CurrentBlue Cross Blue Shield - TexasPolicy N/A

2025 Drug List (Preferred Drug Formulary)

Preferred prescription drug list for Blue Cross and Blue Shield (including BCBS Texas division) describing preferred drugs, tier placement, special requirements (PA, ST, QL, AC, SP) and coverage considerations for pharmacy benefit plans; intended for providers, pharmacies and billing/clinical operations staff.

Policy Summary

PayerBlue Cross Blue Shield - Texas

Policy2025 Drug List (Preferred Drug Formulary)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOctober 2025

Next Review DateN/A

Key ActionSubmit a prior authorization request to the pharmacy benefit manager (Prime Therapeutics) and obtain approval before dispensing any medication that is flagged with 'PA'.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multi-pageDrug list with multiple therapeutic classes

tiers 1-6Possible member payment tiers described

PA, ST, QL, AC, SPSpecial requirement flags used across drugs

hundredsMedications listed in this part

many

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Items with prior authorization (PA)

severalItems flagged SP (specialty)

General coverage, utilization controls, and product-level requirements

General coverage and special requirements

Drugs on this list are preferred and may be covered according to member benefit design; certain special requirements apply as noted:

ALL of the following

Drug placement into payment tiers (Tier 1–Tier 6) determines member cost-share and coverage; some plans may have fewer tiers.
Prior Authorization (PA) — some drugs require PA; if commonly required it is noted with 'PA' in Special Requirements.
Step Therapy (ST) — some drugs require step therapy; noted with 'ST' when commonly required.
Dispensing / Quantity Limits (QL/DL) — noted with 'QL' when limits apply (quantity per prescription or time period).
ACA preventive (AC) — drugs marked 'AC' may have limited or $0 member cost-sharing when ACA conditions are met.
Specialty (SP) — specialty drugs are flagged 'SP' and may have distinct coverage and channel requirements.
Exclusions — Non-FDA approved drugs, repackaged medications, some compounded medications, and OTC equivalents may be excluded per plan.

Utilization management requirements (per drug)

Each listed drug includes one or more of the following requirement/limit flags. Coverage is subject to the listed requirement(s) where present.

ANY of the following

PA = Prior Authorization required (drug-specific).
QL = Quantity Limit (drug-specific) with explicit maximums where listed.
AC = Administrative/coverage code (e.g., contraceptives have AC).
SP = Specialty drug designation.
ST = Step therapy requirement.

Utilization control flags and interpretation

Each listed product in this part is followed by Requirements/Limits flags that indicate utilization controls. Common flags and their conditional meaning:

ALL of the following

PA = Prior Authorization required before coverage is approved
Provider must submit PA request when PA flag is present
QL = Quantity Limit (specified amount/time period)
Specified QL values are shown in parentheses, e.g., QL (30 tablets/30 days)
SP = Specialty drug handling (typically specialty pharmacy distribution)
Often paired with PA and QL
AC = Allowed category (no PA indicated in this list), or requires plan-level review
Interpreted as accessible/covered subject to benefit terms

Product-level Requirements / Limits (listing format)

Each product line indicates which utilization controls apply; when present these must be met for coverage:

ANY of the following

Prior authorization (PA) required — product annotated with 'PA'
Quantity limit (QL) — product annotated with QL and the limit (e.g., 'QL (1 syringe/56 days)')
Specialty pharmacy (SP) designation — product annotated with 'SP'
No explicit requirement listed — product may have no PA/QL/SP in this excerpt

Drug and product code groups (NDC / drug-level / indexed lists)

