Prior authorization required when 'PA' is noted

Obtain prior authorization (PA) when a product line lists 'PA' in the Requirements/Limits column; PA must be approved before the medication will be covered under the plan.

• PA is indicated next to medications where preapproval is required (Special Requirements = 'PA').
• Failure to obtain an approved PA may result in denial or noncoverage.

PA required for select agents (e.g., inhaled aminoglycosides)

Follow the formulary entries for select agents that carry PA or SP flags (examples include inhaled aminoglycosides and tobramycin products); obtain PA and coordinate specialty pharmacy dispensing where indicated.

• Tobramycin nebu soln 300 mg/ml: Requirements/Limits = PA, QL (56 containers/56 days), SP.
• TOBI PODHALER 28 mg: Requirements/Limits = QL (224 capsules/56 days), SP.

Prior authorization for selected antivirals

Request prior authorization for high-cost antiviral agents when indicated; many hepatitis C and antiretroviral products list PA and/or specialty pharmacy (SP) requirements.

• HARVONI (ledipasvir-sofosbuvir): Requirements/Limits = PA, QL (30 tablets/30 days), SP.
• SOVALDI (sofosbuvir): Requirements/Limits = PA, QL (30 tablets/30 days), SP; MAVYRET: PA, QL, SP as listed.

PA requirement for oncology & specialty drugs

Many oncology and specialty agents require prior authorization; obtain PA before dispensing to avoid denial because numerous antineoplastics list PA in Requirements/Limits.

• Examples: ALECENSA, ALUNBRIG, BRAFTOVI and others show 'PA' (often with QL and SP).
• PA is required for coverage of these specialty oncology products.

Submit PA when 'Requirements/Limits = PA' is listed

When a drug's Requirements/Limits field equals 'PA', prescribers must submit a prior authorization request with supporting clinical information demonstrating medical necessity.

• PA entries require documentation of diagnosis, dosing and rationale.
• Use the phone number on the member ID card for exception or expedited requests as needed.

PA required for multiple listed products

Obtain prior authorization for many listed products annotated with 'PA' (examples across multiple sections); do not dispense before PA approval when PA is indicated.

• Testosterone products and several other listed items carry 'PA' flags — secure PA to prevent claim denial.
• Check each product line for a PA annotation prior to dispensing.

PA required for certain testosterone products

Prior authorization is required for specified testosterone formulations shown with 'PA' in Requirements/Limits; follow PA processes and document quantity limits where noted.

• Example: METHITEST methyltestosterone — Requirements/Limits = PA, QL (600 tablets/30 days).
• Testosterone TD gels and injectables list PA and QL values — obtain PA before dispensing.

PA required for certain metformin ER formulations

Prior authorization applies to specified formulations of metformin ER/osmotic forms when annotated 'PA' or 'PA, QL'; providers must obtain PA and adhere to the stated QL.

• metformin HCl ER osmotic 1000 mg: Requirements/Limits = PA, QL (60 tablets/30 days).
• Ensure prescriptions align with listed QLs to avoid denial.

Follow PA and specialty pharmacy (SP) procedures when flagged

Products marked with 'PA' and/or 'SP' require submission of prior authorization and, when applicable, coordination with specialty pharmacy channels before coverage is approved.

• Examples: ACTHAR, GENOTROPIN and SOMAVERT list PA and SP in Requirements/Limits.
• Follow payer PA/SP procedures for submission and dispensing.

PA required for selected extended‑release beta blockers

Certain extended‑release beta‑blocker products (e.g., INDERAL XL, INNOPRAN XL) are listed with 'PA' — obtain prior authorization for these formulations prior to coverage.

• INDERAL XL and INNOPRAN XL have Requirements/Limits = PA.
• Secure PA to prevent claim denial for these ER beta‑blockers.

PA required for selected specialty/biologic agents

Obtain prior authorization for respiratory and biologic specialty agents listed with 'PA' and coordinate specialty pharmacy dispensing (SP) when required for coverage.

• Examples: FASENRA PEN — Requirements/Limits = PA, QL (pen/28 days), SP; XOLAIR — Requirements/Limits = PA, SP.
• Failure to obtain PA or use the specialty pharmacy may lead to denial.

PA required for listed specialty agents (CF modulators, others)

Numerous specialty and high‑cost agents (e.g., ALYFTREK, KALYDECO, TRIKAFTA, ENTYVIO PEN, OMVOH) list 'PA' in Requirements/Limits — obtain PA before dispensing.

• ALYFTREK: Requirements/Limits = PA, QL, SP as shown.
• TRIKAFTA and other CF modulators list PA + QL + SP — secure PA and follow QL.

