Currentblue cross blue shield - tennesseePolicy N/A

Standard Control with Advanced Control Specialty Formulary — Pharmacy Formulary Coverage Criteria

Pharmacy formulary describing drug tiers, coverage requirements (e.g., prior authorization, step therapy, quantity limits), and a categorized list of covered medications for BlueCross BlueShield of Tennessee members under the Standard Control with Advanced Control Specialty Formulary administered by CVS Caremark. Affects prescribers, pharmacies, and members covered by this specific BCBS TN plan.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyStandard Control with Advanced Control Specialty Formulary — Pharmacy Formulary Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line item is annotated with 'PA' and provide supporting documentation for PA/QL requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5drug tiers defined (Tier 1-5)

90opioid daily MME quantity limit

CVSpharmacy benefits administrator

MultiplePA / QL / ST usage across formulary

20+

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drug entries in this partial extract

Coverage Criteria

Formulary-wide coverage conditions

Formulary coverage is determined by drug tier and may require additional utilization management;

General coverage conditions: Member must have a valid prescription from a licensed provider; inclusion on the formulary does not guarantee coverage; coverage is determined by the assigned drug tier and may be subject to prior authorization (PA), step therapy (ST), or quantity limits (QL) as indicated.

Providers and pharmacies should verify product-specific Requirements/Limits on the formulary before dispensing.

Opioid prescribing controls

Opioid-containing products

Opioid quantity and formulation limits: Quantity of opioid products (including combinations with acetaminophen, aspirin, or ibuprofen) is limited to up to 90 morphine milligram equivalents (MME) per day based on a 30‑day supply. Opioid‑naïve members are required to use an immediate‑release (IR) formulation prior to an extended‑release (ER) formulation.<= 90 MME/day

Initial prior authorization may apply to higher strengths of certain opioid ER formulations; many opioid entries carry QL and PA indicators (see formulary lines).

General coverage stance for listed products

Coverage follows formulary tiering with utilization controls; products marked PA or QL require prior authorization and are subject to quantity limits.

Formulary coverage with utilization controls: Drug is covered at the listed tier when standard coverage rules are met; if the formulary entry lists 'PA' and/or 'QL' the provider must obtain prior authorization and adhere to any quantity limits specified for that product.

Product‑level Requirements/Limits on the formulary indicate whether PA, QL, or ST apply; some products also show 'Preferred for' indications which reflect formulary preference.

Formulary utilization controls

Coverage and utilization management as indicated on formulary entries

Products requiring PA and QL: Multiple products and therapeutic classes are subject to prior authorization (PA) and quantity limits (QL) as shown on their formulary lines (examples include ENBREL, OTEZLA, select antineoplastics, and many opioid formulations).

Claims lacking required PA or exceeding QL are subject to denial per the formulary Requirements/Limits entries.

Formulary coverage overview

Coverage indicated by presence on formulary with tier and any requirements/limits

Formulary inclusion: Drugs listed on the formulary are assigned a numeric tier which determines member cost‑sharing; presence on the formulary indicates coverage subject to any product‑specific Requirements/Limits (PA, QL, ST) shown on the line item.

This extract lists tiers and flags but does not provide patient‑level clinical eligibility criteria.

General coverage stance

Coverage is tier-based; many agents require PA/QL

Formulary coverage with controls: Drugs are listed with an assigned tier; entries annotated 'PA' or 'PA, QL' require prior authorization before coverage and quantity limits apply where indicated.

Many antineoplastics and specialty agents carry PA and QL annotations; providers must obtain authorization prior to dispensing.

Hepatitis C antiviral coverage notes

Coverage and utilization management notes for HCV and select antiretroviral agents

EPCLUSA/HARVONI/SOVALDI/VOSEVI: These hepatitis C antiviral products require prior authorization and/or quantity limits as specified on their formulary lines. EPCLUSA and HARVONI include genotype‑specific indications (EPCLUSA: genotypes 1–6; HARVONI: genotypes 1, 4, 5, 6). VOSEVI is limited to patients previously treated with an NS5A‑containing HCV regimen or with specified prior sofosbuvir exposure for certain genotypes.genotype specific

Documentation supporting genotype and prior‑treatment history should be provided with PA requests.

Coverage contingent on PA/QL

Coverage is provided when product-specific rules are met

General requirement: For drugs listed with 'PA' and/or 'QL' in the Requirements/Limits field, coverage requires completion of prior authorization and adherence to any quantity limits specified on the formulary line.

This applies broadly to multiple specialty and high‑cost branded products (e.g., hemophilia factor products, SANDOSTATIN, LIVMARLI, TREMFYA).

