Blue KC Prescription Drug List (PDL) — formulary, tiers, and utilization management

Coverage Summary & Scope

Applies to Blue KC group HMO, PPO and EPO members with a prescription drug benefit; this PDL part lists formulary drug tiers and per-drug flags such as PA (prior authorization), QL (quantity limits), and ST (step therapy), indicates specialty routing and specialty day-supply limits for certain products, and states syringe/needle coverage rules. This file is part 1 of 6. Effective date: January 1, 2024. Last updated: 05/30/2024.

Key thresholds & program limits

Specialty day supply limit34 day supply

Last Updated05/30/2024

PDL committee frequencyQuarterly

Pharmacy network size~44,000+ pharmacies

Prior Authorization, Step Therapy, Quantity Limits — Provider Actions

Prior Authorization/Drug Utilization Management

Covered when ALL of the following are met:

ALL of the following

Prior authorization (PA) is required when indicated on the drug listing — including specialty/brand biologics and select oral agents. Prescribers must submit a PA request when PA is specified for the agent. PA may be requested electronically via BlueKC.com > Providers > Forms > Prior Authorizations for Medications.
Quantity limits (QL) apply where listed; the prescribed quantity must not exceed the plan QL unless a PA/exception is approved. Pharmacies and prescribers should verify QL prior to dispensing.
Step therapy (ST) requirements apply to designated agents. When ST is in effect, lower-step or preferred agents must be tried first unless clinical justification for bypassing ST is provided in the PA request.
Medical management (M) or Medical Necessity review may be required for certain agents and indications; clinical documentation supporting medical necessity should be provided with PA requests.

Formulary Entries — Drugs, Tiers, and Restriction Flags (index)

Formulary entries with Drug Tier and Restrictions/Limitsmixed

CLOZAPINE	clozapine (various formulations/strengths) - see PA/monitoring requirements
ROSUVASTATIN_5MG	rosuvastatin calcium oral tablet 5 mg
ROSUVASTATIN_10MG	rosuvastatin calcium oral tablet 10 mg
SIMVASTATIN_5MG	simvastatin oral tablet 5 mg
SIMVASTATIN_10MG	simvastatin oral tablet 10 mg
SIMVASTATIN_20MG	simvastatin oral tablet 20 mg
SIMVASTATIN_40MG	simvastatin oral tablet 40 mg
TAZTIA_XT_120MG	taztia xt oral capsule extended release 24 hour 120 mg
TAZTIA_XT_180MG	taztia xt oral capsule extended release 24 hour 180 mg
TAZTIA_XT_240MG	taztia xt oral capsule extended release 24 hour 240 mg

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Formulary entries (partial list) with Drug Tier and Restrictionsmixed

AMPHETAMINE-DEXTROAMPHETAMINE_5MG	amphetamine-dextroamphetamine oral tablet 5 mg
AMPHETAMINE-DEXTROAMPHETAMINE_7_5MG	amphetamine-dextroamphetamine oral tablet 7.5 mg
AMPHETAMINE-DEXTROAMPHETAMINE_10MG	amphetamine-dextroamphetamine oral tablet 10 mg
AMPHETAMINE-DEXTROAMPHETAMINE_12_5MG	amphetamine-dextroamphetamine oral tablet 12.5 mg
AMPHETAMINE-DEXTROAMPHETAMINE_15MG	amphetamine-dextroamphetamine oral tablet 15 mg
AMPHETAMINE-DEXTROAMPHETAMINE_20MG	amphetamine-dextroamphetamine oral tablet 20 mg
AMPHETAMINE-DEXTROAMPHETAMINE_30MG	amphetamine-dextroamphetamine oral tablet 30 mg
CLONIDINE_HCL_ER_12HR	clonidine hcl er oral tablet extended release 12 hour
DEXTROAMPHETAMINE_ER_10MG	dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg
DEXTROAMPHETAMINE_ER_15MG	dextroamphetamine sulfate er oral capsule extended release 24 hour 15 mg

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Drugs listed with Restrictions / Limitsmixed

