2026 Essential Formulary

Coverage summary

Partial listing from the 2026 Essential Formulary — this is a formulary part used by the payer. Coverage stance: mixed (multiple products are covered but many entries carry utilization management). This part assigns drug tiers and administrative designators and includes PA, QL, MT, LD, and ACA notations for listed products and ties to payer materials (member service and evidence of coverage).

Formulary requirement designators (PA / QL / MT / LD / ACA / OTC)

Formulary product-level requirements

Each listed product includes one or more of the following requirement/limit designators (PA, QL with specific quantities/periods, MT, OTC, LD, ACA):

PA: Products annotated with 'PA' require prior authorization before coverage.
See plan PA process (CoverMyMeds, phone or fax).
QL: Products annotated with 'QL' have a quantity limit; the specific QL values are listed per product (examples include '9 tabs every 30 days','4 pens every 28 days','90 mL every 30 days').
Exact QL stated at product line in formulary part.
MT: Products annotated with 'MT' are part of the Maintenance Matters / mail/managed therapy program (e.g., 90-day maintenance supply rules).
Plan guidance applies for 90-day supplies.
OTC: Products annotated with 'OTC' are over-the-counter when noted (requires prescription to be eligible if plan notes OTC).
Examples: some nicotine products, spermicides.
LD: Products annotated with 'LD' are limited distribution and may be available only through designated specialty pharmacies or channels.
Coordinate per limited distribution instructions.
ACA: Products annotated with 'ACA' indicate Affordable Care Act preventive or ACA-related coverage (may be $0 copay depending on plan).
Examples: many contraceptives and vaccines.

Each drug entry in this part lists one or more Requirements/Limits (for example: PA, QL with an explicit quantity and interval, MT, LD, OTC, or ACA). When a product shows QL the formulary provides the specific quantity/time threshold for that exact product and presentation (examples in this part: 9 tabs every 30 days for XIFAXAN 200mg; 90 vials every 30 days for CAYSTON).

Formulary entry requirements / examples

Formulary entry requirements/limits

Each drug entry includes Requirements/Limits which may include PA, QL (with explicit quantity/time), LD, ACA, MT or blank.

LENVIMA CAP 24 MG: Requirements/Limits = PA, QL (90 caps every 30 days); LD
product-level entry
HERNEXEOS TABS 60MG: Requirements/Limits = PA, QL (120 tabs every 30 days); LD
product-level entry
TUKYSA TABS 50MG, 150MG: Requirements/Limits = PA; LD
product-level entry

General utilization management rules

General Formulary Requirements/Limits

Drugs are listed with Requirements/Limits codes that indicate utilization management actions to be applied:

PA = Prior Authorization required when indicated next to drug
Provider must submit PA via CoverMyMeds, phone or fax per plan instructions.
QL = Quantity Limit specified (exact limit provided per drug where listed)
Examples: '30 tabs every 30 days', '4 pens every 28 days', '2 sprays every 30 days'.
MT = Maintenance Matters / Mail Tier designation (90-day supply or managed therapy routing)
Used for chronic condition maintenance supply rules.
LD = Limited Distribution designation (requires specialty channel)

What providers must do

Prior Authorization

Prior Authorization Required

Prior authorization is required for many specialty, high-cost, and certain routed agents before coverage is approved. Providers must submit prior authorization requests electronically via CoverMyMeds, call 1-800-924-7141, or fax 1-888-343-4232. Examples of drugs that commonly require prior authorization include: EPCLUSA, HARVONI, CAMZYOS, and pulmonary hypertension agents. Prior authorization may also apply to immunoglobulin and IVIG products (see LD handling below).

PA required for: EPCLUSA
PA required for: HARVONI
PA required for: CAMZYOS
PA required for: pulmonary hypertension agents (class)
PA required for: immunoglobulins and IVIG when also LD

Billing Rule

Adhere to Quantity Limits (QL)

Applicable products and code groups

Products with Prior Authorization (PA)NDC

vancomycin_hcl_solr_25mg_ml	Vancomycin HCl oral solution 25 mg/mL (PA at product level)
vancomycin_hcl_solr_50mg_ml	Vancomycin HCl oral solution 50 mg/mL (PA at product level)
vancomycin_caps_oral_250mg_5ml	Vancomycin oral 250 mg/5 mL (oral liquid)
nucala_various	Nucala (mepolizumab) multiple presentations — PA required
yupelri_nebu_175mcg_3ml	YUPELRI Nebulizer solution 175 mcg/3 mL — PA required
asmanex_inhalants	Asmanex and other inhaled corticosteroids — PA required for certain strengths/forms
wixela_inhub_100_50	Wixela Inhub Aerosol 100/50 — PA required
wixela_inhub_250_50	Wixela Inhub Aerosol 250/50 — PA required
wixela_inhub_500_50	Wixela Inhub Aerosol 500/50 — PA required
vigabatrin_500mg	Vigabatrin tablets/pack 500 mg — PA required

