CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Preferred Formulary Guide — Prescription Drug Benefits (Coverage Criteria)

This document governs the prescription drug formulary, coverage rules, pharmacy networks, and benefit programs for BlueCross BlueShield of Tennessee members; it affects members, prescribers, and pharmacies participating in BCBST plans.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPreferred Formulary Guide — Prescription Drug Benefits (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 2026

Next Review DateN/A

Key ActionProviders must request prior authorization via CoverMyMeds, by calling 1-800-924-7141, or faxing 1-888-343-4232 when PA is indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90-dayRetail 90 / home delivery

1-800-552-8159Home delivery contact

1-800-924-7141Prior authorization phone

MultiplePA / Step Therapy mentions

6Formulary tiers

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Coverage Criteria and Formulary Listings

Product-level PA and QL conditions

Covered when PA is obtained and QL is within specified limits

Stimulant/ADHD product coverage: Coverage requires prior authorization (PA) when indicated in the formulary line and dispensing quantity must not exceed the specified quantity limit (QL) for the listed product strength and formulation.see QL values per product

Examples: PA and QL (60 caps every 30 days); PA, QL (120 tabs every 30 days); PA, QL (1200 mL every 30 days)

Formulary coverage by tier and utilization control

Coverage indicated by drug tier and constrained by listed utilization controls; clinical criteria not provided in this excerpt.

Formulary entry applies when product is prescribed: Drug is on formulary with listed Drug Tier and Requirements/Limits (PA, QL, MT, LD) as specified.

No additional clinical criteria in this excerpt; prior authorization or QL must be met where listed.

Formulary coverage (partial)

Covered when dispensed within listed tiers and quantity limits

Formulary coverage conditions: Drug is covered according to listed Drug Tier and within stated Quantity Limits (QL) or Requirements/Limits tags (MT, ACA) where present.see QL entries

This chunked section does not include explicit step therapy or PA logic beyond QL and Requirements/Limits flags.

Formulary listing / coverage annotations

Formulary listing with coverage/requirement annotations

Formulary coverage entries: Each listed antihypertensive product includes a Drug Tier and a Requirements/Limits entry (commonly 'MT'). Coverage and benefit tier assignment are provided per formulation.

No explicit medical necessity criteria or clinical inclusion/exclusion rules are present in these chunks.

Oncology formulary annotations

Antineoplastic and select specialty drugs

Oncology drug coverage annotations: Several oncology agents have a two-column tier indication (1 =, 2 =) with second-tier entries often requiring PA and having QL or LD designations.

Operational coverage criteria (diagnoses, prior therapies) are not present in this window.

Per-product coverage controls

Coverage and utilization controls as listed per-product

Formulary controls: Each drug entry includes a Drug Tier and may include Requirements/Limits flags such as QL (quantity limit), PA (prior authorization), LD (limited distribution)

Providers must follow per-product controls indicated in Requirements/Limits.

Certain products are subject to legislative, regulatory, or program-specific distribution rules that affect coverage. Limited Distribution (LD) specialty drugs are typically available only through designated specialty pharmacies and may require coordination with those pharmacies. Specialty medications usually require prior authorization (PA) and are generally limited to a 30-day supply; see the formulary line for the specific Requirements/Limits entry and contact member services for network routing. Providers must submit PA requests as described in the formulary (for example via CoverMyMeds, by phone at 1-800-924-7141, or fax at 1-888-343-4232) when the Requirements/Limits field indicates PA or LD is required.

For patient safety the document explicitly advises against sharing prescriptions and against stopping a prescribed medication without clinician guidance. Members are instructed to keep medications away from children and consult their prescriber or pharmacist about side effects or switching to over‑the‑counter alternatives. These are safety guidance statements and not coverage determinations, but they are included to reduce risk from unsupervised medication changes or sharing.

Within the extracted formulary segments many therapeutic classes and headers are shown with the note that "Some prescriptions need an approval for coverage." The listing presents class-level headings and indicates that individual drug rows may carry Requirements/Limits flags (e.g., PA, MT) but does not contain explicit exclusion language in these chunks. Coverage decisions for specific agents therefore rely on the per‑product Requirements/Limits entries rather than a general exclusion statement in this excerpt.

The provided extract shows formulary Tier assignments and associated utilization controls (for example PA, QL, MT, or LD) for many products but does not include expanded medical‑necessity decision criteria in this window. Where a row lists a Drug Tier and Requirements/Limits, coverage is governed by that tier assignment and the listed utilization control; providers should consult the specific product line for the exact QL values and whether PA or other management applies.

This excerpt contains product listings with tier and Requirements/Limits tags (e.g., MT, PA, QL) but no explicit exclusion conditions are stated in the visible lines. Operational exclusions, if any, are not present in this chunk and must be verified elsewhere in the complete formulary or policy document.

The opioid‑antagonist (naloxone) entries and surrounding rows include quantity limits and OTC designations in this segment but do not present explicit coverage exclusions. Coverage is represented by the Requirements/Limits (for example QL) shown for each product rather than by exclusion statements in these chunks.

The antihypertensive section lists numerous ACE inhibitor and combination products with Drug Tier assignments and a recurring Requirements/Limits tag of MT. These chunks focus on per‑product tiering and utilization management indicators; they do not include explicit exclusion language for the antihypertensive class within this extract.

The antiparkinson and related therapy lines show per‑product quantity limits and tier flags (including some LD annotations) but contain no explicit exclusions in the visible segment. Coverage is determined by the Drug Tier and any Requirements/Limits present for each listed formulation.

In the portions of the formulary included here there are no explicit 'not medically necessary' determinations documented. The listings instead show class headings and indicate that some individual prescriptions require approval; formal ‘not medically necessary’ language is not present in these chunks.

The antiepileptic and related product rows in this excerpt include Requirements/Limits tags such as PA, QL, and MT, but this segment does not contain explicit statements declaring any items as ‘not medically necessary.’ Operational medical‑necessity determinations would be defined elsewhere in the full policy.

