CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Preferred Formulary Guide (Prescription Drug Formulary, PA/Step Therapy/QL Programs)

This document describes the prescription drug formulary, coverage programs (prior authorization, step therapy, quantity limits), pharmacy networks, and member instructions for BlueCross BlueShield of Tennessee members. It applies to members whose plans use this formulary guide.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPreferred Formulary Guide (Prescription Drug Formulary, PA/Step Therapy/QL Programs)

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateFebruary 2026

Next Review DateN/A

Key ActionWhen a drug row shows 'PA', the prescriber must request prior authorization via CoverMyMeds, by calling 1-800-924-7141, or faxing 1-888-343-4232.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90-dayRetail 90 / home delivery

1-800-924-7141Prior auth phone

1-800-552-8159Home delivery contact

PA & QLRequirement types

multipleDrug entries with PA/QL

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OTC mentionOTC alternatives noted

Coverage Criteria

Admin-controlled coverage (PA + QL)

Coverage is conditional on administrative controls indicated on each drug row (examples below).

Example stimulant/ADHD entries: Coverage allowed when prior authorization is obtained if the formulary row indicates 'PA', and the dispensed quantity does not exceed the stated QL for the specified time period.see QL per drug

Per-product QLs shown in formulary (examples: amphetamine‑dextroamphetamine, dextroamphetamine, lisdexamfetamine, methylphenidate: QL values range from 30–150 units per 30 days or specified mL for solutions).

General coverage with PA and QL

Coverage is managed by drug-specific requirements; many products are covered subject to PA and within specified QLs.

General formulary controls: Drug is covered on formulary when benefit conditions are met and prior authorization is obtained where indicated ('PA' listed in Requirements/Limits).see product QL in Requirements/Limits

Applies per product entry in the formulary table; failure to obtain PA or exceeding QL may result in denial or claim limitation.

Formulary coverage entries

Covered products are listed with drug tier and any requirements/limits.

Formulary entries (examples): Example entries include: XIFAXAN 200 mg (PA, QL 9 tabs every 30 days); NUCALA presentations (MT = PA, QL specified — e.g., 1–3 injections/vials every 28 days; LD noted); vancomycin oral caps/solutions (QL per 30 days); BREO ELLIPTA (QL 60 blisters every 30 days, MT).per-entry QL as listed

Each line in the formulary identifies tier and any PA, QL, MT, or LD attributes; these administrative controls govern coverage and claims adjudication.

Members must use an in-network pharmacy for covered prescriptions. The formulary states that if a member uses an out-of-network pharmacy, the member may be responsible for paying all costs for the prescription.

The formulary notes that the availability of an over-the-counter (OTC) alternative can affect coverage: some prescription drugs may not be covered when an OTC product that "works just as well" is available. Members and prescribers should consult the pharmacist or plan guidance before substituting OTC products.

There are no explicit clinical exclusions) stated in the extracted formulary lines. Instead, coverage for many products is controlled administratively: drugs listed with a Requirements/Limits annotation of PA (prior authorization) and a QL (quantity limit) must have the PA obtained and be dispensed within the stated QL (e.g., QL values such as 60 caps every 30 days, 120 caps every 30 days, etc.). Failure to obtain PA or exceeding the listed QL may result in nonpayment or denial at claim adjudication.

Within the provided excerpt there are no explicit exclusions listed. The entries instead show formulary tiers and product-level Requirements/Limits (for example, monoclonal antibody asthma agents annotated with PA, QL, and sometimes LD), indicating administrative controls rather than itemized clinical exclusions.

The extract does not provide discrete patient-level medical necessity criteria. Coverage information is presented as formulary tiers and per-product utilization management flags (for example, entries annotated with PA, QL, MT, or LD), which imply program requirements must be satisfied for coverage but do not spell out clinical inclusion/exclusion rules in this excerpt.

No explicit clinical exclusions are stated in this segment of the formulary. Instead, several products are shown with Requirements/Limits indicators (e.g., PA, LD) that denote administrative coverage controls.

This excerpt does not list explicit clinical exclusions. Coverage decisions in the visible lines are governed by administrative annotations: many drug rows include PA (prior authorization), QL (quantity limits), and sometimes LD (limited distribution). These flags indicate that prescriptions may be denied if program requirements (PA, step therapy, or QL) are not met.

This inventory placeholder does not contain source text in the provided excerpt and therefore no coverage detail can be stated here.

No statements in this extract are labeled explicitly as 'not medically necessary.' The document segment focuses on formulary listings, tiers, and utilization management flags rather than explicit non‑medical‑necessity determinations.

This inventory placeholder has no corresponding source text in the supplied excerpt and cannot be populated with coverage-specific language.

Coding and Code Lists

Drug entries (no procedure/diagnosis codes)mixed

not provided

Document lists drug names, strengths, forms and utilization annotations; no CPT/HCPCS/ICD codes present in these chunks.