Certain NDCs of HYRIMOZ are explicitly excepted from utilization management: the formulary line for HYRIMOZ (SOAJ/SOSY presentations) is annotated with Requirements/Limits = PA, QL; Except NDCs 61314-XXXX-XX, indicating those specific NDCs are not subject to the PA/QL requirement shown for other HYRIMOZ NDCs.

Testosterone gel formulations are listed with Requirements/Limits = PA, with an explicit exception for authorized generics: the entry notes Except authorized generics for TESTIM and VOGELXO, meaning PA is required for testosterone gel except when the product is one of those authorized generic presentations.

Within the portion of the formulary provided in this extract there are no other explicit clinical exclusions listed by name; the document primarily shows product lines with tiers and Requirements/Limits entries rather than standalone exclusion statements.

The VOSEVI formulary entry includes a prior-treatment limitation: VOSEVI is listed with Requirements/Limits = PA, QL and is specified for use only in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1–6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).

The formulary makes coverage conditional on product-specific utilization rules: drugs annotated with PA and/or QL require completion of prior authorization and adherence to quantity limits, and claims may be denied if those requirements are not met.

Coverage criteria for individual products are presented on the formulary lines (drug name, tier, and Requirements/Limits). (Inventory item reserved for a detailed, product-specific criteria summary — no additional summary text provided here.)

No explicit 'Not Medically Necessary' determinations are stated in the chunks included in this extract; the document limits coverage primarily through utilization controls such as PA, QL, and prior-treatment requirements rather than NMN language.

Across the provided extract there are no explicit 'Not Medically Necessary' determinations presented; utilization management is enforced via prior authorization, quantity limits, and specified prior-treatment conditions.

The document consistently uses PA (prior authorization) and QL (quantity limits) annotations on formulary entries to manage coverage; these utilization controls are the mechanism used in the extract rather than explicit NMN statements.

Within the provided chunks there are no explicit NMN (Not Medically Necessary) statements; coverage constraints are implemented by marking products with PA and/or QL and by applying prior-treatment or genotype conditions where specified.

Drug Listings & Coding

Provider Responsibilities & Authorization Actions

Prior Authorization

Prior Authorization & Documentation Overview

Many medications listed in this formulary require prior authorization (PA) before they will be covered. Inclusion on the drug list does not guarantee coverage — coverage is conditional on meeting PA, quantity limit (QL), and other utilization controls as noted. Providers must follow the plan's PA and QL procedures and supply supporting documentation (medical evidence, clinical notes, genotype or prior-treatment history when applicable) with authorization requests. Claims submitted without required authorizations or documentation may be denied.

Coverage conditional on PA — inclusion on the list is not a guarantee of coverage
Follow PA/QL procedures — submit complete documentation to support medical necessity
PA/QL enforcement — claims lacking required PA/QL may be denied
Evidence of PA/QL requirements — clinical records, prior-treatment history, or genotype data may be requested

Prior Authorization

Prior Authorization — ADHD Stimulants

Prior authorization is required for many ADHD stimulant products (PA flagged on numerous amphetamine/dextroamphetamine and lisdexamfetamine entries). Providers should submit PA requests for these agents per the plan's PA process.

Initial Therapy Criteria

Opioid formulation step

Opioid-naïve formulation sequencing

Opioid‑naive requirement: Opioid‑naïve members are required to use an immediate‑release (IR) formulation before an extended‑release (ER) formulation.

This sequencing supports quantity‑limit and PA enforcement for ER formulations.

ADHD agents (formulary placement & PA/QL)

ADHD agents and stimulants

ADHD stimulant coverage: Various stimulant and non‑stimulant ADHD agents are listed with assigned tiers and Requirements/Limits; many extended‑release and branded stimulant presentations carry 'PA' on the formulary line and some are designated preferred at lower tiers.

No explicit clinical step criteria are provided in this extract; providers should follow PA procedures where indicated.

