Currentblue cross blue shield - tennesseePolicy H3259_26FORMFIDE_C (04/01/2026) 26162, Version 14

List of Covered Drugs (Drug List)

Defines the drugs covered by BlueCare Plus & BlueCare Plus Choice (HMO D‑SNP) plans, how to find covered drugs, and describes coverage rules (prior authorization, quantity limits, step therapy) that affect members and prescribers.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyList of Covered Drugs (Drug List)

Policy CodePolicy H3259_26FORMFIDE_C (04/01/2026) 26162, Version 14

Change TypeNo material change (as of 04/01/2026)

Effective Dateas written

Next Review DateN/A

Key ActionObtain prior authorization from the plan before dispensing any drug flagged 'PA' to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026List year

Version 14document version

30-daytransition supply

$950specialty tier threshold

1-800-332-5762member service

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General medical necessity coverage

Covered when ALL of the following are met:

Standard coverage conditions: Prescriber states the drug is medically necessary for the member.

Standard coverage conditions: The plan agrees the drug is medically necessary for the member.

Standard coverage conditions: The prescription is filled at a plan network pharmacy (a pharmacy with an agreement to provide services to plan members).

Transition and Exception Criteria

Transition supplies and exceptions

New member transition supply: Plan may cover a temporary 30-day supply of a drug during the first 90 days of membership to allow time to transition to formulary alternatives; if the prescription is written for fewer days, multiple refills will be allowed to provide up to a 30-day supply.30 days / first 90 days

Applies when drug is not on the Drug List, plan rules limit amount, drug requires prior authorization, or drug is subject to step therapy.

Long-term care transition: For members in long-term care facilities who have been in the plan more than 90 days and need a supply immediately, the plan will cover one 31-day supply (unless prescription is for fewer days).31 days

Also allows a one-time supply when level-of-care changes outside the transition window by contacting Member Service.

Exception request timing: Members or prescribers may request an exception to cover a drug not on the Drug List or to change plan rules (for example, to increase a quantity limit or remove step therapy/prior authorization). After receipt of the prescriber's supporting statement, routine exception decisions are issued within 72 hours and expedited exception decisions within 24 hours if urgency is supported by the prescriber.72 hours routine; 24 hours expedited

How to request an exception: Exception requests are initiated by calling Member Service; the Member Service representative will work with the prescriber. Prescriber's supporting statement can be faxed, mailed, or provided by phone then followed up with fax or mail per plan instructions.

This document lists the drugs included on the plan's List of Covered Drugs (the "Drug List"). It does not guarantee coverage for any drug that is not on the Drug List; coverage is limited to drugs that meet the plan's network and benefit rules and are dispensed at a plan network pharmacy. Members and prescribers should confirm network pharmacy participation and current Drug List status online or by calling Member Service at 1-800-332-5762.

If a drug is not on the Drug List, members may either select an alternative drug that is on the Drug List (after consulting with their prescriber) or request an exception from the plan. Exception requests require a prescriber's supporting statement and follow the plan's exception process and timelines; contact Member Service or review the plan website for details on submitting exception requests.

No explicit coverage exclusions are stated in the referenced formulary excerpts. The listings show drug-specific formulary controls such as Drug Tier, Requirements/Limits (for example NDS, QL, PA), but do not present standalone exclusion language in these chunks.

The cited sections do not list explicit excluded drugs; instead they document formulary management controls applied per product (for example, Quantity Limits (QL), Prior Authorization (PA), and NDS). Coverage decisions depend on satisfying those controls where shown for each drug.

The plan covers drugs only when they are medically necessary. Coverage is provided when the prescriber states the drug is medically necessary, the plan agrees the drug is medically necessary for the member, and the prescription is filled at a plan network pharmacy. Coverage is therefore subject to the plan's determination of medical necessity.

Within the provided excerpts there are no explicit statements labeling specific drugs as universally "not medically necessary." The document instead applies utilization controls and clinical requirements at the product level (e.g., PA, QL, NDS) which inform coverage determinations.

