Medicaid Preferred Drug List — formulary segment (analgesics, antacids, antiasthmatics, opioids, and related agents)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Wisconsin policy alerts
Know when Blue Cross Blue Shield - Wisconsin releases new policies or updates existing guidance.
Monitor payer policy activity
Portion of the Blue Cross Blue Shield - Wisconsin Medicaid Preferred Drug List detailing formulary entries, references, and utilization controls (e.g., PA, QL, AL, SP) for multiple therapeutic classes affecting prescribers and pharmacists.
No material clinical or coverage changes in this revision.
Formulary Coverage Notes
Coverage modifiers and application
Products listed on the Medicaid Preferred Drug List include one or more of the following administrative modifiers; when present the modifier dictates the coverage control that applies to that specific product.
Modifiers are applied per product entry on the formulary and must be met for coverage.
Examples: LINZESS (PA; AL) requires PA and meets AL controls; TRUE METRIX test strips are noted PA; OTC; QL — PA may be required despite OTC/QL status; XOLAIR entries include PA; SP; AL (see formulary).
See diagnostic test strips and CGM/device listings where PA and QL flags are used to control coverage.
STARJEMZA is listed PA; AL and PYZCHIVA is listed SP — follow specialty channel rules per product.
Numerous items in this formulary segment are annotated as OTC in the product listing. The OTC designation indicates the product is identified as an over‑the‑counter item on the Medicaid Preferred Drug List (examples include acetaminophen/TYLENOL, multiple antacid preparations and other consumer analgesic/antacid products). Where items are marked OTC, the listing reflects their administrative status on the formulary rather than detailed prescription coverage criteria.
This excerpt does not contain formal medical‑necessity decision trees or explicit coverage criteria language. Instead, it functions primarily as a formulary listing that catalogs products and administrative annotations (for example, OTC, PA, QL, SP, AL) associated with each product entry.
No explicit product exclusions are stated in the provided excerpt. The list enumerates included products and administrative flags but does not present a separate exclusions section for the named items in this segment.
Products marked OTC in the formulary are, as listed, identified as over‑the‑counter items and are not annotated with prior authorization requirements in these entries. The listing shows many topical and consumer products (e.g., moisturizing lotions, urinary analgesics) with OTC notes, indicating they generally do not require prior authorization when the OTC designation applies.
Administrative notes in the list indicate that items explicitly labeled OTC are over‑the‑counter; the plan’s rules will govern any member cost‑sharing or program eligibility. For devices and supplies (for example, lancets and other glucose monitoring supplies) entries show OTC annotations often alongside QL, which implies quantity restrictions may apply even when OTC status is recorded.
Coding and Code Groups
| PA | Prior Authorization required (annotation in formulary list) |
| QL | Quantity Limit (annotation in formulary list) |
| AL | Age Limitation or access-limited annotation (annotation in formulary list) |
| SP | Specialty pharmacy or specialty site requirement (annotation in formulary list) |
| ACCU-CHEK AVIVA PLUS | ACCU-CHEK AVIVA PLUS IN VITRO STRIP (Notes = OTC; QL) |
| ACCU-CHEK GUIDE TEST | ACCU-CHEK GUIDE TEST IN VITRO STRIP (Notes = OTC; QL) |
| TRUE METRIX | TRUE METRIX BLOOD GLUCOSE TEST IN VITRO STRIP (Notes = PA; OTC; QL) |
| PYZCHIVA | PYZCHIVA INTRAVENOUS SOLUTION (Notes = SP) |
| STARJEMZA | STARJEMZA INTRAVENOUS SOLUTION (Notes = PA; AL) |
| 60 MG | BRILINTA ORAL TABLET 60 MG (listed dosage) |
| 90 MG | BRILINTA ORAL TABLET 90 MG (listed dosage) |
Prior Authorization, Documentation & Provider Requirements
Prior authorization required for select analgesics
Obtain prior authorization before dispensing any product marked “PA” on the formulary. Examples include fentanyl transdermal patch (72‑hour), morphine sulfate ER oral tablets, oxycodone abuse‑deterrent formulations, and buprenorphine sublingual tablets — failure to secure PA can result in claim denial.