The antidote/opioid antagonist listings show coverage annotations (for example OTC and QL values) and do not include explicit ‘not medically necessary’ statements in the provided lines. Coverage is indicated by the per‑product Requirements/Limits entries.

No content available for this placeholder item.

The drug lines in this segment present Drug Tier and Requirements/Limits data (including QL values) but do not contain explicit ‘not medically necessary’ language. Any determinations that a drug is not medically necessary would be documented in other policy sections not included in these chunks.

Coding, Drug Lists, and Definitions

AMPHETAMINES - Covered/NDC-like listingmixedCovered

amphetamine-dextroamphetamine cap ER 24hr 37.5 mg	generic — PA, QL (30 caps every 30 days)
amphetamine-dextroamphetamine cap ER 24hr 50 mg	generic — PA, QL (30 caps every 30 days)
amphetamine-dextroamphetamine cap ER 24hr 25 mg	generic — QL (60 caps every 30 days)
amphetamine-dextroamphetamine cap ER 24hr 5 mg	generic — PA, QL (90 caps every 30 days)
amphetamine-dextroamphetamine cap ER 24hr 10 mg	generic — PA, QL (90 caps every 30 days)
amphetamine-dextroamphetamine cap ER 24hr 15 mg	generic — PA, QL (30 caps every 30 days)
amphetamine-dextroamphetamine cap ER 24hr 20 mg	generic — PA, QL (30 caps every 30 days)
amphetamine-dextroamphetamine cap ER 24hr 30 mg	generic — PA, QL (30 caps every 30 days)

AMPHETAMINES - Tablet formsmixedCovered

amphetamine-dextroamphetamine tab 5 mg	generic — QL (90 tabs every 30 days)
amphetamine-dextroamphetamine tab 7.5 mg	generic — QL (90 tabs every 30 days)
amphetamine-dextroamphetamine tab 10 mg	generic — QL (90 tabs every 30 days)
amphetamine-dextroamphetamine tab 12.5 mg	generic — QL (90 tabs every 30 days)
amphetamine-dextroamphetamine tab 15 mg	generic — QL (60 tabs every 30 days)
amphetamine-dextroamphetamine tab 20 mg	generic — QL (60 tabs every 30 days)
amphetamine-dextroamphetamine tab 30 mg	generic — QL (30 tabs every 30 days)

ANALEPTICS / ADHD AgentsmixedCovered

atomoxetine HCl caps 40 mg	generic — QL (60 caps every 30 days)
atomoxetine HCl caps 60 mg	generic — QL (30 caps every 30 days)
atomoxetine HCl caps 80 mg	generic — QL (30 caps every 30 days)
atomoxetine HCl caps 100 mg	generic — QL (30 caps every 30 days)
clonidine hcl (ADHD) tb12 0.1 mg	generic — QL (120 tabs every 30 days)
guanfacine hcl (ADHD) tb24 1 mg	generic — QL (30 tabs every 30 days)
guanfacine hcl (ADHD) tb24 2 mg	generic — QL (30 tabs every 30 days)
guanfacine hcl (ADHD) tb24 3 mg	generic — QL (30 tabs every 30 days)
guanfacine hcl (ADHD) tb24 4 mg	generic — QL (30 tabs every 30 days)

WAKEFULNESS AGENTS / ANALEPTICSmixedCovered

armodafinil tabs 50 mg	generic — PA, QL (60 tabs every 30 days)
armodafinil tabs 150 mg	brand/generic — PA, QL (30 tabs every 30 days)
armodafinil tabs 200 mg	brand/generic — PA, QL (30 tabs every 30 days)
armodafinil tabs 250 mg	brand/generic — PA, QL (30 tabs every 30 days)
modafinil tabs 100 mg	generic — PA, QL (60 tabs every 30 days)
modafinil tabs 200 mg	generic — PA, QL (60 tabs every 30 days)

DEXMETHYLPHENIDATE / METHYLPHENIDATEmixedCovered

dexmethylphenidate HCl cp24 5 mg	generic — PA, QL (60 caps every 30 days)
dexmethylphenidate HCl cp24 10 mg	generic — PA, QL (60 caps every 30 days)
dexmethylphenidate HCl cp24 15 mg	generic — PA, QL (60 caps every 30 days)
dexmethylphenidate HCl cp24 20 mg	generic — PA, QL (60 caps every 30 days)
dexmethylphenidate HCl cp24 25 mg	generic — PA, QL (30 caps every 30 days)
dexmethylphenidate HCl cp24 30 mg	generic — PA, QL (30 caps every 30 days)
dexmethylphenidate HCl cp24 35 mg	generic — PA, QL (30 caps every 30 days)
dexmethylphenidate HCl cp24 40 mg	generic — PA, QL (30 caps every 30 days)
methylphenidate HCl tb24 54 mg	generic — PA, QL (30 tabs every 30 days)
methylphenidate HCl cp24 40 mg	generic — PA, QL (30 caps every 30 days)

BRAND ADHD / ER ProductsmixedCovered

QUILLICHEW ER CHER 20 mg	brand — PA, QL (60 tabs every 30 days)
QUILLICHEW ER CHER 30 mg	brand — PA, QL (60 tabs every 30 days)
QUILLICHEW ER CHER 40 mg	brand — PA, QL (30 tabs every 30 days)
QUILLIVANT XR SRER 25 mg/5 mL	brand — PA, QL (360 mL every 30 days)

ADDITIONAL BRANDS / BIOLOGICSmixedCovered

HADLIMA 40 mg/0.4 mL; 40 mg/0.8 mL	brand adalimumab biosimilar — PA, QL (4 pens every 28 days)
SIMLANDI kits 20 mg/0.2 mL; 40 mg/0.4 mL; 80 mg/0.8 mL	brand adalimumab biosimilar kits — PA, QL (varies by presentation)
HADLIMA / SIMLANDI kits	included as above — PA, QL per kit packaging

