CurrentBlue Cross Blue Shield - TexasPolicy N/A

2025 Drug List (Pharmacy & Specialty Drugs) — Coverage Criteria

This document lists covered prescription and specialty drugs, explains coverage rules (tiers, prior authorization, step therapy, quantity limits), and guides members and providers on using the pharmacy benefit for Blue Cross and Blue Shield of Texas.

Policy Summary

PayerBlue Cross Blue Shield - Texas

Policy2025 Drug List (Pharmacy & Specialty Drugs) — Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual formulary update (no material changes)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization and include documentation when a drug line-item lists 'PA' and adhere to specified quantity limits (QL) and specialty pharmacy routing (SP) where indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~150+drug entries

multiplerequire PA or QL

2 business days / 72 hrsexception response

30/90day supply examples

Accredospecialty partner

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Coverage Criteria

General Drug List Coverage

Covered when ALL of the following general conditions are met:

General Coverage Conditions: All drugs shown on the Drug List are covered; drugs not shown are not covered. Coverage is subject to plan exclusions, FDA labeling, and recognized evidence‑based clinical guidelines.

From Drug List introduction and coverage considerations.

Tier and Payment Rules: Drugs are assigned to member payment tiers (Preferred Generic, Non‑Preferred Generic, Preferred Brand, Non‑Preferred Brand, Preferred Specialty, Non‑Preferred Specialty) and member cost share depends on tier and specific benefit plan.

See tier definitions and How member payment is determined.

Administrative Limits and Exclusions: Coverage may exclude repackaged or non‑FDA‑approved drugs, compounded medications, OTC‑equivalent prescription products, or agents used for cosmetic indications per plan materials.

Refer to Coverage considerations and plan materials for exceptions.

Utilization Management: Certain drugs may require prior authorization (PA), step therapy (ST), or have dispensing/quantity limits (QL); these requirements are noted on each formulary line and must be satisfied for coverage.

See Coverage considerations and Special Requirements column.

PA-required group

Covered when ANY of the following apply (products flagged 'PA' require an approved prior authorization before coverage):

PA‑flagged drugs: The member has an approved prior authorization when the formulary line item lists 'PA'. Examples include direct‑acting HCV antivirals (EPCLUSA, HARVONI, MAVYRET, VOSEVI) and other high‑cost specialty agents.

PA notation is shown in Special Requirements; see PA process guidance.

PA for specialty antimicrobials: Selected inhaled aminoglycosides and specialty antifungals (e.g., ARIKAYCE, TOBI PODHALER, posaconazole, voriconazole) require PA prior to coverage.

Prior authorization requirement indicated on line items; absence of PA may trigger denial.

Quantity limit group

Covered when the following quantity limits are observed:

Quantity‑limited products: When a formulary entry lists 'QL', the quantity supplied must not exceed the specified maximum per the stated time period. Examples vary by product (e.g., many antiretrovirals and antivirals list 30 tablets/30 days or other limits).See individual drug QL entries

Dispensing/Quantity Limits explained in Coverage considerations; exceeding QL may result in member financial responsibility.

Specialty pharmacy group

Covered when ALL specialty pharmacy routing requirements are met:

Specialty Pharmacy Dispensing: Drugs marked 'SP' on the formulary must be dispensed through the plan's specialty pharmacy channel or designated specialty program to be covered.

Examples include certain hepatitis C DAAs and multiple specialty/oncology agents; specialty routing and documentation should accompany PA requests.

Vaccine and biological coverage annotations

Vaccine and biologic entries are covered when administrative coverage conditions are met:

Vaccine/Biologic administrative coverage: Many vaccines and selected biologics are listed with Requirements/Limits = AC; coverage is subject to the administrative/coverage conditions shown on the formulary line and applicable plan rules.

Examples include influenza, RSV, pneumococcal, hepatitis, HPV and COVID‑19 vaccines.

Specialty/Antineoplastic coverage annotations

Covered when ALL of the following are satisfied for specialty and antineoplastic agents:

PA and QL required: Drugs annotated with PA and QL require an approved prior authorization and dispensing within the listed quantity limits for coverage (e.g., many oncology agents).

Line‑item shows PA and product‑specific QL; specialty pharmacy (SP) often applies.

Specialty dispensing: When SP is indicated the drug must be routed through specialty pharmacy as specified to qualify for coverage.

Applies to many antineoplastic and specialty agents listed.

Palforzia (peanut immunotherapy) coverage

Covered when ALL of the following program requirements are met:

Palforzia specialty program: Palforzia dose‑level products (levels 0–11, starter, titration, maintenance) are designated 'SP' and are handled via the specialty program/site‑of‑care; coverage requires adherence to the program's dispensing and documentation requirements.

Dose levels and SP notation are shown on the line items.

Coverage stance by product

Coverage depends on meeting the exact requirements and limits listed on each product line:

Formulary entry requirements: Each product listing specifies a Drug Tier and may include Requirements/Limits (PA, QL, SP, AC, ST). Coverage is contingent on meeting those requirements shown for that product.

