specified first-line drug(s) before covering alternatives.

LD — Limited Distribution: drug available only at designated pharmacies/distributors.

MME — Morphine Milligram Equivalent: PA required for members taking greater than 120 mg morphine equivalents/day.

MT — Maintenance Matters: program for long‑term condition drugs (often 90‑day supply rules).

ACA — Affordable Care Act: indicator for drugs that may be available with no out‑of‑pocket cost depending on plan.

OTC — Over‑the‑counter: nonprescription product designation; plan may still require prescription or limit quantity for coverage.

Formulary context and member services

Part 1 of the Essential Plus Formulary Guide (May 2026) lists covered drugs and program rules across multiple therapeutic classes through anti‑infectives, and includes introductory material, network and home delivery information, and appeals/reconsideration instructions. The document notes network and home delivery contacts (e.g., home delivery: 1-800-552-8159) and explains reconsideration/appeals submission (fax 1-888-343-4232 or mail to Pharmacy Management Reconsiderations at the address provided). This part is a fragment of the full formulary — see the full Essential Plus Formulary Guide for complete entries and the full document index.

Revision History

2026-05-01EffectiveLatest

Effective date / published (Part 1 extract)