Currentblue cross blue shield - tennesseePolicy H3259_26FORMFIDE_C

List of Covered Drugs (Drug List) — BlueCare Plus Tennessee

Defines the drugs covered by BlueCare Plus & BlueCare Plus Choice (Tennessee), including how to find covered drugs, restrictions (prior authorization, quantity limits, step therapy), and how members/providers are notified of changes.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyList of Covered Drugs (Drug List) — BlueCare Plus Tennessee

Policy CodePolicy H3259_26FORMFIDE_C

Change TypeNo material changes reported

Effective Date

Next Review Date

Key ActionObtain prior authorization from the plan before dispensing drugs flagged 'PA' to avoid denial of coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026drug list year

1-800-332-5762Member service phone

30 daysadvance notice for most Drug List changes

100-daymail-order & retail supply

> $950/mospecialty cost threshold

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Coverage Criteria and Formulary Rules

General coverage criteria

Covered when ALL of the following are met

General coverage: (1) Drug is on the Drug List; (2) Prescriber states the drug is medically necessary; (3) Prescription is filled at a plan network pharmacy.

Coverage and rules summary

Member access and finding drugs: Members should use the Index of Covered Drugs (Section D) or List of Drugs by Medical Condition (Section C1) to find covered drugs; drug rows list brand/generic names and Requirements & Limits.

Transition supply for new members: Plan may cover a temporary 30-day supply during the first 90 days of membership for drugs not on the Drug List, where plan rules (PA/QL/step therapy) prevent immediate access; for long-term care residents or level-of-care changes, a one-time 31-day supply may be provided.30 days / 90 days / 31 days

Multiple refills allowed to provide up to 30-day supply if prescription shorter.

Exceptions process and timelines: Members or prescribers can request exceptions; after receipt of a prescriber supporting statement, the plan will decide within 72 hours, or within 24 hours for expedited requests with prescriber support.72 hours / 24 hours

Prescriber may submit supporting statement by fax, mail, or phone (with subsequent fax/mail).

Selected drug-specific coverage rules

Drug-specific limits and requirements (selected entries in this partial extract)

NSAIDs and related drugs: Examples show tier placement and quantity limits: celecoxib (QL 60 caps/30 days for 50–200mg; 30 caps/30 days for 400mg), diclofenac potassium (QL 120 tabs/30 days), naproxen TBEC (QL 120 tabs/30 days).varies by drug

Entry format: drug, form, strengths, tier columns, and requirements/limits.

Opioid analgesics and opioid-related products: Buprenorphine patches QL (4 patches/28 days) with PA and MME; fentanyl PT72 patches QL (10 patches/30 days or 8 patches/30 days for 100mcg/hr) with PA and MME; methadone solution QL (600–1200 mL / 30 days) with PA and MME.patch or mL limits as listed

MME monitoring applies across opioid class.

Formulary coverage with QL/PA

Coverage follows formulary entries subject to quantity limits and prior authorization where indicated.

Formulary coverage with limits: Drug listed on the formulary with a specified tier and quantity limit is covered when dispensed within the listed QL and any required PA is obtained.see QL per item

Entries show per-item QL and PA flags.

Formulary coverage by listing

Covered when listed on formulary with specified tier and any listed Requirements/Limits

Formulary listing: Drug is listed with a Drug Tier; coverage follows the formulary tier and any listed Requirements & Limits (e.g., contraceptives and androgens are assigned tiers and corresponding limits).

Coverage subject to any Requirements/Limits/QL/PA indicated for each product.

Prior authorization / quantity-managed specialty drugs

Additional management for specialty/high-cost agents

Utilization management flags: Products flagged with PA, NDS, or QL require adherence to those authorization or quantity rules prior to coverage; examples include SOMATULINE DEPOT (NDS, PA) and multiple tolvaptan formulations (NDS, QL, PA).

Prescribers should submit PA requests where indicated to avoid denial.

Formulary coverage with product-specific administrative controls

Covered when dispensed per formulary entry subject to listed restrictions

Formulary coverage with restrictions: Products listed are covered under the pharmacy benefit subject to the product-specific Requirements & Limits shown (e.g., QL, PA, NDS).

This segment provides administrative controls per product rather than clinical eligibility criteria.

General coverage rule for listed products

Coverage of listed drugs is subject to the requirement codes and quantity limits shown for each product.

List-entry coverage rule: A drug entry is covered when the payer's listed requirement codes (e.g., PA, NDS) are satisfied and quantity limits (QL) are not exceeded.satisfy PA and QL where present

Document lists per-drug PA and QL; specific clinical NCD/NMN criteria are not included in this excerpt.