Prior Authorization, Step Therapy, Documentation and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs on the Drug List. When a drug entry is flagged with "PA" (or with combined flags such as "NDS, PA"), the prescriber or member must obtain approval from the plan before the prescription is filled. Failure to obtain required prior authorization may result in the plan not covering the drug.

PA applies to drugs explicitly labeled "PA" in the Requirements & Limits column.
Drugs marked "NDS, PA" or "NDS" frequently also require PA and specific distribution (e.g., specialty pharmacy) per the Drug List.
Examples of agents requiring PA: many oncology and specialty agents (e.g., IMBRUVICA, XPOVIO, TRIKAFTA), hepatitis C agents (e.g., EPCLUSA, HARVONI, MAVYRET), biologics and immunologic agents (e.g., REPATHA, HUMIRA, COSENTYX, DUPIXENT), selected specialty injectables (e.g., MOUNJARO, SOMATULINE DEPOT), and tier 4 / high-cost drugs (multiple entries).

Prior Authorization

Prior Authorization and Quantity Limits

Some drugs require both prior authorization and specific quantity limits (QL). Claims submitted without an approved PA or that exceed the specified QL may be denied. Prescribers must document medical necessity when requesting PA or an exception to QLs.

Quantity limits are shown per product (examples: opioid MME limits, insulin/pen limits, inhaler/inhalation device limits).
Examples: REPATHA 140 mg/ml requires PA and a QL of 3 syringes/28 days or 3 pens/28 days; many hepatitis C agents have NDS, QL and PA (EPCLUSA, HARVONI, MAVYRET).
Requests exceeding QL or without required PA may be denied; prescribers should include supporting documentation with the PA request.

Denial Risk

Denial Triggers: PA, NDS, MME and Other Flags

Drugs flagged with additional controls (NDS, B/D, MME) can trigger denials if supporting information is missing. Opioid products flagged with MME limits require cumulative MME calculations; failing to document justification or to obtain PA may cause denial.

MME (morphine milligram equivalent) limits apply across opioid class products; prescribers must document rationale when requesting quantities above the MME threshold.
B/D entries may require information describing the use and setting to determine Part B vs Part D coverage.
NDS/PA flagged products (e.g., ARIKAYCE, CAYSTON, many immunoglobulins) require PA and may have specialized dispensing rules; lack of PA or incorrect distribution may result in denial.

Documentation Required

Documentation Required for PA, Exceptions and Quantity Overrides

Prescribers must provide supporting documentation when requesting prior authorization, step therapy exceptions, or coverage beyond quantity limits. The plan processes standard exception requests within 72 hours after receiving the prescriber's supporting statement (24 hours for expedited requests when clinically necessary).

Supporting statement may be faxed, mailed, or provided by phone per plan instructions; contact numbers appear in member/provider materials.
For expedited exceptions, prescriber's support allows decision within 24 hours; standard exceptions are decided within 72 hours.
Documentation should include clinical rationale, prior treatments tried (when applicable), and dose/quantity justification.

Step Therapy

Step Therapy Restrictions and Exceptions

Step therapy rules may apply for certain drugs. Although specific step sequences are not listed in this extract, step therapy restrictions and any posted step requirements are available on the plan website and can be appealed with a prescriber-supported exception.

Members may request an exception to step therapy if the prescriber documents that the required prior agent is inappropriate or ineffective.
Step therapy rules are subject to change; check the online formulary documents for current protocols.

Billing Rule

Use Requirements & Limits Fields; Maintain PA/NDS/QL Documentation

Maintain and submit the Drug List Requirements & Limits fields (PA, NDS, QL, MME) with claims and PA requests. Use the Requirements & Limits indications on the Drug List to determine needed actions to avoid denials.

Verify tier assignment and QL on the Drug List when submitting claims; higher-tier specialty agents commonly require PA and may be limited to specialty distribution.
For immunoglobulins and IVIG products, entries list NDS and PA — ensure PA and any required infusion documentation are in place prior to dispense.
Support QL with clinical documentation (e.g., RESTASIS QL examples) when requesting quantities at or above the limit.