- Fentanyl transdermal patch 72 hour — Notes = PA; QL
- Morphine sulfate ER oral tablet — Notes = PA; QL
- Oxycodone abuse‑deterrent formulations — listed with PA annotations
- Buprenorphine sublingual tablets — Notes = AL; QL or PA as listed
XOLAIR requires prior authorization and specialty dispensing
Submit a prior authorization and route dispensing through specialty pharmacy where required for all XOLAIR presentations. XOLAIR subcutaneous auto‑injector, prefilled syringe, and reconstituted solution are annotated “PA; SP; AL.”
- PA required
- SP (specialty pharmacy/site) required
- AL (access/age limits) noted — confirm plan criteria
Prior authorization required for PA‑labeled products
Obtain prior authorization for products specifically labeled “PA” in the list. Examples include linezolid (oral suspension and tablets), imatinib (Gleevec), gefitinib (Iressa), mesna, MVASI, lurasidone, and antiretrovirals like BIKTARVY when annotated.
- Linezolid oral suspension and oral tablet — Notes = PA; QL
- Imatinib (Gleevec) — Notes = PA; SP; QL
- Gefitinib (Iressa) — Notes = PA; SP; QL
- MVASI — Notes = PA; SP
- BIKTARVY and other antiretrovirals — PA noted where listed
PA required for select antivirals and PAH agents
Providers must obtain prior authorization for antiviral, hepatitis C, and specified pulmonary hypertension agents when annotated with PA before dispensing. Examples include MAVYRET, sofosbuvir‑velpatasvir, and PA/AL/QL‑flagged PAH agents.
- MAVYRET and sofosbuvir‑velpatasvir — Notes = PA; AL
- Pulmonary hypertension agents (sildenafil, tadalafil/Alyq, ambrisentan) — PA/SP/AL/QL as listed
PA may apply to certain OTC topicals
Some over‑the‑counter topical products nonetheless carry a “PA” annotation and require prior authorization for coverage. Check product notes for PA before dispensing OTC topicals.
- Compound W external liquid — Notes = PA; OTC
- Gets‑It corn/callus remover — Notes = PA; OTC
- PANOXYL acne body external liquid — Notes include PA; AL; OTC
PA required for selected GI and specialty agents
Obtain prior authorization where indicated for selected gastrointestinal and specialty agents. Examples with PA/AL notes include LINZESS, Amitiza (lubiprostone), APRISO (balsalazide), and mesalamine products.
- LINZESS — Notes = PA; AL
- Amitiza (lubiprostone) — Notes = PA; AL
- APRISO (balsalazide) — Notes = PA
- Mesalamine rectal enema/suppository (Canasa) — listed with PA where indicated
PA required for APRISO, MOVANTIK, and select specialty agents
Prior authorization is required for listed products such as APRISO and MOVANTIK and for certain hematologic and complement‑inhibitor therapies; secure PA before dispensing to avoid denials.
- APRISO (balsalazide) — Notes = PA
- MOVANTIK (peripheral opioid receptor antagonist) — Notes = PA; AL
- KALBITOR and other plasma kallikrein/complement agents — Notes = PA; SP; AL; QL
PA required for select CGMs and Omnipod supplies
Submit prior authorization for continuous glucose monitoring (CGM) devices and insulin administration systems when annotated PA. Devices requiring PA include DEXCOM G6/G7, FREESTYLE LIBRE sensors/readers, and OMNIPOD kits/pods.
- DEXCOM G6/G7 receiver, sensor, transmitter — Notes = PA; QL
- FREESTYLE LIBRE sensors/readers — Notes = PA; QL
- OMNIPOD kits and pods — Notes = PA; QL
AL/QL annotations indicate step/access controls for opioid‑dependence agents
Products annotated “AL” or “QL” for opioid‑dependence treatments and buprenorphine formulations indicate access or step constraints; follow payer access programs and obtain required authorizations or meet step/alternative requirements.
