CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Medicaid-Approved Preferred Drug List — Analgesics/Antipyretics and Related OTC & Prescription Products

Portion of the Medicaid-Approved Preferred Drug List detailing analgesics (including acetaminophen, aspirin, opioid and non-opioid combinations), anorectal products, antacids, and related OTC and prescription formulations and notes for Blue Cross Blue Shield - Wisconsin members.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMedicaid-Approved Preferred Drug List — Analgesics/Antipyretics and Related OTC & Prescription Products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when items are marked PA before submitting claims to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+line items in excerpt

manyOTC items

PA / QL / AL / SPutilization flags present

Analgesics → Opioidsopioid entries with PA/QL

~20+distinct drug/product entries

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria Summary

This excerpt does not contain explicit clinical exclusion language. Instead, it documents a segment of the preferred drug list for Blue Cross Blue Shield - Wisconsin that catalogs many over‑the‑counter and prescription analgesic, antacid, anorectal and related products and annotates them with utilization flags. Items are commonly marked OTC when available without a prescription and many entries also show utilization controls such as QL (quantity limits) or AL (age‑related note), indicating payer management rather than an outright exclusion. Providers should therefore review individual line items for any PA/QL/AL notes prior to billing or dispensing.

Billing and Code References

Specialty biologics / PCSK9 inhibitorsmixedCovered

PRALUENT	PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR — PA
REPATHA	REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE — PA
REPATHA-SURECLICK	REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR — PA

Combination lipid-lowering agentmixedCovered

Vytorin

ezetimibe-simvastatin oral tablet — PA

Fibrate agents (fenofibrate)mixedCovered

fenofibrate 134 mg, 200 mg

fenofibrate micronized/oral capsule — Notes indicate PA for some strengths

No codes providedmixed

No explicit CPT/HCPCS/ICD-10 codes listed in this part; only product names and payer notes appear.

inv-06: Quantity limits — summary

ScopeQuantity limits (QL) are noted for many over-the-counter and prescription products in this segment; exact numeric limits are not provided in this excerpt.

Examples (categories)OTC analgesics/children's formulations, antidiarrheals, antihistamines, antiseptic skin cleansers, lancets and lancing devices show QL annotations (see product listings).

Implication for claimsClaims may be denied or limited if dispensed quantity exceeds the plan's QL or if documentation does not support an override.

Prior Authorization, Documentation, and Provider Steps

Prior Authorization

Prior authorization required for many opioid and specialty agents

Prior authorization (PA) is required for many opioid products and select addiction-treatment agents; claims may be denied without prior approval. This includes immediate- and extended-release opioids, combination products, transdermal patches, and buprenorphine-related treatments (e.g., SUBLOCADE, BRIXADI, SUBOXONE/SUBLINGUAL/buprenorphine formulations). Providers should obtain PA before dispensing and include supporting documentation of medical necessity.

Examples: hydrocodone-, oxycodone-, morphine-, fentanyl-, hydromorphone-containing products (PA; many with QL)
Addiction-treatment: SUBLOCADE (PA; SP; AL; QL), BRIXADI and other buprenorphine depot products (PA)
Buprenorphine films/tablets (some noted AL; QL)

Prior Authorization

Mesna prior authorization

Mesna (Mesnex oral tablet) requires prior authorization. Failure to secure PA may result in claim denial; submit indication and supporting clinical rationale with the authorization request.

Policy Background and Scope

The list highlights numerous analgesic formulations (including adult and pediatric acetaminophen products, extended‑release acetaminophen, extra strength non‑aspirin options and combination OTC migraine remedies) and related OTC pediatric suspensions and chewables. Many of these items are labeled OTC and carry a QL designation in the document, signifying plan quantity limits for coverage of over‑the‑counter analgesics and pediatric pain/fever formulations.

Key Terms and Abbreviations

inv-39: PA — Prior Authorization definition

DefinitionPA (Prior Authorization) — the plan requires pre-approval/authorization from the payer before coverage is granted for the listed product or device.