Biologic product strengths listedmixed

40MG/0.4ML	ADALIMUMAB-ADAZ SOAJ 40MG/0.4ML
80MG/0.8ML	ADALIMUMAB-ADAZ SOAJ 80MG/0.8ML

Soluble TNF receptor agents strengthsmixed

25MG/0.5ML	ENBREL SOLN 25MG/0.5ML
50MG/ML	ENBREL SOSY 50MG/ML

No CPT/HCPCS/ICD-10 codes in this excerptmixed

No codes listed

Formulary quantity/prior auth notationsmixed

QL (60 tabs every 30 days)	Quantity limit example listed for many oral tablet products (exact per-product limits vary)
QL (4 pens every 28 days)	Quantity limit example for some injectable GLP-1 products (e.g., MOUNJARO, TRULICITY)
QL (1 pen every 28 days)	Quantity limit example for OZEMPIC
QL (30 tabs every 30 days)	Common monthly quantity limit for many oral agents (example: JANUVIA)

Formulary drug listings (selected examples)NDC|Mixed

benztropine mesylate	tabs .5mg, 1mg, 2mg
pramipexole dihydrochloride	tabs .125mg, .25mg, .5mg, .75mg, 1mg, 1.5mg; tb24 .375mg, .75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg
abacavir sulfate	tabs 300mg

Brand injectables/long-acting agentsMixed

REXULTI	TABS .25MG, .5MG, 1MG, 2MG, 3MG, 4MG
CABENUVA	SUS 400-600 / 600-900 (long-acting injectable)

Selected antiviral products with PA/QLmixed

PAXLOVID PAK	PAXLOVID PAK — Requirements/Limits = QL (11 tabs every 5 days)
PAXLOVID TAB 150-100	PAXLOVID TAB 150-100 — Requirements/Limits = QL (20 tabs every 5 days)
PAXLOVID TAB 300-100	PAXLOVID TAB 300-100 — Requirements/Limits = QL (30 tabs every 5 days)
EPCLUSA PAK 150-37.5	EPCLUSA PAK — Requirements/Limits = PA, QL (30 packs every 30 days)
EPCLUSA PAK 200-50MG	EPCLUSA PAK — Requirements/Limits = PA, QL (60 packs every 30 days)
EPCLUSA TAB 200-50MG	EPCLUSA TAB — Requirements/Limits = PA, QL (60 packs every 30 days)
EPCLUSA TAB 400-100	EPCLUSA TAB — Requirements/Limits = PA, QL (30 tabs every 30 days)
HARVONI PAK	HARVONI PAK — Requirements/Limits = PA, QL (30 packs every 30 days)
HARVONI PAK 45-200MG	HARVONI PAK — Requirements/Limits = PA, QL (30 packs every 30 days)
HARVONI TAB 45-200MG	HARVONI TAB — Requirements/Limits = PA, QL (30 tabs every 30 days)

1–10 of 12

1/2

Selected HIV antiretrovirals with QLmixed

EMTRIVA SOLN 10MG/ML	EMTRIVA SOLN 10MG/ML — QL (680 mL every 28 days)
FUZEON SOLR 90MG	FUZEON SOLR 90MG — QL (60 mL every 30 days)
ISENTRESS CHEW 25MG, 100MG	ISENTRESS CHEW — QL (180 tabs every 30 days)
ISENTRESS PACK 100MG	ISENTRESS PACK 100MG — QL (300 packets every 30 days)
ISENTRESS TABS 400MG	ISENTRESS TABS 400MG — QL (120 tabs every 30 days)
ISENTRESS HD TABS 600MG	ISENTRESS HD TABS 600MG — QL (60 tabs every 30 days)
TRIUMEQ TAB	TRIUMEQ TAB — QL (30 tabs every 30 days)
TRIUMEQ PD TAB	TRIUMEQ PD TAB — QL (180 tabs every 30 days)

Herpes and influenza agentsmixed

acyclovir caps/tabs/susp	Acyclovir formulations — tier 1-2 entries; quantity limits not specified
oseltamivir phosphate caps	Oseltamivir caps 30/45/75mg — QL (20 caps every 180 days for 30mg; 10 caps every 180 days for 45/75mg)
LAGEVRIO CAPS 200MG	LAGEVRIO CAPS 200MG — QL (40 caps every 5 days)

Morphine milligram equivalent (MME) threshold

MME threshold> 120 mg morphine equivalents per day — prior authorization required

Action to obtain PAProvider must request coverage review via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232

ScopeThreshold applies to combined total MME across medications

Common quantity limits example

Common QL pattern

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs on this formulary. Providers must request a coverage review electronically through CoverMyMeds, by calling 1-800-924-7141, or by faxing 1-888-343-4232. Specialty drugs typically require PA and are usually limited to 30-day supplies and specialty pharmacies in-network.

