2025 Drug List (Pharmacy Benefit) — Formulary and Coverage Criteria
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Governs the pharmacy drug list for Blue Cross and Blue Shield of Texas members, describing covered drugs, tiers, specialty drug handling, and processes for exceptions, prior authorization, step therapy, and limits. Affects members, prescribing providers, pharmacies, and specialty pharmacy partners.
No material clinical or coverage changes in this revision.
Coverage framework and per-product criteria
Pharmacy Coverage Framework
Covered when ALL of the following are met:
Drugs not shown on the Drug List are not covered under the pharmacy benefit; see plan materials for exceptions.
Tier flags include Preferred Generic (p), Non‑Preferred Generic (np), Preferred Brand (P), Non‑Preferred Brand (NP), Preferred Specialty, Non‑Preferred Specialty; check MyPrime.com or bcbstx.com for plan-specific tiering.
Prior authorization must be approved before coverage where 'PA' is indicated; failure to obtain PA or adhere to QL may result in denial.
Common QL formats include e.g., 30 tablets/30 days, 100 mL/30 days for insulin, or pack/180 days for titration kits; see specific product line for numeric QL.
Formulary coverage entries (product-specific requirements)
Covered when the following product‑level requirements are met:
Formulary entries include Special Requirements (e.g., PA, QL, SP) that govern coverage.
Examples in the listing: EPCLUSA shows Requirements/Limits = PA.
Example: QL (30 tablets/30 days) applies to some antiretroviral entries.
Hepatitis C agents — DAA agents listed with PA and specialty flags on selected products
Direct‑acting antivirals for hepatitis C are covered when ALL of the following are met:
Products such as MAVYRET and EPCLUSA appear on the list with tier assignments.
EPCLUSA, HARVONI, MAVYRET, SOVALDI and VOSEVI are shown with PA flags in the formulary.
Many hepatitis DAAs include 'SP' in Requirements/Limits.
EPCLUSA examples: QL (30 tablets/30 days) for tablets; QL (28 tablets/28 days) for pellet pack.
Vaccine coverage notes
Vaccines are covered when the listed administrative criteria are satisfied:
Examples include COMIRNATY 2024-25 and AFLURIA 2024-2026 listings.
Many vaccine entries (COMIRNATY, AREXVY, AFLURIA, BEXSERO, CAPVAXIVE) are annotated with AC.
Contraceptives / Progestins
Contraceptives and progestin products are covered when ALL of the following are met:
Tier and Requirements/Limits determine coverage and member cost-share.
Several combined oral contraceptives and emergency contraception (ELLA) show AC and some lines include PA.
Examples: combined oral contraceptives QL (28 tablets/21 days); ELLA QL (2 tablets/365 days); NUVARING QL (1 ring/21 days).
Antidiabetics / GLP-1 / GIP agents
GLP‑1, GIP/GLP‑1 and other antidiabetic agents are covered when ALL of the following are met:
Examples include FARXIGA, GLYXAMBI, JARDIANCE, MOUNJARO, OZEMPIC, TRULICITY in the listing.
Many GLP‑1/GIP agents are annotated with PA in formulary entries.
MOUNJARO, OZEMPIC, TRULICITY examples: MOUNJARO PA, QL (4 pens/28 days); OZEMPIC PA, QL (1 pen/28 days); TRULICITY PA, QL (4 pens/28 days).
Rapid-acting Insulin
Rapid‑acting insulins and insulin pens/cartridges are covered when ALL of the following are met:
Examples include FIASP, HUMALOG, NOVOLOG, LYUMJEV entries.
Pen and cartridge formats are included under the same volume QL in the listings.
Formulary coverage entries — Insulin and related endocrine drugs
Coverage and utilization controls for insulin and related endocrine products:
This formulary segment lists multiple insulin formulations and associated QLs (commonly 100 mL/30 days).
Specialty drug management
Specialty endocrine and other high‑cost drugs are covered when ALL of the following are met:
Examples include ACTHAR, CRENESSITY, GENOTROPIN and other specialty endocrine agents.