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Products with Quantity Limits (QL)NDC

ql_4_pens_30_days	QL: 4 pens every 30 days (specified products)
ql_2_pens_30_days	QL: 2 pens every 30 days
ql_4_sprays_30_days	QL: 4 sprays every 30 days
ql_1_pack_28_days	QL: 1 pack per 28 days
ql_14_inj_28_days	QL: 14 injections every 28 days
ql_30_inj_30_days	QL: 30 injections every 30 days
ql_12_inj_28_days	QL: 12 injections every 28 days
ql_56_caps_28_days	QL: 56 capsules every 28 days
ql_60_caps_30_days	QL: 60 capsules every 30 days
ql_30_caps_30_days	QL: 30 capsules every 30 days

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Products with Maximum Therapy / MTNDC

mt_maintenance_matters

MT: Maintenance Matters program — 90-day supply requirement for certain chronic therapies

Products listed with LD (limited distribution)NDC

ld_specialty_oncology	Multiple oncology agents and orphan drugs (e.g., certain ARV/oncology agents) — limited distribution applies
ld_hae_agents	HAE and enzyme-replacement products with limited distribution (Berinert, Cinryze, Haegarda, Ruconest)
ld_biologics_repatha	Some biologics (e.g., REPATHA Pushtronex) — limited distribution

Formulary products and tiers with requirements/limits (selected entries)mixedCovered

insulin_family_full_list	Comprehensive insulin product list included: Humulin R U-500 (concentrate & KwikPen), Insulin glargine-yfgn 100U/mL, Levemir (100U/mL), Novolin family (70/30, N, R, FlexPen, Relion), NovoLog family (100U/mL, mixes, FlexPen), Toujeo SoloStar/Max SoloStar (300U/mL), Tresiba (100U/mL & 200U/mL), plus pens/cartridges — QL and PA rules apply per product
glucose_regulators_and_glp1s	GLP-1/GIP agents and oral antidiabetes: Mounjaro, Ozempic, Rybelsus, Trulicity, Glyxambi, Janumet, Synjardy, Trijardy XR, Xultophy, Soliqua — PA and QL as specified
antibiotics_key_entries	Vancomycin oral forms (solutions and capsules), fidaxomicin — PA/QL as specified
statins_and_lipids	Statins (atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin) and ezetimibe, icosapent ethyl (Vascepa), fibrates — tiering and PA/QL notes included
contraceptives_selected	Selected contraceptives and devices: many combined oral contraceptives, patches (Twista/Xulane/Twirla/Zafemy), rings (Annovera, eluryng), IUDs (Paragard, MiUdeIIa), emergency contraceptives, Depo-Provera (subq & IM) — ACA preventive coverage notes and any applicable QL/PA
influenza_and_antivirals	Oseltamivir (caps 45/75 mg, suspension), RELENZA Diskhaler, XOFLUZA — QL and PA notes
hep_c_and_antivirals	Hepatitis agents including ribavirin, valacyclovir, acyclovir, famciclovir and HBV agents (Vemlidy) — PA/LD as applicable

Selected specialty and high-cost injectablesNDC

emgality_pen_100_120mg	EMGALITY pen/syringe 100 mg/120 mg — PA and QL as applicable
repatha_pushtronex_420mg	REPATHA Pushtronex system 420 mg/3.5 mL — PA and specialty channel
gvoke_variants	GVOKE (Hypopen, Kit, PFS) variants — QL limits (e.g., 1 pack per 28 days) and PA
glemb_nurtec_sumatriptan	NURTEC ODT, sumatriptan formulations — PA/QL as applicable

Contraceptives and related (ACA coverage notes)mixedCovered

combined_oral_many	Wide range of combination oral contraceptives (Affirmelle, Altavera, Alyacen, Aurovela, Averi, Aviane, Apri, Aranelle, Balziva, Aubra EQ, others) — ACA preventive coverage applies for eligible plans; PA generally not required for ACA-equivalent products
transdermal_patches	Transdermal patches: Norelgestromin-ethinyl estradiol 150-35 mcg/24 hr; TWIRLA, Xulane, Zafemy — coverage subject to ACA rules; some patches may have QL or step-therapy
vaginal_rings	Vaginal rings: ANNOVERA, eluryng, ENILLOring, etonogestrel-ethinyl estradiol ring — ACA preventive coverage for eligible products; device-specific distribution
iuds	IUDs: MIUDELLA copper IUD, Paragard T380A, and levonorgestrel IUDs (Kyleena, Liletta, Mirena, Skyla) — coverage and provider billing may vary; many are ACA-covered
emergency_contraceptives	Emergency contraceptives: Plan B One-Step, Aftera, ella — OTC/covered rules vary; ella may require PA depending on plan
depo_provera	DEPO-SUBQ PROVERA 104 (104 mg/0.65 mL) and medroxyprogesterone acetate 150 mg/mL injections — coverage and administration site rules apply