Step Therapy Rules

Product	Step therapy / ST	Requirements/Limits
Amphetamine-dextroamphetamine mixed salts (extended-release cap, multiple strengths)	ST indicated for certain tier 2 presentations per legend (ST noted in document legend); specific entries show Tier 1 vs Tier 2 with PA for higher-tier strengths	Many strength/formulations list Requirements/Limits = PA for tier 2 entries (document lists numerous strengths with '2 = PA')
Dextroamphetamine (DEXEDRINE) 5–15 mg (CP24)	No explicit ordered step sequence shown; higher-tier DEXEDRINE entries list PA	Tier and Requirements/Limits shown (e.g., '2 = PA' for CP24 strengths) per formulary lines
Lisdexamfetamine (caps/chewable, multiple strengths)	Formulary shows both Tier 1 and Tier 2 entries; ST may apply where ST/PA legend invoked but no explicit step ordering provided in listings	Tier 1 entries listed as '1 = 1' while corresponding '2 = PA' entries indicate prior authorization for certain presentations

Preference statement	Implication for ordering	Source example
Adalimumab biosimilars marked 'Preferred for' multiple autoimmune indications	Implies biosimilars are preferred treatments within class before other non-preferred brands; not an explicit step requirement	ADALIMUMAB-ADAZ / ADALIMUMAB-FKJP lines show 'Preferred for Ankylosing Spondylitis, Crohn's Disease, ...' and include PA, QL for some presentations
OTEZLA/XR and Select agents marked 'Preferred for Rheumatoid Arthritis'	Indicates formulary preference for specified indications but does not define a stepped failure/transition pathway	OTEZLA/XR TAB 28 DAY, Requirements/Limits = PA, QL; Preferred for Rheumatoid Arthritis
TREMFYA, CIMZIA, ENTYVIO SC annotated 'Preferred for' specific indications	Preference suggests these agents are first-line within class where indicated, but explicit step sequences are not provided	TREMFYA and CIMZIA entries list 'Preferred for' with Requirements/Limits = PA, QL in some presentations

Indication / Class	Preferred agent(s)	Formulary note
Rheumatoid arthritis / related autoimmune conditions	Adalimumab biosimilars (ADALIMUMAB-ADAZ, ADALIMUMAB-FKJP) and ORENCIA; OTEZLA preferred for select indications	Listings show 'Preferred for Rheumatoid Arthritis' and include PA, QL annotations for many biologic presentations
Crohn's disease / Ulcerative colitis	ENTYVIO SC, ADALIMUMAB biosimilars (preferred for IBD indications)	ENTYVIO SC and some adalimumab biosimilar lines list preferred indication language; PA/QL may apply
Psoriasis / Psoriatic arthritis	TREMFYA, SKYRIZI, adalimumab biosimilars	Preference notes present (e.g., TREMFYA 'Preferred for Crohn's Disease, Ulcerative Colitis'); Requirements/Limits often PA, QL

Topic	Step therapy sequence present?	Notes
General formularies and tiering	No explicit multi-step sequences shown	Listings primarily present tier assignments and PA/QL flags rather than ordered step transitions (e.g., many entries show '1 = 1' vs '2 = PA').
Neurologic / anticonvulsant examples	No explicit ST ordering	Entries (oxcarbazepine, OXTELLAR XR) show tier and Requirements/Limits.PA, QL but do not define step failures or prerequisites
Insulins and antidiabetic agents	No explicit ST sequences provided	Products (NOVOLOG MIX, TOUJEO, TRESIBA) include tier assignments; PA/QL not consistently shown as step requirements

Topic	Step therapy sequence present?	Notes
Insulins / antidiabetic generics	No ST sequences shown	Formulary lists tiers for insulins and oral antidiabetics; Requirements/Limits fields are present but do not establish step order in this extract
SGLT2 inhibitors and oral agents	No explicit ST	FARXIGA and JARDIANCE listed with tiers; PA/QL not presented as step transitions in these chunks

Class / Category	Class-level management	Formulary indication
Antineoplastics and adjunctive therapies	Multiple agents grouped with Requirements/Limits = PA, QL at class or product level, implying class-level utilization management	Examples include GILOTRIF, TAGRISSO, ERIVEDGE with Requirements/Limits = PA, QL
Hedgehog pathway and hormonal antineoplastics	Class-level PA/QL consistently applied to many entries	ERIVEDGE and other agents listed with PA, QL in antineoplastic sections

Product	Step / prior-treatment requirement	Coverage condition
VOSEVI (tab)	Step-like prior-treatment requirement: coverage limited to patients previously treated with an NS5A-containing HCV regimen or sofosbuvir without NS5A for select genotypes	Requirements/Limits = PA, QL; For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).
EPCLUSA / HARVONI / SOVALDI	Require PA and QL; genotype-specific applicability shown (EPCLUSA genotypes 1-6; HARVONI genotypes 1,4,5,6)	EPCLUSA PAK: Requirements/Limits = PA, QL; HARVONI lines include genotype indications and PA, QL