Submission methods: CoverMyMeds (digital), phone 1-800-924-7141, fax 1-888-343-4232
Specialty drugs usually require PA and may be limited to 30-day supply and specialty pharmacies

Prior Authorization

PA Required for Stimulants / ADHD Agents

Many stimulant and ADHD-class products require prior authorization and have quantity limits (QL). Examples include amphetamines, methylphenidate, lisdexamfetamine and related agents — most strengths/forms are listed with PA and specific QLs (caps/tabs per 30 days). Failure to obtain PA or exceeding QL may result in claim denial.

Stimulant-class products: PA and QL apply to many formulations and strengths
Examples: amphetamine-dextroamphetamine, dextroamphetamine, methylphenidate, lisdexamfetamine — check listed QL per 30 days

Background

Background: This formulary guide categorizes drugs by therapeutic category and formulary tier to indicate member cost-sharing and program requirements. It highlights utilization management programs used to ensure appropriate use, including Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), and Limited Distribution (LD). The listings show product-level annotations (for example, stimulant/ADHD agents and many specialty biologics are annotated with PA and specific QL values) that determine coverage at the pharmacy claim level. Specialty drugs are typically subject to PA and are commonly limited to 30-day supplies unless otherwise noted; quantity limits in the excerpt include examples such as QL (60 caps every 30 days), QL (120 caps every 30 days), and NUCALA QL (3 injections every 28 days).

Definitions and Abbreviations

PA — Prior Authorization definition and submission methods

Specialty drugs supplySpecialty drugs are usually limited to a 30-day supply

Retail 90 availabilityRetail 90 Network allows up to a 90-day supply for retail prescriptions when using participating pharmacies

Most actionable: prior authorization channelsRequest PA via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232 — required for many specialty drugs

ST — Step Therapy definition

DefinitionStep Therapy (ST) — a prior authorization program that requires trying specified drugs first before covering another drug for the condition

Provider actionPrescriber must request coverage review through CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232 when step therapy applies

Step Therapy / Managed Therapy

Program	Requirement / Prescriber action
Step therapy program (ST)
Must try specified first-line agents before coverage of alternative drugs. Prescriber must request coverage review via CoverMyMeds, call 1-800-924-7141, or fax 1-888-343-4232.

Scope	Note
Selected prescriptions
Some prescriptions require step therapy prior to authorization; check product Requirements/Limits on the formulary and submit required documentation if indicated.

Step	Details
Step ?:
No explicit step sequence provided in this excerpt; refer to full plan step therapy list for specific fail-first agents.

Therapeutic class	Formulary marker / implication
NSAIDs and related agents
Many NSAIDs are marked 'MT' in Requirements/Limits; this may indicate managed therapy, step edits, or monitoring requirements prior to coverage.

Drug class	MT observation
Antiasthmatic / monoclonal antibody agents (e.g., NUCALA)
Entries include 'MT' alongside PA and QL (e.g., NUCALA MT = PA, QL), suggesting MT flags may indicate utilization management or step requirements.

Product set	MT implication
Generic drug entries (various classes)
Many generic entries are annotated 'MT', indicating managed therapy which may reflect step edits or internal utilization management prior to brand coverage.

Drug examples	Coverage requirement
GLP-1 / incretin agents (MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY)
Marked 'PA' with specified QL (e.g., MOUNJARO PA, QL 4 pens every 28 days; OZEMPIC PA, QL 1 pen every 28 days); prior authorization required before coverage.

MT markers	Note
MT present across many entries
Document shows MT markers but does not provide explicit step therapy sequences in this excerpt; MT may denote maintenance program or managed therapy edits.

Antineoplastic / antimyobacterial agents	Authorization / limits
Selected oncology / antimycobacterial agents (e.g., ONUREG, INLYTA, VENCLEXTA)
Many are designated 'PA' with QL (e.g., ONUREG PA, QL 14 tabs every 28 days; INLYTA PA, QL 240 tabs every 30 days) — prior use steps may be required implicitly via PA.

Generic hormonal agents	Coverage implication
Various generic hormonal agents (e.g., anastrozole, exemestane)
Some list ACA/MT/MT indicators, suggesting alternative-first coverage programs or managed therapy requirements to try lower-cost alternatives first.

Formulary flags	Effect on coverage
Requirements/Limits codes (PA, MT, LD)
Many medications show PA or internal requirement codes (MT, LD); coverage is conditional on meeting those administrative requirements before claims are paid.

Hepatitis C agents	Authorization status
Direct-acting antivirals (EPCLUSA, HARVONI, VOSEVI)
Listed with 'PA' and QL (e.g., EPCLUSA PA, QL 30 packs every 30 days; HARVONI PA, QL 30 packs every 30 days) — prior authorization required for coverage.