Verify the Special Requirements column for the product; submit PA or follow ST/QL/SP instructions as indicated.

Formulary utilization controls (examples)

The following examples illustrate common utilization controls used across the formulary:

GLP‑1 agents (example): GLP‑1 agonists (e.g., OZEMPIC, RYBELSUS, TRULICITY) are listed with PA and specific QL per strength; prior authorization must be obtained when 'PA' is indicated.OZEMPIC: 1 pen/28 days (0.25/0.5 mg pen); 3 mls/28 days (other strengths); RYBELSUS: 3 mg = 30 tablets/180 days; 7/14 mg = 30 tablets/30 days

PA and QL shown on line items.

Insulin products (example): Multiple insulin products are Tier = P and commonly have QL = 100 mls/30 days; dispensing must not exceed the listed QL.100 mls/30 days

Insulin QL appears on many insulin line items.

Specialty PA/QL examples: Some specialty drugs (e.g., CRENESSITY/crinecerfont, carglumic acid) are annotated PA, QL and SP indicating specialty PA and dispensing requirements.

Per-drug coverage conditions

Coverage of each product requires meeting the per‑product conditions listed:

Per‑product requirements: For coverage, the provider must follow the drug tier and the Requirements/Limits shown for the specific product (PA, QL, SP, ST). Submit required documentation with PA requests and adhere to QL and specialty routing when indicated.

Operational: include clinical/supporting documentation in PA requests as listed.

Formulary coverage with requirements/limits

Coverage is granted WHEN the listed Requirements/Limits are satisfied for the product:

Per‑product formulary rules: Each product entry includes a Drug Tier and may list Requirements/Limits such as PA (prior authorization), QL (quantity limits), SP (specialty pharmacy), AC (administrative coverage), or ST (step therapy). Coverage is conditional on meeting the exact requirements shown for that product.Refer to each product line for specific QL values or PA/ST instructions

Examples: multiple specialty/immunomodulatory and oncology products list PA, QL and SP; adherence avoids denial risk.

The Drug List notes that certain categories of products are excluded from pharmacy coverage. Specifically, repackaged medications, compounded medications, and drugs that have not received FDA approval are not covered under the pharmacy benefit. The policy also explains that some products may be excluded when prescribed for cosmetic indications or when an over‑the‑counter equivalent exists; refer to member benefit materials for plan‑specific exclusions and exceptions. Prior authorization (noted as PA on the line items) may be required for some drugs before coverage is available.

Within the drug listings provided in these segments, the document does not present a single blanket exclusion statement covering all drugs; rather, each line item shows a Drug Tier and may include per‑product Requirements/Limits (e.g., PA, QL, SP, AC) that govern coverage. Several entries have blank or dot ('.') values in Requirements/Limits, which indicates no additional formulary restriction is shown on that line rather than an explicit universal exclusion. For plan‑level exclusion rules (for example, categories excluded across a benefit), refer to the member’s specific benefit materials.

The extracted segments do not contain standalone clinical exclusion criteria (for example, a list of diagnoses or clinical scenarios that would make a drug ineligible). Instead, coverage controls are expressed as per‑product annotations such as PA (prior authorization), QL (quantity limits), SP (specialty pharmacy), or AC (administrative condition). Clinical eligibility requirements, when required, are implemented through the prior authorization process rather than explicit clinical exclusions in these chunks.

In these portions of the Drug List many products have Requirements/Limits fields that are either blank or shown as a period ('.'); the document does not state explicit exclusions in those entries. Blank or '.' entries reflect that no additional formulary restriction (e.g., PA, QL, SP) is shown for that particular line, rather than an explicit determination that the product is not covered. Any plan‑specific exclusions or coverage limitations should be confirmed in the member’s benefit documents.

Across the chunks reviewed here there is no explicit exclusion language directed at particular clinical populations or indications. The listings primarily provide product names, tiers, and per‑product Requirements/Limits. Where limitations exist they are shown as line‑level controls (for example, QL or PA) rather than as broad clinical exclusion statements.

These segments do not include explicit exclusion statements; product coverage is governed by the tiering and the per‑product annotations displayed in the Requirements/Limits column. Several specialty and high‑cost products are flagged with PA, QL, and/or SP, which are the operational controls used to manage coverage rather than explicit exclusion language.

No explicit exclusion language is present in these extracted chunks. Instead, coverage for specialty products is controlled through product‑specific settings such as PA (prior authorization), QL (quantity limits), and SP (specialty pharmacy). These annotations indicate the administrative and utilization requirements that must be met for coverage rather than categorical exclusions.

The reviewed vaccine, biologic, and specialty product lines do not contain clinical exclusion statements; they are listed with requirements such as AC (administrative coverage condition), PA, or QL where applicable. When Requirements/Limits are blank, no additional line‑level restriction is shown in these chunks.

No explicit 'not medically necessary' determinations are included in these chunks. The document expresses coverage constraints through per‑product utilization controls (for example, PA, ST, QL) and administrative flags rather than by labeling products as 'not medically necessary' within the extracted sections.