Drugs with explicit special requirements (examples from this part)NDC/name (drug-level)

fidaxomicin 200 mg tab (DIFICID)	Listed; QL (60 tablets/180 days) for azithromycin earlier — DIFICID entries present
azithromycin tab 250 mg, 500 mg (Zithromax)	QL (60 tablets/180 days) noted for azithromycin for susp/tab earlier
NOXAFIL - posaconazole DR susp packet 300 mg	Requirements/Limits = PA
BIKTARVY - bictegravir-emtricitabine-tenofovir AF	Requirements/Limits = QL (30 tablets/30 days)
EPCLUSA - sofosbuvir-velpatasvir	Requirements/Limits = PA, QL (30 tablets/30 days), SP
HARVONI - ledipasvir-sofosbuvir	Requirements/Limits = PA, QL (30 tablets/30 days), SP
MAVYRET - glecaprevir-pibrentasvir	Requirements/Limits = PA, QL (90 tablets/30 days), SP
PAXLOVID - nirmatrelvir & ritonavir packs	Requirements/Limits = QL (varies by pack)
PEGASYS - peginterferon alfa-2a	Requirements/Limits = PA, SP
SOVALDI - sofosbuvir	Requirements/Limits = PA, QL (30 tablets/30 days), SP

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Drugs flagged as ACA preventive (examples)drug-level

anastrozole 1 mg (Arimidex)	Requirements/Limits = AC
desogestrel & ethinyl estradiol (Desogen)	Requirements/Limits = AC, QL
drospirenone-ethinyl estradiol (Yaz)	Requirements/Limits = AC, QL
ELL A - ulipristal acetate 30 mg (ELLA)	Requirements/Limits = AC, QL (2 tablets/365 days)

NDC / drug products listed (excerpted by brand/formulation)mixed

MYFEMBREE	relugolix-estradiol-norethindrone acetate tab 40-1-0.5 mg — Requirements/Limits = PA, QL (30 tablets/30 days)
ORIAHNN	elagolix-estrad-noreth 300-1-0.5 mg & elagolix 300 mg cap pack — Requirements/Limits = PA, QL (56 capsules/28 days)
FARXIGA	dapagliflozin tab 5 mg, 10 mg — Requirements/Limits = QL (30 tablets/30 days)
GLYXAMBI	empagliflozin-linagliptin tab 10-5 mg, 25-5 mg — Requirements/Limits = QL (30 tablets/30 days)
JANUMET	sitagliptin-metformin tab 50-500 mg, 50-1000 mg — Requirements/Limits = QL (60 tablets/30 days)
JANUMET XR	sitagliptin-metformin er 50-500 mg, 100-1000 mg — Requirements/Limits = QL (30 or 60 tablets/30 days listed variants)
JANUVIA	sitagliptin tab 25 mg, 50 mg, 100 mg — Requirements/Limits = QL (30 tablets/30 days)
JARDIANCE	empagliflozin tab 10 mg, 25 mg — Requirements/Limits = QL (30 tablets/30 days)
MOUNJARO	tirzepatide soln auto-injector (multiple strengths) — Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on pack)
OZEMPIC	semaglutide soln pens (multiple strengths) — Requirements/Limits = PA, QL (1-3 pens/28 days depending on strength)

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Products with PA and QL specified (examples from this part)NDC/Drug Name (listing)

risankizumab-rzaa 150 mg/ml auto-injector	Requirements/Limits = PA, QL (1 injection device/84 days), SP
deucravacitinib 6 mg tab (SOTYKTU)	Requirements/Limits = PA, QL (30 tablets/30 days), SP
ustekinumab 45 mg/0.5ml inj (STELARA)	Requirements/Limits = PA, QL (1 vial/84 days), SP
ustekinumab 90 mg/ml prefilled syringe (STELARA)	Requirements/Limits = PA, QL (1 syringe/56 days), SP
guselkumab 100 mg/ml (TREMFYA) syringe/auto-injector	Requirements/Limits = PA, QL (1 syringe/56 days or 1 pen/56 days), SP
lenalidomide caps (REVLIMID) various strengths	Requirements/Limits = PA, QL (30 capsules/30 days or 21 capsules/28 days), SP
thalidomide cap 50 mg (THALOMID)	Requirements/Limits = PA, QL (90 capsules/30 days), SP
thalidomide cap 100 mg (THALOMID)	Requirements/Limits = PA, QL (120 capsules/30 days), SP
lenalidomide caps 15-25 mg	Requirements/Limits = PA, QL (21 capsules/28 days), SP
dexcom G6 receiver	Requirements/Limits = PA, QL (1 receiver/365 days)

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Products listed without explicit controls in this excerptDrug Name listing

triamcinolone acetonide cream/ointment (various strengths)	Requirements/Limits = (no controls shown in this excerpt)
mechlorethamine gel (VALCHLOR)	Requirements/Limits = SP (specialty)
naloxone products (various)	Requirements/Limits = . (no PA/QL shown here)
succimer (CHEMET) 100 mg cap	Requirements/Limits = .

