Blue Cross Blue Shield TN prescription drug coverage

Formulary Coverage and Conditions

General Coverage

Covered when ALL of the following are met

General formulary coverage: Drug is listed on the plan formulary; the drug is medically necessary; prescription is filled at a plan network pharmacy; other plan rules (prior authorization, quantity limits, step therapy) are followed.

See the Requirements/Limits column in the formulary for product‑level flags (PA, QL, NDS, B/D) and exact limits.

Transition/Temporary Coverage

Temporary coverage during transitions or early membership

Transition supply for non‑formulary or restricted drugs: For each drug that is not on the formulary or that has a coverage restriction, the plan will cover a temporary supply while the member and prescriber pursue an exception or alternative therapy.30 days (31 days for long‑term care residents)

If coverage is not approved after the temporary supply, the plan will not pay thereafter.

Mid-year Formulary Changes

Rules when formulary is changed during the year

Mid‑year changes and member options: The plan may add, remove, or re‑tier drugs during the year (including immediate substitutions when a generic or certain biosimilar is added); members currently taking a drug affected by a change may request a formulary exception to continue coverage.

Updates are posted monthly; when changes impose new restrictions or tier increases affected members will be notified at least 30 days before the change or provided a 30‑day supply at refill.

Formulary coverage and limits

Formulary coverage and supply rules for BlueCare Plus Select members

Supply duration and tier‑specific rules: Standard retail and mail‑order drugs are available as a 30‑day supply; Tiers 1 & 2 may be eligible for up to a 100‑day supply, Tier 3 up to 90 days, and Tier 4 (specialty) eligible for 30‑day supply only; drugs marked NDS (non‑extended day supply) are not eligible for long‑term supplies.30/90/100 days

Copays/coinsurance vary by tier and Extra Help level.

Cost‑sharing by tier (BlueCare Plus Select): Tier 1 = Preferred Generics; Tier 2 = Preferred Brands; Tier 3 = Non‑Preferred Drugs; Tier 4 = Specialty (cost over $950/month). Cost sharing examples: Tier 1 $0 copay; Tiers 2–4 generally subject to coinsurance (example: 25% coinsurance shown in formulary summary).

Refer to benefit documents for exact member cost‑share amounts.

Utilization management indicators: Drugs labeled PA require prior authorization; QL indicates a quantity limit; B/D entries may require documentation to determine Medicare Part B vs Part D coverage; MME monitoring applies across opioid class.

Coverage with quantity limits and PA

Covered when supplied within listed quantity limits and prior authorization obtained where indicated

Coverage gating for QL/PA items: Member coverage applies when the medication is dispensed within the listed quantity limit for that formulation and when prior authorization is obtained for products marked PA.See per‑drug QL entries (e.g., PREVYMIS QL 120 packets/30 days; INQOVI QL 5 tabs/28 days; PEGASYS QL 4 vials/28 days).

Per‑product clinical eligibility criteria are not provided in this formulary; PA requests must follow the plan’s prior authorization process.

Formulary entries (administrative coverage parameters)

Formulary coverage entries indicate drug tier and whether prior authorization and quantity limits apply. No diagnostic or clinical criteria provide product‑level medical‑necessity rules in these chunks.

Formulary entry structure: Each listed drug/form displays an assigned Drug Tier and Requirements/Limits flags such as NDS (non‑extended day supply), QL (quantity limit with exact units/time period), PA (prior authorization), and occasionally B/D (Part B vs D determination).

Clinical inclusion/exclusion criteria are not included in the listing; use the Requirements/Limits column to identify administrative controls.

Coverage by formulary listing

Coverage listed per drug is subject to the stated tier and any Requirements/Limits (e.g., QL, PA, NDS).

Per‑product coverage rule: A drug shown on the formulary is covered according to its assigned drug tier provided any listed Requirements/Limits (quantity limits, prior authorization, NDS, B/D) for that formulation/strength are satisfied.

Examples in the formulary: sacubitril‑valsartan QL (60 tabs/30 days); REPATHA requires PA and QL (3 syringes/28 days or 3 pens/28 days); droxidopa higher strengths marked NDS, QL and PA.

Formulary requirements per drug

Coverage and requirements as listed for individual drugs (formulary rules per product):

PA and NDS for specialty/high‑tier drugs: Many specialty or high‑tier drugs are listed with 'NDS, PA' — prior authorization is required and non‑extended day supply or nonstandard distribution rules apply.

Examples include ADEMPAS, UPTRAVI, VYNDAMAX, droxidopa (200/300 mg), bosentan, ambrisentan.

Adherence to specified quantity limits: Specified QL values in the Requirements/Limits column must be adhered to for covered dispensing (for example, UPTRAVI QL (140 tabs/28 days) or sildenafil QL (360 tabs/30 days)).

Requests exceeding QL may require additional prior authorization or be denied.