Similarly, these portions of the Drug List do not include any explicit statements declaring products as 'not medically necessary.' Coverage is framed as contingent on meeting the product‑level requirements shown (e.g., prior authorization, quantity limits, specialty pharmacy routing) and by plan terms noted in member benefit materials.

Across these chunks there are no explicit 'not medically necessary' statements. The policy communicates coverage controls via the Requirements/Limits column on each formulary line (such as PA, QL, SP), and any clinical justification for coverage is expected to be provided through the prior authorization process when required.

Coding and Formulary Entries

Formulary drug listing entries (examples)mixed

amoxicillin (trihydrate) chew tab 125 mg, 250 mg	Listed with Drug Tier = NP
amoxicillin (trihydrate) cap 250 mg, 500 mg	Listed with Drug Tier = p
azithromycin tab 250 mg, 500 mg (Zithromax)	Drug Tier = p; QL (60 tablets/180 days)
clarithromycin tab er 24hr 500 mg	Drug Tier = np; QL (28 tablets/30 days)
ARIKAYCE - amikacin sulfate liposome inhal susp 590 mg/8.4ml	Drug Tier = NP; Requirements: PA, QL (235.2 mls/28 days), SP
TOBI PODHALER - tobramycin inhal cap 28 mg	Drug Tier = NP; Requirements: PA, QL (224 capsules/56 days), SP
tobramycin nebu soln 300 mg/5ml (Tobi)	Requirements: QL (56 containers/56 days), SP
posaconazole tab delayed release 100 mg (Noxafil)	Requirements: PA
voriconazole for susp 40 mg/ml (Vfend)	Requirements: PA
APRETUDE - cabotegravir im extended release susp 600 mg/3ml	Drug Tier = P; Requirements = AC

Formulary requirement codes presentmixed

PA	Prior Authorization
QL	Quantity Limit (specified per drug entry, e.g., 30 tablets/30 days)
SP	Specialty Pharmacy
AC	Administrative Coverage flag (used on vaccine entries)

Quantity Limits (examples)mixed

120 capsules/30 days

QL for vancomycin hcl cap 125 mg/250 mg (Vancocin)

Quantity Limits (rifaximin)mixed

9 tablets/30 days	QL for rifaximin 200 mg (XIFAXAN)
60 tablets/30 days	QL for rifaximin 550 mg (XIFAXAN)

Selected oncology QL annotationsmixed

QL (120 tablets/30 days)	abiraterone acetate (Zytiga) 250 mg QL
QL (60 tablets/30 days)	abiraterone acetate (Zytiga) 500 mg QL
QL (240 capsules/30 days)	ALECENSA (alectinib) 150 mg QL

Listed product strengthsmixed

0.75 mg/0.75gm (0.1%)	Divigel estradiol topical gel strength listed
EVAMIST 1.53 mg/spray	estradiol transdermal spray
MYFEMBREE 40-1-0.5 mg	relugolix-estradiol-norethindrone acetate tablet
ORIAHNN 300-1-0.5 mg	elagolix-estradiol-norethindrone acetate pack
MOUNJARO 2.5 mg/0.5ml, 5-15 mg/0.5ml	tirzepatide solution auto-injector strengths
OZEMPIC 0.25/0.5 mg/dose; 1 mg/dose; 2 mg/dose	semaglutide solution pen-injector strengths

Formulary entries (no explicit billing codes)mixed

NDCs not provided

No NDC or billing codes are listed in these chunks; entries are medication-name, strength, tier, and requirements only.

Drugs and formulations (examples)mixed

Miacalcin	calcitonin (salmon) inj 200 unit/ml
Rocaltrol	calcitriol cap 0.25 mcg; calcitriol cap 0.5 mcg
Carbaglu	carglumic acid soluble tab 200 mg
Sensipar	cinacalcet hcl tab 30 mg, 60 mg, 90 mg
CRENESSITY	crinecerfont cap 25 mg, 50 mg, 100 mg; oral soln 50 mg/ml
DDAVP	desmopressin acetate inj 4 mcg/ml; nasal spray 0.01%; tabs 0.1 mg, 0.2 mg

Growth hormone and related specialty productsmixed

FOLLISTIM AQ	follitropin beta inj 300u, 600u, 900u cartridges
GENOTROPIN	somatropin for subcutaneous inj cartridges
GALAFOLD	migalastat hcl cap 123 mg
OMNITROPE	somatropin solution cartridge 5 mg/1.5ml, 10 mg/1.5ml

Rare-disease specialty injectablesmixed

STRENSIQ	asfotase alfa subcutaneous inj (multiple strengths)
PALYNZIQ	pegvaliase-pqpz subcutaneous soln
MYALEPT	metreleptin for subcutaneous inj 11.3 mg