JAK INHIBITORS / IMMUNOMODULATORSmixedCovered

RINVOQ (upadacitinib) 15 mg	TB24 — PA, QL (30 tabs every 30 days)
RINVOQ (upadacitinib) 30 mg	TB24 — PA, QL (30 tabs every 30 days)
RINVOQ (upadacitinib) 45 mg	TB24 — PA, QL (84 tabs every 180 days)
RINVOQ LQ soln 1 mg/mL	liquid — PA, QL (360 mL every 30 days)
ILARIS soln 150 mg/mL	brand — PA; LD
ARCALYST solr 220 mg	brand — PA; LD

NSAIDs and PDE4 InhibitorsmixedCovered

celecoxib caps 50 mg, 100 mg, 200 mg	generic — MT
diclofenac potassium tabs 50 mg	generic — MT
diclofenac sodium tb24 100 mg	generic — MT
naproxen tabs 250 mg, 375 mg, 500 mg	generic — MT
ibuprofen tabs 400 mg, 600 mg, 800 mg	generic — MT
meloxicam tabs 7.5 mg, 15 mg	generic — MT
OTEZLA (apremilast) tabs 10 mg, 20 mg, 30 mg	brand — PA, QL (60 tabs every 30 days)
OTEZLA XR tb24 75 mg	brand XR — PA, QL (30 tabs every 30 days)

RESPIRATORY / INHALATION PRODUCTSmixedCovered

budesonide (inhalation) susp 0.25 mg/2 mL	generic — MT
budesonide (inhalation) susp 0.5 mg/2 mL	generic — MT
budesonide (inhalation) susp 1 mg/2 mL	generic — MT
budesonide-formoterol fumarate dihydrate aerosol 80-4.5 mcg/act	generic — QL (1 inhaler every 30 days); MT
fluticasone-salmeterol aer powder 100-50 mcg/act	generic — QL (60 inhalations every 30 days); MT
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3 mL	generic — MT
levalbuterol HCl nebu 0.31 mg/3 mL	generic — MT
levalbuterol HCl nebu 0.63 mg/3 mL	generic — MT
levalbuterol HCl nebu 1.25 mg/0.5 mL	generic — MT
levalbuterol HCl nebu 1.25 mg/3 mL	generic — MT

1–10 of 15

1/2

ANTICOAGULANTS / HEPARINSmixedCovered

ELIQUIS tabs 2.5 mg	brand — Drug Tier 3; MT
ELIQUIS tabs 5 mg	brand — Drug Tier 3; MT
enoxaparin sodium soln 30 mg/0.3 mL; 40 mg/0.4 mL; 60 mg/0.6 mL; 80 mg/0.8 mL; 100 mg/mL; 120 mg/0.8 mL; 150 mg/mL; 300 mg/3 mL	generic — multiple presentations listed
heparin sodium (porcine) soln 1000 unit/mL	generic — multiple concentrations up to 20000 unit/mL
heparin sodium (porcine) soln 5000 unit/0.5 mL	generic — multiple concentrations

ANTICONVULSANTS / NEUROTHERAPEUTICSmixedCovered

gabapentin caps 100 mg, 300 mg, 400 mg	generic — PA, QL (180 caps every 30 days)
gabapentin tabs 600 mg	generic — PA, QL (180 tabs every 30 days)
gabapentin soln 250 mg/5 mL, 300 mg/6 mL	generic — PA, QL (2160 mL every 30 days)
pregabalin caps 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg	generic — PA, QL (90 caps every 30 days)
pregabalin caps 225 mg, 300 mg	generic — PA, QL (60 caps every 30 days)
pregabalin soln 20 mg/mL	generic — PA, QL (900 mL every 30 days)

OPIOID ANTAGONISTS / ANTIDOTESmixedCovered

naloxone HCl liqd 4 mg/0.1 mL	generic — QL (2 sprays every 30 days); OTC status noted
KLOXXADO liqd 8 mg/0.1 mL	brand — QL (2 sprays every 30 days)
Narcan liqd 4 mg/0.1 mL	brand/generic — QL (2 sprays every 30 days); OTC
ZIMHI SOSY 5 mg/0.5 mL	brand — QL (2 injections every 30 days)
naloxone HCl soln 4 mg/10 mL	generic — QL (1 vial every 30 days)
naloxone HCl soln 0.4 mg/mL	generic — QL (2 vials every 30 days)

ANTIEMETICS / 5-HT3mixedCovered

ondansetron tbdp 4 mg	generic — listed; standard 4 mg dose
ondansetron tbdp 8 mg	generic — listed; standard 8 mg dose
granisetron HCl tabs 1 mg	generic — listed

ANTIFUNGALSmixedCovered

posaconazole susp 40 mg/mL	generic — QL (630 mL every 30 days)
posaconazole tab 100 mg	generic — QL (93 tabs every 30 days)
voriconazole susp 40 mg/mL	IC drug — QL (600 mL every 30 days)
voriconazole tabs 50 mg	generic — QL (480 tabs every 30 days)

ANTIVIRALS / INFLUENZA / COVID-19mixedCovered

VIREAD tabs 150 mg	brand/generic tenofovir DF — QL (30 tabs every 30 days)
VIREAD tabs 200 mg	brand/generic — QL (30 tabs every 30 days)
VIREAD tabs 250 mg	brand/generic — QL (30 tabs every 30 days)
oseltamivir phosphate caps 30 mg	generic — QL (20 caps every 180 days)
XOFLUZA tbpk 40 mg	brand — QL (2 tabs every 180 days)
XOFLUZA tbpk 80 mg	brand — QL (2 tabs every 180 days)
LAGEVRIO caps 200 mg	brand — QL (40 caps every 5 days)

CARDIOVASCULAR - BETA / ALPHA-BETA / ANTIHYPERTENSIVESmixedCovered

carvedilol phosphate cp24 10 mg	generic — MT
carvedilol phosphate cp24 20 mg	generic — MT
carvedilol phosphate cp24 40 mg	generic — MT
carvedilol phosphate cp24 80 mg	generic — MT
labetalol HCl tabs 100 mg	generic — MT
labetalol HCl tabs 200 mg	generic — MT
labetalol HCl tabs 300 mg	generic — MT
metoprolol tartrate tabs 25 mg	generic — MT
metoprolol tartrate tabs 37.5 mg	generic — MT
metoprolol tartrate tabs 50 mg	generic — MT