Specialty drugs — PA and QL

Coverage is tiered with specific limits and prior authorization for select high-tier specialty agents:

Specialty Tier Requirements: Tier 4 specialty drugs (examples: nintedanib/OFEV, pirfenidone, ORKAMBI, TRIKAFTA, XOLAIR) are listed with flags 'NDS' and 'PA' and defined quantity limits; coverage requires meeting the payer's NDS/PA requirements and adherence to QL.

Examples shown in chunks 267-269.

Respiratory/inhaled products — tiering and QL

Many respiratory and inhaled products are covered with tier assignments and quantity limits:

Respiratory inhalers and combos: Products are assigned tiers (commonly 2 or 3) and many have QL entries limiting number of inhalers, blisters, or inhalations per 30 days; some products are preferred (lower tier) while others have QL.

See chunks 263, 270-271 for examples (e.g., 1 inhaler / 30 days; 60 inhalations / 30 days).

Ophthalmic/otic coverage

Ophthalmic and otic agents are listed with tier and some with quantity limits:

Ophthalmic/otic coverage: Multiple ophthalmic anti-infective and anti-inflammatory agents are included with tier assignments; certain products include QL or NDS/PA flags (examples: ciprofloxacin ophth QL 30 mL/30 days; RESTASIS QL 60 vials/30 days; XDEMVY marked NDS/PA).

See chunks 256-261 for product-level examples.

If a drug is removed from the market or is found to be unsafe, the plan may immediately remove that drug from the Drug List and it will not be covered. The policy states the plan will notify members and prescribers after such an immediate removal and help them identify an alternative therapy. (See notice and exception instructions.)

When the plan replaces a product with a new generic or certain biosimilar versions, it may also adjust coverage rules or limits for the original product and may make those changes effective immediately; members and prescribers will be informed after the change.

If a requested drug is not on the Drug List, coverage is not automatic. Members may call Member Service to identify therapeutically similar drugs on the Drug List, or the member/prescriber may request an exception to cover the non‑listed drug. The plan describes the exception process and timelines (including prescriber supporting documentation) for such requests.

When changes to the Drug List occur, the plan may provide a temporary supply (for example a 30‑day or 31‑day supply where applicable) and will notify members of steps to request an exception or to coordinate an alternative drug with their prescriber.

The extracted segment of the formulary listing does not include any standalone explicit exclusion statements; instead it presents product entries with administrative requirement flags and quantity limits. The document excerpt therefore does not state specific drugs as categorically excluded within these chunks.

Within this excerpt there are no explicit exclusion conditions described. Entries in the Miscellaneous section show NDS or other requirement flags for specific products but do not present discrete exclusion criteria in the provided text.

Some entries in this segment are marked with administrative flags such as NDS or PA, which may limit coverage or distribution without an explicit textual exclusion being listed. These codes indicate non‑standard supply or prior authorization requirements rather than a named exclusion in the excerpt.

The formulary listings for immunomodulators and immunosuppressants include requirement flags (e.g., NDS, PA, B/D) and quantity/administration controls, but this segment does not set out explicit exclusion conditions for the named products.

No explicit clinical exclusions are listed for the specialty products in this portion of the Drug List. Several high‑tier products are annotated with NDS and PA and have quantity limits, indicating restricted distribution and authorization requirements rather than documented exclusions.

This excerpt does not contain any statements that designate items as Not Medically Necessary. The listings focus on product-specific administrative controls (tier, QL, NDS, PA) rather than NMN determinations.

No 'Not Medically Necessary' (NMN) determinations are present for the thyroid and related product listings shown in this excerpt. Coverage entries enumerate strengths, tiers and requirements but do not declare NMN status.

The provided segment does not include explicit NMN language for listed drugs; instead it uses administrative flags such as NDS and PA to indicate special handling or authorization requirements that restrict coverage unless satisfied.

For immunomodulators and similar specialty agents in this portion of the Drug List, the document does not specify any Not Medically Necessary conditions. Coverage is controlled through NDS/PA/B-D flags and product‑specific limits.

This part of the formulary does not declare any items as 'Not Medically Necessary.' Instead, it lists administrative requirements (e.g., NDS, PA) and quantity limits that must be met for coverage of specialty products.

Coding, Requirement Codes, and Examples

Actions Required by Prescribers and Pharmacies

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many Non-extended Day Supply (NDS) items, Tier 4 and specialty drugs. Prescribers must obtain plan approval before dispensing NDS/Tier‑4 agents and other drugs flagged "PA" or "NDS" in the Drug List. Failure to obtain required PA may result in the plan denying coverage for the drug.

PA required for many NDS/Tier 4 agents (see NDS/PA flags on Drug List).
Products marked NDS and/or PA require additional documentation at claim submission.
Tier 4/specialty agents (biologics, injectables, high-cost oral oncology, antivirals, antifungals) commonly require PA.