Cardiovascular agents (examples)mixedCovered

Norvasc	amlodipine besylate tab 2.5 mg, 5 mg, 10 mg
Digoxin	digoxin oral soln 0.05 mg/ml; tabs 62.5 mcg, 125 mcg, 250 mcg
Nitrostat	nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg
Ranexa	ranolazine tab er 12hr 500 mg, 1000 mg
Inderal LA	propranolol hcl cap er 24hr 60 mg, 80 mg
Procardia XL	nifedipine tab er 24hr osmotic release 30 mg, 60 mg, 90 mg

Formulary entries (no CPT/HCPCS/ICD codes present in these chunks)mixed

No codes listed

inv-35: Azithromycin tablet QL — 60 tablets/180 days

Azithromycin (tab 250 mg, 500 mg)QL 60 tablets per 180 days

Azithromycin (tab 600 mg)QL 60 tablets per 180 days

Azithromycin (suspensions)No QL noted for some suspension presentations

inv-36: Clarithromycin ER QL — 28 tablets/30 days

Clarithromycin ER 500 mg (tab, 24-hr)

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Many specialty, antineoplastic, antiviral, antifungal, hepatitis C and other select agents listed in the Drug List require prior authorization (PA) before coverage is available. Providers must obtain an approved PA before dispensing when the formulary line item indicates "PA"; claims submitted without a required PA are subject to denial.

Examples of specialty agents commonly requiring PA: ARIKAYCE, KITABIS PAK, TOBI PODHALER, abiraterone (Zytiga), many oncology oral therapies and biologics listed with PA flags.
Select hepatitis C direct-acting antivirals requiring PA: EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI (PA, often QL and SP).
Select antifungals and antimycobacterial agents requiring PA: CRESEMBA (isavuconazonium), NOXAFIL (posaconazole), voriconazole; some formulations (suspensions, delayed-release tabs) list PA.

Documentation Required

PA + Specialty Pharmacy / Administrative Controls

PA + Specialty Pharmacy and Administrative Controls — Certain products require both prior authorization and specialty pharmacy (SP) distribution, or other administrative controls (AC). When noted, PA requests should indicate the specialty routing and adhere to plan-specific SP requirements.

Step Therapy

Rule	Notes
Try specified alternative(s) before coverage when Step Therapy (ST) applies
Step Therapy (ST): when a plan's step therapy program applies, members may need to try a proven, cost‑effective alternative before coverage for the requested drug. ST is indicated by 'ST' in the Special Requirements column.

Product examples	Requirements/Limits
BIKTARVY (bictegravir-emtricitabine-tenofovir AF)
Requirements/Limits = QL (30 tablets/30 days)
CIMDUO (lamivudine‑tenofovir disoproxil fumarate)
Requirements/Limits = QL (30 tablets/30 days)
DOVATO (dolutegravir‑lamivudine)
Requirements/Limits = QL (30 tablets/30 days)

Category	Policy note
High‑cost hepatitis and antiviral agents
No explicit step therapy sequences are provided for many high‑cost antivirals in the extract; prior authorization (PA) and QL (quantity limits) are specified for multiple direct‑acting antivirals (e.g., EPCLUSA, HARVONI, MAVYRET) and other agents.

Palforzia dose level	Requirement
Palforzia INITIAL DOSE ES / LEVEL 0–11 (dose series)
Requirements/Limits = SP (specialty program). The dose‑level products are listed by level with SP designation, implying programmatic handling across titration and maintenance.

Section	Summary
General specialty/antidiabetic agents in this extract
No explicit step therapy rules are listed in these chunks; prior authorization (PA) is used as the primary utilization management control for many agents.

Section	Summary
GLP‑1s and related agents
No explicit step therapy sequences present; utilization is managed by PA and quantity limits (QL) for listed products (examples: OZEMPIC, MOUNJARO, RYBELSUS).

Section	Summary
Formulary entries in this segment
No specific step therapy steps are detailed here; PA and QL are the primary controls noted on line items.

Product	Coverage status
KERENDIA (finerenone) 10 mg, 20 mg
Requirements/Limits = QL (30 tablets/30 days), ST

Section	Notes
Cardiovascular and specialty agents
This part does not provide explicit step therapy sequences; some products are designated 'SP' or require PA/QL as the primary utilization controls.

Flag meaning	Implication
SP (Specialty) indicated on product lines
SP denotes specialty program or specialty pharmacy routing; it implies programmatic handling or step/program edits though specific step sequences are not provided in the extract.

CNS product examples	ST indicated?
FETZIMA (levomilnacipran)
Requirements/Limits = ST (step therapy applies)
FLUOXETINE DR (fluoxetine DR 90 mg)
Requirements/Limits = ST (step therapy applies)

Formulation	Step therapy status
Risperidone ODT (orally disintegrating) formulations
Requirements/Limits = QL (60 tablets/30 days), ST — marked 'ST' indicating step therapy requirement for certain ODT presentations.
Clozapine suspension (Versacloz)
Requirements/Limits = QL (540 mls/30 days), ST — marked 'ST' indicating step therapy requirement for suspension formulation.