1–10 of 15

1/2

MISCELLANEOUS SPECIFIED ITEMSmixedCovered

ondansetron HCl soln 4 mg/5 mL	generic — listed
granisetron HCl tabs 1 mg	generic — listed

BRAND / SPECIALTY NOTATIONSmixed

HADLIMA / SIMLANDI kits	see biosimilars group — PA, QL per kit
QUILLICHEW ER CHER 20/30/40 mg	brand — PA, QL per strength
OTEZLA tabs and XR	see PDE4 inhibitors group

Provider Submission, Prior Authorization, and Denial Risk

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed on the formulary — including specialty, biologic, allergenic biologicals, select branded agents, many stimulant/amphetamine products, certain antineoplastics, hepatitis C agents, and other specialty/limited-distribution drugs. Prescribers must submit PA requests digitally through CoverMyMeds, by phone at 1-800-924-7141, or by fax to 1-888-343-4232. Specialty drugs typically require PA, are often limited to 30-day supplies, and may be dispensed only by network specialty pharmacies.

Include patient name and cardholder ID, physician name and phone, drug and diagnosis information when requesting reconsideration or PA.
Share the formulary drug list with prescribers (especially when using out-of-network or out-of-state providers).
PA submission channels: CoverMyMeds (digital), phone 1-800-924-7141, fax 1-888-343-4232.

Denial Risk

Stimulant/ Amphetamine PA and Quantity Limits

Quantity Limits and Supply Rules

specialty drugs — typical supply rules (usually limited to a 30-day supply)

Specialty drug supply ruleSpecialty drugs are usually limited to a 30-day supply

Specialty dispensingSpecialty drugs typically require PA and are dispensed through specialty pharmacies in-network

ReferenceMembers should check Evidence of Coverage or member handbook for network details

various stimulant products QL examples (tabs/caps/ml)

Stimulant product QL examplesVarious stimulant entries show tab/cap QLs such as 30, 60, 90, 120 per 30 days and liquid QLs (e.g., 1200 mL/30 days)

SpecificsAmphetamine/dextroamphetamine and lisdexamfetamine strengths have differing QLs by strength and formulation (see per-line entries)

Site of Care and Biosimilar Handling

Billing Rule

Use specialty pharmacy and obtain PA for specialty drugs (30‑day supply)

Specialty drugs are usually limited to a 30-day supply and typically require prior authorization and specialty pharmacy dispensing; ensure PA and use of in‑network specialty pharmacies where indicated.

Specialty drugs: usually require PA, are limited to a 30-day supply, and are usually available only from network specialty pharmacies

Billing Rule

Include presentation-specific QL when requesting PA for adalimumab biosimilars

Adalimumab biosimilars are listed with PA and quantity limits per presentation (pens, injections); include the specific presentation and quantity in the PA request to match the QL (e.g., 4 pens/28 days or 2 injections/28 days).

ADALIMUMAB‑ADAZ entries show PA, QL (4 pens/28 days; 2 injections/28 days depending on presentation)

Step Therapy Programs and MT/ACA Flags

Program	Description
Step therapy (ST) program
Requires trial of specified first‑line drugs before covering alternative agents; prescriber must request coverage review via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232.

Formulary note	Requirement
Some therapeutic classes and specific drugs are flagged in the formulary as requiring step therapy
When step therapy is indicated, members must try the specified preferred agents before the plan will cover alternative products; prescribers should consult the formulary lines for class-specific ST flags.

Situation	Policy action
Entries with PA and QL but no explicit step sequence provided
Coverage at initiation is controlled by prior authorization (PA) and quantity limits (QL) as listed for the product (e.g., amphetamine and dextroamphetamine lines show 'PA, QL' values).

Indicator	Interpretation
MT or LD designation present on some entries
'MT' (Maintenance Matters) and 'LD' (Limited Distribution) suggest additional utilization management or monitoring steps may apply even when explicit ST sequences are not listed.

Products with MT	Implication
Multiple respiratory, neurologic and other generics marked 'MT' (e.g., fluticasone‑salmeterol, lamotrigine, valproate)
MT marking indicates a medication‑therapy/monitoring requirement or utilization control that may function as a step/monitor prior to alternative coverage.

Class/Examples	Management flag
Many generic antidepressants (e.g., mirtazapine, trazodone, desvenlafaxine, duloxetine)
Designated 'MT' in Requirements/Limits, implying medical therapy/maintenance program or step preference before coverage of non‑preferred agents.

Drug examples	Requirement
GLP‑1 receptor agonists (MOUNJARO, OZEMPIC, RYBELSUS)
Listed with Prior Authorization (PA) and Quantity Limits (e.g., MOUNJARO: PA, QL 4 pens/28 days; OZEMPIC: PA, QL 1 pen/28 days; RYBELSUS: PA, QL 30 tabs/30 days) — PA required before coverage.

Agent group	Management indicators
Statins and lipid‑lowering combinations (e.g., atorvastatin, rosuvastatin, ezetimibe)
Requirements/Limits show 'ACA' and/or 'MT' flags, indicating utilization management or maintenance program steps apply to these products.

Oncology listing feature	Effect on coverage
Formulary includes '1 =' and '2 =' tier/step columns for oncology agents
Second‑tier (2 =) entries frequently require prior authorization (PA), have quantity limits (QL), or limited distribution (LD) — PA commonly required for tier‑2 oncology products.

Hormonal agents	Requirements/Limits
Hormonal oncology agents (e.g., anastrozole, exemestane, tamoxifen)
Marked with 'MT' and/or 'ACA' in Requirements/Limits, indicating medical‑therapy program or utilization management before coverage of alternatives.

Antiparkinson entries	Formulary flags
Multiple antiparkinson drugs and formulations (e.g., benztropine, entacapone, carbidopa/levodopa lines)
Marked with 'MT' or numeric program codes in Requirements/Limits; these annotations imply plan‑specific management steps that may act like step therapy or monitoring requirements.