Indexed drug and product mentions (excerpt)mixed

ROMVIMZA	listed product
ROZLYTREK	listed product
RUBRACA	listed product
RYBELSUS	listed product
RYDAPT	listed product
SAXENDA	listed product
SAVELLA	listed product and titration pack
SEMGLEE	listed product
SYMBICORT	listed product
TAFINLAR	listed product

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Indexed generic medication forms/dosesmixed

sulfamethoxazole-trimethoprim tab 800-160 mg	generic product/dose listed
sulfamethoxazole-trimethoprim tab 400-80 mg	generic product/dose listed
rizatriptan benzoate tab 5 mg; 10 mg	listed product/dose
sumatriptan succinate tab 25 mg, 50 mg, 100 mg	listed product/doses
sertraline hcl tab 25 mg, 50 mg, 100 mg	listed product/doses
sildenafil citrate tab 25 mg, 50 mg, 100 mg	listed product/doses
tramadol hcl tab 50 mg	listed product/dose
tramadol-acetaminophen tab 37.5-325 mg	listed product/dose
zaleplon cap 5 mg, 10 mg	listed product/doses
zolpidem tartrate tab 5 mg, 10 mg; er 6.25 mg, 12.5 mg	listed product/doses

What providers must do — prior authorization, step therapy, documentation, quantity limits, specialty handling

Prior Authorization

Submit prior authorization when drug marked PA

For medications flagged with 'PA' the prescriber must submit a prior authorization request to the pharmacy benefit manager (Prime Therapeutics) and receive approval before coverage will be provided.

NOXAFIL
EPCLUSA
HARVONI
MAVYRET
SOVALDI
PEGASYS
ALECENSA
IMBRUVICA
XALKORI
many oncology and specialty agents listed

Prior Authorization

Prior authorization required for specified drugs

Quantity limits and example thresholds

Quantity limits (selected examples)

Quantity Limits (examples)azithromycin QL 60 tablets/180 days

Quantity Limits (examples)BIKTARVY QL 30 tablets/30 days

Quantity Limits (examples)MAVYRET QL 90 tablets/30 days

Quantity Limits (examples)ALECENSA QL 240 capsules/30 days

Quantity Limits (examples)TRULICITY QL 4 pens/28 days

Quantity Limits (examples)FIASP/HUMALOG/LYUMJEV/NOVOLOG QL 100 mls/30 days

Quantity Limits (examples)Dexcom G6 receiver QL 1 receiver/365 days

Clinical and administrative background

This document is the 2025 Blue Cross and Blue Shield Drug List (formulary), compiled with input and recommendations from a physician‑pharmacist committee and including at least one representative from participating health plans; the committee evaluates drugs based on FDA status, safety, efficacy and cost and classifies formulary placement by therapeutic class and member payment tier. The list flags specialty (SP) drugs and lists utilization management controls such as Prior Authorization (PA), Step Therapy (ST), and Quantity Limits (QL)

Defined terms used in this document

Definitions (utilization flags)

PAPrior Authorization — approval required prior to coverage.

STStep Therapy — trial of specified alternatives required before coverage.

QL / DLQuantity Limit / Dispensing Limit — limits on amount dispensed per time period.

ACACA preventive — medicines that may have limited or $0 member cost-sharing under ACA when conditions are met.

SPSpecialty — specialty drugs with special handling/coverage and often PA/QL; may require specialty pharmacy dispensing.

Document dates and changes

Effective: October 2025. This Drug List is the 2025 edition and is regularly updated; the most current list and specialty drug list are available at MyPrime.com.

Policy Summary

PayerBlue Cross Blue Shield - Texas

Policy2025 Drug List (Preferred Drug Formulary)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOctober 2025

Next Review DateN/A

Key ActionSubmit a prior authorization request to the pharmacy benefit manager (Prime Therapeutics) and obtain approval before dispensing any medication that is flagged with 'PA'.