When appliedUsed on multiple prescription products (e.g., many opioids, certain antipsychotics, biologics, devices such as True Metrix meters and Omnipod kits) to indicate prior approval is required.

Provider actionSubmit prior authorization documentation per payer process; lack of PA may result in claim denial.

inv-40: OTC — Over-the-counter definition

DefinitionOTC (Over‑the‑counter) — product available without a prescription; listed here for coverage guidance though may still appear on the formulary with utilization notes.

Examples

Step Therapy and Sequencing Notes

Product / group	Step therapy note
Buprenorphine products and opioid-use-disorder therapies (examples: SUBLOCADE, SUBOXONE, ZUBSOLV, BUTRANS)
Formulary notes: flagged 'SP' on some items (e.g., SUBLOCADE: Notes = PA; SP; AL; QL), indicating specialty program handling; explicit step sequence not provided in the excerpt.

Product / group	Step therapy note
PCSK9 inhibitors (PRALUENT; REPATHA; REPATHA SURECLICK)
Prior authorization required prior to coverage: each listed PCSK9 product is annotated 'PA'.

Product / group	Step therapy note
Antipsychotics and related agents (examples: CAPLYTA, lurasidone/Latuda, VRAYLAR, ziprasidone/Geodon, ERZOFRI)
Multiple antipsychotics carry notes such as PA; AL; QL and some agents in adjacent classes are marked SP or QL — the excerpt does not specify explicit step sequences.

Product / group	Step therapy note
Products with 'AL' or 'PA; AL; QL' notes (examples: MYFEMBREE: AL; QL; ORIAHNN: PA; AL; QL; ESTROGEL: Notes = PA)
Notes indicate alternate/age limits or prior-authorization plus alternative pathway/quantity limits, suggesting alternative therapies or step requirements may apply; explicit step order not listed in excerpt.

Product / group	Step therapy note
G-CSF and ESA products (examples: FULPHILA, FYLNETRA, NEUPOGEN; ESAs such as ARANESP, EPOGEN, RETACRIT referenced elsewhere)
These hematopoietic agents are marked 'SP' (specialty) in the listing, indicating specialty program management; explicit step therapy sequencing is not provided in the excerpt.

Product / group	Step therapy note
Glucose meters and insulin-administration devices (example: TRUE METRIX meter device / kits)
Omnipod introducer kits and pods and True Metrix meter/kits are noted 'PA' (prior authorization required); no explicit step sequence is specified in the excerpt.

Quantity Limit Summaries

inv-60: multiple OTC analgesic and pediatric formulations — QL indicated on many products

Representative entriesAcetaminophen 8‑hour ER, pediatric oral suspensions/chewables, Midol extended release and other OTC pain relievers are shown with OTC; QL or AL; OTC; QL notes.

Actionable implicationPharmacies should confirm applicable quantity limits for OTC analgesic products when dispensing to avoid denials or member charges.

inv-61: opioid and opioid-combination products — PA; QL

Controls notedOpioid and opioid‑combination products in the listing are marked PA and frequently QL (e.g., hydrocodone combinations, oxycodone formulations, tramadol entries).

ExamplesHydrocodone‑acetaminophen oral tablet/solution, oxycodone tablets/solutions, morphine sulfate solutions and fentanyl patches carry PA; QL annotations in many entries.

Provider requirement

Biosimilar and Specialty Program Notes

Billing Rule

Specialty program management applies to SP‑flagged products

Products marked SP are subject to specialty program management; follow specialty program billing and authorization processes for these items.

FULPHILA, FYLNETRA, NEUPOGEN — Notes = SP.
Specialty program may require different provider enrollment, billing pathways, or pharmacy support.

Billing Rule

Confirm specialty program processing for SP‑flagged biosimilars

Duplicate SP markings in the inventory reinforce that these biosimilars and injectable agents are managed under the specialty program; ensure specialty authorization and billing processes are followed.