CRENESSITY lists PA, QL and SP; ACTHAR lists PA and SP as examples.
CRENESSITY capsule QL (60 capsules/30 days) and oral solution QL (120 mls/30 days) are shown in the formulary.
Formulary inclusion with utilization controls
Formulary inclusion and utilization control rules:
Prescribers must follow listed PA, QL and SP controls to secure coverage; tiering affects member cost-share.
Product-level coverage controls
Product‑level coverage controls — apply to each listed product line item:
Providers must obtain PA and adhere to QL/SP where indicated for each product.
Coverage conditional on PA/QL/ST flags
Per‑product controls — coverage conditional on listed attributes:
Drugs not listed on the payer's Drug List are not covered under the pharmacy benefit; coverage applies only to products that appear on the published drug list and are consistent with the member's benefit plan. In addition, the formulary excludes certain categories of products: compounded medications, repackaged medications, and drugs that have not received FDA approval are not covered under the pharmacy benefit. Members and providers should confirm coverage and tier placement at MyPrime.com or via the number on the member ID card.
The provided excerpts do not define any standalone, explicit exclusion clauses for individual products; instead they present formulary line items with assigned Drug Tier and associated administrative flags (e.g., PA, QL, SP, AC). Where an entry lacks a specific exclusion statement, coverage is governed by the product's tier and any listed Requirements/Limits.
This excerpt contains product listings with utilization controls but does not present explicit per-product exclusion language. Coverage determination for each listed product is informed by its Drug Tier and any Requirements/Limits shown (for example, entries listing PA or QL), rather than by separate stated exclusions in these chunks.
Some formulary lines in this segment show the Requirements/Limits field as blank (displayed as '.'), which indicates that no specific utilization restriction (such as PA, QL, or SP) is listed for that particular presentation in the excerpt. Absence of a Requirements/Limits entry in the excerpt does not guarantee unrestricted coverage; providers should verify the current status on the official drug list.
The document fragments do not list explicit clinical exclusion criteria. Instead, contraceptive, progestin and thyroid product entries (and others) display product-level Requirements/Limits (for example, AC, PA, QL) that govern coverage and dispensing. If clinical exclusions apply, they are not stated in these chunks and must be determined from plan-specific criteria or authorizations.
Within these excerpts there are no explicit exclusion conditions recorded; the content consists of formulary line items (drug names, tiers) and occasionally shows Requirements/Limits as blank or with administrative flags. Any formal clinical exclusion rules are not present in this portion of the document.
This segment lists drug products together with utilization controls such as PA, QL, and SP where applicable, but it does not include explicit clinical exclusion language. For listed products, coverage is conditioned on meeting any applicable Requirements/Limits shown next to the product.
The formulary listings in this fragment define coverage in terms of Drug Tier and any associated administrative flags (for example, PA, QL, SP). They do not set out standalone clinical medical necessity rules within the excerpt; providers should follow the Requirements/Limits shown per product when seeking coverage.
No specific exclusions for individual products appear in this excerpt. Instead, specialty biologics and other high-cost agents are listed with explicit utilization controls (for example, SKYRIZI and TREMFYA show PA and QL and are designated SP), indicating that coverage is contingent on meeting those controls rather than reflecting explicit per-product exclusions in these chunks.
Drugs used solely for cosmetic purposes are identified as potentially not covered by the pharmacy benefit; the source lists hair growth agents (e.g., Propecia) as an example of a cosmetic indication that may be excluded from coverage under the pharmacy benefit.
The extracts provided do not contain any entries explicitly labeled as 'Not Medically Necessary.' Across these chunks, the document shows formulary tiers and Requirements/Limits (such as AC, PA, QL), but it does not mark any products in these excerpts with a formal 'not medically necessary' determination.
No statements explicitly declaring products as 'not medically necessary' appear in these chunks. Contraceptive and progestin lines show administrative controls and quantity limits (for example, many combined oral contraceptives list AC and QL (28 tablets/21 days)), but not 'not medically necessary' language in this excerpt.