Step Therapy Rules and Exceptions

Summary	Notes
Some drugs are subject to step therapy (members must try specified drugs first).
Details of step therapy rules and the current Drug List are posted online and may change during the year.

Policy statement	Operational note
Step therapy applies where indicated in the Requirements & limits on use and Drug List tables; members may request an exception to step therapy.
Exception requests are processed per the plan’s exception process (prescriber supporting statement required; decision timelines: routine 72 hours, expedited 24 hours).

Observation	Implication
Multiple antiretroviral products are listed with QL and NDS designations (examples: APTIVUS, atazanavir, darunavir, etravirine and combination agents).
The extract shows QL and NDS flags but does not specify explicit step‑therapy sequencing for these antiretroviral entries in this excerpt.

Covered products	Requirement
Select hepatitis C products are listed (examples: EPCLUSA, HARVONI, MAVYRET, VOSEVI).
Where the Requirements/Limits column shows 'PA' for these products, prior authorization is required before coverage.

Observation	Management flags
Many oncology and multiple‑sclerosis or other cancer therapies are listed (examples: INQOVI, LONSURF, AVONEX, COPAXONE, fingolimod).
These therapies include Requirements/Limits such as PA, NDS and QL, indicating prior authorization and quantity limits or other utilization controls may apply.

Listing	Clarification
Starter packs, patient titration packs and PAK presentations appear for some products (examples: AUSTEDO XR patient titration, XCOPRI PAK, MAYZENT starter packs referenced in inventory).
Although starter/titration pack presentations are listed, explicit step‑therapy sequencing rules tied to these starter packs are not provided in this extract.

Summary	How utilization is managed
No explicit step therapy sequences are specified in this extract.
Utilization is managed through product flags and controls shown in the Drug List (e.g., Prior Authorization (PA), Non‑drug‑specific/NDS designations, and Quantity Limits (QL)).

Quantity Limits — Examples and Specific Product Limits

Unspecified plan-set amount limits

Plan may set amount limitsUnspecified quantity limits may be applied by the plan for some drugs; consult Section D tables for drug-specific limits

Where to find specificsSee Section D tables in the Drug List for the product-specific QL and requirements

Effect on coverageQuantity limits can affect coverage and may trigger exception or PA processes if additional quantity is needed

Colchicine quantity limits

Colchicine (generic)QL 120 tabs / 30 days

MITIGARE (colchicine) capsQL 60 caps / 30 days

Buprenorphine patch quantity limit

Buprenorphine transdermal patch (PTWK)QL 4 patches / 28 days

NotesListed with PA and MME where indicated

Fentanyl PT72 (various strengths) QLs

Fentanyl PT72 (12-75 mcg/hr)QL 10 patches / 30 days

Fentanyl PT72 (100 mcg/hr)QL 8 patches / 30 days

Methadone solution 5mg/5ml QL

Methadone HCl solution 5mg/5mlQL 1200 mL / 30 days

Methadone HCl solution 10mg/5mlQL 600 mL / 30 days

Methadone solution 10mg/5ml QL

Methadone HCl solution 10mg/5mlQL 600 mL / 30 days

Fentanyl PT72 12-75 mcg/hr QL

Fentanyl PT72 12-75 mcg/hrQL 10 patches / 30 days

Fentanyl PT72 100 mcg/hr QL

Fentanyl PT72 100 mcg/hrQL 8 patches / 30 days

Methadone HCl solution 5mg/5ml

Methadone HCl solution 5mg/5mlQL 1200 mL / 30 days

Methadone HCl solution 10mg/5ml

Methadone HCl solution 10mg/5mlQL 600 mL / 30 days

Morphine sulfate TBCR common strengths QL

Morphine sulfate TBCR (common strengths)QL 60 tabs / 30 days; PA; MME

Posaconazole suspension QL

Posaconazole suspension 40 mg/mLQL 630 mL / 30 days; NDS

Posaconazole tablets QL

Posaconazole TBEC 100 mgQL 93 tabs / 30 days; NDS

ISENTRESS PACK QL

ISENTRESS PACK 100 mgQL 300 packets / 30 days

Maraviroc 150 mg QL

Maraviroc tablets 150 mgQL 240 tabs / 30 days (per listing)