Example	Tier implication	Formulary note
Amlodipine-atorvastatin (generic) vs CADUET (brand)	Generic formulations listed with lower tier indicators vs branded CADUET entries at higher tiers	CADUET entries show brand-tier distinctions (e.g., CADUET 5-10MG listed with tier assignments) implying preferred generics where available
OPSYNVI vs generic isosorbide-hydralazine	Brand OPSYNVI shown with Requirements/Limits = PA, QL for some strengths while generic alternatives carry different tiering	OPSYNVI TAB 10-20MG entries list '2 = PA, QL' for some strengths; generics listed as tier 1 in parallel

Note	Preferred agent implied	Explicit step?
Adalimumab biosimilars 'Preferred for' multiple autoimmune indications	ADALIMUMAB-ADAZ, ADALIMUMAB-FKJP indicated as preferred	No explicit stepwise transition or failure criteria provided in these lines; preference only
ORENCIA / OTEZLA preference for rheumatoid arthritis	ORENCIA listed with Preferred for Rheumatoid Arthritis	Preferred status shown alongside PA/QL annotations; step therapy ordering not detailed

Migraine agent	ST indicated	Requirements/Limits
AJOVY (SOAJ/SOSY 225 mg)	ST indicated	Requirements/Limits = ST, QL; PA (document shows 'ST, QL; PA')
EMGALITY (SOAJ/SOSY 100/120 mg)	ST indicated	Requirements/Limits = ST, QL; PA**
NURTEC ODT (75 mg)	ST indicated	Requirements/Limits = ST, QL; PA**
QULIPTA (tabs 10/30/60 mg)	ST indicated	Requirements/Limits = ST, QL; PA**
UBRELVY (tabs 50/100 mg)	ST indicated	Requirements/Limits = ST, QL; PA**

Quantity Limits

Opioid-containing products QL — up to 90 MME

Opioid MME QLOpioid‑containing products limited to up to 90 MME per day (30‑day supply)

Applies to combinationsIncludes opioid products combined with acetaminophen, aspirin, or ibuprofen

Opioid‑naïve ruleOpioid‑naïve members required to start with immediate‑release formulations before extended‑release

Various agents with QL flag — QL specified via flag where present

QL flag usageVarious agents (e.g., armodafinil, methylphenidate ER, select ADHD products, some biologics) are specified via a QL flag where present (numeric QLs not shown)

Examples in ADHD classMultiple stimulant and wakefulness agents show 'PA, QL' or 'PA' in Requirements/Limits fields

Site of Care / Administration

Note

Background

This document is a payer-managed pharmacy formulary for BlueCross BlueShield of Tennessee that defines drug coverage, cost-tier placement, and utilization management controls (including Prior Authorization (PA), Quantity Limits (QL), and Step Therapy (ST)) for the Standard Control with Advanced Control Specialty Formulary administered by CVS Caremark. It is intended to guide prescribers, pharmacies, and adjudicators on which products are listed, the assigned tier, and any documented requirements that must be met for coverage.

Definitions

PA definition — Prior Authorization

PA definitionPA: Prior Authorization — a review required for some medications; provider must provide rationale for prescription

PurposePA requires physician documentation and plan review before coverage is approved

Legend originDefinition provided in the formulary legend explaining PA abbreviation

QL definition — Quantity Limit

QL definitionQL: Quantity Limit — the highest amount of medication covered by your plan for a period of time (for example, 30 tablets per month)

PurposeQL indicates plan‑defined limits on quantity or frequency of dispensing

Biosimilar Notes

Note

Revision History

2026-04-01policy_effective_dateLatest

Standard Control with Advanced Control Specialty Formulary effective date; document lists coverage, tiers, and utilization controls administered by CVS Caremark for BlueCross BlueShield of Tennessee.

2026-04-01preface_update

Preface clarified that inclusion on the formulary does not guarantee coverage and noted requirement for valid prescription and possible prior authorization, plus opioid-specific MME limit and opioid‑naïve sequencing requirements (up to 90 MME/day; IR before ER).

2026-04-01legend_definitions_update

Policy Summary

Payerblue cross blue shield - tennessee

PolicyStandard Control with Advanced Control Specialty Formulary — Pharmacy Formulary Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line item is annotated with 'PA' and provide supporting documentation for PA/QL requests.

SourceLink

On This Page

ADHD stimulant products — PA required where 'PA' is indicated in the Requirements/Limits column
Valid prescription and PA required — ensure PA is approved prior to dispensing

Prior Authorization

Prior Authorization — Specialty Biologics

Many specialty biologics and anti‑TNF agents are subject to PA and QL (examples include adalimumab biosimilars, HYRIMOZ, TREMFYA, CIMZIA). When 'PA' or 'PA, QL' appears on a drug line, providers must submit an authorization request with supporting clinical documentation.