Obtain PA for numerous listed agents

Many agents throughout the list require prior authorization; providers must obtain PA before coverage is approved for these products to avoid denied claims.

• Examples: LIVDELZI, LIVMARLI, OMVOH, SKYRIZI and VOWST list PA in Requirements/Limits.
• Submit PA with supporting clinical documentation and follow specialty pharmacy instructions when present.

PA required for select specialty drugs (examples)

Certain specialty medications (e.g., IMCIVREE, tasimelteon) require prior authorization when listed; follow PA processes and respect any quantity limits (QL) noted.

• IMCIVREE: Requirements/Limits = PA, QL (10 vials/30 days), SP.
• Tasimelteon (Hetlioz) and select antipsychotic entries carry PA when indicated.

Step therapy (ST) applies where 'ST' is listed

Step therapy may be required for some medications and is indicated by 'ST' in the Special Requirements column; follow plan step‑therapy rules where 'ST' is shown.

• ST appears next to certain antidepressants and CNS agents (e.g., AUVELITY, FETZIMA, FLUOXETINE DR entries).
• Providers must document failure or intolerance of required prior steps if requesting coverage for ST‑listed agents.

Products with additional clinical criteria (AC flag)

Products flagged 'AC' indicate additional clinical or administrative criteria; prescribers must meet those additional conditions (e.g., APRETUDE shows 'AC').

• APRETUDE cabotegravir IM extended release: Requirements/Limits = AC.
• AC flags may represent additional documentation or eligibility criteria required for coverage.

Specialty pharmacy / step program flags (SP)

Entries marked 'SP' indicate specialty program or specialty pharmacy handling; where 'SP' appears providers must follow specialty program requirements and dispensing channels.

• Many oncology, biologic and cystic fibrosis agents are designated 'SP' and require specialty pharmacy dispensing.
• SP entries commonly appear alongside PA and QL.

Utilization management indicators require provider action

The formulary uses utilization management indicators (PA, QL, SP, AC) to control access; when these appear providers must follow the listed controls to avoid denials.

• PA = prior authorization; QL = quantity limit; SP = specialty pharmacy; AC = additional criteria/administrative flag.
• Noncompliance with these flags may lead to denied or limited coverage.

Contraceptive entries with AC, PA, and QL flags

Some contraceptive products include 'AC' and may also carry PA and QL annotations; providers must follow those administrative and quantity requirements when prescribing.

• Examples: drospirenone-ethinyl estradiol (Yaz) — Requirements/Limits = AC, QL (28 tablets/21 days); some contraceptives list AC, PA, QL.
• Claims exceeding QL or lacking required administrative criteria risk denial.

No explicit step‑therapy sequence provided for many products

Where step therapy is not specified in the formulary excerpt, providers must still follow any PA, QL or SP controls shown for the product; explicit multi‑step sequences are not provided here.

• Many entries list PA/QL/SP but do not include explicit ST sequences in this excerpt.
• When ST is absent, ensure PA/QL/SP requirements are met for coverage.

SP flags indicate specialty program/step requirements

Some product lines show SP flags which imply step or specialty program controls; where SP is present follow payer step edit and specialty program requirements.

• Products marked 'SP' (e.g., GENOTROPIN, CRENESSITY) require adherence to specialty program rules and may also require PA/QL.
• Providers should use the payer's step‑edit processes when requesting SP agents.

Step therapy not specified for most entries in this excerpt

This extract does not list step‑therapy rules for many products; where ST appears it is limited to selected agents (noted separately). For other products, follow PA/QL/SP controls documented on the product line.

• No explicit ST algorithms are included in these chunks; use product Requirements/Limits to determine provider actions.
• When in doubt, submit PA with full clinical rationale.

When ST not specified, follow PA/QL/SP controls

Where step therapy is not described, providers must still obtain prior authorization and document adherence to QL and SP requirements shown on product lines to avoid denials.

• Many products rely on PA/QL/SP flags instead of step therapy sequences in this excerpt.
• Follow the plan's PA submission requirements and include supporting clinical documentation.

Step therapy not detailed in this section

This segment does not present explicit step therapy sequences; providers must rely on the Requirements/Limits (PA, QL, SP) shown per product when requesting coverage.

• For products with 'ST' elsewhere in the list, follow the payer's step edit requirements.
• Document prior steps if requesting overrides for ST‑listed agents.

Step therapy applies to selected antidepressants/CNS agents

Selected antidepressants and related CNS agents are marked 'ST' — providers must follow step therapy protocols when requesting coverage for these medicines.