Documentation Required

Requirement Flags and Claim Documentation

Products on the Drug List carry visible requirement flags — PA, NDS, QL, B/D, MME — that indicate utilization management rules and billing requirements. Prescribers and pharmacies must follow the displayed Requirements & Limits (including QL and NDS) on the Drug List and include applicable codes/flags on the claim or PA request.

Present QL and NDS information on the claim or in the PA request.
Adhere to the Requirements & Limits column in Section D when submitting claims.
Products with B/D may require additional setting/use documentation to determine Part B vs Part D coverage.

Denial Risk

Denial Risk — PA, NDS and Quantity Limits

Many specialty, high‑cost, or tier‑4 drugs require both prior authorization and quantity limits (QL). If a claim lacks an approved PA or exceeds the displayed QL (including MME limits for opioids), the plan may deny the claim. Prescribers should request exceptions or expedited reviews when medically necessary.

Claims missing required PA or exceeding QL/NDS limits are at risk of denial.
Opioid prescriptions may be subject to cumulative MME limits; document MME justification if exceeding thresholds.
Exception requests can be submitted if prescriber documents medical necessity.

Documentation Required

Exceptions and Supporting Documentation

Follow the plan's exception process when prior authorization, quantity limits, or step therapy would otherwise prevent coverage. Prescribers must provide a supporting medical statement; standard exception decisions are made within 72 hours after receipt of the prescriber's documentation, and expedited exceptions are decided within 24 hours when waiting could seriously harm the member.

Prescriber must submit a supporting statement for exceptions (fax, mail, or phone then fax/mail).
Standard exception decision timeframe: 72 hours after receiving supporting statement.
Expedited exception decision timeframe: 24 hours when clinically necessary.

Documentation Required

Opioid MME and Quantity Documentation

For opioids and other controlled medications, document Morphine Milligram Equivalent (MME) calculations and any clinical rationale when requesting quantities above cumulative limits. Quantity limits and MME thresholds shown in the Drug List must be applied at claim adjudication.

Provide MME calculation and prescriber justification for opioid doses that exceed plan MME limits.
Ensure QL and MME flags appear on claims to avoid adjudication delays or denials.

Step Therapy

Step Therapy and Benefit Considerations

When step therapy is indicated on the Drug List, no explicit step sequences may be listed in this excerpt — but tiering and preferred hierarchies can imply required trials. If step therapy applies, prescribers may request an exception or provide medical necessity documentation to waive steps. Temporary transition supplies (30‑day supply) are available for new members under specified conditions.

Step therapy may be waived via an exception with prescriber documentation.
New members may receive a temporary 30‑day supply while exception/step issues are resolved.
Benefit design markings (B/D) may affect step/coverage determination for certain immunosuppressants/immunomodulators.

Background and Scope

This document is an administrative formulary (the List of Covered Drugs) for BlueCare Plus Tennessee that describes which drugs are covered, how to find covered drugs (Index of Covered Drugs and List of Drugs by Medical Condition), and the administrative controls that apply (for example PA, QL, NDS, and step therapy).

The formulary is intended for use by providers and pharmacies to determine coverage rules, required prior authorization, and quantity limits; it also explains member processes such as transitions, exception requests, and notice timelines for Drug List changes.

Note

Key Definitions and Abbreviations

Definitions — PA, step therapy, and formulary abbreviations

Prior authorization (PA)Permission from the plan before you can get a drug; required where listed and may cause noncoverage if not obtained

Step therapyRequirement to try drugs in a specified order before coverage of alternatives

Formulary abbreviationsPA = Prior Authorization; QL = Quantity Limit; NDS = Non-extended day supply; MME = Morphine Milligram Equivalent

Definitions — QL, NDS, MME

QL — Quantity LimitMaximum quantity allowed per specified time period as shown (e.g., 'QL (4 pens / 28 days)')

NDS — Non-extended day supplyIndicates limited day supply (may be available up to a 30-day supply only)

MME — Morphine Milligram EquivalentMetric used as an authorization flag/limit across opioid class to monitor cumulative opioid dosing

Initial Therapy Access and Limits

Initial therapy access

Access during transitions and long-term supply options

Initial access for new members: May cover a temporary 30-day supply during the first 90 days of membership for drugs not on the Drug List or when plan rules (PA/QL/step therapy) prevent immediate access; multiple refills allowed up to a 30-day supply if prescription is for fewer days.30 days / 90 days

This temporary supply allows time to pursue an exception or therapy change.

Initial therapy quantity limits

Initial dispensing limits: Initial outpatient dispensing is subject to the listed Quantity Limits for each product (e.g., metformin solution QL 765 mL/30 days; metformin 500 mg tabs QL 150 tabs/30 days).see item-specific QL

Initial therapy governed by listed QL and PA flags.