PA and QL required for many anti‑TNF and other biologics
Formulary preference noted — preferred biosimilars/agents are identified in the list (use these where clinically appropriate)
PA/QL enforcement for specialty biologics — requests lacking PA/QL may be denied

Prior Authorization

ENBREL — Authorization Required

ENBREL specifically is listed with Prior Authorization and Quantity Limit requirements. Providers must request PA for ENBREL and include clinical documentation supporting the requested indication.

ENBREL — Requirements/Limits = PA, QL
Preferred indications are listed on the formulary — include indication in PA request

Prior Authorization

XIFAXAN 550 mg — Authorization Required

XIFAXAN 550 mg requires prior authorization. Submit PA with clinical justification consistent with the plan's criteria for use.

XIFAXAN 550 mg — Requirements/Limits = PA
Provide indication and relevant documentation with the PA request

Prior Authorization

Prior Authorization — Antineoplastics & Selected Oncology Agents

Many antineoplastics and selected oncology agents require PA and often have QLs. Providers must submit PA requests that include diagnosis, prior therapies, and any required lab or genotypic information.

Antineoplastics — multiple entries flagged PA, QL (e.g., capecitabine, ONUREG, XELODA, GILOTRIF, TAGRISSO, everolimus, IBRANCE)
Prior authorization required for PA products — include prior-therapy history and staging information as applicable
PA and QL documentation — evidence and medical necessity may be required

Prior Authorization

Prior Authorization — Specialty Agents (Hematology, Enzyme/Replacements, Complement)

Numerous specialty agents across therapeutic classes require prior authorization (examples: hemophilia factors, complement inhibitors, enzyme replacement therapies). Specialty brands are frequently PA‑controlled; providers should verify PA status and submit required documentation.

Specialty hematological products (ELOCTATE, HEMLIBRA, FIBRYGA, etc.) — Requirements/Limits include PA
Prior authorization required for many specialty brands — prepare comprehensive clinical justification
Specialty agents often also have quantity limits — requests exceeding QL require PA

Prior Authorization

Prior Authorization — Specialty Cardiovascular / Pulmonary Agents

Many cardiovascular and pulmonary specialty agents (including inhaled/infused prostacyclins, endothelin receptor antagonists, PDE inhibitors, and others such as TYVASO, VELETRI, ORENITRAM, ADEMPAS, ambrisentan, bosentan, tadalafil, sildenafil, YUTREPIA) require PA and often QL. Submit PA requests with supporting clinical data and prior‑therapy history.

PA/QL for pulmonary hypertension agents and prostacyclins (TYVASO, VELETRI, UPTRAVI, ADEMPAS, ORENITRAM, YUTREPIA)
PA/QL for select specialty cardiovascular agents (CAMZYOS)
Documentation for PA/QL — include hemodynamics, functional class, prior treatments when applicable

Prior Authorization

Prior Authorization — HCV Agents & Antivirals

Certain antivirals and HCV therapies require PA and genotype documentation. Agents like EPCLUSA, HARVONI, SOVALDI, VOSEVI, and ribavirin have explicit PA/QL requirements and genotype or prior-treatment conditions noted; include genotype results and prior antiviral exposure history when applicable.

Genotype documentation for HCV drugs — EPCLUSA and HARVONI specify applicable genotypes
VOSEVI prior‑treatment requirement — limited to patients with prior NS5A exposure or prior sofosbuvir without an NS5A inhibitor
PA/QL requirements for HCV agents — submit genotype and prior‑treatment history with PA

Prior Authorization

Prior Authorization — Antiretrovirals

Some antiretrovirals and long‑acting injectable HIV agents have PA and QL annotations (e.g., CABENUVA). Providers must follow PA processes for these agents and include relevant clinical and dispensing information.

PA for select antiretrovirals — CABENUVA entries include PA, QL
Provide clinical justification and prior therapy/exposure history with PA requests

Prior Authorization

Prior Authorization — Addiction, Antidotes, Chelators

Certain addiction-treatment and opioid‑related products (e.g., VIVITROL) and selected antidotes/chelators (deferasirox, deferiprone, deferoxamine) are flagged with PA and/or QL. Ensure PA is obtained where required and include necessary supporting documentation.

VIVITROL — Requirements/Limits = PA, QL
Deferasirox and deferiprone — Requirements/Limits = PA
Authorization documentation — include indication and supporting clinical evidence

Step Therapy

Step Therapy & Formulary Preference

Step therapy (ST) may apply to some products; ST notation indicates when step requirements must be met before a drug is covered. Several migraine CGRP agents (AJOVY, EMGALITY, NURTEC ODT, QULIPTA, UBRELVY) show step‑therapy (ST) requirements. Where ST is shown providers should follow the plan's step‑therapy process and may need to document prior trial(s) of preferred agents.