• AUVELITY, FETZIMA, FLUOXETINE DR and some paroxetine and sertraline entries are designated ST.
• If requesting an ST agent, document failure or intolerance of required prior therapies.

ST indicated for select products (paroxetine, clozapine ODT)

Multiple products are marked 'ST' in the list (examples include paroxetine oral suspension and clozapine ODT); providers must document previous therapy trials per the payer's step program when submitting requests.

• PAROXETINE oral suspension and CLOZAPINE ODT entries include ST alongside QL.
• Include prior treatment history when submitting PA or exception requests for ST agents.

Prescriber submission route for Drug List exceptions / expedited review

For Drug List exceptions or expedited reviews, the prescriber or authorized representative must submit the request via the phone number on the member's ID card; the payer will notify the prescriber and member of the decision within two business days (or within 72 hours for expedited requests).

• Use the phone number on the member ID card to request an exception.
• Standard decisions: within two business days; expedited: within 72 hours.

Follow PA/QL procedures for flagged products

Follow the plan's PA/QL procedures for products with QL, PA or SP flags (examples include azithromycin QL and ARIKAYCE PA/QL/SP); submit PA requests and document QL adherence on claims.

• Azithromycin tablet: QL (60 tablets/180 days).
• ARIKAYCE: Requirements/Limits include QL and SP/PA — follow PA/QL/SP submission steps.

Document QL and PA indicators on PA requests and claims

When a product lists QL and PA/SP flags, ensure the quantity limits and authorization indicators are documented on the PA request and on the pharmacy claim to support coverage.

• Examples: BIKTARVY QL (30 tablets/30 days); HARVONI QL (30 tablets/30 days) with PA and SP.
• Include quantity and timeframe details from the Requirements/Limits field in submissions.

Products marked 'PA' require prior authorization

Products labeled 'PA' in the formulary require prior authorization per the listing; providers must obtain PA before dispensing to ensure coverage.

• Many antineoplastic and specialty agents explicitly show 'PA' — obtain authorization prior to dispensing.
• Claims submitted without required PA may be denied.

Submit PA/QL/SP documentation when indicated

When PA, QL, or SP apply, prescribers must submit required prior authorization documentation as specified; include clinical justification for the request.

• PA/QL/SP documentation should include diagnosis, prior therapy history, dosing and quantity justification.
• Specialty agents typically require submission to specialty pharmacy channels and PA processes.

Provide supporting clinical documentation with PA requests

Provide clinical documentation to support PA requests for products with 'PA' noted (include diagnosis, dosing, prior therapy and quantity justification as applicable).

• Include relevant clinical records and prior treatment history when requesting PA.
• Expedited requests must include supporting information to justify the urgent need.

Document Requirements/Limits on the claim per product listing

Follow the product-level Requirements/Limits fields when submitting claims — include drug tier, PA, QL and SP details from the formulary entry on the claim to facilitate processing.

• Entries list Drug Tier and Requirements/Limits (e.g., PA, QL amounts and timeframes) that must be respected when submitting pharmacy claims.
• Claims lacking required PA or exceeding QL may be denied or partially paid.

Ensure prescriptions conform to specified QLs or obtain PA

When a product lists a specific quantity limit (QL), ensure prescriptions and PA requests align with the stated QL to avoid denial or out‑of‑pocket responsibility for excess quantities.

• Examples: metformin ER osmotic forms list PA and QL values; azithromycin QL (60 tablets/180 days).
• If dosing requires exceeding the QL, submit PA with justification before dispensing.

Attach supporting documentation for PA/QL (specialty products)

Provide supporting clinical documentation for PA/QL requests where products are designated 'PA' or 'SP', and include quantity limits when specified (e.g., GALAFOLD, CRENESSITY).

• GALAFOLD: Requirements/Limits = PA, QL (14 capsules/28 days), SP — include clinical rationale in PA submission.
• CRENESSITY: Requirements/Limits = PA, QL (60 capsules/30 days), SP — document diagnosis and dosing.

Document QL volumes for oral suspensions/solutions

Quantity limits for oral suspensions and solutions are specified and must be documented (examples include KATERZIA and other suspension products); include volume and timeframe in requests.

• KATERZIA: Requirements/Limits = PA, QL (300 ml/30 days).
• Some entries list large-volume QLs (e.g., 1920 ml/30 days) — document clinical need if requesting override.

Respect product QLs and include on PA/claim submissions

When a product has a defined QL (e.g., ALYFTREK, IMCIVREE), ensure dispensing is within the specified quantity or obtain an approved override; include QL details in PA submissions.