Quantity Limits and Supply Restrictions

specialty drugs — typical 30-day supply

Typical specialty supplySpecialty drugs are usually limited to a 30-day supply

Retail 90 optionRetail 90 Network can provide up to a 90-day supply for retail prescriptions when using participating pharmacies

Most actionableWhen PA is required for specialty drugs, request via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232

retail prescriptions — up to 90-day supply in Retail 90 Network

Retail 90 supplyUp to a 90-day supply available through Retail 90 Network pharmacies

Non-network limitationUsing a pharmacy not in the Retail 90 Network limits supply to 30 days

Site of Care and Specialty Dispensing

Note

Use network specialty pharmacies / coordinate infusion/home administration

Specialty drugs are usually administered in provider settings or at home and are generally available only from specialty pharmacies in the network; coordinate site‑of‑care and specialty pharmacy use as appropriate.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPreferred Formulary Guide (Prescription Drug Formulary, PA/Step Therapy/QL Programs)

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateFebruary 2026

Next Review DateN/A

Key ActionWhen a drug row shows 'PA', the prescriber must request prior authorization via CoverMyMeds, by calling 1-800-924-7141, or faxing 1-888-343-4232.

SourceLink

On This Page

Examples include 30, 60, 90, or 120 units (caps/tabs) per 30 days depending on product and strength

Stimulant examplesMultiple amphetamine and methylphenidate entries show PA with QL values (e.g., 60 caps every 30 days; some strengths 30/90/120 per 30 days)

Formulary noteQL is specified per drug row and must be documented on the claim

Example QL — 120 caps every 30 days

Example QL120 caps every 30 days (e.g., atomoxetine/methylphenidate solution/tablet entries)

ContextQuantity limits vary by formulation and strength; documentation should reflect the QL

Related PAMany entries with this QL are also marked PA — prior authorization required when indicated

ENBREL QL examples

ENBREL (25 mg/0.5 mL) SOSYQL = 8 syringes every 28 days

ENBREL (50 mg/mL) SOSYQL = 4 syringes every 28 days

ENBREL SURECLICK / MINI / SOLN formulationsQL commonly = 4 pens/syringes/injections every 28 days depending on presentation

Quantity limits examples (XIFAXAN, vancomycin, NUCALA, BREO etc.)

XIFAXAN200 mg QL = 9 tabs every 30 days; 550 mg QL = 90 tabs every 30 days

Vancomycin HClOral caps QL = 120 caps every 30 days; solutions QL = 900 mL (25 mg/mL) or 1350 mL (50 mg/mL) every 30 days

NUCALA formulationsQL = 3 injections/vials every 28 days (varies by presentation); PA and LD noted

BREO ELLIPTAQL = 60 blisters every 30 days

Example quantity limits (e.g., 180 packets every 30 days)

VigabatrinQL = 180 packets or 180 tabs every 30 days

SYMLINPENQL = 4 pens every 30 days

Example combinedQL entries include both high-count packet/tab limits and multi-pen injectable limits — follow per-product listing

Per-product quantity limits (tabs, pens, mL examples)

Tablet QLsExamples include 60 tabs every 30 days and 30 tabs every 30 days depending on strength (e.g., SYNJARDY/SYNJARDY XR)

Pen/injection QLsExamples include 4 pens every 28–30 days (MOUNJARO/TRULICITY) or 1 pen every 28 days (OZEMPIC)

mL limits for insulinFIASP and insulin presentations have QLs expressed in mL (e.g., 60–90 mL every 30 days) — document per product

Quantity limits per period (sprays, injections, vials examples)

Naloxone spraysQL = 2 sprays every 30 days (NARCAN, generic naloxone, KLOXXADO)

Naloxone injections/vialsQL = 2 injections every 30 days or 1 vial every 30 days depending on formulation

Antifungal suspensions/tabsExamples: posaconazole suspension QL = 630 mL/30 days; voriconazole suspension QL = 600 mL/30 days; tabs have QL in tabs per 30 days

Quantity limits examples (84 caps/28 days; 240 tabs/30 days; 120 tabs/30 days)

Common oncology QLsExamples include QL = 84 caps every 28 days (FRUZAQLA), QL = 240 tabs every 30 days (VIREAD powder example), QL = 120 tabs every 30 days for select agents

Everolimus examplesQL ranges by formulation: 28, 56, or 84 tabs every 28 days depending on presentation

DasatinibQL = 90 tabs every 30 days for 20 mg; 30 tabs every 30 days for higher strengths

Quantity limits examples (30 tabs/30 days; 50 mL/365 days)

Common oral antiviral QLExamples: many antivirals QL = 30 tabs every 30 days (e.g., CIMDUO, many HIV combos)

Long-acting injectable QLSome injectables list annual volume QLs (e.g., CABENUVA QL = 50 mL every 365 days)

Submit claims per QLDocument adherence to product-specific QL when submitting claims (e.g., 30 tabs/30 days or 50 mL/365 days)

Examples of quantity limits (PAXLOVID, EPCLUSA, LAGEVRIO)

PAXLOVIDPAXLOVID PAK QL = 11 tabs every 5 days; PAXLOVID TAB 150-100 QL = 20 tabs every 5 days

EPCLUSAEPCLUSA PAK/TAB QL = PA with QL (30 packs or 60 packs every 30 days depending on presentation)

LAGEVRIOLAGEVRIO CAPS 200 mg QL = 40 caps every 5 days

Prior Authorization

PA Required for Biologics / Anti‑TNF Agents

Biologic agents, including anti‑TNF-alpha monoclonal antibodies and other monoclonal biologics, commonly require prior authorization and quantity limits; some products are limited distribution (LD). Examples: adalimumab products (PA, QL), NUCALA (PA, QL, LD).