Step therapy may apply — ST legend applies where noted
Step therapy for select migraine agents — AJOVY, EMGALITY, NURTEC ODT, QULIPTA, UBRELVY show ST; PA may apply if ST criteria not met

Denial Risk

Quantity Limits & Overrides

Quantity limits are enforced on many products. If a requested quantity exceeds the plan limit, a PA may be required (PA*). Providers should review QL values and submit justification when requesting overrides.

Quantity limits enforcement — exceeding QL without authorization may trigger denial
PA* — If Quantity Limit is exceeded, Prior Authorization may apply
Prior authorization and quantity limits present for select drugs — ensure requests include rationale for higher quantities

Documentation Required

Provider Operational Actions for PA Submissions

Operational notes for PA submissions: include specific clinical details requested on the formulary (diagnosis, prior therapies, lab/genotype results, treatment history), provide copies of relevant clinical notes, and reference the formulary drug line and NDC when available. Use plan-administered PA channels and follow up on incomplete requests to avoid denial.

Submit PA when flagged — submit authorization when 'PA' is shown on the drug line
Authorization documentation — providers must supply clinical documentation and any specified evidence (e.g., genotype for HCV, prior‑treatment history)
Requirements/Limits notes — many entries include explicit 'Requirements/Limits' fields; follow those annotations

Initial therapy PA considerations

Initial prior authorization notes where present

Higher‑strength opioids: Initial prior authorization may apply to higher strengths of certain opioid products (examples include fentanyl transdermal, hydrocodone extended‑release, hydromorphone extended‑release, methadone, and tramadol extended‑release) as indicated on formulary lines.

Exact PA clinical criteria for initial approval are not detailed in this extract; see prior authorization process for required documentation.

Initial therapy

No specific initial therapy criteria included in this extract.

No initial therapy rules: This section lists drug names, tiers, and Requirements/Limits but does not provide specific stepwise initial therapy algorithms or patient‑level clinical eligibility criteria in the provided extract.

Refer to product‑specific PA policies or clinical guidelines for initial therapy requirements where applicable.

Provider actionWhen QL appears, providers must follow quantity‑limit procedures and supply supporting documentation if requested

ENBREL; various opioids — QL applies where indicated

ENBRELENBREL (SOAJ/SOCT/SOLN/SOLR/SOSY formulations) — Requirements/Limits = PA, QL; Preferred for several autoimmune indications

Opioids QLMultiple opioid formulations are annotated with QL and PA* indications (see fentanyl, hydrocodone, hydromorphone listings)

Formulary impactWhere 'QL' applies, dispensing is limited per plan rules as shown on the formulary line item

OTEZLA XR TAB 28 DAY — 28 day supply indicated

OTEZLA XR supplyOTEZLA / XR TAB is listed with a 28‑day supply indication

Requirements/LimitsOTEZLA shows 'PA, QL' in the Requirements/Limits field in this extract

Preferred indicationsOTEZLA is noted as preferred for select rheumatoid arthritis and psoriasis indications where annotated

ZURZUVAE and select antidiabetics — QL noted but not numeric in extract

ZURZUVAE and GLP‑1s QL flagZURZUVAE and selected antidiabetic/GLP‑1 agents (liraglutide, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) are noted with 'QL' though numeric limits are not shown here

Provider checkProviders should verify specific quantity limits for these agents on the full formulary entry

PA presenceSome of these agents also carry 'PA' annotations in Requirements/Limits where applicable

VIVITROL SUSR 380MG — QL

VIVITROL QLVIVITROL SUSR 380MG — Requirements/Limits = PA, QL

Formulary tierVIVITROL listed at Drug Tier 5 in this extract

Authorization implicationPA and QL annotation implies prior authorization documentation and quantity‑limit compliance are required for coverage

VISTOGARD PACK 10GM — QL

VISTOGARD QLVISTOGARD PACK 10GM — Requirements/Limits = QL

Drug tierVISTOGARD appears at Drug Tier 4 in this extract

Coverage noteQuantity limit annotation indicates dispensing restrictions per plan rules

naloxone liquid 4mg/0.1ml — QL

naloxone QLnaloxone liqd 4mg/0.1ml — Requirements/Limits = QL

Naloxone tierListed at Drug Tier 1 in this extract

Quantity implicationQL indicates a plan‑defined limit on how much naloxone liquid will be covered