Entry type	Detail
Various product lines with AC or PA
Some products list 'AC' (access/coverage condition) or 'PA' (prior authorization) in Requirements/Limits; explicit step‑therapy sequencing is not detailed in these chunks.

Quantity Limits (QL)

inv-165: various (see drug list) — up to 30-day supply generally; some plans allow up to 90-day supply for maintenance medications

Typical day-supply policyUp to a 30-day supply is covered generally; some plans allow up to a 90-day supply for maintenance medications

Dispensing/Quantity Limits (QL)If dispensing exceeds a QL, member may be responsible for the full cost of the excess; state laws may restrict coverage for controlled substances

Where to find full QL listRefer to MyPrime.com or bcbstx.com for the full list of medication dispensing limits

inv-166: azithromycin tab 250 mg, 500 mg (Zithromax) — 60

Azithromycin tab 250 mg, 500 mgQL 60 tablets per 180 days

Tiering noteDrug Tier = p for 250/500 mg tablets (Zithromax) as listed

Site of Care and Specialty Pharmacy

Note

Definitions and Notation

inv-118: Specialty drugs — definition (low importance)

Specialty drug designationSpecialty drugs are used for complex conditions and may be self- or provider‑administered; provider‑administered medications are not covered under the pharmacy benefit

Where to view specialty listVisit MyPrime.com or bcbstx.com for current specialty medication list

ImplicationSpecialty drugs may carry PA, QL, and SP requirements as listed on the formulary

inv-119: Tiering and notation — p, np, P, NP, SP conventions (low importance)

Tier and notation conventionsPreferred Generic = 'p'; Non-Preferred Generic = 'np'; Preferred Brand = 'P'; Non-Preferred Brand = 'NP'; Specialty marked 'SP' in Special Requirements

Preferred specialty notationPreferred specialty drugs may appear in lower-case bold or all caps and also carry 'SP'

Initial Therapy Criteria

Background

Specialty drugs treat complex, chronic, or rare conditions (for example, hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis) and may be administered orally, topically, by injection, or by a health care professional. The policy clarifies that medications administered by a health care professional are not covered under the pharmacy benefit and may instead be billed under the medical benefit; specialty products may also carry SP designations requiring specialty pharmacy dispensing and program handling.

Policy Summary

PayerBlue Cross Blue Shield - Texas

Policy2025 Drug List (Pharmacy & Specialty Drugs) — Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual formulary update (no material changes)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization and include documentation when a drug line-item lists 'PA' and adhere to specified quantity limits (QL) and specialty pharmacy routing (SP) where indicated.

SourceLink

On This Page

Follow product line Requirements/Limits for authorization and dispensing.

QL 28 tablets per 30 days

Clarithromycin (250 mg, 500 mg tab)No QL noted for these immediate-release strengths in this entry

Clarithromycin suspension presentationsRequirements/Limits = . (no QL specified)

inv-37: ARIKAYCE QL — 235.2 mls/28 days

ARIKAYCE (amikacin liposome inhalation) 590 mg/8.4 mLQL 235.2 mLs per 28 days; Requirements: PA, SP

ARIKAYCE tieringDrug Tier = NP (specialty)

Related inhaled aminoglycosides (TOBI, TOBI PODHALER)Also listed with PA, QL and SP — see respective entries for exact QL

inv-38: Sample quantity limits — assorted examples

Common tablet QLs (examples)QL 30 tablets/30 days; QL 60 tablets/30 days; QL 90 tablets/30 days

Oral solution QLs (examples)QL 4 bottles/30 days; QL 720 mLs/30 days; QL 1200 mLs/30 days

Capsule/packet QLs (examples)QL 14–180 tablets/capsules per 28–30 days depending on product

inv-39: Quantity limits examples — various QL values

Pack/therapy pack limits1 pack/180 days (example: ALUNBRIG initiation pack)

High tablet-count QLs120 tablets/30 days (example: some oncology entries)

Typical 30-day tablet QLs60 tablets/30 days (common for many antineoplastics/antivirals)

inv-40: Quantity limits examples — 1 carton/28 days, 21-90 tablets, up to 240 tablets/30 days

Carton-level QL1 carton per 28 days (COMETRIQ cabozantinib kit)

Tablet range QLs21–90 tablets per 28–30 days depending on presentation/strength

Large-monthly tablet QLsUp to 240 tablets/30 days for select agents (strength/pack dependent)

inv-41: Quantity limits examples — patches, rings, pens, mls

Transdermal patch QL example30 patches per 30 days (selected estradiol patches)

Vaginal ring QL example1 ring per 365 days (ANNOVERA)

Pens/prefilled devices and small-volume injectables4 pens/180 days or 4 pens/28 days depending on product; 3 mL/28 days for some pen strengths

inv-42: Insulin common QL — 100 mls/30 days

Insulin common QL (many products)QL 100 mLs per 30 days

Insulin presentations coveredIncludes cartridges, pens, vials and concentrated formulations — QL applies per listed presentation

Exceeding insulin QLRequests above 100 mLs/30 days may require justification and risk denial if not supported

Examples: PEGASYS (peginterferon alfa-2a) = PA, SP; many oncology agents (PA, QL, SP) and hepatitis C products (PA, QL, SP).
Administrative coverage controls (AC) are also used for some vaccines and contraceptives and must be followed per the Drug List.