• ALYFTREK: QL examples = 84 tablets/28 days or 56 tablets/28 days depending on formulation.
• IMCIVREE: Requirements/Limits = PA, QL (10 vials/30 days).

Supply required PA documentation on submission

Providers must supply the documentation required by prior authorization processes when submitting for drugs noted 'PA' (diagnosis, prior treatment, dosing and quantity justification).

• Use the payer's PA forms/process and include required clinical information.
• Expedited reviews are available for urgent clinical situations (decision within 72 hours).

Submit PA and supporting clinical documentation when PA/QL/ST/SP indicated

When products list 'PA', 'QL', 'ST' or 'SP', submit prior authorization and supporting clinical documentation and prescribe within the listed quantity limits and specialty pharmacy channels as specified.

• OMVOH: Requirements/Limits = PA, QL (2 pens/28 days) or QL (2 syringes/28 days), SP — include clinical documentation with PA.
• SKYRIZI: Requirements/Limits = PA, QL (1 cartridge/56 days), SP.

Obtain PA and observe QL for PA‑listed products

Providers must submit prior authorization when a product entry includes 'PA'; quantity limits must be respected per product QL entries (e.g., IMCIVREE QL 10 vials/30 days).

• IMCIVREE: Requirements/Limits = PA, QL (10 vials/30 days), SP.
• Follow the documented QL and include justification if requesting additional quantity.

Noncoverage risk for drugs not on the Drug List

Drugs not shown on the formulary are not covered; prescribing a non‑listed drug without an approved Drug List exception or PA may result in noncoverage.

• If a drug is not on the Drug List, request a Drug List exception via the phone number on the member ID card.
• BCBSTX will notify prescriber/member of the decision within two business days (or 72 hours for expedited reviews).

PA/QL denial risk for inhaled aminoglycosides

Prescriptions for inhaled or nebulized aminoglycosides and tobramycin products show PA/SP/QL designations; failure to obtain PA or exceeding QL may trigger denial.

• Tobramycin nebu soln 300 mg/ml: Requirements/Limits = PA, QL (56 containers/56 days), SP.
• ARIKAYCE (amikacin liposome inhal): QL (235.2 mls/28 days), SP/PA as listed.

PA/SP/AC flags — coverage denial risk if unmet

Entries marked with PA, SP, or AC indicate prior authorization, specialty pharmacy, or additional clinical requirements which, if not met, can trigger denial of coverage.

• HARVONI and SOVALDI list PA and SP along with QL — missing PA or wrong dispensing channel risks denial.
• AC flags (e.g., APRETUDE) indicate additional clinical criteria that must be satisfied.

PA triggers for antineoplastics — denial risk if not obtained

Prior authorization is required for many antineoplastic and specialty products; failure to obtain PA where listed may result in coverage denial or restriction.

• Examples: abiraterone acetate (Zytiga) — Requirements/Limits = PA, QL (60 tablets/30 days), SP.
• BOSULIF and BRAFTOVI entries show PA with QL and SP — obtain PA to secure coverage.

Claims risk if PA not obtained where listed

Coverage may be denied or restricted if prior authorization is not obtained for a drug when the formulary lists 'PA' next to the product.

• Many products in the listing require PA as indicated — secure PA before dispensing.
• Claims submitted without required PA are at risk for denial.

PA triggers for hormone and contraceptive formulations

Prior authorization is required for multiple testosterone and estrogen formulations shown with 'PA'; dispensing without PA risks claim denial.

• Examples: multiple testosterone TD gels and injectables list PA and QL (e.g., testosterone TD gel — PA, QL (30 packets/30 days)).
• Some contraceptive products list AC, PA and QL — follow administrative requirements.

Quantity limit triggers for contraceptives — denial risk if exceeded

Quantity limits (QL) on contraceptives and related products (e.g., 28 tablets/21 days, 2 tablets/365 days) are enforced; claims exceeding QL or lacking documentation may be denied.

• drospirenone‑ethinyl estradiol (Yaz): Requirements/Limits = AC, QL (28 tablets/21 days).
• ELLA: Requirements/Limits = AC, QL (2 tablets/365 days).

Prior authorization risk for 'PA' / 'PA, QL' entries

Products listed with 'PA' or 'PA, QL' indicate prior authorization may be required and claims may be denied without PA; obtain PA and document QL adherence.

• Metformin ER osmotic forms and other listed products show 'PA, QL' — secure PA before dispensing.
• Claims missing PA documentation are subject to denial.