General formulary coverage

Drugs are covered subject to the listed drug tier and any associated utilization management requirements (PA, QL, NDS).

General coverage gating: A listed drug is covered when dispensed within the product‑specific quantity limit and when prior authorization (if listed) has been obtained.Per‑product QL and PA as listed in the formulary

This formulary segment does not provide detailed clinical eligibility criteria; follow PA instructions when indicated.

Covered with conditions (QL/PA)

Formulary coverage is conditional based on per‑product Quantity Limits and Prior Authorization as listed.

Condition for coverage when QL/PA apply: Coverage is available only when the requested dispensing does not exceed the listed Quantity Limit AND prior authorization is obtained for products marked PA.QL and PA per product

If PA is not approved or QL is exceeded, the claim may be denied.

Product-level coverage indicators

Coverage and utilization controls are product‑specific as listed; items are either tiered with optional QL, or marked NDS and PA indicating prior authorization/nonstandard coverage.

Product‑level tiering: Products are assigned Drug Tier values (1–4) that determine benefit placement and potential cost sharing.

See product rows for exact tier assignments across the formulary.

General coverage statement

Coverage follows product tiering with PA and quantity limits as indicated per product.

Formulary gating summary: Each product is covered according to its assigned tier when prior authorization and any listed quantity limits (if applicable) are satisfied for that item.See per‑product QL and PA entries

This document excerpt lists administrative controls per product; clinical‑level medical necessity criteria are not present in these chunks.

Drugs that are withdrawn from sale by the manufacturer or that the FDA determines to be withdrawn for safety or effectiveness reasons may be immediately removed from the formulary; the plan will provide notice to affected members who take the drug as described in the formulary change policy.

A long-term supply is not available for drugs labeled with the NDS indicator. NDS denotes non-extended day supply and drugs with this flag are eligible for up to a 30-day supply only (longer retail/mail supplies allowed for other tiers as noted elsewhere).

Within this document segment there are no explicit formulary exclusions listed; the extract contains product listings with utilization flags (QL, PA, NDS) but does not enumerate specific excluded therapies.

No explicit medical exclusions are stated in the provided extract; the listing presents drug-level tiering and requirements (e.g., NDS, QL, PA) rather than clinical exclusion criteria.

Entries marked NDS in the Requirements/Limits column denote non-standard dispensing or special handling; operationally these entries function as flags that may limit long-term supply or require additional review prior to coverage.

The excerpt does not list any explicit coverage exclusions for the drugs shown; product rows instead display tier assignments and utilization controls (NDS, QL, PA) without stating that listed items are excluded.

Absence of a drug from the included formulary segment is not explicitly described as noncoverage in this extract; the document lists covered items with associated flags, and omission from a segment may imply noncoverage but is not stated here.

No explicit exclusions are provided in this excerpt; the formulary lines shown focus on tier, quantity limits and prior authorization indicators rather than listing excluded medications.

Certain products are indicated as NDS (non‑extended/non‑standard distribution) in the Requirements/Limits column (for example, some budesonide and high-strength CREON entries). This suggests such products require special handling and may be subject to restricted coverage or additional review.

Some entries include a B/D designation in Requirements/Limits, which reflects benefit/dispense or Part B/Part D considerations and may require documentation to determine the correct benefit and coverage pathway.

Specialty agents flagged as NDS (e.g., cystic fibrosis and orphan drug entries) are commonly paired with PA and QL controls; the NDS designation for specialty drugs typically indicates restricted coverage pathways or non‑standard dispensing that require prior authorization and claim-level documentation.

This segment does not include any explicit 'not medically necessary' determinations; listings show product-level utilization management flags (NDS, PA, QL) but do not label items as not medically necessary in the provided extract.

No 'Not Medically Necessary' determinations appear in these chunks; the document focuses on tiering and utilization controls rather than explicit medical necessity denials in this excerpt.

Within the provided content there are no items explicitly labeled 'Not Medically Necessary'; product lines primarily indicate NDS, PA or QL requirements rather than NMN determinations.

This portion of the formulary does not include explicit 'not medically necessary' statements; coverage is presented as conditional on meeting listed utilization controls (PA, QL, NDS).

No explicit 'Not Medically Necessary' findings are provided in these chunks; the extract lists product-level requirements and limits without NMN language.

There are no explicit 'not medically necessary' rationale statements in this extract. Some products are labeled NDS, which in practice may operate as an operational limit that could result in noncoverage absent required prior authorization or documentation.

No explicit 'Not Medically Necessary' statements are present in the provided segments; formulary lines emphasize benefit-design flags and utilization management rather than NMN determinations.

Formulary Codes, Tiers, and Supply Rules

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Our plan requires prior authorization (PA) for many drugs listed in the formulary. When a drug line shows the Requirements/Limits flag PA (or NDS, PA), you or the prescriber must obtain approval from the plan before the prescription will be covered. Failure to secure required PA may result in denial of coverage.