Anti‑TNF agents and other biologics: PA and QL frequently required
NUCALA: MT = PA, QL (injection/syringe limits) and LD noted
Some biologics noted as PA; several also have LD designations

Documentation Required

PA and Documentation for Select Biologics

Select specialty biologics require PA, quantity limits and sometimes limited distribution (LD). Document medical necessity, dosing intervals, and any LD channel required when requesting authorization (examples in formulary: NUCALA, ILARIS).

Document PA justification: clinical indication, dosing schedule, prior therapies tried
Check LD notes — providers may need to use specified specialty distribution channels

Prior Authorization

PA and QL for XIFAXAN

XIFAXAN (rifaximin) is subject to prior authorization and quantity limits: formulary lists PA and QL for both the 200 mg and 550 mg strengths. Claims exceeding QL or lacking PA may be denied.

XIFAXAN 200 mg: PA, QL (9 tabs/30 days)
XIFAXAN 550 mg: PA, QL (90 tabs/30 days)

Prior Authorization

PA and QL for Oncology / Selected Antimicrobials

Many oncology, antineoplastic, and select antimicrobial oral specialty agents require prior authorization, have strict quantity limits, and are often limited distribution (LD). Examples include ONUREG, VENCLEXTA, INLYTA, LENVIMA, and multiple agents listed with PA, QL and LD.

Onureg: PA, QL (14 tabs/28 days); LD
Venclexta: PA, QL (various tab counts), LD for some strengths
Many oncology agents: PA + QL and LD notes — document dosing and LD channel

Denial Risk

PA, QL and Management Flags — Denial Risk

PA and quantity limits (QL) are enforced for many listed drugs; management flags (PA, QL, MT, ST, LD) may cause claim denials if requirements are not met. Providers should verify formulary Requirement/Limits fields and include required documentation on the PA and claim.

Management flags to check: PA, QL, MT (Maintenance), ST (Step Therapy), LD (Limited Distribution), ACA indicators
Claims exceeding QL or missing PA/documentation risk denial

Prior Authorization

Prior Authorization for Specified Antipsychotics

Several antipsychotics and related agents require prior authorization; some are also limited distribution. Examples include lurasidone, VRAYLAR, FANAPT, ziprasidone and NUPLAZID — verify PA and LD designations before dispensing.

Lurasidone: Requirements/Limits = PA
NUPLA ZID: PA; LD
FANAPT and related pack(s): Requirements/Limits = PA

Prior Authorization

PA for Select Incretin / GLP‑1 Agents

Select incretin/GLP‑1 agents and other diabetes biologics require prior authorization and have quantity limits. Examples include MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY — check PA and QL before prescribing/dispensing.

Mounjaro: PA, QL (4 pens per 28 days)
Ozempic: PA, QL (1 pen per 28 days)
Rybelsus: PA, QL (30 tabs/30 days); Trulicity: PA, QL (4 pens/28 days)

Documentation Required

Quantity Limits, MT Indicators and Claim Documentation

Quantity limits (QL) and Maintenance (MT) indicators are used for specialty and chronic therapy drugs; these must be documented on claims. QL enforcement may deny claims that exceed allowed amounts.

MT flag may require adherence to 90‑day fills or specific supply rules
Document QL on the claim and include PA justification when applicable
Over‑limit dispensing risks denial

Documentation Required

Documentation and Reconsideration Requirements

Providers must include supporting documentation when submitting PA or when requesting reconsideration of denials: patient name and ID, physician name and contact, drug and diagnosis details, medical necessity rationale, dosing schedule, prior therapy history, and any LD handling notes.

Reconsideration submissions: fax 1-888-343-4232 or mail to Pharmacy Management Reconsiderations, BlueCross BlueShield of Tennessee, 1 Cameron Hill Circle, Chattanooga, TN 37402-2555
Required information: patient name and ID, physician name and phone, drug and diagnosis information, clinical rationale

Step Therapy

Step Therapy and Managed‑Therapy (MT) Notes

Step therapy (ST) and managed‑therapy (MT) flags appear in the formulary. Where ST applies, prescribers must follow step edits or request a coverage review. Note: MT flags are present across many classes though explicit step rules may not be printed — contact pharmacy management for specifics.

Step therapy requires trying specified drugs first; prescribers may request a coverage review if clinically necessary
MT flags indicate maintenance programs (e.g., 90‑day supply rules) but may not list all step details

Billing Rule

Limited Distribution / Special Handling

Limited distribution (LD) and special handling are indicated for some products. When LD is noted, providers must use designated pharmacies or distribution channels; include LD documentation in PA requests and on claims to avoid delays.