METHYLPHENIDATE_ER_OSM_18MG	methylphenidate hcl er (osm) oral tablet extended release 18 mg
METHYLPHENIDATE_ER_OSM_27MG	methylphenidate hcl er (osm) oral tablet extended release 27 mg
METHYLPHENIDATE_ER_OSM_54MG	methylphenidate hcl er (osm) oral tablet extended release 54 mg
METHYLPHENIDATE_ER_OSM_72MG	methylphenidate hcl er (osm) oral tablet extended release 72 mg
METHYLPHENIDATE_ER_OSM_36MG	methylphenidate hcl er (osm) oral tablet extended release 36 mg
METHYLPHENIDATE_ER_10MG	methylphenidate hcl er oral tablet extended release 10 mg
METHYLPHENIDATE_ER_20MG	methylphenidate hcl er oral tablet extended release 20 mg
METHYLPHENIDATE_ER_24HR_18MG	methylphenidate hcl er oral tablet extended release 24 hour 18 mg
METHYLPHENIDATE_ER_24HR_27MG	methylphenidate hcl er oral tablet extended release 24 hour 27 mg
METHYLPHENIDATE_ER_24HR_54MG	methylphenidate hcl er oral tablet extended release 24 hour 54 mg

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Drugs with Prior Authorization (PA)mixed

GLATIRAMER_20MGML	glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml - PA may apply
GLATIRAMER_40MGML	glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml - PA may apply
GLATOPA_20MGML	glatopa subcutaneous solution prefilled syringe 20 mg/ml - PA may apply
GLATOPA_40MGML	glatopa subcutaneous solution prefilled syringe 40 mg/ml - PA may apply
PREGABALIN_ER_82_5MG	pregabalin er oral tablet extended release 24 hour 82.5 mg - PA/QL as indicated
PREGABALIN_ER_165MG	pregabalin er oral tablet extended release 24 hour 165 mg - PA/QL as indicated
PREGABALIN_ER_330MG	pregabalin er oral tablet extended release 24 hour 330 mg - PA/QL as indicated
PREGABALIN_CAP_25MG	pregabalin oral capsule 25 mg
PREGABALIN_CAP_50MG	pregabalin oral capsule 50 mg
PREGABALIN_CAP_75MG	pregabalin oral capsule 75 mg

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Drugs with Quantity Limits (QL)mixed

ESOMEPRAZOLE_MAG_CAPDR	esomeprazole magnesium oral capsule delayed release - QL as indicated
LACULOSE_10GM_15ML	lactulose encephalopathy oral solution 10 gm/15ml - QL as indicated
OCTREOTIDE_50MCGML	octreotide acetate injection solution 50 mcg/ml - QL/Specialty
OCTREOTIDE_100MCGML	octreotide acetate injection solution 100 mcg/ml - QL/Specialty
OCTREOTIDE_500MCGML	octreotide acetate injection solution 500 mcg/ml - QL/Specialty

Drugs with M (medical management)mixed

AFFIRMELLE	Affirmelle - contraceptive/appliance category - M applied per benefit
LEVONORG-ETH_91DAY	levonorg-eth estrad 91-day - M/contraceptive management
MEDROXYPROGESTERONE_IM	medroxyprogesterone acetate intramuscular suspension - M/administered product

Drugs listed without specific restrictionsmixed

EVEROLIMUS_0_25MG	everolimus oral tablet 0.25 mg
EVEROLIMUS_0_5MG	everolimus oral tablet 0.5 mg
EVEROLIMUS_0_75MG	everolimus oral tablet 0.75 mg
EVEROLIMUS_1MG	everolimus oral tablet 1 mg
HYDROCORTISONE_ACE_PRAMOXINE_CRM	hydrocortisone ace-pramoxine external cream 1-1 %
TERIPARATIDE_PEN_600MCG	teriparatide (recombinant) subcutaneous solution pen-injector 600 mcg/2.4ml
INCONTROL_ULTICARE_PEN_NEEDLES_31G_8MM	INCONTROL ULTICARE PEN NEEDLES 31G X 8 MM
INSULIN_PEN_NEEDLES_30G_6MM	INSULIN PEN NEEDLES 30G X 6 MM
INSULIN_PEN_NEEDLES_31G_8MM	INSULIN PEN NEEDLES 31G X 8 MM

Index entries / listed productsmixed

DENTAL_ORAL_CEVIMELINE_HCL	dental and oral agents - cevimeline hcl
DERMATOLOGICAL_AGENTS_PARTIAL	numerous dermatological agents (partial list)
DIABETES_AGENTS_PARTIAL	diabetes agents - various (partial)
DIABETES_GLUCOSE_MONITORING	diabetes - glucose monitoring kits/test strips
INSULINS_PARTIAL	insulins (partial)
ELECTROLYTES_MINERALS_VITAMINS_PARTIAL	electrolytes/minerals/vitamins (partial)
INCASSIA	INCASSIA
ISOSORBIDE_DINITRATE-HYDROALAZINE	isosorbide dinitrate-hydralazine
LAMOTRIGINE_STARTER_KITS	lamotrigine starter kits (blue/green/orange)
LEVONORGESTREL-ETHINYL_ESTRADIOL_PRODUCTS	levonorgestrel-ethinyl estradiol products

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Definitions, FAQs & Background

The PDL is maintained by the Blue KC Medical and Pharmacy Management Committee composed of practicing physicians and pharmacists; the committee meets quarterly to evaluate new therapies and drug utilization.

