Prescription Drug List (PDL) and Pharmacy Services — Coverage Criteria
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Defines the Prescription Drug List (PDL), pharmacy benefit management, prior authorization and utilization management processes, specialty pharmacy requirements, and member/provider resources for Blue KC members with a prescription drug benefit.
No material clinical or coverage changes in this revision.
Coverage and Formulary Rules
General PDL coverage criteria
Coverage and utilization management apply as follows for members with pharmacy benefits:
Committee meets quarterly
Includes tier exception process for contraceptives and HIV PrEP
Specialty Pharmacy dispensing and benefit rules
Covered when ALL of the following are met
See Optum Specialty Pharmacy contact for dispensing.
Providers must obtain PA when listed.
Certain drug classes may not be covered under the standard pharmacy benefit unless the member has an additional benefit rider. Examples called out in the PDL include classes such as fertility, birth control, impotency, and weight loss. Providers should confirm member benefit design and submit a tier-exception or rider request when coverage of these classes is needed.
Most specialty medications are covered under the pharmacy benefit but must be filled at the designated Specialty Pharmacy listed in the PDL (the document identifies the network Specialty Pharmacy). The Specialty Pharmacy provides care coordination, clinical support, shipment and billing coordination and typically dispenses specialty drugs in a 34‑day supply; prescriptions not filled at the listed Specialty Pharmacy may not receive those Specialty Pharmacy services.
The extracted formulary segments in these chunks do not state explicit exclusion policies for specific products; instead they show drug line items with tiers and restriction flags (e.g., PA, ST, QL, M). Where a formal exclusion applies it would be identified elsewhere in the member benefit language.
Within this extract there are no explicit exclusion conditions described. The listings primarily display formulary tier designations and restriction flags (for example, PA, QL, ST, M or ACA) that govern coverage and utilization management rather than declarative exclusion text.
Items that are identified as OTC in the formulary (for example many test strips and glucose monitoring supplies) nevertheless include quantity limits in the listings (commonly shown as QL (10 EA per 1 day) for many test-strip brands). Providers and pharmacies should observe those QL values when processing claims or prior authorization requests.
The extract does not contain any statements labeling products as 'not medically necessary'. Coverage determinations in these chunks are communicated via tier labels and utilization controls (e.g., PA, ST, QL, M) rather than explicit NMN language.
Formulary Flags, Codes, and Quantity Examples
| QL (0.34 EA per 1 day) | Quantity limit example shown for NAYZILAM and VALTOCO |
| ST | Step Therapy flag |
| NPB | Drug Tier label used throughout (exact meaning not defined in extract) |
| PA | Prior Authorization |
| M | Medical management |
| QL (14 supply per 30 fills) | Quantity limit example for antiemetics |
| OZEMPIC | Restrictions Limits = PA; M; QL (0.11 ML per 1 day) |
| GLYXAMBI | Drug Tier = PB. Restrictions Limits = ST; M |
| DEXCOM G6 RECEIVER | Restrictions Limits = PA; QL (1 EA per 273 days) |
| DEXCOM G6 SENSOR | Restrictions Limits = PA; QL (0.1 EA per 1 day) |
| AFREZZA | Restrictions Limits = PA; M |
| Various Test Strips | Restrictions Limits = OTC; QL (10 EA per 1 day) for many listed brands |
| INSULIN PRODUCTS | Multiple insulin entries with Restrictions Limits = PA; M or M or ST depending on product (examples include AFREZZA = PA; M; ADMELOG = ST; M; FLEXTOUCH = PA; M) |
| QL (2 EA per 1 day) | Quantity limit example for SAMSCA (2 each per day) |
| QL (0.6 ML per 1 day) | Quantity limit for RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML |
| QL (0.4 ML per 1 day) | Quantity limit for RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML |
| QL (24 EA per 365 days) | Quantity limit for VOWST |
| QL (3 EA per day) | Quantity limit for XERMELO |
| QL (8 ML per 1 day) | Quantity limit for EVRYSDI |
| QL (0.5 EA per 1 day) | Quantity limit for GALAFOLD |
| QL (1 EA per 1 day) | Frequent quantity-limit notation for oral packets/pills |
| PA | Prior Authorization required |
| ST | Step Therapy required |
| M | Restriction/Limit code 'M' (document lists without definition here) |
| ACA | Restriction code 'ACA' appearing for certain bowel prep/PEG products |
| 0.15 EA per day | Quantity limit example listed for several products (e.g., ADALIMUMAB entries) |
| 0.13 ML per day | Quantity limit example for ACTEMRA ACTPEN |
| 0.12 ML per day | Quantity limit example for AMJEVITA auto-injector |
| 0.06 ML per day | Quantity limit example for AMJEVITA prefilled syringe |
| 0.02 ML per day | Quantity limit example for medroxyprogesterone acetate IM |
| 1 EA per day | Quantity limit example for certain contraceptives (e.g., listed oral contraceptives) |
| 2 EA per 1. | Partial QL text present for ORIAHNN (document truncated) |
Prior Authorization, Step Therapy, Documentation, and Denial Risks
Prior Authorization Required
Prior authorization is required for many drugs listed in this document. Blue KC may require prior authorization because a medication has safety concerns, is approved only for certain uses, has potential for misuse, has a lower-cost or preferred alternative, or requires clinical review to confirm medical necessity. Failure to obtain required prior authorization may result in claim denial or lack of coverage.