Examples with LD: NUCALA, ILARIS, multiple oncology and specialty agents (ONUREG, LENVIMA, VITRAKVI, etc.)
Document LD channel and related shipping/handling notes in the PA request

ScopeApplies to drugs listed on formulary that are annotated as requiring ST

QL — Quantity Limit definition

DefinitionQuantity Limit (QL) — coverage is limited to a specified amount of a drug within a defined time period

ExamplesQLs are shown per product row (e.g., '60 caps every 30 days','2 sprays every 30 days') and must be followed when dispensing

ClaimsDocument dispensed quantity on the claim consistent with the listed QL

LD — Limited Distribution definition

DefinitionLimited Distribution (LD) — drug may only be available through specified pharmacies or channels

Provider noteProviders may need to use designated distribution channels and provide supporting documentation for LD products

ExamplesMultiple specialty products in the formulary are noted with LD (see product rows)

MT — Maintenance Matters definition

DefinitionMT (Maintenance Matters) — program for long-term condition drugs; plans enrolled in MT require 90-day supplies for MT-designated drugs

ImplicationMT flags on product rows indicate members may receive extended supplies and certain fulfillment channels (e.g., mail-order)

DocumentationClaims should reflect MT flags and adhere to QL and supply rules

MME — Morphine Milligram Equivalent definition

DefinitionMME — Morphine Milligram Equivalent; plan requires prior authorization when total MME > 120 mg/day

ApplicationMME is calculated across opioid medications to determine requirement for PA

How to request PASubmit via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232

Over-the-counter (OTC) medicines definition

DefinitionOver-the-counter (OTC) medicines — sold without a prescription; presence of an OTC alternative may affect coverage for a prescription drug

Member actionDiscuss OTC alternatives with pharmacist or prescriber before switching therapies

Coverage impactSome prescription drugs may not be covered if an equally effective OTC exists

PA (definition repeat)

PA definition (repeat)Prior Authorization — approval required before coverage; submit via CoverMyMeds, phone, or fax

When usedMarked 'PA' in Requirements/Limits column for many formulary entries

ConsequenceLack of PA may lead to claim denial or nonpayment

QL (definition repeat)

QL definition (repeat)Quantity Limit — maximum allowed quantity within a specified time period (e.g., '60 caps every 30 days')

Product-levelEach drug row specifies its own QL; follow per-product values

Claim documentationDocument the dispensed quantity to match the listed QL

QL example definition

QL example (repeat)Example listed QL: 120 caps every 30 days

ContextUsed for multiple stimulant/ADHD product entries

DocumentationClaims should reflect this QL when dispensing

PA (definition repeat)

PA (repeat)Prior Authorization — authorization required prior to coverage; submission methods include CoverMyMeds, phone, or fax

ImplicationProducts marked 'PA' will require a coverage review before payment

ReconsiderationDenials may be reconsidered if provider submits clinical reasons in writing

PA = Prior Authorization (definition repeat)

PA = Prior Authorization (repeat)Indicator 'PA' denotes that prior authorization is required for coverage

NUCALA exampleNUCALA entries show MT = PA and have QLs specified — PA required for biologic asthma agents

SubmissionUse listed PA submission channels

QL = Quantity Limit (definition repeat)

QL = Quantity Limit (repeat)QL indicates the maximum allowed quantity per specified period as listed on the product row

ExamplesXIFAXAN, vancomycin, NUCALA, BREO entries include QLs per 30 days or per 28 days

EnforcementExceeding QL may lead to denial or step edits

MT / LD internal codes (definition)

MT / LD internal codesMT and LD appear as internal requirement/limit codes; MT indicates Maintenance Matters, LD indicates Limited Distribution

Operational noteExact operational details of MT/LD programs are handled via plan channels and may affect supply and fulfillment

DocumentationClaims should reflect MT/LD flags where applicable

QL examples (Requirements/Limits)

QL examples (requirements/limits)Multiple products show QL (e.g., SYNJARDY QL 60 tabs/30 days; MOUNJARO QL 4 pens/28 days; OZEMPIC QL 1 pen/28 days)

MT pairingMany QL entries are paired with MT indicating managed therapy or fulfillment considerations

PA pairingSome QL entries are also marked PA — both must be satisfied for coverage

PA (definition repeat)

PA repeatPrior Authorization — may be required for certain drugs; submit requests via CoverMyMeds, phone, or fax

Provider actionFailure to obtain PA may result in claim denial

ReferenceSee product rows for PA annotation

MT (definition repeat)

MT (definition repeat)Maintenance Matters — program for long-term drugs, may require 90-day supplies if the plan participates

ImplicationMT flags may change allowed supply and fulfillment route

ActionCheck plan EOC for MT program participation and rules

QL (definition repeat)

QL (definition repeat)Quantity Limit denotes maximum quantity allowed per the listed time period (e.g., '60 caps every 30 days')

Product specificityAlways follow the per-product QL listed in the Requirements/Limits column