Medications are reviewed for safety, effectiveness, adverse events, comparative advantages over existing agents, and cost when assigning tier status and utilization management (PA/QL/ST) rules.

New drugs are handled operationally by placing them on formulary with an exception or prior authorization requirement until the committee has formally reviewed them; prescribers may request exceptions or submit electronic prior authorization requests via the provider forms on BlueKC.com.

Tier, PA, QL and ST codes are used throughout the PDL to indicate coverage rules (see the List of Abbreviations); changes to PA/UM rules are communicated to providers via direct mailings.

Term	Definition
PA	Prior Authorization — approval required before prescription can be filled; without approval the drug may not be covered.
QL	Quantity Limit — limits the amount of drug covered per fill/day/period (specified as units per time period).
ST	Step Therapy — requirement to try specified drugs first for a condition; exceptions via prior authorization if prescriber deems first-line inappropriate.
G / G-S / M / ACA / OTC	Abbreviations used in PDL: G = Generic Drug; G-S = Generic Specialty Drug; M = Maintenance Drug; ACA = Affordable Care Act preventive drugs; OTC = Over The Counter.
M	Medical management review required — may require clinical documentation for approval (flag used in formulary).
ACA	Affordable Care Act preventive coverage note — designation for certain preventive or contraceptive drugs; may be covered at no cost per plan benefits.
Formulary tier codes (G / G-S)	Formulary tiers: G indicates general formulary tier; G-S indicates specialty tier for select agents.
PDL maintenance notes	PDL is maintained by Blue KC Medical and Pharmacy Management Committee; committee meets quarterly and notifies providers of changes (effective date shown: January 1, 2024; Last Updated: 05/30/2024).

Does Blue KC cover all prescription drugs? Blue KC covers most prescription drugs, but some classes require an added benefit rider (examples: fertility, birth control, impotency, weight loss).

How to request an early refill? Have your pharmacist call Pharmacy Customer Service at 816-395-2176 or 800-228-1436, Monday–Friday 8 a.m.–5 p.m. CT.

Who to contact with questions about prescription drug coverage? Call the Pharmacy Customer Service unit at 816-395-2176 or 800-228-1436, Monday–Friday 8 a.m.–5 p.m. CT.

Clinical Evidence & Notes

This part does not include clinical-trial level evidence. Clinical decisions rely on the Medical and Pharmacy Management Committee review process and approved drug labeling as described in the Background. Specialty designations and PA/M (medical management) flags may require submission of clinical documentation to support authorization decisions.

Quantity Limits & Thresholds (selected examples)

Quantity Limit Enforcement and Representative Thresholds

Quantity limits (QL) must be enforced; claims exceeding listed QL require justification or prior authorization per plan rules. Representative QL thresholds are listed below as examples from the formulary.

Enforcement of QL/thresholds: Quantity limits (QL) must be observed; claims exceeding listed QL may require justification via prior authorization or may not be covered.

Prescribers/dispensers must adhere to per-drug QL values; exceptions processed through PA/electronic forms.

Representative QLs - tolvaptan: Tolvaptan quantity limit: 2 EA per 1 day.2 EA per 1 day

QL entry for tolvaptan in the formulary.

Representative QLs - mifepristone: Mifepristone quantity limit: 4 EA per 1 day.

Contacts & Accessibility

Contact and customer service guidance:

Pharmacy Customer Service: 816-395-2176 or 800-228-1436 (Monday–Friday, 8 a.m.–5 p.m. Central Time) for early refill and general pharmacy assistance.

Optum Specialty Pharmacy (designated specialty provider): 1-855-427-4682 for specialty medication dispensing and coordination.

Blue KC Customer Service (accessibility/language and general customer support): 844-395-7126; email: languagehelp@bluekc.com.

Interpreter and accessibility services: Blue KC provides free interpreter services (including qualified sign language interpreters) and written materials in alternate formats; request these services by contacting Customer Service at 844-395-7126 or languagehelp@bluekc.com.

Policy Revision History

2024-01-01effective_date

PDL effective date published as Effective January 1, 2024

2024-05-30last_updatedLatest

Last Updated Date shown in document: 05/30/2024

quarterlymaintenance_clarification

PDL maintained by Blue KC Medical and Pharmacy Management Committee with quarterly meetings; quarterly PDL maintenance and potential PA/UM changes are communicated to providers via direct mailings