Documentation Required

PA, Quantity Limits and Required Documentation

Quantity Limits, QL and PA Documentation — Numerous agents subject to PA also have quantity limits (QL). Prior authorization requests must include documentation of medical necessity and a justification for the quantity requested consistent with the listed QL; exceeding QLs without prior approval may be denied or the member may be financially responsible.

Insulin products commonly have QL = 100 mL/30 days; requests exceeding this amount must include supporting rationale to avoid claim denial.
CRINESSITY (crinecerfont) requires PA and has QL and SP flags — PA submissions should specify formulation (capsule vs oral solution) and requested quantity (capsule QL 60/30 days; solution QL 120 mL/30 days).
FUROSCIX lists PA with QL (8 kits/180 days) — adhere to the stated limit when requesting PA.

Denial Risk

Denial Triggers — Missing PA, QL or SP

Denial Risk and Operational Triggers — Claims or prescriptions lacking required PA, exceeding specified QL, or not routed through the required specialty channel (SP) risk denial. Providers should verify requirements before dispensing and include all supporting clinical documentation with the PA to reduce denial risk.

Denial triggers include: no approved PA when "PA" is indicated; quantity exceeding QL without prior approval; dispensing outside specialty pharmacy when "SP" is indicated.
Examples: REPATHA, VASCEPA, many oncology and biologic agents are annotated PA, QL, SP and may be denied if requirements are unmet.

Step Therapy

Step Therapy Requirement / Flags

Step Therapy and Program Flags — Some drugs are subject to step therapy (ST) requirements and program flags; if an ST is indicated on the Drug List the provider must demonstrate trial and failure (or contraindication) of required alternatives per the plan. Not all listed agents in this section have step edits; follow the Special Requirements column for ST flags.

Examples of ST: select CNS and psychiatric agents (eg, FETZIMA, certain aripiprazole and clozapine formulations) and some cardiovascular agents may carry an ST flag.
Where a product is not marked with ST in this portion of the Drug List, no step-therapy rule is specified here — but other plan materials may apply.

Documentation Required

Submit PA / Exception Process

Provider Action — How to Submit PA and Exceptions — Submit prior authorization requests per the payer’s PA process and include documentation supporting medical necessity, QL justification and specialty routing when applicable. For Drug List exceptions or expedited reviews contact the number on the member ID card; standard exception decisions are communicated within two business days and expedited reviews within 72 hours when applicable.

Document QL and SP requirements in the PA request (e.g., hepatitis C products: list regimen, duration, and tablet/packet counts).
For exceptions or expedited requests, call the number on the member ID card. If denied, the plan will explain the reason and suggest covered alternatives when available.

Suspension presentationsSeparate suspension lines listed; QL not specified for some suspension strengths in this entry

inv-167: azithromycin tab 600 mg — 60

Azithromycin tab 600 mgQL 60 tablets per 180 days

Tiering noteDrug Tier = np for 600 mg tablet as listed

Use noteSame QL as other azithromycin tablets despite different strength

inv-168: clarithromycin ER 500 mg — 28

Clarithromycin ER 500 mg (ER 24-hour)QL 28 tablets per 30 days

Other clarithromycin strengths250 mg and 500 mg immediate-release tabs listed separately without QL in some entries

TieringDrug Tier = NP for ER formulation as shown

inv-169: ARIKAYCE — 235.2 mls

ARIKAYCE (amikacin liposome inhalation) 590 mg/8.4 mLQL 235.2 mLs per 28 days; Requirements: PA, SP

TieringDrug Tier = NP

Related inhaled aminoglycosidesOther inhaled aminoglycosides (TOBI PODHALER, KITABIS PAK, Tobi) have PA/QL/SP entries — see individual lines

inv-170: TOBI PODHALER — 224

TOBI PODHALER - tobramycin inhalation cap 28 mgQL 224 capsules per 56 days; Requirements: PA, SP

TOBI (tobramycin nebu soln 300 mg/5 mL)QL 56 containers per 56 days; Requirements: PA, SP

TieringDrug Tier = NP for inhaled tobramycin products

inv-171: Tobramycin nebu soln (Tobi) — 56

Tobramycin nebu soln 300 mg/5 mL (Tobi)QL 56 containers per 56 days; Requirements: PA, SP

Bethkis presentation300 mg/4 mL listed with same QL (56 containers/56 days)