Policy Definitions and Abbreviations

PA — prior authorization definition

PA definitionPrior Authorization (PA) — may be required for certain drugs; provider must request coverage review via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232

QL definitionQuantity Limit (QL) — coverage limited to a specified amount of a drug per timeframe

ST definitionStep Therapy (ST) — requires trial of specified drugs before covering alternatives

QL — quantity limit definition

QL definitionQuantity Limit (QL) — maximum amount covered in a specified time period (e.g., '60 caps every 30 days') as listed in Requirements/Limits

Example usageUsed throughout product rows to constrain dispensed units (tabs, caps, mL, inhalers, pens) per period

Background and Support

Pharmacists are positioned as a frontline resource to help prescribers and members navigate the formulary. They can identify potential drug–drug interactions, recommend lower‑cost generics or preferred alternatives, and assist with prior authorization workflows. The formulary directs prescribers to request PA via CoverMyMeds, phone (1-800-924-7141), or fax (1-888-343-4232), and encourages patients to consult pharmacists before switching to OTC options or stopping therapy without clinician input.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPreferred Formulary Guide — Prescription Drug Benefits (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 2026

Next Review DateN/A

Key ActionProviders must request prior authorization via CoverMyMeds, by calling 1-800-924-7141, or faxing 1-888-343-4232 when PA is indicated.

SourceLink

On This Page

Many stimulant and amphetamine products are subject to both prior authorization and specific quantity limits (QL). Claims exceeding listed QLs (for example caps/tabs per 30 days or mL per 30 days) may be denied if PA/QL requirements are not met. Prescribers must document product, strength, and requested quantity consistent with the formulary entry.

Examples of PA + QL enforcement: amphetamine-dextroamphetamine (multiple strengths) — PA, QL (varies by strength; common limits: 30–90 tabs/caps per 30 days).
Methylphenidate and dextroamphetamine formulations — PA, QL with mL or tab caps (examples: solution mL limits; 900–1800 mL or 30–120 tabs depending on product).
Denial risk exists if prescribed product/strength does not match listed product or exceeds QL without PA.

Prior Authorization

Selected Drugs and Specialty Biologics: PA, QL, and LD

Selected branded and specialty agents require prior authorization and may also have quantity limits (QL) or limited distribution (LD) status. Examples across categories include XIFAXAN, CAYSTON, NUCALA, DIACOMIT, EPIDIOLEX, FINTEPLA, ZTALMY SUSP, MOUNJARO, OZEMPIC, REPATHA, and many antineoplastics (see formulary listings). Requests must include clinical justification and dosing to demonstrate compliance with QL and LD requirements.

Examples: XIFAXAN — PA, QL (9 or 90 tabs per 30 days depending on formulation).
CAYSTON — PA, QL (90 vials per 30 days); LD.
NUCALA — MT = PA, QL (injections/vials per 28 days); LD.
DIACOMIT, EPIDIOLEX, FINTEPLA, ZTALMY — PA and often LD.
MOUNJARO, OZEMPIC, RYBELSUS — PA, QL (pen/tab limits per 28/30 days).
REPATHA — QL and PA expectations; support dosing to match QL on PA requests.

Denial Risk

Antineoplastics — PA and Quantity Limits

Many antineoplastic agents and adjunctive cancer therapies require prior authorization and are subject to strict quantity limits; several are limited-distribution. Claims for antineoplastics may be denied at adjudication without an approved PA and adherence to the listed QL. Prescribers must submit documentation supporting the PA and any LD handling instructions.

PA + QL examples: IBRANCE — PA, QL (21 tabs every 28 days); IMBRUVICA — PA, QL with varying caps/tabs or mL limits; many oral antineoplastics list specific cap/tab/mL QLs.
LD applies to many oncology products — follow LD directions and include LD pharmacy information when requesting PA.
Denials can be triggered by missing PA, exceeding QL, or insufficient supporting documentation for oncology regimens.

Documentation Required

Reconsideration, Documentation, and Submission Channels

If you want us to reconsider a denial or limitation, submit a written request with reasons from the prescribing physician. Reconsideration requests and PA documentation should include the patient and prescriber identifiers, clinical rationale, and product/strength/quantity to match formulary entries. Fax reconsideration materials to 1-888-343-4232 or mail to Pharmacy Management Reconsiderations, BlueCross BlueShield of Tennessee, 1 Cameron Hill Circle, Chattanooga, TN 37402-2555.

Include: patient name and cardholder ID number; physician name and phone number; drug and diagnosis information; clinical justification and dosing.
Denial triggers to address: benefit exclusions, unmet PA or step therapy, QL overages, insufficient PA details.
Use the same submission channels for PA and reconsideration (CoverMyMeds, phone, fax).

PA noteMany stimulant products also require prior authorization as indicated in Requirements/Limits

armodafinil tabs 50mg QL

Armodafinil 50 mg QL60 tabs every 30 days (for 50 mg strength)

Strength-dependent QLsHigher armodafinil strengths listed with different QLs (e.g., 150/200/250 mg QL 30 tabs/30 days)

PAArmodafinil entries include PA in Requirements/Limits

methylphenidate HCl solution 5mg/5mL QL

Methylphenidate 5mg/5mL solution QL1800 mL every 30 days (5 mg/5 mL formulation)

Alternate strengths10 mg/5 mL solution listed with QL 900 mL every 30 days

PASolution presentations require PA per Requirements/Limits

QUILLIVANT XR SRER 25MG/5ML QL

QUILLIVANT XR SRER 25mg/5mL QL360 mL every 30 days

Product typeBrand methylphenidate liquid formulation with PA and specified liquid QL

Prescription implicationPharmacy claims must adhere to the 360 mL/30 days limit unless PA provided

ENBREL presentations QL (pens/syringes)

ENBREL QL examplesENBREL presentations QL = 4 pens every 28 days or 8 syringes every 28 days (varies by presentation)

PA and LDENBREL entries include PA and in some presentations LD or other requirements