This portion of the extract does not include any 'not medically necessary' declarations. It provides thyroid and endocrine product listings with tiers and, where applicable, Requirements/Limits (often blank in the excerpt), but no explicit 'not medically necessary' statements are present here.
These chunks do not contain explicit 'Not Medically Necessary' statements for the listed products. Instead, they show product-level utilization controls (for example, PA, QL, SP) that determine coverage conditions; absence of 'not medically necessary' language in the excerpt means such determinations are not provided here.
Across these formulary fragments there are no explicit entries labeled 'Not Medically Necessary.' The listings focus on tier placement and utilization management flags (for example, PA, QL, SP) rather than labeling products as not medically necessary in the provided excerpts.
Formulary listings and code tables
| AMOXICILLIN | amoxicillin (trihydrate) various forms and strengths listed |
| AMOXICILLIN/CLAVULANATE | amoxicillin & k clavulanate various formulations (susp, tabs, ER) |
| CEFACLOR | cefaclor cap 250 mg, 500 mg |
| CEFPODOXIME | cefpodoxime proxetil tab 100 mg, 200 mg |
| AZITHROMYCIN | azithromycin susp and tablets; QL examples |
| FIDAXOMICIN (DIFICID) | fidaxomicin tab 200 mg; susp 40 mg/ml |
| DOXYCYCLINE | doxycycline hyclate and monohydrate various forms |
| BAXDELA (delafloxacin) | delafloxacin meglumine tab 450 mg; QL noted |
| CIPROFLOXACIN | ciprofloxacin oral susp and tablets |
| LEVOFLOXACIN | levofloxacin oral solution and tablets |
| DOVATO | dolutegravir sodium-lamivudine tab 50-300 mg (base eq) |
| EDURANT | rilpivirine hcl tab 25 mg (base equivalent) |
| efavirenz | efavirenz tab 600 mg (Sustiva) |
| emtricitabine | emtricitabine caps 200 mg (Emtriva) |
| EPCLUSA | sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg |
| EFAVIRENZILAMIVUDINEITENO | efavirenz-lamivudine-tenofovir df tab 400-300-300 mg |
| GENVOYA | elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg |
| HARVONI | ledipasvir-sofosbuvir tab 45-200 mg; 90-400 mg |
| ISENTRESS | raltegravir potassium tab/packet/chew formulations |
| JULUCA | dolutegravir sodium-rilpivirine hcl tab 50-25 mg |
| LIVTENCITY | maribavir tab 200 mg |
| MAVYRET | glecaprevir-pibrentasvir tab 100-40 mg |
| PAXLOVID | nirmatrelvir + ritonavir pack (multiple pack sizes) |
| PREVYMIS | letermovir tab/pellet pack |
| PREZISTA | darunavir formulations (tabs, oral suspension) |
| RIBAVIRIN | ribavirin cap/tab 200 mg |
| SOVALDI | sofosbuvir tab 200 mg, 400 mg |
| STRIBILD | elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg |
| SUNLENCA | lenacapavir sodium tab and therapy packs |
| SYMTUZA | darunavir-cobic-emtricitab-tenofov af tab 800-150-200-10 mg |
| VIREAD | tenofovir disoproxil fumarate formulations |
| SOLOSEC | secnidazole granules packet 2 gm |
| CAYSTON | aztreonam lysine for inhalation solution 75 mg |
| XIFAXAN | rifaximin tab 200 mg, 550 mg |
| VANCOMYCIN | vancomycin oral capsule/solution formulations (Vancocin, Firvanq) |
| COMIRNATY | COVID-19 mRNA vaccine (2024-25) 30 mcg/0.3 ml |
| ABRYSVO | RSV pre-fusion vaccine recomb for IM |
| AREXVY | RSV pref3 vaccine recomb adjuvanted for IM |
| BEXSERO | meningococcal B vaccine (recombinant) |
| CAPVAXIVE | pneumococcal 21-valent conjugate vaccine |
| N/A | No CPT/HCPCS/ICD codes provided in this excerpt; entries are drug product names with tiers and requirements. |