Noncompliance with PA/QL/SP may cause denial

Coverage may be denied or limited if Prior Authorization (PA), Quantity Limits (QL), or Step Program (SP) requirements listed for specific products are not met; ensure compliance with all listed controls.

• Noncompliance with PA/QL/SP on specialty products like IMCIVREE or GENOTROPIN can result in denial or limited coverage.
• Submit full supporting documentation when seeking exceptions or overrides.

PA/QL trigger — denial risk if requirements unmet

Products noted with 'PA' or 'QL' may trigger a prior authorization or quantity‑limit denial if the listed requirements are not met; confirm PA approval and QL compliance prior to dispensing.

• Example: KATERZIA: Requirements/Limits = PA, QL (300 ml/30 days).
• VENTOLIN HFA: QL (2 inhalers/30 days) — exceeding QL without approval risks denial.

PA and specialty pharmacy requirements create denial risk if unmet

Drugs listed with 'PA' and 'SP' designations (e.g., FASENRA PEN, NUCALA, XOLAIR) require prior authorization and may be dispensed via specialty pharmacy; failure to obtain PA or use SP may trigger denial or noncoverage.

• FASENRA PEN: Requirements/Limits = PA, QL (pen/28 days), SP.
• XOLAIR: Requirements/Limits = PA, SP — obtain PA and route dispensing through specialty pharmacy.

Specialty pharmacy requirement — PA + SP must be followed

Entries that require specialty pharmacy (SP) must be dispensed through the specialty channel when indicated; failure to use SP or obtain PA may result in denial.

• ALYFTREK: Requirements/Limits = PA, QL, SP — specialty dispensing is required.
• Many biologic and infusion products list SP alongside PA and QL.

Quantity limit exceedance risks denial without override

Requests that exceed specified quantity limits (QL) without an approved override are at risk for denial; submit PA with justification if a larger quantity is clinically necessary.

• PAXLOVID QL examples: QL (20 tablets/90 days) or QL (30 tablets/90 days) depending on pack.
• Requests exceeding tablet/packet QLs or annual limits require documented override approval.

Authorization documentation required for PA/QL/ST/SP triggers

When a drug line requires Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST) or Specialty Pharmacy (SP), requests must be accompanied by the required authorization documentation to avoid denial.

• OMVOH and SKYRIZI entries include PA, QL and SP — include the PA approval and QL adherence on claims.
• Missing documentation for any of these controls may result in denial of coverage.

PA/QL/ST program triggers — follow listed program controls

Medications listed with 'PA', 'ST' or 'QL' require adherence to the stated prior authorization, step therapy or quantity limits; follow the product Requirements/Limits and include supporting documentation when seeking exceptions.

• IMCIVREE: Requirements/Limits = PA, QL (10 vials/30 days), SP — follow PA/QL/SP rules.
• For ST‑marked agents, document prior trials and failures as part of the request.

Check medical benefit for provider‑administered drugs

Medications requiring professional administration may be billed to the medical benefit and not the pharmacy benefit; check site-of-care guidance and call the number on the ID card if unclear.

• Provider-administered drugs (e.g., certain infusions, contraceptive implants) may be covered under the medical benefit rather than pharmacy.

No site‑of‑care restrictions specified here

No explicit site‑of‑care restrictions are provided in this extract; when present elsewhere, follow payer site‑of‑care guidance.

Dispense 'SP' products via specialty pharmacy

Products with 'SP' must be dispensed via specialty pharmacy channels; use the payer‑specified specialty pharmacy for these medications.

• Specialty-designated products are expected to be dispensed via specialty pharmacy channels.

Manage SP products through specialty channels

Specialty‑designated products (SP) are expected to be managed through specialty pharmacy channels and may require specialty handling or distribution through infusion/home administration pathways.

• Certain infusions and biologics designated SP may require infusion centers, specialty pharmacy, or home administration per payer guidance.

Use specialty pharmacy for 'SP' designated products

Products listed with 'SP' must be dispensed via specialty pharmacy; follow payer specialty pharmacy network requirements for these medications.

• Specialty channels apply to multiple listed biologics and specialty drugs.

Follow AC administrative pathways for select contraceptives

Some contraceptive/vaginal products carry 'AC' indicating administrative coverage controls; follow the administrative coverage pathways or pharmacy channels designated by the plan.

• Examples: nonoxynol-9 products and PHEXXI show AC flags.

Route specialty products to the payer's specialty pharmacy

Certain specialty-designated products are managed through specialty pharmacy channels; ensure prescriptions for these items are routed to the specialty pharmacy noted by the payer.

• Specialty channel management applies to many high-cost and biologic agents.