Follow presentation-specific QLUse the Requirements/Limits value corresponding to the exact kit/presentation dispensed

praziquantel 600 mg tabs QL

Praziquantel 600 mg tabs QL24 tabs every 365 days (24 per year)

Therapeutic contextListed under androgens/antiparasitic section with annual QL specified

Claims noteAnnual QL differs from standard monthly QLs — check timeframe on the product row

XIFAXAN 200 mg QL

XIFAXAN 200 mg QL9 tabs every 30 days

XIFAXAN 550 mg QL90 tabs every 30 days

CAYSTON noteCAYSTON QL = 90 vials every 30 days and marked LD

XIFAXAN 550 mg QL

XIFAXAN 550 mg QL90 tabs every 30 days

Tier and PAListed with PA in Requirements/Limits — claims must meet PA and QL

Indication-specificDifferent strengths have distinct QLs (200 mg vs 550 mg) — honor per-line limits

nitazoxanide 500 mg tabs QL

Nitazoxanide 500 mg tabs QL14 tabs every 30 days

Vancomycin capsule QLVancomycin HCl capsules 125/250 mg QL = 120 caps every 30 days

Vancomycin solution QLsVancomycin solution 25 mg/mL QL = 900 mL/30 days; 50 mg/mL (250 mg/5 mL) QL = 1350 mL/30 days

vancomycin HCl capsules 125/250 mg QL

Vancomycin capsule QL120 capsules every 30 days

Vancomycin solution 25 mg/mL QL900 mL every 30 days

Vancomycin higher-concentration solution QL50 mg/mL (250 mg/5 mL) QL = 1350 mL every 30 days

vancomycin HCl solution 25 mg/mL QL

Vancomycin solution 25 mg/mL QL900 mL every 30 days

Vancomycin solution 50 mg/mL QL1350 mL every 30 days

Use per formulationDifferent concentrations have separate mL QLs — confirm product strength on the claim

vancomycin HCl solution 50 mg/mL QL

Vancomycin 50 mg/mL (250 mg/5 mL) QL1350 mL every 30 days

Packaging noteExpressed as mL per 30 days for liquid formulations

AuthorizationExceeding the listed mL limit may trigger need for PA or denial

CAYSTON 75 mg QL

CAYSTON 75 mg QL90 vials every 30 days (PA required); also noted LD

Linezolid QLLinezolid 600 mg listed QL = 14 day supply every 30 days

Antimicrobial enforcementMany anti-infectives include explicit QLs and PA/LD flags — follow per-line entries

linezolid 600 mg QL

Linezolid 600 mg QL14 day supply every 30 days

Benzodiazepine examplesDiazepam and lorazepam solutions/tabs show mL/tab QLs (e.g., diazepam soln QL 600 mL/30 days; lorazepam tabs 150 tabs/30 days)

Varies by productBenzodiazepine QLs differ by formulation and concentration — check the product row

benzodiazepines QL examples

Benzodiazepine QL patternsExamples include alprazolam, diazepam, lorazepam with QLs expressed as tabs or mL per 30 days (e.g., diazepam tabs 120 tabs/30 days; lorazepam 150 tabs/30 days)

Formulation-specificLiquid concentration formulations list mL QLs (e.g., diazepam soln 600 mL/30 days)

Claim complianceExceeding QLs may require PA or be subject to denial

selected inhalers QL examples

Selected inhaler QL setExamples: QVAR REDIHALER 10.6 gm or 21.2 gm/30 days; BREO ELLIPTA 60 blisters/30 days; many others at 1 inhaler/30 days or 2 inhalers/30 days

Rescue inhaler noteAlbuterol and similar rescue inhalers QL = 2 inhalers every 30 days (VENTOLIN HFA, PROAIR RESPICLICK)

Powder/inhalation countsFluticasone-salmeterol aer powder QL = 60 inhalations every 30 days

QVAR REDIHALER 40MCG/ACT QL (10.6 gm)

QVAR REDIHALER 40mcg/act QL10.6 gm every 30 days

Product noteListed with Drug Tier = 3 and MT alongside the QL

Claims implicationPharmacy claims must adhere to the 10.6 gm/30 days limit unless PA or other authorization applies

QVAR REDIHALER 80MCG/ACT QL (21.2 gm)

QVAR REDIHALER 80mcg/act QL21.2 gm every 30 days

TieringDrug Tier = 3 and MT noted alongside QL

EnforcementAdjudicate per QL unless PA/override documented

BREO ELLIPTA QL (60 blisters)

BREO ELLIPTA QL60 blisters every 30 days

Multiple strengthsAll BREO strengths listed share the 60-blister/30-day QL in this extract

TierDrug Tier = 3 for BREO entries

BREYNA / budesonide-formoterol / BREZTRI / COMBIVENT QL (1 inhaler)

Single-inhaler QL examplesBREYNA, budesonide-formoterol, BREZTRI, COMBIVENT, STIOLTO, STRIVERDI listed QL = 1 inhaler every 30 days

Applies to multiple productsThese combination/brand inhalers are limited to one inhaler per 30 days in the listing

MT flagMany are also tagged MT in Requirements/Limits

albuterol and similar rescue inhalers QL (2 inhalers)

Albuterol and like rescue inhalers QL2 inhalers every 30 days (e.g., VENTOLIN HFA, PROAIR RESPICLICK)

Rescue classificationThese are commonly classified as SABA with QL = 2 inhalers/30 days

Claim processingPharmacies should limit dispensed units to the QL unless PA/instruction provided

fluticasone-salmeterol aer powder QL (60 inhalations)

Fluticasone-salmeterol powder QL60 inhalations every 30 days

Applicable productsMultiple strengths of fluticasone-salmeterol powder list the 60-inhalation QL

MonitoringMT designation accompanies the QL for many entries

gabapentin / pregabalin QLs — various examples including large volume solution limits

Gabapentin / pregabalin QLsExamples include gabapentin QL 180 caps/30 days or solution QL 2160 mL/30 days; pregabalin QL examples include 900 mL/30 days for solution