Related inhaled aminoglycosidesKITABIS PAK entries also list PA, QL and SP

inv-172: Itraconazole cap 100 mg / oral soln — 120 / 1200

Itraconazole capsule 100 mg (Sporanox)QL 120 capsules per 30 days

Itraconazole oral solution 10 mg/mLQL 1200 mLs per 30 days

TieringDrug Tier = NP for itraconazole formulations listed

inv-173: EDURANT (rilpivirine) 25 mg tab — 30

EDURANT (rilpivirine) 25 mg tabQL 30 tablets per 30 days

EDURANT pediatric/oral suspensionSome presentations list higher QL (e.g., 180 tablets/30 days for pediatric suspension) — see product line

TieringDrug Tier = NP for EDURANT entries

inv-174: EMTRIVA solution 10 mg/ml — 720

EMTRIVA (emtricitabine) oral solution 10 mg/mLQL 720 mLs per 30 days

EMTRIVA capsule/tablet presentationsCapsule/tablet lines list QL 30 tablets/30 days for many formulations

TieringDrug Tier = NP for EMTRIVA solution entry

inv-175: GENVOYA — 30

GENVOYA (combined antiretroviral)QL 30 tablets per 30 days

RequirementsListed with QL; see formulary for PA/SP where applicable

TieringDrug Tier = P for GENVOYA

inv-176: ISENTRESS chewable 25/100 mg — 180

ISENTRESS (raltegravir) chewable 25/100 mgQL 180 tablets per 30 days (chewable formulation)

ISENTRESS packet/other presentationsOther presentations list QL 60 tablets/30 days or 60 packets/30 days depending on form

TieringDrug Tier = P for ISENTRESS chewable/pack/pill entries

inv-177: SUNLENCA (lenacapavir) — 4

SUNLENCA (lenacapavir) 300 mg tabletQL 4 tablets per 365 days (therapy/treatment pack limits)

Therapy pack optionsTherapy packs list QL 4–5 tablets per 365 days depending on pack

TieringDrug Tier = NP; SP designation applies

inv-178: VOSEVI — 30

VOSEVI (sofosbuvir-velpatasvir-voxilaprevir)QL 30 tablets per 30 days; Requirements: PA, SP

TieringDrug Tier = P for VOSEVI

Related HCV agentsSee EPCLUSA, HARVONI, SOVALDI entries for similar PA/QL/SP controls

inv-179: vancomycin capsules (Vancocin) — 120

Vancomycin capsules (Vancocin)QL 120 capsules per 30 days

Vancomycin HCl capsules 125 mg, 250 mgQL 120 capsules per 30 days

Firvanq (vancomycin oral solution)No explicit QL string shown for Firvanq in inventory — consult full formulary line

inv-180: vancomycin hcl cap 125/250 mg — 120 capsules

Vancomycin HCl cap 125 mg / 250 mg (Vancocin)QL 120 capsules per 30 days

Formulation noteCapsule presentations listed with same QL; oral solution (Firvanq) line has no explicit QL string in inventory

TieringDrug Tier = NP for capsule and solution lines

inv-181: Firvanq (vancomycin oral solution) — (no explicit QL string in inventory)

Firvanq (vancomycin oral solution)No explicit quantity limit string provided in the inventory line

Related vancomycin entriesVancocin capsules have QL 120 capsules/30 days while Firvanq solution QL not specified in this extract

ActionRefer to full formulary line for Firvanq QL when processing claims

inv-182: XIFAXAN 200 mg — 9 tablets

XIFAXAN (rifaximin) 200 mgQL 9 tablets per 30 days

Indication-related higher-strength packSee 550 mg line for hepatic encephalopathy/other indications with different QL

XIFAXAN 550 mgQL 60 tablets per 30 days (separate entry)

inv-183: XIFAXAN 550 mg — 60 tablets

XIFAXAN (rifaximin) 550 mgQL 60 tablets per 30 days

Usage noteDifferent strengths have different QLs reflecting indication (e.g., hepatic encephalopathy vs. travelers' diarrhea)

TieringDrug Tier = P for 550 mg presentation

inv-184: abiraterone acetate 250 mg — 120 tablets

Abiraterone acetate 250 mg (Zytiga)QL 120 tablets per 30 days; Requirements: PA, SP

Abiraterone acetate 500 mgQL 60 tablets per 30 days; Requirements: PA, SP

TieringDrug Tier = NP for abiraterone entries

inv-185: abiraterone acetate 500 mg — 60 tablets

Abiraterone acetate 500 mg (Zytiga)QL 60 tablets per 30 days; Requirements: PA, SP

Lower monthly packDifferent strength has proportionally lower QL

TieringDrug Tier = NP

inv-186: ALECENSA 150 mg — 240 capsules

ALECENSA (alectinib) 150 mgQL 240 capsules per 30 days; Requirements: PA, SP

Alternate strengthsOther strength presentations list QL 60 capsules/30 days depending on pack

TieringDrug Tier = P

inv-187: BOSULIF — 90 or 30 tablets/30 days depending on presentation

BOSULIF (bosutinib) — presentation-dependent QLQL 90 tablets/30 days or QL 30 tablets/30 days depending on presentation; Requirements: PA, SP