PA indicator present in Requirements/Limits column for many specialty, antiviral/hepatitis, antifungal, oncology, biologic, and high‑cost agents
NDS, PA entries indicate non‑extended supply items that also require prior authorization
B/D flagged products may require additional documentation to determine Part B vs Part D coverage

Prior Authorization

PA Required for Specific Drugs (specialty/oncology)

Specific drugs and drug groups that require prior authorization include — but are not limited to — listed specialty and high‑cost agents in the formulary. Examples: ARIKAYCE, many IV/injectable antimicrobials, numerous oncology agents (eg, LONSURF, XTANDI, many oral targeted therapies), and many specialty oral packs and starter packs that show NDS, PA.

Terms and Abbreviations

Initial Dispensing and Therapy Guidance

Initial therapy dispensing guidance

Tiering and quantity limits guide initial dispensing.

Initial dispensing guidance: Initial prescriptions should be dispensed consistent with the drug’s assigned tier and the quantity limit shown; Tier 1 products are preferred for cost‑share and may be dispensed without PA, while higher tiers may require PA or have QLs.Refer to per‑drug QL values

Specific step‑therapy algorithms are not provided in these segments; follow PA procedures when PA is indicated.

Step Therapy Rules and Examples

Step	Description	Notes/Indicators
1
Plan may require members to try specified alternative drugs before covering another agent (step therapy).
See formulary Requirements/Limits flags (PA, QL, NDS) per drug; specific step sequences are not listed in the provided formulary extract.

Drug / Category	Tier	Requirements/Limits
colchicine (tabs 0.6 mg)
Tier 2
QL (120 tabs / 30 days)
amlodipine‑atorvastatin combination (multiple strengths)
Tier 3
QL (30 tabs / 30 days)
tadalafil (tabs 2.5 mg, 5 mg)
Tier 3
QL (30 tabs / 30 days); PA

Therapeutic Area / Example	Step Therapy Specified?	Requirements/Limits
Oncology (e.g., XTANDI, lenalidomide)
No explicit step therapy sequences provided in this segment
Many entries show NDS, QL (e.g., XTANDI QL 120 caps/30 days) and PA as applicable
Multiple Sclerosis agents (e.g., AVONEX, COPAXONE)
No explicit step therapy sequencing provided
Requirements: NDS, QL (injections/tabs per period), PA

Product / Class	Tier	Requirements/Limits
Amlodipine‑atorvastatin combination products
Tier 3
QL (30 tabs / 30 days) — no explicit step sequence provided
Immunosuppressants / small‑molecule agents (e.g., everolimus, mycophenolate)
Tiers 3–4
B/D or NDS flags present; some formulations require PA and/or have QL

MS Agent / Example	Step Therapy Specified?	Requirements/Limits
AVONEX, BETASERON, COPAXONE (multiple formulations)
Specific step therapy sequencing not detailed in extract
Requirements: NDS; QL (injections or tabs per period, e.g., 1 injection / 28 days, 12–30 injections / period); PA required

Product	Requirement(s)	Notes
tadalafil (tabs 2.5 mg, 5 mg)
QL (30 tabs / 30 days); PA
PA plus QL may function as utilization management before coverage is approved; explicit step predecessor not listed

Product / Flag	Implication	Step Therapy Specified?
mycophenolate mofetil (suspension) — NDS, B/D
Indicates special benefit/dispense handling and non‑extended day supply — may require documentation to adjudicate B/D
No explicit step therapy rule provided in extract
Various specialty agents marked NDS/PA (e.g., ADEMPAS, UPTRAVI, droxidopa)
NDS/PA flags imply prior authorization and nonstandard distribution; may necessitate provider documentation
Step therapy sequencing not specified in these entries

Product / Device	Requirement/Limit	Coverage Implication
ATROVENT HFA, PROAIR RESPICLICK, SPIRIVA RESPIMAT (inhalers)
QL entries (e.g., QL 1–2 inhalers / 30 days) and some B/D flags
Quantity limits and B/D indicators may restrict refill frequency; no explicit step therapy sequencing provided
Ipratropium/nebulized solutions
Some forms marked B/D or QL (e.g., QL 30 mL / 30 days)
May require documentation and adherence to QL before refill or coverage

Per-product Quantity Limits (Selected Examples)

Administration and Dispensing Locations

Note

Formulary Background

The formulary groups medications by medical condition and provides coverage information including drug tier, quantity limits, prior authorization, and special requirement flags (such as NDS and B/D) to guide prescribing and dispensing decisions for plan members.

Policy Revision History

2026-04-01effectiveLatest

Formulary posted as current and effective on 04/01/2026; no subsequent changes reported in this document.

2026-03-24approval

Formulary version 14 (Formulary ID 26162 v14) was approved by CMS on 03/24/2026.

2026-01-01annual_update

OpenPayer

2026 BlueCare Plus Select (HMO D-SNP) Formulary — Prescription Drug Coverage Criteria