Formulation sensitivityCaps, tabs, and solution presentations each have specific QLs — check per-line entry

PA flagMany entries list PA alongside QL for gabapentin/pregabalin formulations

pregabalin solution 20mg/mL QL (900 mL)

Pregabalin solution 20 mg/mL QL900 mL every 30 days

Product rowPregabalin solution 20 mg/mL explicitly listed with QL 900 mL/30 days

Denial cautionRequests above 900 mL/30 days risk denial absent PA or documented medical necessity

vigabatrin QL (180)

Vigabatrin QL180 (tabs or packets) every 30 days

Presentations notedBoth pack and tablet presentations show QL = 180 per 30 days; some listings include LD

Authorization noteFollow PA/LD flags where present for coverage and dispensing

acarbose tabs QL examples (360/180/90)

Acarbose tablet QLsExamples include 360, 180, or 90 tabs every 30 days depending on strength

Strength-dependenceHigher or lower strength formulations have differing QLs as indicated per product row

Follow per-lineConfirm exact QL on the product line when adjudicating claims

antidiabetic combo tablets QLs (30-120 tabs or 15 mL Soliqua)

Antidiabetic combo tablets QLsMany combos (e.g., GLYXAMBI, JANUMET, SYNJARDY, TRIJARDY, XIGDUO) have QLs ranging 30–120 tabs per 30 days or 15 mL for SOLIQUA every 25 days

Product-specificSYNJARDY XR QL = 60 tabs/30 days; TRIJARDY XR QL = 30 or 60 tabs/30 days depending on strength

Metformin solution tie-inMetformin solution listed with 765 mL/30 days QL alongside combination product rows

metformin HCl solution QL (765 mL)

Metformin HCl solution QL765 mL every 30 days

Associated tablet QLMetformin 500 mg tablets example QL = 150 tabs every 30 days

MT flagMT is commonly attached to metformin entries alongside QL

SYNJARDY XR QL (60 tabs)

SYNJARDY XR QL60 tabs every 30 days

Product familySYNJARDY and SYNJARDY XR rows show multiple QLs by strength and presentation

MT indicatorMT accompanies many antidiabetic QLs in the listing

TRIJARDY XR QL (30 tabs)

TRIJARDY XR QL30 tabs every 30 days (example strength)

Multiple strengthsOther TRIJARDY XR strengths show 60 tabs/30 days in separate rows

MT flagMT is listed alongside QL for TRIJARDY XR entries

metformin HCl solution QL (765 mL every 30 days)

Metformin solution QL (repeated)765 mL every 30 days

Reference rowMetformin HCl solution 500 mg/5 mL explicitly lists 765 mL/30 days

Claims handlingDispensed volume must not exceed 765 mL per 30 days without PA

metformin HCl tabs 500mg QL (150 tabs)

Metformin 500 mg tablets QL150 tablets every 30 days

Alternate tablet QLsOther metformin tablet strengths have different QLs (e.g., 90, 75, 120 tabs/30 days) listed per-line

MT associationMT appears on many metformin tablet rows

MOUNJARO pens QL (4 pens/28 days)

MOUNJARO pens QL4 pens every 28 days

PA requirementMOUNJARO entries include PA plus the 4-pen/28-day QL

Prescribing implicationPrescribers must document dosing and supply consistent with 4 pens/28 days for coverage

OZEMPIC pens QL (1 pen/28 days)

OZEMPIC pen QL1 pen every 28 days

PA indicatedOZEMPIC rows list PA with the 1-pen/28-day QL

Coverage noteClaims should match the pen presentation and the 28-day supply limit

RYBELSUS QL (30 tabs/30 days)

RYBELSUS QL30 tablets every 30 days

PA flagRYBELSUS listed with PA and QL 30 tabs/30 days

Strength rangeMultiple strengths covered under the 30-tab/30-day QL listing

Insulin products QL examples (60-90 mL; 4 pens/28 days)

Insulin QL examplesExamples include 60–90 mL every 30 days for vial/soln presentations; 4 pens every 28 days for many pen products

Product specificsFIASP QLs vary by presentation (e.g., QL 90 mL or 60 mL per 30 days depending on presentation)

OTC noteSome insulin presentations are noted OTC in the listing while still having QLs/PA entries

intranasal naloxone sprays QL (2 sprays/30 days)

Intranasal naloxone sprays QL2 sprays every 30 days

Naloxone injection QL2 injections (syringes) every 30 days for injectable presentations

Naloxone vial QL1 vial every 30 days for solution vials

naloxone injection syringes QL (2 injections/30 days)

Naloxone injection syringe QL2 injections every 30 days

ZIMHI QLZIMHI syringe QL = 2 injections every 30 days

OTC statusSome naloxone nasal sprays are OTC and still carry a QL in the formulary

naloxone solution vials QL (1 vial/30 days)

Naloxone solution vial QL1 vial every 30 days (naloxone solution 4 mg/10 mL)

Alternate vial QLSome solution presentations list QL = 2 vials every 30 days depending on formulation

Claims noteFollow product-specific QL and OTC designation where present

ZIMHI syringe QL (2 injections/30 days)

ZIMHI syringe QL2 injections every 30 days

Brand noteZIMHI listed explicitly with QL = 2 injections/30 days

Coverage implicationPA/coverage requirements should be confirmed per-line though ZIMHI is shown with QL

naloxone nasal sprays QL (2)

Naloxone nasal sprays (various) QL2 sprays every 30 days (common across Narcan, KLOXXADO, generic nasal sprays)

OTC designationSeveral nasal spray entries are OTC while still carrying a QL in the formulary

Dispensing guidanceAdjudicate per 2-spray/30-day QL unless PA/documentation indicates otherwise

naloxone injectable syringes/vials QL (1-2)

Naloxone injectable syringes/vials QL range1–2 units every 30 days depending on formulation (vials vs syringes)

Formulation examplesSome entries list 1 vial/30 days, others 1–2 syringes/30 days — check product row