Multiple entries for FULPHILA, FYLNETRA, and NEUPOGEN indicate SP designation and specialty handling requirements.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMedicaid-Approved Preferred Drug List — Analgesics/Antipyretics and Related OTC & Prescription Products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when items are marked PA before submitting claims to avoid denial.

SourceLink

On This Page

Mesnex (mesna) — PA required

Prior Authorization

Antipsychotics prior authorization

Antipsychotics — including many oral agents and all long-acting injectables (LAIs) — are subject to prior authorization, alternate coverage (AL), and quantity limits (QL) as specified. Obtain PA and document diagnosis, prior trials, or rationale for LAIs per payer requirements.

Oral examples: lurasidone (PA; AL; QL), cariprazine (CAPLYTA) and others (PA; AL; QL)
LAIs and injectables: Invega Hafyera, Sustenna, Trinza (PA; AL; QL); Risperdal Consta, Perseris, Paliperidone ER (PA; QL)
Operational note: documentation of prior medication trials or contraindications may be requested

Documentation Required

PA + Specialty (SP) program requirements

Several specialty drugs and biologics require both prior authorization and specialty handling (SP). These products often have additional documentation and fulfillment pathways; coordinate with the payer’s specialty pharmacy program when required.

Examples: select TNF-alpha biologics (infliximab, CIMZIA) — PA; SP; some with QL
ESAs and supportive oncology biologics (ARANESP, EPOGEN, RETACRIT) — PA; SP
Other specialty agents: octreotide, CARBAGLU, SKYTROFA — PA; SP

Prior Authorization

PA required for select ESAs and G‑CSF

Prior authorization is required for select erythropoiesis‑stimulating agents (ESAs) and many granulocyte colony‑stimulating factors (G‑CSFs). These agents are frequently managed as specialty drugs and need PA plus specialty pharmacy coordination.

ESAs: Aranesp (all presentations) — PA; SP
G‑CSFs: Neupogen and biosimilars (SP) — specialty handling; confirm PA requirements per product

Prior Authorization

Prior authorization required for some biologics and selected agents

Certain biologics and other high‑cost agents (e.g., PCSK9 inhibitors, ezetimibe‑simvastatin combinations) require prior authorization. Confirm PA before initiating therapy to avoid denials.

PCSK9 inhibitors: PRALUENT, REPATHA — PA required
Ezetimibe‑simvastatin (Vytorin) — PA required

Documentation Required

Formulary notes and documentation expectations

Products flagged with PA, AL, QL, or SP are subject to utilization management; include clinical documentation when submitting prior authorization requests. For PA/AL/QL items, provide medical necessity rationale, prior therapy details, and any requested clinical thresholds to support approval.

Formulary abbreviations: PA = prior authorization, QL = quantity limit, AL = alternate/step pathway, SP = specialty program
Documentation: diagnosis, prior treatment history, labs/imaging where relevant, and explicit reason for chosen therapy

Documentation Required

Specialty drug documentation and handling

Specialty drugs and items marked SP or SP; QL require specialty‑level documentation and may follow unique fulfillment processes (specialty pharmacy, limited distribution). Submit all supporting clinical records with PA requests and coordinate with the payer’s specialty pharmacy as directed.

Examples: antiretrovirals, many oncology/supportive agents, biologics noted as SP
Operational note: specialty-designated products may need dispense via an identified specialty pharmacy

Prior Authorization

Prior authorization for specified meter devices/kits and Omnipod products

Certain durable medical equipment, glucose meters/kits, and insulin administration supplies require prior authorization. Verify PA for specified meter models/kits and for Omnipod introducer kits and pods to prevent claim denials.

Meters/kits: TRUE METRIX devices and meter kits — PA indicated on several models
Insulin supplies: OMNIPOD intro kits and pods (multiple generations) — PA; QL

Denial Risk

Quantity limit enforcement

Quantity limits (QL) are actively enforced for many products; claims may be denied if submitted quantities exceed the listed limits. Check the formulary entry for QL status before prescribing or dispensing.