TieringDrug Tier = P for many BOSULIF lines

ActionApply the QL that corresponds to the specific strength/presentation dispensed

inv-188: COMETRIQ (cabozantinib kit) — 1 carton/28 days

COMETRIQ (cabozantinib kit)QL 1 carton per 28 days; Requirements: PA, SP

Kit presentationsMultiple kit presentations listed; apply the 1-carton/28-days limit for kit formulations

TieringDrug Tier = P

inv-189: erlotinib (Tarceva) — 60 or 30 tablets/30 days

Erlotinib (Tarceva) — strength-specific QLQL 60 tablets/30 days or QL 30 tablets/30 days depending on strength; Requirements: PA, SP

TieringDrug Tier = NP for erlotinib entries

ActionUse the QL tied to the specific tablet strength being dispensed

inv-190: GOMEKLI (mirdametinib) — 168 or 84 tablets/28 days depending on strength

GOMEKLI (mirdametinib) — strength-dependent QLQL 168 tablets/capsules per 28 days or 84 capsules per 28 days depending on strength; Requirements: PA, SP

Pack distinctionsDifferent cap/tab strengths and pack types determine the applicable QL

TieringDrug Tier = NP

inv-191: LAZCLUZE (lazertinib) — 60 or 30 tablets/30 days

LAZCLUZE (lazertinib) — strength-specific QLQL 60 tablets/30 days or QL 30 tablets/30 days depending on strength; Requirements: PA, SP

TieringDrug Tier = NP for certain strength lines

ActionApply the QL associated with the dispensed tablet strength

inv-192: PIQRAY — 28-56 tablets/28 days depending on pack

PIQRAY (alpelisib) — pack-dependent QLQL 28–56 tablets per 28 days depending on the daily-dose pack (200 mg = 28; 250/300 mg = 56)

RequirementsPA and SP apply to PIQRAY entries

ActionSelect the QL that matches the prescribed daily-dose pack

inv-193: OJEMDA 25 mg/ml — 8 bottles

OJEMDA (tovorafenib) 25 mg/mL (oral suspension)QL 8 bottles per 28 days; Requirements: PA, SP

TieringDrug Tier = NP

ActionApply 8-bottle/28-day limit for oral suspension presentations

inv-194: OJJAARA tablets — 30 tablets

OJJAARA (momelotinib) tabletsQL 30 tablets per 30 days; Requirements: PA, SP

TieringDrug Tier = NP

ActionApply 30-tablet monthly limit

inv-195: ONUREG tablets — 14 tablets

ONUREG (azacitidine) tabletsQL 14 tablets per 28 days; Requirements: PA, SP

TieringDrug Tier = NP for ONUREG entries

ActionApply 14-tablet/28-day limit for tablet formulation

inv-196: PIQRAY 200 mg pack — 28 tablets

PIQRAY 200 mg daily-dose packQL 28 tablets per 28 days; Requirements: PA, SP

PIQRAY 250 mg packQL 56 tablets per 28 days; Requirements: PA, SP

PIQRAY 300 mg packQL 56 tablets per 28 days; Requirements: PA, SP

inv-197: PIQRAY 250 mg pack — 56 tablets

PIQRAY 250 mg daily-dose packQL 56 tablets per 28 days; Requirements: PA, SP

Dose-pack notePack composition determines QL; follow pack-specific QL

TieringDrug Tier = P for PIQRAY therapy packs

inv-198: PIQRAY 300 mg pack — 56 tablets

PIQRAY 300 mg daily-dose packQL 56 tablets per 28 days; Requirements: PA, SP

Dose-pack notePack composition determines QL; follow pack-specific QL

TieringDrug Tier = P

inv-199: POMALYST — 21 capsules

POMALYST (pomalidomide)QL 21 capsules per 28 days; Requirements: PA, SP

Pack-dependent dispensingTherapy packs and capsule strengths define the monthly QL

TieringDrug Tier = P

inv-200: QINLOCK — 90 tablets

QINLOCK (ripretinib)QL 90 tablets per 30 days; Requirements: PA, SP

StrengthTab 50 mg listed with 90-tablet monthly QL

TieringDrug Tier = NP

Group-specific coverageA '+' after a drug indicates group-specific coverage — check plan materials

inv-120: QL definition — Quantity Limit (low importance)

Quantity Limit (QL) definitionMaximum quantity of a medication allowed in a specified time frame (e.g., 60 tablets/180 days); noted as 'QL' in Special Requirements

PurposeEncourages medication use as intended by FDA and limits excess dispensing

Claim impactDispensing above QL may result in member financial responsibility for excess; controlled-substance limits may be restricted by state law

inv-121: PA definition — Prior Authorization (low importance)

Prior Authorization (PA) definitionPlan-required approval before coverage is provided; drugs flagged 'PA' require authorization prior to benefit payment

When PA appliesHigh-cost, specialty, or certain clinical agents (e.g., many antineoplastics, HCV DAAs, GLP-1s) are listed with PA

DocumentationSubmit clinical justification and requested quantity consistent with listed QL when applying for PA