Claim requirementDocument quantity dispensed on claims to match the QL

MT (definition repeat)

MT (repeat)MT indicates Maintenance Matters — see plan rules for 90-day supply options and fulfillment

EffectMT often paired with QL and may require mail-order or specialty dispensing

Check EOCConfirm member plan participation for MT program in Evidence of Coverage

PA / QL / LD (definition group)

PA / QL / LD groupPA = Prior Authorization; QL = Quantity Limit; LD = Limited Distribution — these codes are used together on product rows to indicate coverage controls

Operational impactProducts marked with these flags typically require additional provider actions and specific fulfillment channels

DocumentationSupporting clinical documentation may be required for PA/LD and to justify quantities dispensed

LD (definition repeat)

LD (repeat)Limited Distribution — indicates restricted distribution channel for the drug (see product row)

Provider actionProviders may need to use specified specialty pharmacies and provide enrollment/documentation

ExamplesMultiple oncology and specialty agents are noted with LD in the formulary

QL (definition repeat)

QL (repeat)Quantity Limit indicates the maximum allowed quantity per specified time (e.g., 9 tabs every 30 days for XIFAXAN 200 mg)

EnforcementExceeding QL may cause claim denial or step edits

Check product rowAlways use the QL shown in Requirements/Limits for dispensing and claims

PA (definition repeat)

PA (repeat)Prior Authorization — approval required prior to coverage; use listed submission channels

ConsequenceClaims submitted without required PA may be denied

Provider guidanceSubmit clinical rationale when requesting PA or reconsideration

PA (definition repeat)

PA = Prior Authorization (repeat)Denotes that an approval is required before coverage is provided

UseMarked on many product rows throughout the formulary

Submission methodsCoverMyMeds, phone 1-800-924-7141, fax 1-888-343-4232

QL (definition repeat)

QL = Quantity Limit (repeat)Specifies maximum quantity per listed period — follow per-product values

ExamplesXIFAXAN 9 tabs/30 days; vancomycin 120 caps/30 days; NUCALA 3 injections/28 days

DocumentationClaims should reflect quantities per QL

LD (definition repeat)

LD (repeat)Limited Distribution — indicated for multiple specialty products in the formulary

ImpactMay limit dispensing channels and require provider coordination with specialty pharmacy

ExamplesONUREG, INLYTA, LENVIMA and others noted with LD

PA (definition repeat)

PA (repeat)Prior Authorization — approval required before coverage; submit via listed channels

Where shownIndicated in Requirements/Limits for many products

EffectClaims lacking PA may be denied

QL (definition repeat)

QL (repeat)Quantity Limit — maximum allowed within the time period (product-specific)

EnforcementExceeding QL may be subject to denial or edits

ExamplesSee product rows for exact QL values

LD (definition repeat)

LD (repeat)Limited Distribution — restricted channels for certain specialty drugs

Provider noteEnrollment or use of designated pharmacies may be required

ExamplesMultiple oncology and specialty agents list LD

Prescriber requirementDoctor must write prescription for a 90-day supply to use this benefit

various stimulants and ADHD agents — QL examples 30/60/90/120 per 30 days

Stimulant QL rangesExamples include 30, 60, 90, 120 units per 30 days depending on product/strength (see stimulant entries)

PA commonMany stimulant entries are marked PA in addition to QL — authorization required where shown

Per-product variationQL varies by strength/formulation; check specific product row for exact limit

dextroamphetamine sulfate solution / procentra — 1200 mL every 30 days

Dextroamphetamine solution / ProcentraQL = 1200 mL every 30 days

ApplicabilityShown for liquid formulations of dextroamphetamine and Procentra entries

Related PAPA indicated on many of these entries — submit authorization when required

atomoxetine hcl caps 40mg — 120 caps

Atomoxetine 40 mg capsQL = 120 caps every 30 days

Entry noteListed under ADHD agents with QL specified per formulation and strength

Claim supportDocument QL on claim to ensure proper adjudication

methylphenidate hcl soln 5mg/5ml — 1800 mL

Methylphenidate HCl solution 5 mg/5 mLQL = 1800 mL every 30 days (some strengths list 900 mL) depending on formulation

Formulation-specificLiquid presentations list mL-based QLs while tablets list caps/tabs per 30 days

PAMany entries also marked PA — check Requirements/Limits

ENBREL SOSY 25MG/0.5ML — 8 syringes

ENBREL SOSY 25MG/0.5MLQL = 8 syringes (or 8 syringes every 28 days) per entry depending on presentation

ENBREL SURECLICK / SOSY variantsSome ENBREL presentations list QL = 4 syringes/pens every 28 days

Most actionableFollow the QL per ENBREL presentation (4 or 8 syringes/pens per 28 days) when dispensing