Selected drugs with QL (quantity limits) specifiedNDC

ql_4_pens_example	Example QL: 4 pens every 30 days (e.g., certain GLP-1/GIP pens)
ql_2_pens_example	Example QL: 2 pens every 30 days
ql_4_sprays_example	Example QL: 4 sprays every 30 days
ql_1_pack_28d_example	Example QL: 1 pack per 28 days (e.g., naloxone / rescue kits)
ql_14_inj_28d_example	Example QL: 14 injections every 28 days (selected biologics)
ql_30_inj_30d_example	Example QL: 30 injections every 30 days (insulin/allergen immunotherapy supplies)
ql_56_caps_28d_example	Example QL: 56 capsules every 28 days (chronic oral regimens)
ql_60_caps_30d_example	Example QL: 60 capsules every 30 days

Selected drugs with PA; LDNDC

vancomycin_oral_forms	Vancomycin oral solutions and capsules (25 mg/mL, 50 mg/mL, 250 mg/5 mL, oral capsules) — PA required; LD for certain manufacturer-limited products
nucala_various_pa_ld	Nucala (mepolizumab) — PA required; limited distribution for some presentations
arike_mar_and_hae_ld	ARIKAYCE, HAE agents, many orphan/REMS drugs — PA and limited distribution as noted
pegasys_and_hep_ld	PEGASYS and other hepatitis injectables — PA/LD possible
repatha_and_biologics_ld	REPATHA and other biologic injectables — PA and specialty limited distribution
lenalidomide_rems_ld	Lenalidomide (multiple capsule strengths) — PA, REMS, and distribution controls apply

Quantity limits and thresholds (selected examples)

Product	Quantity limit	Interval
XIFAXAN 200 mg (tabs)	9 tabs	every 30 days
XIFAXAN 550 mg (tabs)	90 tabs	every 30 days
praziquantel 600 mg (tabs)	24 tabs	every 365 days
CAMZYOS caps (2.5/5/10/15 mg)	30 caps	every 30 days
EPCLUSA PAK 150-37.5	30 packets	every 30 days
EPCLUSA PAK 200-50 mg	60 packets	every 30 days
EPCLUSA TAB 200-50 mg	60 tabs	every 30 days
EPCLUSA TAB 400-100	30 tabs	every 30 days
oseltamivir caps 30 mg	20 caps	every 180 days
oseltamivir caps 45/75 mg	10 caps	every 180 days
oseltamivir suspension 6 mg/mL	180 mL	every 180 days
LAGEVRIO caps 200 mg	40 caps	every 5 days
RELENZA Diskhaler 5 mg	1 inhaler	every 180 days
XOFLUZA tabs 40/80 mg	2 tabs	every 180 days
FILSPARI tabs 200/400 mg	30 tabs	every 30 days
lenalidomide caps (2.5-15 mg)	28 caps	every 28 days
lenalidomide caps (20/25 mg)	21 caps	every 28 days
EVRYSDI tabs 5 mg	30 tabs	every 30 days
AIMOVIG (pen)	1 pen	every 30 days
EMGALITY (pen)	1 pen (or 3 syr for some presentations)	every 30 days
NURTEC 75 mg	16 tabs	every 30 days
PAXLOVID PAK	11 tabs	every 5 days
PAXLOVID TAB 150/100	20 tabs	every 5 days
PAXLOVID TAB 300/100	30 tabs	every 5 days
TARPEYO CPDR 4 mg	120 caps	every 30 days

The illustrative table in summaries is not exhaustive — quantity limits shown in summary views are examples. Full, product-level QL values and packaging/formulation-specific limits are provided in the formulary entries for each listed product; always check the full formulary entry for the exact QL tied to a specific presentation or pack (e.g., inhaler inhalations, pen counts, mL limits).

Clinical evidence and rationale

This part is a formulary listing and does not include primary clinical trial evidence. Utilization management codes shown (PA, QL, LD, MT, ACA) reflect administrative coverage controls and plan programs; clinical-evidence citations are not present in this fragment.

Background and scope

Background: this is Part of the BlueCross BlueShield Tennessee 2026 Essential Formulary that organizes medications by therapeutic class and assigns drug tiers plus utilization-management designations. The document indicates plan guidance for prior authorization and quantity limits and defines shorthand (e.g., PA, QL, MT, LD, ACA). Payer metadata: Payer = blue cross blue shield - tennessee; Policy = 2026 Essential Formulary.

Revision history

status_noteLatest

Current formulary part — no dated revision history provided in this fragment.