SourceLink

On This Page

ST = Step therapy required

Indicates step edits may apply

Prescribers must obtain prior authorization for the listed drugs before coverage will be provided; these include the specified brands and many specialty biologics shown in the formulary excerpt.

MYFEMBREE
ORIAHNN
MOUNJARO
OZEMPIC
RYBELSUS
TRULICITY
GENOTROPIN
OMNITROPE
ORILISSA
ATTRUBY
ENTRESTO
OPSUMIT/OPSUMIT
UPTRAVI
VERQUVO
VYNDAMAX/VYNDAQEL
FASENRA
NUCALA
TEZSPIRE
XOLAIR
ALYFTREK
KALYDECO
TRIKAFTA
CREON/ZENPEP
many specialty biologics

Step Therapy
Follow step therapy when drug marked ST
When a product is marked with 'ST' the member may be required to try specified alternative(s) first; the prescriber should document prior trials and may request a step-therapy exception if clinically necessary.
Document prior medication trials or submit a step-therapy exception via prior authorization when clinically indicated; see PA process with Prime Therapeutics if escalation is required.

Documentation Required
Provide documentation for ACA preventive exceptions
For medicines marked 'AC' (ACA preventive), prescribers or members may need to submit copay waiver or coverage exception forms to request preventive coverage and potential $0 cost-sharing.
Submit copay waiver or coverage exception forms available at bcbs.com/provider or myprime.com for ACA preventive drugs.
Call the number on the member ID card for assistance and to confirm coverage decision.

Documentation Required
Adhere to dispensing/quantity limits
Prescribers must be aware of and adhere to quantity limits (QL) shown for many products; prescribing quantities above the listed limits may result in member financial responsibility or need for prior authorization.
Examples: azithromycin QL (60 tablets/180 days); BIKTARVY QL (30 tablets/30 days); MAVYRET QL (90 tablets/30 days); many specialty agents show QL ranges (30–240 tablets/30 days).
If prescribing above the QL, submit supporting documentation and/or a PA to avoid denial or member paying full cost.

Documentation Required
Quantity limits enforced
Providers must prescribe within the specified quantity limits for products that list a maximum supply; claims exceeding QL may require prior authorization or may be denied.
Codes/examples: MYFEMBREE, ORIAHNN, FARXIGA, GLYXAMBI, JANUMET, JANUVIA, JARDIANCE, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, SOLIQUA, SYNJARDY, ENTRESTO, OPSUMIT, UPTRAVI, VERQUVO, VYNDAMAX, CF modulators, respiratory biologics, CREON, ZENPEP.
Claims must match authorized quantity/timeframe; excess quantities may be billed to member or denied without approved PA.

Note
Specialty drug routing
Drugs flagged 'SP' are specialty medications and typically require specialty pharmacy dispensing; prescribers must route these products through the specialty channel and provide any additional documentation required by the benefit.
Codes/examples: GENOTROPIN, OMNITROPE, ENTRESTO, ATTRUBY, OPSUMIT/OPSUMIT, VYNDAMAX/VYNDAQEL, CF modulators, ENTYVIO PEN, OMVOH, SKYRIZI, TREMFYA.
Specialty products may require PA and adherence to QL and distribution through an approved specialty pharmacy per benefit rules.

Documentation Required
Adhere to quantity limit documentation
When a QL is specified for an item, the claim and supporting documentation must match the authorized quantity and interval; discrepancies may trigger claim denial.
Applies to all items annotated with QL in the formulary excerpt (e.g., syringes/pens/vials per days).
Ensure dispensing quantity and interval on the claim match the authorized QL to avoid denial.

Prior Authorization
Specialty pharmacy dispensing
Certain specialty products must be dispensed through an approved specialty pharmacy per benefit rules; obtain prior authorization and route the prescription to the designated specialty channel before dispensing.
Codes/examples: risankizumab-rzaa, deucravacitinib, ustekinumab (STELARA and biosimilars), guselkumab (TREMFYA), REVLIMID (lenalidomide), THALOMID (thalidomide).
These SP products require PA and must be dispensed via an approved specialty pharmacy to meet benefit terms.