| no CPT/HCPCS/ICD codes listed | This section contains NDC-like product listings, tiers, and utilization controls but does not list procedure or diagnosis codes. |
| GLASSIA 1000 mg/50 ml | alpha1-proteinase inhibitor (human) inj 1000 mg/50ml |
| GLASSIA 4 g/200 ml; 5 g/250 ml | alpha1-proteinase inhibitor (human) iv soln 4 gm/200ml, 5 gm/250ml |
| KALYDECO 150 mg tab | ivacaftor tab 150 mg |
| KALYDECO packets | ivacaftor packet 5.8 mg, 13.4 mg, 25 mg, 50 mg, 75 mg |
| OFEV 100 mg; 150 mg cap | nintedanib esylate cap 100 mg, 150 mg |
| PRILOSEC packets 2.5 mg; 10 mg | omeprazole magnesium for delayed release susp packet 2.5 mg; 10 mg |
| VOQUEZNA 10 mg; 20 mg | vonoprazan fumarate tab 10 mg, 20 mg |
| CREON multiple strengths | pancrelipase DR cap various unit strengths |
| ZENPEP multiple strengths | pancrelipase DR cap various unit strengths |
| No codes listed |
Prior authorization, step therapy, documentation and denial risks
Prior Authorization Requirement
Prior Authorization Required — Many medications in this Drug List require prior authorization (PA) before coverage. Items noted with “PA” in the Special Requirements/Requirements/Limits column must have an approved prior authorization request on file or the claim may be denied.
- Prescribers must submit PA requests and receive approval prior to dispensing PA-marked drugs.
- Claims submitted without required PA or missing documentation may be denied.
- PA status often accompanies QL (quantity limits), SP (specialty pharmacy routing), and AC (authorization criteria) — confirm all applicable flags when requesting coverage.
Prior authorization required for select agents
Prior authorization is specifically required for a range of select agents across categories — examples found in the Drug List include certain inhaled antibiotics, antifungals, antivirals/hepatitis agents, oncology and specialty drugs, endocrine and metabolic agents, GI specialty agents, biologics and vaccines.
- Antimicrobials/antifungals: TOBRAMYCIN nebu soln (PA, QL, SP); POSACONAZOLE (PA); VORICONAZOLE (PA).
- Antivirals/Hepatitis: EPCLUSA, MAVYRET, VOSEVI, many HCV and HIV products listed with PA and QL.
- Oncology/specialty oral agents and injectables: numerous oral targeted therapies and immunotherapies (examples: ABIRATERONE, IBRUTINIB, PALBOCICLIB, VENETOCLAX, many with PA, QL, SP).
- Endocrine/specialty agents: select agents (e.g., ACTHAR, OMNITROPE, SKYTROFA, MYALEPT) show PA and/or SP requirements.
- GI specialty: VOWST and other specialty GI products show PA and QL flags.
Prior authorization required for select antivirals/hepatitis agents
Prior authorization triggers for antivirals/hepatitis agents — many direct-acting antivirals and select antiviral products are managed with PA, QL and sometimes SP. Examples in the list: EPCLUSA (PA, QL, SP), MAVYRET (PA, QL, SP), VOSEVI (PA, QL, SP), and other HIV/HBV/HCV agents noted with PA.
- When EPCLUSA, MAVYRET, VOSEVI or similar agents are prescribed, submit PA documentation consistent with antiviral coverage criteria and pack/quantity selection.
- Some antiviral products are handled via specialty pharmacy (SP) — confirm routing and supply limits when submitting PA.
Prior authorization required for select oncology/specialty drugs
Prior authorization required for oncology and specialty drugs — Many oral and injectable oncology agents and other specialty therapies are labeled PA and frequently combined with QL and SP. Prescribers must submit PA requests with clinical documentation supporting medical necessity and dosing.