SUNLENCA QL

SUNLENCA tablets 300 mgQL 24 tabs / year; NDS noted

HARVONI PAK QL

HARVONI PAKQL 28 packets / 28 days; PA; NDS

MAVYRET QL

MAVYRET tabletsQL 84 tabs / 28 days; PA; NDS

Multiple oncology examples — QLs

Oncology examplesSample QLs include 14 tabs / 28 days; 100 tabs / 28 days; 60 tabs / 30 days depending on product

ManagementMany oncology agents listed with NDS, PA and product-specific QLs

Multiple product limits (varies by product and strength)

Assorted product limitsExamples vary by product/strength: 28 tabs/28 days; 30 tabs/30 days; 60 tabs/30 days; specific mL limits per 28–30 days

Check Section DProduct-specific QLs are shown in Section D entries

KERENDIA QL

KERENDIA (finerenone)QL 30 tabs / 30 days

ENTRESTO / sacubitril-valsartan QLs

ENTRESTO (sacubitril-valsartan) capsQL 240 caps / 30 days

sacubitril-valsartan (tabs)QL 60 tabs / 30 days

REPATHA QL

REPATHA (evolocumab) 140 mg/mLQL 3 syringes or 3 pens / 28 days; PA

INBRIJA QL

INBRIJA capsules 42 mgQL 300 caps / 30 days; PA; NDS

Clozapine and INVEGA HAFYERA QLs

Clozapine tablets 100 mgQL 270 tabs / 30 days

INVEGA HAFYERA SUSYQL 1 injection / 180 days; NDS

BRIVIACT, perampanel, phenobarbital QLs

BRIVIACT solution 10 mg/mLQL 600 mL / 30 days

Perampanel tabletsQL 30 tabs / 30 days

Phenobarbital elixir 20 mg/5 mLQL 1500 mL / 30 days

Pregabalin, rufinamide, SYMPAZAN QLs

Pregabalin solution 20 mg/mLQL 900 mL / 30 days

Rufinamide suspension 40 mg/mLQL 2400 mL / 30 days

SYMPAZAN film 5 mgQL 60 films / 30 days

VALTOCO, vigabatrin, XCOPRI QLs

VALTOCO (various strengths)QL 10 blister packs / 30 days; NDS

Vigabatrin 500 mg tabsQL 180 tabs / 30 days

XCOPRI PAK 12.5-25QL 28 tabs / 28 days

EMGALITY QL

EMGALITY 120 mg/mL (SOAJ)QL 2 pens / 30 days; PA

UBRELVY QL

UBRELVY tabletsQL 16 tabs / 30 days; PA

KLOXXADO QL

KLOXXADO liquid 8 mg/0.1 mLQL 2 sprays / 30 days

Testosterone gel QLs (1% and 1.62%)

Testosterone gel 1%QL 300 gm / 30 days; PA

Testosterone gel (alternate entry) 1%QL 300 gm / 30 days; PA

Testosterone gel 1.62%QL 150 gm / 30 days; PA

GLP-1 pen QLs (MOUNJARO, TRULICITY)

MOUNJARO pensQL 4 pens / 28 days; PA

TRULICITY pensQL 4 pens / 28 days; PA

Insulin pen/vial quantity limits

FIASP solution 100 unit/mLQL 9 vials / 30 days

Insulin pen/vial examplesOther insulin QLs include 6 pens / 30 days or 9 vials / 30 days depending on product

Patch and mesalamine QLs examples

Patch examplesQL 8 patches / 28 days (dotti, estradiol PTTW, lyllana)

Estradiol PTWK patchQL 4 patches / 28 days

Mesalamine CP24 (caps)QL 120 caps / 30 days

Tolvaptan QLs

Tolvaptan formulationsQL varies by formulation/pack: examples include 30–60 tabs/28–30 days or 56 tabs/28 days for therapy packs; PA and NDS as listed