Commonly QL‑flagged categories: opioids, antipsychotics, specialty injectables, meters/pods
Operational note: when QL applies, include clinical justification for higher quantities in the PA request

Step Therapy

Step edits and alternate/step requirements (sequencing)

Step edits, alternate/step requirements, and sequencing constraints are indicated by AL or PA; AL entries imply a required trial of an alternate agent or step. Specific step sequences are not fully enumerated in this source; when AL is shown, expect prior authorization to require documentation of trial/failure or contraindication to preferred agents.

AL indicates alternate/step requirements — submit prior therapy history or rationale for bypassing step edits
Note: some agents show PA; AL; QL — these will typically require both step documentation and PA approval

Many analgesics, pediatric acetaminophen formulations, antidiarrheals (Kaopectate), antiseptic skin cleansers (Betasept, Hibiclens), and various lancets are designated OTC.

NoteOTC designation does not preclude application of other controls such as QL or PA for specific items (e.g., some meter kits noted PA; OTC).

inv-41: QL — Quantity Limit definition

DefinitionQL (Quantity Limit) — a plan-imposed restriction on the amount or frequency of a product that may be dispensed during a specified time period.

Scope in this documentQL annotations appear across OTC and prescription items (examples include acetaminophen formulations, opioids, antifungals, hematopeitic agents, laxatives, and device consumables).

EnforcementClaims may be denied or limited if quantity exceeds the plan's QL unless prior authorization or supporting documentation is provided.

inv-42: AL — Age Limit (or alternative) definition

DefinitionAL (Age Limit / Administrative Limit) — coverage is restricted by age or labeled as an administrative/alternative limit in formulary notes.

ExamplesChildren's acetaminophen and many pediatric formulations include AL; some specialty products also list AL alongside PA/QL notes.

ImplicationAge-based restrictions require verification of member age and may affect coverage eligibility at claim time.

inv-43: SP — Specialty program designation definition

DefinitionSP (Specialty program) — designation indicating the product is managed under the payer's specialty drug/program processes (often for complex, injectable, or high-cost agents).

ExamplesProducts marked SP include certain ESAs (ARANESP, EPOGEN), G‑CSF agents (FULPHILA, NEUPOGEN), biologics (CIMZIA, AVSOLA), and select plasma kallikrein inhibitors (TAKHZYRO).

Operational effectSP items typically require specialty benefit handling and submission of supporting documentation per specialty pharmacy requirements in addition to any PA or QL controls.

inv-44: PA (duplicate) — Prior Authorization definition (alternate)

Definition (alternate)PA — prior authorization: the payer requires approval prior to coverage for the listed product or device.

Supporting examplesApplied to many opioids, certain antipsychotics, SUBLOCADE/BRIXADI buprenorphine products, and device kits (True Metrix, Omnipod) in the listing.

ConsequenceClaims for items labeled PA may be denied without an approved prior authorization and require documentation per payer processes.

inv-45: QL (duplicate) — Quantity Limit definition (alternate)

Definition (alternate)QL — quantity limit: a restriction on the maximum dispensed amount or frequency; noted across OTC and Rx listings in the document.

Illustrative itemsAnastrozole, amantadine, many OTC antihistamines and antiseptic skin cleansers, and numerous lancets/lancing devices are annotated with QL in the list.

Practical noteExact numeric limits are not provided in this excerpt; refer to payer systems or full formulary details to determine specific QL values.

inv-46: OTC (duplicate) — Over-the-counter (alternate)

Definition (alternate)OTC — over‑the‑counter: available without prescription; used in formulary to indicate non‑prescription status while still providing coverage guidance.

Notable cross‑notesSome OTC items in the list also include QL or AL annotations (e.g., pediatric acetaminophen with AL; OTC; QL), indicating additional controls may apply.