- Submit electronic prior authorization/exception requests via bluekc.com Providers > Forms > Prior Authorizations for Medications.
- Specialty Pharmacy (Optum Specialty Pharmacy: 1-855-427-4682) coordinates dispensing and billing for specialty medications; providers should work with the specialty pharmacy for shipment, care coordination, and benefit questions.
Formulary Prior Authorization, Step Therapy, and Quantity Limits
Many formulary entries are marked with PA, QL, ST or M in the Restrictions/Limits column. PA (Prior Authorization) indicates the plan requires prior review and approval before the prescription can be filled. QL (Quantity Limit) specifies maximum quantities (e.g., "QL (4 EA per 1 day)"), and ST (Step Therapy) requires trials of specified agents before coverage of others.
- Examples of PA-marked agents: BELBUCA (PA; QL), fentanyl formulations (PA; QL), COPAXONE (PA; QL).
- Examples of specialty agents requiring PA: DOPTELET, PROMACTA, DUPIXENT, HUMIRA, STELARA, COSENTYX (see formulary listings).
- Examples of diabetes and obesity agents with PA/ST/M flags: MOUNJARO (PA; QL), OZEMPIC (PA; M; QL), WEGOVY/other GLP-1 agents (PA or ST may apply).
Denial Risk — PA/ST/QL Triggers
Prior authorization and quantity-limit flags can trigger pre-service review or retrospective denial if not obtained or if requested quantities exceed the listed QL. When entries show 'PA', 'PA; QL', 'ST', or 'M', submit supporting documentation to justify the requested medication, dose, and quantity.
- Claims for PA- or QL-controlled drugs may be denied without an approved authorization.
- Exceeding a listed QL (for example PAXLOVID QL (4 EA per 1 day) or antiviral QLs) may require an exception request.
- PA and medical necessity reviews apply to many specialty biologics (e.g., ADALIMUMAB products, COSENTYX, HUMIRA, CIMZIA).
Documentation Required for Prior Authorization and Quantity Limits
Provide clear supporting documentation with prior authorization requests. Include the diagnosis, relevant clinical history, previous therapies tried (for step therapy), rationale for the requested agent, dosing, and quantity consistent with the formulary QL.
- For ST-flagged medications, document prior use and failure/intolerance of required initial agents or provide justification for an override.
- For M- or maintenance-flagged products, document chronic need and previous response.
- For specialty medications, coordinate with the Specialty Pharmacy and include any specialty pharmacy paperwork or enrollment forms.
Step Therapy Requirement and Override Process
Step therapy applies to selected drugs and drug classes where the plan requires trial of preferred or lower-cost agents before covering an alternative. If a step cannot be met medically, submit a prior authorization with supporting clinical rationale.
- Examples of ST flags: SUBOXONE formulations (ST; QL), certain ADHD medications and starter kits (ST), some antiepileptic and psychiatric agents (ST).
- If a patient cannot tolerate or has contraindications to the required step agent, include that information in the PA request to request a step override.