Promethazine / scopolamine and glycopyrrolate QLs

Scopolamine patch (PT72)QL 10 patches / 30 days

Glycopyrrolate tabletsQL 90–120 tabs / 30 days where specified

Selected immunologic biologic QLs

DUPIXENT (dupilumab)QL 4 pens / 28 days; NDS, PA

COSENTYX (secukinumab)QL 17 syringes / year or 34 syringes / year depending on presentation; NDS, PA

HUMIRA (various presentations)Examples: QL 2 injections / 28 days (some kits) or 4 injections / 28 days for pens/syringes; NDS, PA

MOVANTIK QL

MOVANTIK (naloxegol)QL 30 caps / 30 days

HUMIRA presentations QLs

HUMIRA PSKT 10 mg/0.1 mLQL 2 injections / 28 days; NDS, PA

HUMIRA PSKT 20 mg/0.2 mL; 40 mg/0.4 mL; 40 mg/0.8 mLQL 4 injections / 28 days; NDS, PA

HUMIRA PEN AJKT 80 mg/0.8 mLQL 2 injections / 28 days; NDS, PA

SIMLANDI, SKYRIZI, TREMFYA QLs

SIMLANDI PSKT (various)QL examples: 1–6 injections / 28 days depending on presentation; NDS, PA

SKYRIZI SOCTQL 1 cartridge / 56 days; NDS, PA

TREMFYA SOPN 100 mg/mLQL 1 pen / 28 days; NDS, PA

XELJANZ QL

XELJANZ tablets 5 mg, 10 mgQL 60 tabs / 30 days; NDS, PA

GAMMAPLEX NDS/PA note

GAMMAPLEX solution (various strengths)NDS indicated; PA required

Ophthalmic QLs examples

Ciprofloxacin ophthalmic solution 0.3%QL 30 mL / 30 days

RESTASIS single-use vialsQL 60 single-use vials / 30 days

RESTASIS QLs

RESTASIS emulsion .05% (single-use vials)QL 60 single-use vials / 30 days

RESTASIS multidose emulsion .05%QL 5.5 mL / 30 days

Inhaler QLs

ANORO ELLIPT AERQL 60 blisters / 30 days

Albuterol inhalers (examples)QL 2 inhalers / 30 days

Multiple CF specialty product QLs

KALYDECO / TRIKAFTA / ORKAMBI examplesPack/packet/tab limits vary: e.g., 56 packets / 28 days; 84 tabs / 28 days depending on product; NDS, PA

Key Terms and Abbreviations

Prior authorization definition

Prior authorization (PA)Permission from the plan obtained before filling a prescription to confirm coverage is approved.

Step therapy definition

Step therapyA coverage rule requiring members to try specified drugs in sequence before covering others.

Quantity limits definition

Quantity limits (QL)Plan-imposed limits on the amount of a drug that can be dispensed during a set time period (e.g., 'QL (120 tabs / 30 days)').

Common abbreviations (PA, QL, B/D)

PA abbreviationPA = Prior Authorization (plan requires approval before filling certain drugs)

QL abbreviationQL = Quantity Limit (plan limits amount covered per time period)

B/D abbreviationB/D = May be covered under Medicare Part B or D depending on use/setting

Tier 4 definition and implication

Tier 4 definitionTier 4 = Specialty Tier: drugs with cost over $950 per month

Example implicationTier 4 drugs frequently have PA and QL controls listed in Section D

Examples of QL/PA/NDS usage

QL usage exampleQuantity Limit example formatting: 'QL (120 tabs / 30 days)' as shown in listings

PA usage examplePrior Authorization indicated by 'PA' in Requirements/Limits field

NDS usageNDS appears with PA/QL for certain specialty products (e.g., posaconazole, ISENTRESS entries)

OpenPayer

List of Covered Drugs (Drug List)

Coverage Criteria and Scope

Document Identifiers, Drug Lists and Codes

Prior Authorization, Step Therapy, Documentation and Denial Risks

Step Therapy Rules and Exceptions

Quantity Limits — Examples and Specific Product Limits

Setting-Specific Coverage Considerations

Biosimilars and Interchangeable Products

Key Terms and Abbreviations

Policy Background and Scope