Reference examplesKaopectate products, Betasept/Hibiclens antiseptics, lancets and many iron/vitamin B‑12 formulations are shown as OTC in the excerpt.

inv-47: AL (duplicate) — Administrative/age limit (alternate)

Definition (alternate)AL — age limit or administrative/alternative labeling used to indicate coverage restrictions based on age or as an alternative pathway in formulary notes.

ExamplesPediatric formulations of acetaminophen and certain antipsychotic long‑acting injectables include AL in their notes.

ActionVerify member age and applicable program rules when AL is listed to determine coverage eligibility and required documentation.

inv-48: PA (duplicate) — Prior authorization definition (alternate chunk)

Definition (alternate)PA — prior authorization required: an item marked PA must have an approved authorization before the plan will cover dispensing or claim payment.

Contextual examplesBiologics (e.g., PRALUENT, REPATHA), ESAs (ARANESP, EPOGEN), and many specialty/injectable agents in the listing are shown with PA notes.

Provider requirementSubmit PA with documentation of medical necessity; specialty items may also require SP handling in addition to PA.

inv-49: OTC (alternate) — Over-the-counter definition for device/drug listings

Definition (device/drug listing)OTC — for device and supply listings, OTC indicates the item is available without prescription but may still be subject to quantity limits or other controls.

ExamplesMany lancets, BD insulin syringes and pen needles are marked OTC with QL noted in the device/supply sections.

ImplicationEven OTC-designated devices may carry QL or require documentation for coverage; check payer rules for specific limits.

inv-50: QL (alternate) — Quantity limit definition (alternate chunk)

Definition (alternate)QL — quantity limit notation used in device and supply listings to limit units dispensed (e.g., lancets, lancing devices, insulin syringes).

ExamplesLancets (multiple brands), Dexcom sensors/receivers/ transmitters, and PEG‑3350 packets (Miralax) in the excerpt are annotated with QL.

Operational noteSpecific numeric limits are not shown in this excerpt; providers should consult the payer's full formulary or claims system for exact QL values.

inv-51: SP (alternate) — Specialty program designation (alternate chunk)

Definition (alternate)SP — specialty program designation: indicates the product is managed under specialty pharmacy or program controls and may have additional handling requirements.

ExamplesFULPHILA, FYLNETRA, NEUPOGEN, CIMZIA, TAKHZYRO, and CINRYZE are examples of items marked SP in the listing.

Effect on authorizationSP items often require specialty prior authorization processes and documentation beyond standard PA; check specialty program procedures.

inv-52: PA (device) — Prior authorization required for listed devices/kits

ScopePA required for listed devices/kits: certain glucose meters/kits and Omnipod introducer kits/pods are explicitly annotated PA in the device sections.

ExamplesTRUE METRIX meter device/kit entries and OMNIPOD introducer kits/pods across generations include PA notes (see device listings).

Provider actionObtain and submit prior authorization documentation per payer process before dispensing these devices to avoid claim denials.

inv-53: OTC (device) — Over-the-counter device items may still have QL

ObservationSome OTC device items remain subject to QL — the antiseptic skin cleansers and many lancet/lancing device entries are OTC but show QL annotations.

ExamplesBetasept, Hibiclens, Aurora lancets, Auto-Lancet and multiple branded lancing devices are annotated OTC; QL in the listing indicates quantity controls apply.

Practical noteCoverage systems may enforce quantity limits on OTC supplies; verify limits when processing claims or authorizations.

Obtain prior authorization and adhere to quantity limits for opioid products; documentation may be required to support exceptions.

inv-62: KAOPECTATE; various OTC antidiarrheals and antihistamines — QL applied

ExamplesKAOPECTATE oral suspension/tablet and several OTC antidiarrheals and pediatric antihistamines are annotated AL; OTC; QL or OTC; QL in the list.

ImplicationThese OTC antidiarrheal and antihistamine products may be subject to quantity restrictions despite OTC status.

ActionCheck formulary QL settings before dispensing to ensure quantities are within allowed limits.

inv-63: anastrozole; letrozole; exemestane; amantadine examples — QL noted

ExamplesAromatase inhibitors (anastrozole, letrozole, exemestane) and antiparkinson agent amantadine are each annotated QL in the listing.