- BRIXADI, SUBLOCADE and buprenorphine formulations — Notes = AL; QL or PA as listed
- SUBOXONE sublingual film — Notes = AL; QL
Follow payer step/access programs for AL‑labeled agents
When an agent is labeled “AL” (access limited), adhere to plan‑specific step or access programs before prescribing. This commonly applies to certain antipsychotics and related agents noted with AL.
- Lurasidone (Latuda) — Notes = AL; QL
- VRAYLAR dosing ranges — Notes include PA; AL; QL
AL indicates step or preferred‑alternative requirements
AL flags signal that a preferred alternative or step requirement may apply; confirm and document that required prior steps or preferred alternatives were tried where the formulary notes AL.
- TRUVADA, SUNLENCA, and other AL‑flagged antiretrovirals — Notes = AL; QL where specified
- PAXLOVID therapy packs — Notes = AL; QL
No explicit step therapy sequences listed
No explicit step‑by‑step therapy algorithms are provided in this formulary excerpt. Providers may need to rely on PA/AL annotations and payer program rules rather than a listed step sequence.
- Step therapy sequences are not detailed in this segment
- PA annotations may functionally require prior authorization even without explicit steps
Step therapy presence only — specific steps not listed
Starred classes and AL/PA headings are present, but specific sequential step requirements are not enumerated in these excerpts; presence only indicates step edits may exist elsewhere in payer rules.
- Starred classes indicate where step edits may apply
- Specific step algorithms not included in this excerpt
Formulary annotations (PA/QL/AL/SP) imply authorization/documentation processes
PA, QL, AL, and SP annotations in the formulary indicate administrative processes that affect coverage: PA requires prior authorization submission; QL denotes quantity limits; AL identifies access limitations or age/program constraints; SP indicates specialty pharmacy handling.
- PA = prior authorization required
- QL = quantity limit applies
- AL = access limited / plan program constraints
- SP = specialty pharmacy or specialty site dispensing
Linezolid formulations require PA and are subject to QL
Linezolid oral suspension and tablets are annotated “PA; QL” — submit PA and follow quantity‑limit rules when requesting coverage for these formulations.
- Linezolid oral suspension reconstituted — Notes = PA; QL
- Linezolid oral tablet — Notes = PA; QL
Document and respect administrative flags on claims
Formulary entries carry administrative flags (PA, QL, AL, SP); include these flags on claims and supply supporting documentation as required by the payer when submitting authorization requests.
- PA = prior authorization
- QL = quantity limit — support required to exceed limits
- AL = alternative/access limitations
- SP = specialty pharmacy handling
Quantity limits (QL) require documentation to exceed limits
Products labeled “QL” are subject to quantity limits; provide medical necessity/dosing documentation when requesting quantities above the limit to support approval.
- Many OTC topicals and devices list QL — exact numeric limits not shown here
- Document dosing/medical necessity to request overrides
Submit PA request for PA‑labeled products
Submit a prior authorization request when a product is marked “PA” on the formulary; PA is required to document medical necessity and secure coverage before dispensing.
- PA requests must be submitted per payer processes
- Coverage may be denied without an approved PA
Provide documentation to support quantity‑limit overrides
When requesting an override of a QL restriction, include clinical notes and dosing rationale; entries annotated QL indicate payer may require this documentation for approval.
- Provide treatment history and dosing details when requesting QL overrides
- Examples: hematologic and specialty injectables often carry QL/PA requirements
Provide authorization forms and supporting clinical notes for PA/QL requests
Providers should supply completed authorization forms and supporting clinical documentation (progress notes, diagnoses, prior trials) when requesting PA or exceeding QL for devices and drugs annotated with PA/QL.
- Include indication, prior therapies tried, and objective measures where applicable
- Attach specialty site enrollment documents for SP items when required
Denial risk if PA/QL documentation missing
Failure to obtain required prior authorization or to provide supporting documentation for PA/QL items can result in claim denial or noncoverage at the point of adjudication.
- PA or QL annotations can trigger denials if requirements are unmet
- Examples include fentanyl patches, morphine ER, and buprenorphine entries
Monoclonal antibody (XOLAIR) controls can trigger denial
XOLAIR entries annotated “PA; SP; AL” indicate prior authorization, specialty pharmacy/site dispensing, and access limitations (e.g., age) — failure to meet these will likely cause claim denial or misrouting.