DEMSER caps 250mg — QL noted (unspecified)

DEMSER QL/PADEMSER caps 250mg — Requirements/Limits = PA, QL (unspecified numeric limit in extract)

Drug tierDEMSER listed with Drug Tier .3 = 5 in the extract

Provider actionPrior authorization and quantity‑limit documentation may be required for coverage

Antineoplastics & selected agents — QL indicated where noted

Antineoplastics QLMultiple antineoplastics and adjunctive agents are annotated with 'PA, QL' where noted; numeric QLs are not provided in this extract

ExamplesAgents such as INLYTA, ONUREG, VENCLEXTA, XELODA, GAVRETO, IBRANCE are shown with PA and/or QL annotations

Coverage implicationPA and QL annotations indicate prior authorization and quantity monitoring apply before coverage

Brand specialty drugs — QL flag present

Brand specialty QL flagMultiple branded specialty drugs in the extract are marked with a QL flag indicating quantity limits apply

Hemophilia and factor productsHemophilia products (ELOCTATE, ESPEROCT, FIBRYGA, etc.) include 'PA' and some include QL annotations

Provider implicationClaims exceeding QL or lacking PA may be denied per the Requirements/Limits entries

Antiretrovirals and antivirals — QL indicated next to entries

Antiretrovirals QL annotationSelected antiretrovirals and antivirals (e.g., ABACAVIR‑LAMIVUDINE, BIKTARVY, CABENUVA, GENVOYA) display 'QL' or 'PA, QL' next to product entries

Per‑prescription notationSeveral antiretroviral entries show '1 = X' packaging/units alongside QL annotations

Coverage noteWhere QL is indicated, quantity restrictions apply and prior authorization may be required for some long‑acting injectables

APRETUDE — 1 = 4 units per defined measure

APRETUDE unit mappingAPRETUDE SUER 600MG/3ML — listing shows '1 = 4' (units per defined measure) and QL = QL

Implication'1 = 4' denotes dispensing unit count/pack size used for quantity‑limit calculations

Provider checkProviders should reference the full formulary line for how '1 = X' maps to allowed quantities

Specialty pulmonary hypertension agents — QL applies

Pulmonary hypertension agents QLVarious specialty pulmonary hypertension agents (TYVASO, YUTREPIA, UPTRAVI, ORENITRAM, ADEMPAS, etc.) are annotated with PA and/or QL

ExamplesTYVASO entries show 'PA, QL'; YUTREPIA entries show 'PA, QL' in Requirements/Limits

Coverage implicationPA and QL annotations indicate prior authorization and quantity restrictions apply to these specialty agents

Multiple branded specialty drugs — QL indicated

Multiple branded specialtiesNumerous branded specialty drugs across therapeutic classes are listed with 'PA' and/or 'QL' annotations where indicated (exact numeric QLs not in this extract)

Therapeutic breadthIncludes endocrinology, hematology, gastroenterology, and other specialty categories shown with PA/QL flags

Action for providersConfirm product‑specific PA and QL details on the full formulary entry before prescribing or dispensing

icatibant 30mg/3ml — QL present (unspecified)

icatibant QL/PAicatibant SOSY 30mg/3ml — Requirements/Limits = PA, QL (numeric limit not specified here)

Drug tierListed at Drug Tier 1 in the extract

Documentation implicationPrior authorization and quantity‑limit documentation will be required for coverage when annotated

Legend originDefinition provided in the formulary legend explaining QL abbreviation

ST definition — Step Therapy

ST definitionST: Step Therapy — a defined set of conditions that must be met prior to a drug being covered

FunctionST may require trying preferred/step agents before covering higher‑tier drugs

Legend originDefinition provided in the formulary legend explaining ST abbreviation

Prior authorization (alternate legend)

Alternate PA legendPA*, PA** — legend explains conditional PA where QL is exceeded or step therapy not met (see legend text)

PA* meaningPA* indicates prior authorization may apply if quantity limit is exceeded

PA** meaningPA** indicates prior authorization may apply if step therapy requirements are not met

QL definition (alternate legend)

Alternate QL legendQL — defined in legend as the highest amount of medication covered by the plan for a period of time

Example periodLegend example: 30 tablets per month

Usage noteQL entries in the formulary indicate plan limits which may require PA if exceeded

Prior Authorization (short)

PA short formPA — abbreviation for Prior Authorization used throughout the listing

ContextAppears in Requirements/Limits fields adjacent to drug entries

Provider implicationIndicates that prior approval from the plan may be required before coverage

Quantity Limit (short)