ImplicationQuantity limits apply to these oral oncologic and neurologic agents as noted in the formulary segment; numeric limits are not shown here.

inv-64: multiple antipsychotics and injectables — QL noted

ScopeMultiple antipsychotics and long‑acting injectable formulations are annotated with QL (and often PA/AL) in the antipsychotics section.

ExamplesCAPLYTA, lurasidone (Latuda), VRAYLAR, ERZOFRI, INVEGA products, PERSERIS and RISPERDAL CONSTA include PA; AL; QL or QL annotations in the listing.

Operational noteClaims for antipsychotics may require prior authorization and must observe any quantity limits or age-based restrictions specified by the plan.

inv-65: OTC antiseptic skin cleansers (Betasept, HIBICLENS) — OTC; QL noted

DesignationOTC antiseptic skin cleansers (Betasept, HIBICLENS) are listed as OTC but also annotated with QL in the formulary segment.

ExamplesBETASEPT Surgical Scrub and HIBICLENS external solution entries show Notes = OTC; QL.

ImplicationEven OTC topical antiseptics are subject to quantity controls; verify limits for dispensing and reimbursement.

inv-66: sodium phenylbutyrate; CIMZIA; TAKHZYRO; ORLADEYO; CINRYZE — QL indicated

ExamplesSodium phenylbutyrate (PHEBURANE/PHEBURANE oral pellet) and specialty biologics (CIMZIA, TAKHZYRO, ORLADEYO, CINRYZE) are annotated with QL and often SP/PA notes.

NotesEntries show combinations of PA; SP; QL — indicating specialty handling plus quantity limits and prior authorization requirements.

ActionSpecialty products with QL and SP flags require both specialty program procedures and confirmation of quantity allowances when authorizing.

inv-67: AZO / phenazopyridine; allopurinol; colchicine — QL noted

ExamplesAZO (phenazopyridine) urinary pain relief products, allopurinol and colchicine are annotated with QL in the gout/urinary agent sections.

NotesAZO entries also show AL; OTC; QL indicating age or administrative limits plus quantity limits on OTC urinary analgesics.

ImplicationPharmacies should verify QL for these medications to ensure dispensed quantities align with plan limits.

inv-68: aminocaproic acid (oral tablet) — quantity limit note present

EntryAminocaproic acid (oral tablet) appears in the hematologic/agents grouping with a quantity‑limit note present in the quantity limits module.

ContextThe formal QL value is not provided in this excerpt; the listing indicates a QL annotation in the broader formulary segment.

inv-69: polyethylene glycol 3350 (MIRALAX, packets) — QL indicated

EntryPolyethylene glycol 3350 (MIRALAX) packets/oral powder are annotated PA; OTC; QL or PA; QL in various entries, indicating quantity controls on packeted laxatives.

ExamplesMIRALAX mix‑in packets and polyethylene glycol 3350 oral packets show Notes = PA; OTC; QL or PA; OTC; QL in the listing.

ImplicationDispensing or authorization for PEG‑3350 packets should account for plan QL and any PA requirement shown in the formulary record.

inv-70: Multiple lancet and lancing device items — QL noted

ScopeMultiple branded lancets and lancing devices are listed with OTC designation and QL annotations across several device sections.

ExamplesAurora lancet, Auto‑Lancet, Comfort Assured lancets, Easy Touch, UniStik, TruePlus, Truedraw, and many other lancets/lancing devices show Notes = OTC; QL.

Operational noteQuantity limits apply to lancets and lancing devices; check payer limits when processing supply claims or shipments.

Billing Rule

Biosimilar/G‑CSF products are specialty‑managed (SP)

Entries for certain biosimilars and G‑CSF products are repeatedly marked SP; providers must coordinate with the payer's specialty program for authorization, ordering, and billing.

NEUPOGEN, FULPHILA, FYLNETRA — Notes = SP; follow specialty program steps.