- Obtain PA and route through specialty pharmacy as required
- Confirm any AL (age/access) criteria prior to dispensing
Imatinib (Gleevec) requires PA, specialty routing, and respects QL
Imatinib (Gleevec) is listed with “PA; SP; QL.” Lack of PA, failure to route through specialty channels, or exceeding quantity limits may lead to claim denial.
- Imatinib (Gleevec) — Notes = PA; SP; QL
- Ensure PA approval and specialty dispensing where required
Gefitinib (Iressa) requires PA and specialty routing
Gefitinib (Iressa) is annotated “PA; SP; QL.” Providers must obtain PA and comply with specialty/quantity restrictions to avoid denial.
- Gefitinib (Iressa) — Notes = PA; SP; QL
- Submit PA and follow specialty dispensing instructions
PA required for select hepatitis C agents
Obtain prior authorization for hepatitis C agents and other PA‑marked antivirals prior to dispensing; examples include MAVYRET and sofosbuvir‑velpatasvir.
- MAVYRET and Epclusa (sofosbuvir‑velpatasvir) — Notes = PA; AL
PA may be required for some OTC topicals — risk of denial
Topical OTC items annotated “PA” may be denied if prior authorization is not obtained. Check product notes and secure PA when the formulary shows PA for an OTC product.
- Compound W external liquid and similar OTC topicals noted PA; OTC — obtain PA when PA is present
PA required for some glucose test strips
Certain diagnostic test strips (e.g., TRUE METRIX blood glucose test strips) are annotated PA in the list; submit PA as required to secure coverage for these strips.
- TRUE METRIX blood glucose test strips — Notes = PA; OTC; QL
- Other test strips (Accu‑Chek lines) are OTC; QL but check PA notes per product
General PA notice for listed products
Many listed products include a general “PA” notice — verify product notes and submit PA requests for any item annotated PA to document medical necessity before dispensing.
- Review product listing for PA annotation before prescribing or dispensing
- Submit PA per payer instructions to avoid noncoverage
SP/AL annotations may require specialty channel enrollment or site‑of‑care limits
SP (specialty) or AL (additional limits) annotations may require enrollment in a specialty channel, site‑of‑care requirements, or additional plan limits; confirm specialty handling and any program enrollment prior to dispensing.
- SP may require specialty pharmacy dispensing or infusion center routing
- AL may indicate age or other access restrictions that must be met
PA required for specific CGM devices and Omnipod supplies
DEXCOM G6/G7 receivers and sensors, FREESTYLE LIBRE readers/sensors, and OMNIPOD kits/pods are annotated “PA; QL” — obtain prior authorization and document quantity needs when requesting these devices.
- DEXCOM G6/G7 receiver, sensor, transmitter — Notes = PA; QL
- FREESTYLE LIBRE sensors/readers — Notes = PA; QL
- OMNIPOD kits/pods — Notes = PA; QL
Document Scope and Context
This segment includes a broad set of therapeutic classes and individual products. Examples include analgesics and opioid formulations (hydrocodone combinations, fentanyl patch, morphine ER, buprenorphine products), antacids and gastrointestinal agents, antiasthmatics including anti‑IGE monoclonal antibodies (e.g., XOLAIR), antineoplastics and targeted therapies, antivirals/antiretrovirals, topical OTC products (lotions, antifungals, keratolytics), and glucose monitoring supplies (e.g., ACCU‑CHEK, TRUE METRIX test strips, lancets). The listing highlights payer annotations such as PA, QL, SP, and AL that signal utilization controls or specialty handling where applicable.