- Examples: ABIRATERONE, IBRUTINIB, IMBRUVICA formulations, TAGRISSO, VENCLEXTA, PALBOCICLIB, many others show PA + QL + SP.
- Oral oncology agents often have specific QL (e.g., 30/30, 60/30) and pack-based QLs; ensure PA cites the intended pack/dose.
Prior authorization required for PA-marked drugs
PA-marked drugs across the Drug List require prior authorization — many products in the document are explicitly marked PA. Review Special Requirements/Requirements/Limits columns and submit PA where indicated to avoid claim denials.
- PA indicators appear next to product lines (e.g., “Requirements/Limits = PA”).
- Some entries include combined flags like “PA, QL, SP” or “AC, PA, QL”; include documentation addressing all listed controls in the PA request.
Prior authorization required for listed products
Prior authorization required for products listed with PA, and for many other listed products — the Drug List includes many PA-flagged items across therapeutic classes; verify PA requirements for each item before dispensing.
- Check the Special Requirements/Requirements/Limits column for PA on every drug line.
- Some plans may impose additional PA requirements not shown in this consolidated list — always confirm with the member’s benefit plan.
PA required for selected endocrine/specialty drugs
PA required for selected endocrine and specialty drugs — multiple endocrine, metabolic and rare-disease agents are PA- or SP-managed. Examples include ACTHAR, OMNITROPE, JYNARQUE, SKYTROFA, SOMAVERT, MYALEPT and others shown with PA and SP.
- These products frequently require specialty pharmacy routing (SP) and may have pack- or vial-based QLs — document dose, indication, and quantity used in the PA submission.
- Prescribers should reference product-specific criteria (e.g., prior approvals for growth hormone, corticotropin) when completing PA forms.
Prior authorization required for many GI specialty drugs
PA requirement for many GI specialty drugs — Several GI specialty products (e.g., VOWST, VIBERZI, TREMFYA interactions in GI-immunology overlap) are managed with PA, QL and sometimes SP; verify flags for each product line.
- VOWST (fecal microbiota spores) is listed with PA and QL (12 capsules/12 months) and SP — submit clinical rationale for use.
- TREMFYA and SKYRIZI biologic entries include PA and QL; induction packs and maintenance supplies may have different QLs (example: TREMFYA induction pack QL 3 kits/180 days).
Prior authorization required for specified specialty drugs
Prior authorization is required for numerous specified specialty drugs (biologics, injectables and kits). Many biologic products list PA plus quantity limits and specialty routing; follow the PA process and specialty pharmacy routing instructions.
- Examples: SKYRIZI (PA, QL, SP), TREMFYA (PA, QL, SP, induction pack QL), ZYMFENTRA (PA, QL, SP).
- ZYMFENTRA kit/syringe presentations include specific QLs (2 kits/28 days or 2 syringes/28 days) — ensure PA addresses the exact presentation being requested.
Prior Authorization Triggers and Specialty Product Handling
Prior authorization triggers & specialty product handling — PA flags, SP routing and QL indicators are common triggers for administrative review and specialty handling. Products marked SP may require specialty pharmacy fulfillment or referral.
- When a product is marked SP, coordinate with the payer’s specialty pharmacy or follow prior authorization instructions to route benefit appropriately.
- PA triggers include the presence of PA in the Requirements/Limits column and often accompany QL or SP flags.
Prior authorization and quantity limit enforcement
Prior authorization and quantity limit enforcement — Many products are managed by combined utilization controls (PA + QL). Claims that exceed QL or lack PA/AC may be denied. Providers should document and support any requests to exceed stated QLs.
- Quantity limits are shown per product (e.g., 30 tablets/30 days, 4 pens/28 days, pack/180 days) — verify the exact QL when submitting PA.
- Prescriptions exceeding listed QLs require supporting documentation and will generally need an approved PA to be covered.
Prior authorization / administrative controls and denial risk
Prior authorization, administrative controls and denial risk — Failure to obtain required PA/AC or to follow SP routing or QL limits can lead to claim denial. Administrative flags (PA, AC, SP, QL) indicate controls that must be satisfied for coverage.