QL short formQL — abbreviation for Quantity Limit used throughout the listing

ContextDisplayed next to many products to indicate quantity restrictions

ImplicationMay restrict covered amount per time period; exceeding may require PA

Drug Tier — definition and presentation

Drug Tier explainedNumeric formulary tier assigned to each drug entry indicating benefit level; lower tiers generally have lower member cost share

PresentationTiers appear alongside drug names in the extract (e.g., '1', '2', '3', '4', '5')

ImplicationTier affects member cost share and may reflect formulary preference

Requirements/Limits.PA, QL annotation — explanation

Requirements/Limits annotationAnnotations 'PA' and 'QL' indicate prior authorization and quantity limits apply to that listed product

Formulary fieldThese annotations are shown in the Requirements/Limits column of each drug line

ActionProviders must obtain PA or adhere to QL when the annotation appears to secure coverage

PA (definition repeated)

PA repeated definitionPA: Prior Authorization — utilization control requiring additional approval before coverage

Formulary contextRepeated across multiple legend and section chunks to clarify usage

Provider noteRequests lacking required PA may be denied per Requirements/Limits entries

QL (definition repeated)

QL repeated definitionQL: Quantity Limit — indicates a restriction on the amount or frequency of medication coverage

Formulary examplesUsed next to antidotes, antiretrovirals, and many specialty agents in the extract

ImplicationExceeding QL may require PA or lead to denial if not authorized

PA (definition repeated in other chunk)

PA in other chunksPA is reiterated in multiple sections of the formulary legend and entries as an approval required prior to coverage

ConsistencySame PA meaning applied across drug classes and listings

Provider implicationProviders must reference PA requirements for each drug line

QL (definition repeated in other chunk)

QL repeated elsewhereQL is restated throughout the document as a plan‑defined maximum quantity over a time period

ApplicationUsed for antiretrovirals, specialty drugs, and others in the extract

ActionCheck specific listing for numeric QLs when planning therapy

PA (definition repeated in later chunks)

PA reinforcementPA is reinforced in later chunks of the legend as a utilization control for certain products

Legend cross‑referenceSee PA*, PA** qualifiers in legend for conditional applications

Provider implicationFollow PA instructions per product line to avoid claim denial

QL (definition repeated in later chunks)

QL reinforcementQL reiterated later as a coverage limit on quantity/frequency within a given period

Usage noteMany entries show QL without numeric detail in this extract; full formulary entry may list exact limits

Provider actionConfirm numeric QL on product‑specific listing when needed

QL (antiretroviral context)

QL in antiretroviral contextQL is used next to many antiretroviral product entries to indicate quantity limits apply

Example entriesABACAVIR‑LAMIVUDINE, BIKTARVY, CABENUVA entries include QL or PA, QL annotations

ImplicationPer‑prescription unit counts and QL are used together to define allowed dispensing

PA (HCV/antiretroviral context)

PA for HCV/antiviralsPA is required for select HCV agents and some antiretrovirals as shown in product Requirements/Limits

Genotype and prior‑treatment conditionsEPCLUSA and HARVONI include genotype‑specific indications; VOSEVI requires prior‑treatment criteria

DocumentationSupporting genotype or prior‑treatment documentation may be required for PA determination

PA, QL abbreviation — definition

PA/QL abbreviationPA, QL — combined abbreviation used throughout the formulary to indicate both prior authorization and quantity limit requirements

ApplicationAppears in Requirements/Limits for many specialty and high‑cost agents

ImplicationBoth PA and QL must be satisfied for coverage when annotated together

PA (definition repeated)

PA reiteratedPA: Prior Authorization — coverage requires advance approval (repeated definition)

ContextUsed across drug classes to denote utilization control

Provider actionObtain PA when indicated to avoid denial

QL (definition repeated in later chunk)

QL reiteratedQL: Quantity limit — a restriction on the amount of drug covered over a time period (repeated)

Formulary usageUsed for somatostatic agents, tolvaptan, and other specialty entries in this extract

ActionCheck product line for exact numeric limits when needed

Legend section defined key management terms and flags used in the formulary (PA, PA*, PA**, QL, ST) to indicate prior authorization, quantity limits, and step therapy conditions.

2026-04-01hepatitis_c_agent_management

Hepatitis C antivirals (EPCLUSA, HARVONI, SOVALDI, VOSEVI) require prior authorization and/or quantity limits with genotype- and prior-treatment-specific coverage statements for certain agents (EPCLUSA: genotypes 1–6; HARVONI: genotypes 1,4,5,6; VOSEVI limited to patients with prior NS5A exposure).