Key Annotation Definitions
Step Therapy and Access Controls
| Drug class / agent | Notes / flags |
|---|---|
| Buprenorphine HCl–naloxone HCl sublingual tablet (e.g., SUBOXONE) | |
| Notes = AL; QL (alternative/step preference; quantity limit) | |
| Buprenorphine sublingual products (general) | |
| PA; AL; QL annotations present for some formulations (access-limited and quantity limits) | |
| Butrans transdermal patch | |
| Notes = PA; QL (prior authorization and quantity limit) | |
| Subcutaneous buprenorphine (SUBLOCADE) | |
| Listed without explicit flags in this excerpt (but included among opioid-dependence agents) |
| Context | Implication |
|---|---|
| Antipsychotics and selected related agents (examples: lurasidone, VRAYLAR, ziprasidone) | |
| Notes include AL on multiple agents — indicates additional access controls or step requirements may apply when AL is present | |
| VRAYLAR (various strengths) | |
| Notes = PA; AL (some strengths) — may require prior authorization and follow AL access program |
| Class / product group | AL meaning in this context |
|---|---|
| Antiretrovirals — example: TRUVADA (multiple strengths) | |
| Notes = AL; QL on some TRUVADA listings — AL indicates preferred/alternative step options within the class | |
| Combination contraceptives (multiple brands listed: e.g., KARIVA, many oral combos) | |
| Multiple combination contraceptives are annotated AL; QL — AL flags denote alternative/step-preferred products within the class |
| Observation | Policy implication |
|---|---|
| No explicit step therapy sequences are listed in the extracted segments | |
| Although step sequences are not specified, products marked PA may functionally require authorization before coverage; providers should submit PA where indicated | |
| Starred classes/headings appear but lack step details | |
| Presence of starred categories suggests step edits may be implemented at the payer level even when specific steps are not printed in this excerpt |
| Starred category / class | Note |
|---|---|
| Macrolide immunosuppressants (topical) and PDE4 inhibitors (topical) — starred categories present | |
| Starred headings documented in the formulary indicate classes where step edits may apply; specific step requirements are not provided in this excerpt | |
| Topical agents with PA/AL/QL flags (e.g., pimecrolimus, tacrolimus, EUCRISA) | |
| Notes = PA; AL; QL on some topical immunomodulators — suggests additional access controls though exact step edits not listed |
| Listed agents / groups | Step therapy specified? |
|---|---|
| Gastrointestinal agents and interleukin antagonists (examples: APRISO, LINZESS, PYZCHIVA, STARJEMZA) | |
| No explicit step therapy requirements specified for these agents in the excerpt; some entries carry PA/SP/AL flags separately | |
| Combination contraceptives and antiretrovirals (multiple oral contraceptives listed) | |
| AL/QL flags present but the excerpt does not contain defined step sequences or required prior alternative trials |
| Device / supply | Access control |
|---|---|
| Dexcom G6 receiver / sensors / transmitter; Dexcom G7 sensors/receivers | |
| Notes = PA; QL — prior authorization required for specified DEXCOM G6/G7 devices and sensors | |
| FreeStyle Libre reader devices and sensors | |
| Notes = PA; QL — prior authorization indicated for FreeStyle Libre devices/sensors | |
| Omnipod kits and pods (multiple Gen/KIT listings) | |
| Notes = PA; QL for many Omnipod kits/pods — prior authorization required as documented |
Quantity Limits (QL) — Affected Products
Specialty Pharmacy and Site Requirements
XOLAIR flagged for specialty pharmacy dispensing
Dispense XOLAIR and other SP‑flagged biologics via the specialty pharmacy network or specialty site per plan direction; SP annotation indicates specialty handling is required.
- XOLAIR presentations — Notes = PA; SP; AL
- Other SP‑flagged agents should be routed to specialty pharmacy
SP‑flagged agents require specialty pharmacy dispensing
Agents labeled “SP” must be dispensed through the plan’s specialty pharmacy channel when specified. Confirm specialty routing on claims and coordinate with the specialty pharmacy.
- MVASI, imatinib, gefitinib and other SP‑flagged agents — follow specialty dispensing requirements
Route SP products to specialty pharmacy or infusion center as indicated
Specialty products annotated “SP” may be managed either through specialty pharmacy channels or infusion centers depending on product type; confirm site‑of‑care routing for infusion or clinic‑administered items.
- Infusion‑administered specialty products — route to infusion center or specialty pharmacy per plan notes
- Confirm SP versus infusion site requirement prior to administration
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.