- AC (authorization/criteria) entries require submission of supporting documentation per payer process.
- Claims submitted without required PA or exceeding QL may be denied and members may be financially responsible if dispensed without coverage.
Document QL/PA when submitting (Documentation requirements)
Document QL/PA/AC when submitting — Include clear documentation of requested quantity, dosing, indication, prior treatment history, and any specialty routing required. For AC-listed products, provide the documentation specified by the payer’s authorization process.
- For QL exceedance requests include rationale and expected duration of therapy.
- For AC or PA items, attach relevant clinical notes, prior medication trials, laboratory or diagnostic results that meet the payer’s criteria.
- TREMFYA and similar biologics: when ordering induction kits vs maintenance supplies, document pack/kit needs and submit PA with QL justification (e.g., TREMFYA induction pack QL 3 kits/180 days).
Provide supporting documentation for PA and QL
Documentation to support PA — Prescribers must provide clinical justification for medical necessity, prior therapy history (when step therapy applies), dosing and pack/quantity selection, and any lab or diagnostic evidence required by the payer.
- Liquid formulations and oral solutions often have specific QLs (examples: enalapril oral soln QL 1200 mls/30 days; KALYDECO packets QL 60 packets/30 days) — include dosing and supply rationale.
- Provide dosing schedule and expected duration when requesting PA for induction packs or starter kits (e.g., TREMFYA induction pack documentation).
- If step therapy (ST) or step rules apply, document prior trials and failures of required preferred alternatives.
TREMFYA PA documentation (induction vs maintenance)
TREMFYA and similar biologic PA documentation — Induction packs and maintenance presentations often have discrete QLs and require PA. Submit documentation that specifies kit vs maintenance dosing and supports the requested supply (e.g., induction pack QL 3 kits/180 days).
- TREMFYA induction pack: Requirements/Limits show PA and QL (3 kits/180 days) — indicate induction schedule and justification in the PA request.
- Confirm whether the request is for an induction pack or routine maintenance dosing and supply; document accordingly.
Step Therapy Requirement and Specialty/Step Rules
Step therapy (ST) and specialty/step rules — Some products are subject to step therapy (ST) or specialty program (SP) requirements. ST flags indicate a requirement to try specified alternatives before a non-preferred agent will be covered.
- If an ST flag is present, include documentation of prior trials and outcomes of required step agents when submitting PA or exception requests.
- Some agents are marked ST but specific algorithms may not be listed in this consolidated document — check the member’s benefit plan for exact step requirements.
Supply and step restrictions (Step therapy / supply)
Step therapy specifics and supply/step restrictions — Where supply limits or QLs are listed together with ST or SP (for example GLP-1/GLP‑1 receptor agonists showing QL 4 pens/28 days), ensure PA or exception requests document adherence to supply rules or justify exceptions.
- GLP-1/GIP agents (e.g., MOUNJARO, OZEMPIC, ZEPBOUND) often have PA and QL flags including pen/28-day or pens/180-day limits — include supply needs and prior therapy history.
- When step therapy is not specified in this fragment but an ST flag is present, verify the plan-level step requirements before submitting an exception.