Coverage implicationQuantity allowed varies by presentation; confirm exact QL on the claim

posaconazole suspension QL (630 mL)

Posaconazole suspension QL630 mL every 30 days

Voriconazole suspension QL600 mL every 30 days

Tablet vs suspensionTablet presentations have separate tab QLs (e.g., posaconazole tablets 93 tabs/30 days)

voriconazole suspension QL (600 mL)

Voriconazole suspension QL600 mL every 30 days

Tablet QLsVoriconazole 50 mg tabs QL = 480 tabs/30 days; 200 mg tabs QL = 120 tabs/30 days

Product-specific enforcementAdjudicate per the exact formulation and QL listed

REPATHA prefilled pens QL (2 pens/28 days)

REPATHA prefilled pens QL2 pens every 28 days

REPATHA cartridge QL1 cartridge every 28 days (Pushtronex) — alternate presentation QL varies

MT flagMT accompanies some REPATHA presentations in listing

ONUREG QL (14)

ONUREG QL14 tabs every 28 days

PA and LDONUREG listed with PA, QL and LD in the oncology section

Apply per-lineOncology QLs often use 28-day windows; confirm timeframe on product row

FRUZAQLA QL (84)

FRUZAQLA QL84 caps every 28 days (one strength) or 21 caps every 28 days (other strength)

LD and PAFRUZAQLA entries include PA and LD alongside the QL

Strength-dependentDifferent capsule strengths have separate QLs — follow the specific product row

INLYTA QL (240)

INLYTA QL240 tabs every 30 days (1 mg) or 120 tabs every 30 days (5 mg)

PA and LDINLYTA rows include PA and LD flags — follow per-line requirements

Dose-specificQL differs by tablet strength — confirm on the claim

LENVIMA QL (30|60|90)

LENVIMA QL options30, 60, or 90 caps every 30 days depending on daily dose/strength

PA and LDLENVIMA entries include PA and LD alongside QLs; timeframe is 30 days

Follow exact strengthUse the QL corresponding to the specified daily-dose product row

Multiple per-line QL examples — general instruction to follow per-product QLs

Follow per-line QLsQuantity limits are specified per product (examples: 30 tabs/30 days; 60 tabs/30 days; 24 tabs/year; 360 packets/30 days)

Timeframe variabilitySome QLs use yearly, 24‑day, 28‑day or 30‑day windows — use the timeframe shown on the product row

Check Requirements/LimitsAlso verify PA, LD, or MT flags accompanying the QL for adjudication requirements

IBRANCE tabs QL (21 tabs)

IBRANCE QL21 tabs every 28 days

PA and LDIBRANCE listed with PA, QL and LD — follow per-line requirements

Coverage implicationClaims for IBRANCE must reflect 21-tab/28-day supply or include PA to exceed

IMBRUVICA caps QL (28 caps)

IMBRUVICA QLsExamples: IMBRUVICA caps 70 mg QL = 28 caps/28 days; other IMBRUVICA presentations show 90 caps/30 days or 324 mL/30 days (suspension)

LD and PAIMBRUVICA entries include PA and LD flags — follow distribution requirements

Presentation-specificDifferent formulations (caps, tabs, suspension) have separate QLs and units

LYNPARZA tabs QL (120 tabs)

LYNPARZA QL120 tabs every 30 days

PA and LDLYNPARZA listed with PA, QL and LD — follow per-line authorization for coverage

Use-caseAdjudicate per 30-day QL unless PA documents different need

RETEVMO tabs QL (90 tabs)

RETEVMO QL120 tabs every 30 days (80 mg example) or 60 tabs every 30 days (other strengths)

LD/PARETEVMO rows include PA and LD designations

Strength-dependentQL varies by strength — confirm product line for the correct QL

VITRAKVI soln QL (300 mL)

VITRAKVI solution QL300 mL every 30 days (20 mg/mL solution)

Capsule QLsVITRAKVI caps QLs include 180 or 60 caps/30 days depending on strength

LD and PAVITRAKVI entries include PA and LD in oncology listing

ZELBORAF tabs QL (240 tabs)

ZELBORAF QL240 tabs every 30 days

PA/LDZELBORAF row includes PA and LD flags — follow per-line requirements

Oncology contextHigh tab-count QLs are common for chronic oral oncology agents

Enforcement noteClaims exceeding QL require PA or may be denied per formulary rules

ST — step therapy definition

ST definitionStep Therapy (ST) — a prior authorization program that requires trying specified first-line drugs before another drug is covered

Provider actionPrescriber must request coverage review if ST applies; see formulary step therapy list

Relation to PAST is a form of utilization management that may be enforced via PA requirements

LD — limited distribution definition

LD definitionLimited Distribution (LD) — drug may only be available through specified pharmacies or specialty channels (noted alongside certain specialty/oncology agents)

ExamplesMultiple oncology and specialty entries include LD (e.g., ONUREG, many antineoplastics)

CoordinationPA/LD items may require coordination with specialty distributors per product row

MT — maintenance matters / medical therapy abbreviation

MT definitionMT (Maintenance Matters) — denotes drugs for long-term conditions; programs may require 90-day supplies or other maintenance fills

Program effectMT may affect supply cadence (e.g., 90-day fills) and appears beside many chronic-therapy entries

Claims implicationMT flags should be considered when authorizing maintenance supplies and adjudicating claims

MME — morphine milligram equivalent definition and threshold

MME definitionMorphine Milligram Equivalent (MME) — plan measures opioid strength relative to morphine; PA required when >120 mg equivalents/day

Action requiredPrescriber must request coverage review if patient exceeds 120 mg MME/day

Contact infoCoverage review submitted via CoverMyMeds, phone 1-800-924-7141, or fax 1-888-343-4232

OTC — over-the-counter definition and policy implication

OTC definitionOver-the-counter (OTC) — medicines sold without a prescription; some prescription drugs may not be covered when an OTC alternative exists

Member guidanceDo not switch from a prescription to an OTC without consulting the prescriber

Formulary noteSome entries (e.g., certain naloxone or insulin presentations) are noted OTC while still listing QLs