Transition and Continuity of Therapy

Transition and continuity of therapy

Transition supplies and care setting changes

New member transition: Plan may provide temporary supplies (30-day during first 90 days) and, for long-term care discharge or level-of-care changes outside the transition window, a one-time 31-day supply of transition-eligible drugs upon contacting Member Service.30 days / 90 days / 31 days

Contact Member Service to arrange transition supply.

Step Therapy Rules and Tables

Step therapy summary	Implication / member action
Some drugs require step therapy — members must try drugs in a specified order before the plan will cover alternatives.
Members or prescribers may request an exception to remove step therapy; prescribers must provide supporting documentation as described in the exceptions process.

Scope of step therapy restrictions	How to request exception / temporary access
Some drugs on the Drug List are subject to step therapy restrictions; tables in Section D indicate products with additional management (PA, QL, NDS) that may interact with step rules.
Members may request exceptions to change or remove step therapy; temporary transition supplies may be granted while an exception is processed.

Antiretroviral / specialty notes	Step therapy consideration
Combination antiretroviral products (e.g., BIKTARVY, CIMDUO, DELSTRIGO, DESCOVY) are listed with tier changes (some '3 = 4') and QL/NDS flags; many DAAs (EPCLUSA, MAVYRET) have NDS/PA and QL entries.
Tier reassignments, NDS and PA designations and differing quantity limits may affect whether lower-tier or preferred agents are required first under step edits; prescribers should review formulary entries and may request exceptions if clinically appropriate.

Combination antiretroviral products	Formulary tier notes / impact
Multiple combination antiretroviral products are shown with tier reassignment indicators (example: '3 = 4' for some strengths of BIKTARVY and other combos).
Tier reassignment may change step placement or cost-sharing and could trigger utilization management (NDS/PA); review the drug row for specific QL/NDS/PA flags when assessing step requirements.

Formulary requirement codes present	Relevance to step therapy
Formulary entries include requirement/limit codes such as PA (prior authorization), NDS (non-extended day supply), QL (quantity limit) and B/D (billing/dispensing notes).
PA and NDS flags indicate additional review or restrictions that may accompany or substitute for explicit step edits; presence of these codes on a drug row signals potential utilization management beyond simple tiering.

Explicit step sequences present?	Notes
No — the provided excerpts do not list explicit multi-step sequences or required prior products in a step-by-step algorithm.
The document primarily displays tiers, QL, PA, NDS and other flags per product rather than enumerating ordered step therapy sequences in these chunks.

Specialty agents and controls	Step algorithm present?
Many specialty agents are subject to PA and NDS designations (examples: GATTEX, RELISTOR, various immunomodulators and biologics listed with NDS/PA/B/D).
No explicit multi-step therapy algorithm for these specialty agents is provided in the excerpt; utilization controls are expressed via PA/NDS/QL flags instead.

Benefit design / step edit indicators	Implication for immunosuppressants / immunomodulators
Some immunosuppressants and immunomodulators include B/D (billing/dispensing) or NDS/PA requirement codes in their listings, indicating benefit design considerations or step edits may apply.
These indicators suggest the plan may apply benefit-design or step-edit rules to control use of high-tier immunomodulators; specific step sequences are not listed in the excerpt and require review of full formulary rows or PA criteria.

Inhalers / combination respiratory agents	Step / preferred hierarchy notes
Many inhalers and combination agents (e.g., ANORO, BREZTRI, TRELEGY, SPIRIVA, COMBIVENT) are assigned tiers and quantity limits; preferred agents are often on lower tiers with QL for alternatives.
Explicit step therapy algorithms are not provided in the excerpt; preferred tiering and QL entries imply a formulary preference hierarchy that may function as a step-edit in practice.

Quantity Limits (QL) — Examples and Product-Specific Limits

Site of Care and Dispensing Considerations

Note

Biosimilars and Interchangeable Products

Note

Policy Revision History

2026-06-01policy_reviewLatest

Document last reviewed on 2026-06-01 per policy metadata; no material clinical policy statement changes noted in brief but review date recorded.

2025-09-01policy_version_update

Policy identifier H3259_26FORMFIDE_C shows version dated 09/01/2025 (Version 17) indicating prior published update to the Drug List document.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyList of Covered Drugs (Drug List) — BlueCare Plus Tennessee

Policy CodePolicy H3259_26FORMFIDE_C

Change TypeNo material changes reported

Effective Date

Next Review Date

Key ActionObtain prior authorization from the plan before dispensing drugs flagged 'PA' to avoid denial of coverage.

SourceLink

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