Step therapy flags and program notes
| Program | Indicator in formulary | Notes for providers |
|---|---|---|
| Step therapy programs | ||
| Marked with 'ST' in the Special Requirements column of the drug list | ||
| Plan-specific details apply; members may need to try a specified alternative before coverage. Refer to member benefit materials for exact step requirements. |
| Drug group | Formulary flags | Provider action |
|---|---|---|
| Selected high-cost antivirals (e.g., EPCLUSA, MAVYRET, SOVALDI) | ||
| PA, QL, SP noted for many hepatitis C direct-acting antivirals | ||
| Submit prior authorization and, where indicated, route through specialty pharmacy prior to coverage; adhere to listed QL (e.g., 30 tablets/30 days). |
| Summary | Step therapy sequences provided? | Implication |
|---|---|---|
| Extracted formulary segments | ||
| No explicit step therapy sequences provided in these chunks | ||
| Coverage listings show flags (PA, QL, SP); where ST is required it will be shown next to the product — consult benefit materials for the actual step sequence. |
| Drug category | Requirements noted | Provider action |
|---|---|---|
| Oncology and specialty oral agents (examples: abiraterone, brigatinib, others) | ||
| Many entries list PA and sometimes QL and SP; some may be subject to specialty program or step requirements | ||
| Prescribers must submit prior authorization where shown; specialty routing may be required and step/plan program rules (if any) must be followed per benefit plan. |
| Drug examples | Formulary flags / limits | Provider note |
|---|---|---|
| TRULICITY (dulaglutide) | ||
| PA; QL example listed: 4 pens/28 days | ||
| Obtain prior authorization and adhere to supply limits when prescribing (QL shown on formulary). |
| Drug type | Formulary flags | Routing requirement |
|---|---|---|
| Specialty drugs and select high-cost agents | ||
| Often require PA and are labeled SP in the Requirements/Limits column | ||
| These products are typically dispensed via the plan's specialty pharmacy; providers must obtain PA and use SP channel as indicated. |
| Flag | Meaning | Step therapy detail available? |
|---|---|---|
| SP | ||
| Indicates specialty pharmacy fulfillment required | ||
| Specific step therapy sequences are not provided in this fragment — see benefit documents for plan-level step details. |
| Product examples | Flags in formulary | Provider implication |
|---|---|---|
| Selected specialty agents (e.g., REPATHA, UPTRAVI, TYVASO) | ||
| Often shown as SP with PA and/or QL prior to coverage | ||
| Providers must obtain PA and route prescriptions to specialty pharmacy when indicated; QL must be observed. Step edits are not listed in the extract. |
| Agent / pack | Formulary designation | Step-therapy details |
|---|---|---|
| UPTRAVI TITRATION PACK | ||
| Listed as a titration pack with Requirements/Limits = PA, QL (pack/180 days), SP | ||
| Titration packs are listed, but explicit step-therapy failure rules are not provided in the document fragments. |
| Step therapy presence | Notes found | Action |
|---|---|---|
| Step therapy rules not detailed | ||
| Some products designated 'SP' or have tiering which may imply specialty routing; ST flags appear on select lines elsewhere but no general ST algorithms are present in this fragment | ||
| Follow PA/QL/SP indications on each product line; consult plan materials for any ST program specifics. |
| Products | Formulary flags | Step therapy status |
|---|---|---|
| Aripiprazole formulations; CAPLYTA; certain clozapine entries | ||
| Shown with QL and some lines display 'ST' in Special Requirements | ||
| These selected products are marked ST indicating step edits apply; prescribers must document trials/failures of preferred alternatives when required. |
| Examples | Flags observed | Provider requirement |
|---|---|---|
| FANAPT, RISPERIDONE ODT, VERSACLOZ | ||
| Listed with ST flags (and QL where applicable) | ||
| When ST is flagged, prescribers should document prior trials and failures of preferred agents per plan requirements at claim or PA review. |
| Context | Formulary indication | Coverage implication |
|---|---|---|
| Non-preferred formulations and certain branded products | ||
| Some non-preferred or alternate formulations are subject to ST prior to coverage (ST flag present) | ||
| Providers must document attempted or failed therapies with preferred products when ST is indicated; consult the formulary line for exact expectations. |
Common quantity limits (QL) and product examples
Additional QL product examples
Where drugs are covered (medical vs pharmacy vs specialty)
Terms and abbreviations used in the formulary
Context and scope
Specialty drugs are medications used to treat complex or serious conditions and often require special handling or patient support services. They can be oral, topical, or injectable and may be administered by the member (self-administered) or by a health care professional. When a specialty medication is administered by a health care professional it may be covered under the medical benefit rather than the pharmacy benefit; specialty products in the formulary are commonly identified with the SP (specialty) designation and may require prior authorization and specialty pharmacy routing.
Policy revision timeline
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