XIFAXAN 200 mg — QL 9 tabs

XIFAXAN 200 mgQL = 9 tabs every 30 days

XIFAXAN 550 mgQL = 90 tabs every 30 days

PA notedBoth strengths show PA in Requirements/Limits

XIFAXAN 550 mg — QL 90 tabs

XIFAXAN 550 mgQL = 90 tabs every 30 days

IndicationPA required for coverage per product row

Claim noteDocument dispensed quantity consistent with QL

vancomycin HCL caps 125/250 mg — QL 120

Vancomycin HCl caps 125/250 mgQL = 120 caps every 30 days

Vancomycin solution 25 mg/mLQL = 900 mL every 30 days

Vancomycin solution 50 mg/mLQL = 1350 mL every 30 days

vancomycin HCL solution 25mg/ml — QL 900

Vancomycin solution 25 mg/mLQL = 900 mL every 30 days

Vancomycin solution 50 mg/mLQL = 1350 mL every 30 days

Caps QLOral caps QL = 120 caps every 30 days

NUCALA formulations — QL 3 injections/vials every 28 days

NUCALA formulations (SOAJ/SOLR/SOSY)QL = 3 injections/vials every 28 days (varies by presentation); PA and LD noted

MT flagNUCALA entries show MT = PA indicating managed therapy and PA requirements

DistributionLD indicates limited distribution channels for some NUCALA presentations

BREO ELLIPTA — QL 60

BREO ELLIPTAQL = 60 blisters every 30 days

MT indicatorBREO entries also show MT (managed therapy) where noted

Formulary tierBREO listed as Drug Tier 3 with QL

vigabatrin — QL 180 packets/tabs every 30 days

Vigabatrin packs/tabsQL = 180 packets or 180 tabs every 30 days; some entries also note LD

LD impactLimited Distribution noted for certain pack presentations

Claim documentationAdhere to QL when submitting claims to avoid denial

SYMLINPEN 60/120 — QL 4 pens every 30 days

SYMLINPEN 60/120QL = 4 pens every 30 days

Multiple presentationsBoth 1500 mcg/1.5 mL and 2700 mcg/2.7 mL pens list the same pen QL

MTMT flag present indicating managed therapy

GLYXAMBI / JANUMET / SYNJARDY / TRIJARDY / XIGDUO XR — various QLs

GLYXAMBI / JANUMET / SYNJARDY / TRIJARDY / XIGDUO XRVarious QLs noted (commonly 30 or 60 tabs every 30 days) depending on strength and formulation

SYNJARDY specificsSYNJARDY QL = 60 tabs every 30 days (some strengths QL = 30 tabs every 30 days); MT flagged

TRIJARDY / XIGDUO XRQL values vary by strength (30–60 tabs every 30 days) and are paired with MT

SYNJARDY — QL 60 or 30 tabs every 30 days depending on strength

SYNJARDY (various strengths)QL = 60 tabs every 30 days for many strengths; certain strengths QL = 30 tabs every 30 days

MT flagMT present for SYNJARDY entries indicating managed therapy

Provider noteFollow the per-strength QL when dispensing and on claims

MOUNJARO — QL 4 pens every 28 days; OZEMPIC — QL 1 pen every 28 days

MOUNJAROQL = 4 pens every 28 days

OZEMPICQL = 1 pen every 28 days

Most actionableThese GLP-1/incretin agents are commonly marked PA and QL — obtain PA when required and dispense per pen QL

Naloxone and related products — QL examples

Naloxone nasal spraysQL = 2 sprays every 30 days (NARCAN, generic naloxone, KLOXXADO) — many are also OTC

Injection formulationsQL = 2 injections every 30 days or 1 vial every 30 days depending on formulation

OTC noteSome naloxone spray entries are noted OTC — coverage may be affected by OTC status and plan rules

FIASP formulations — QL 60-90 mL every 30 days

FIASP formulationsQL = 60–90 mL every 30 days depending on presentation (e.g., FIASP, FIASP FLEXTOUCH, PENFILL)

Insulin examplesMultiple insulin products list mL-based QLs (30–90 mL ranges) and MT flags

Claim detailDocument mL dispensed to match QL when submitting claims

itraconazole/posaconazole/voriconazole — QL examples

Itraconazole capsulesQL = 120 caps every 30 days

Posaconazole suspensionQL = 630 mL every 30 days

Voriconazole tabs/suspensionExamples include QL = 480 tabs (50 mg) or 120 tabs (200 mg) every 30 days; suspension QL = 600 mL every 30 days

REPATHA QL examples

REPATHA SOSY 140 mg/mLQL = 2 pens every 28 days

REPATHA PUSHTRONEX 420 mg/3.5 mLQL = 1 cartridge every 28 days

REPATHA SURECLICK 140 mg/mLQL = 2 syringes every 28 days — follow per presentation

Antivirals (PAXLOVID, EPCLUSA, LAGEVRIO) — QL examples

PAXLOVID PAKQL = 11 tabs every 5 days

PAXLOVID 150/100 tabQL = 20 tabs every 5 days

EPCLUSAPA required; QL = 30 packs every 30 days (other presentations may list 60 packs/30 days)

LAGEVRIOQL = 40 caps every 5 days