Policy Background and Maintenance
The Prescription Drug List (PDL) is maintained and periodically reviewed by Blue KC’s Medical and Pharmacy Management Committee — a multidisciplinary group of practicing physicians and pharmacists that evaluates medications for safety, effectiveness, adverse events, comparative advantages and cost; the committee oversees PDL status and utilization management decisions.
Key Definitions and Abbreviations
Step Therapy Rules and Affected Products
| Requirement | Notes |
|---|---|
| Step therapy may be required for some drugs as indicated by an 'ST' flag in the formulary entry. | |
| If first‑line agents are inappropriate, the provider must submit a prior authorization explaining why; without PA the drug may not be covered. |
| Policy statement | Example(s) from formulary |
|---|---|
| Certain drugs require Step Therapy (ST) to be tried before alternate drugs will be covered. | |
| Fioriceticodeine is listed with 'ST' in the Restrictions/Limits column; other opioid entries show QL/PA along with ST where applicable. |
| How ST is indicated | Formulary examples |
|---|---|
| Step therapy is applied where the formulary Restrictions/Limits column shows 'ST'. | |
| SUBOXONE sublingual film entries show 'ST' (e.g., multiple strengths with ST and QL); EPIDIOLEX and other entries list ST where applicable. |
| Scope | Examples |
|---|---|
| Products labeled with 'ST' in Restrictions/Limits require adherence to step therapy per the formulary before the listed product will be covered. | |
| Examples include MOTPOLY XR, QUDEXY XR and TROKENDI XR which are shown with 'ST' in the formulary extracts. |
| Formulation-specific ST | Formulary entry |
|---|---|
| Certain formulations (cartridge/auto-injector or system presentations) are designated 'ST' in Restrictions/Limits. | |
| IMITREX STATDOSE refill and system presentations are listed with 'ST' and a QL (0.17 mL per day) in the formulary. |
| Therapeutic classes | ST examples |
|---|---|
| Step therapy may apply to antipsychotics and other central nervous system agents where 'ST' appears in Restrictions/Limits. | |
| INVEGA HAFYERA and other antipsychotic entries are shown with 'ST' in the formulary excerpts. |
| Indicator | Sample drugs |
|---|---|
| Entries marked 'ST' in the Restrictions/Limits column indicate a step therapy requirement applies to that drug. | |
| Examples from cardiovascular and related listings include EDARBI, KAPSPARGO SPRINKLE and LASIX entries shown with 'ST' (or 'ST; M') where noted. |
| Provider action | Implication |
|---|---|
| When a drug is marked 'ST', the prescriber must ensure required prior steps have been tried or submit PA documenting why steps are inappropriate. | |
| Multiple CNS and ADHD medication entries (e.g., ADDERALL XR, APTENSIO XR) display 'ST' indicating prior-step requirements should be followed. |
| Where ST appears | Examples |
|---|---|
| Step therapy applies to products where 'ST' appears next to the drug entry in the formulary's Restrictions/Limits field. | |
| Diabetes agents and related products (e.g., entries for GLYXAMBI, FARXIGA, and others) show 'ST' or 'M ST' indicating step therapy requirements. |
| Coverage requirement | Examples listed |
|---|---|
| Several agents require step therapy prior to coverage as indicated by 'ST' next to product names in the formulary extract. | |
| GLYXAMBI and other oral combination products are specifically shown with 'ST' in their Restrictions/Limits entries. |
| ST flag examples | Products |
|---|---|
| The formulary indicates 'ST' for certain products—coverage requires prior steps per the plan's step therapy rules. | |
| Examples include ACCRUFER, GATTEX, LINZESS, MOVANTIK and PLENVU which are listed with 'ST' in the Restrictions/Limits field. |
| Flag presence | Example products |
|---|---|
| Some listed products carry an 'ST' flag indicating step therapy applies before coverage of that product. | |
| Formulary fragments show ST flags for products including PANCREAZE and VELPHORO in broader specialty listings. |
| General rule | Formulary indication |
|---|---|
| Entries marked 'ST' indicate step therapy applies and prior steps must be completed or an exception requested via prior authorization. | |
| Hormonal agent and contraceptive listings include products (e.g., SLYND, TAYTULLA) where ST appears alongside other restriction codes in the formulary. |
Quantity Limit Rules and Examples
Specialty Pharmacy and Dispensing Site
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