Prescription Drug List (PDL) — Pharmacy Utilization Management and Coverage Criteria
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Governs the Prescription Drug List (PDL), prior authorization, tiering, quantity limits, step therapy, specialty pharmacy use, and related pharmacy benefit processes for Blue KC members with a prescription drug benefit. Affects prescribers, pharmacists, and covered HMO, PPO, and EPO members.
No material clinical or coverage changes in this revision.
Coverage and Benefit Rules
General coverage criteria
Covered when administrative and utilization management requirements listed in the PDL are satisfied:
PDL status is determined by the Medical and Pharmacy Management Committee which reviews drugs quarterly.
Prescribers must submit electronic prior authorization requests via the Blue KC provider portal.
Quantity limits are part of the plan's utilization management rules.
Specialty Pharmacy provides clinical support, shipment and patient care coordination services.
Some drug classes are not covered under the standard pharmacy benefit unless the member’s plan includes an additional rider/benefit. Examples called out in the formulary include fertility, birth control, impotency, and weight loss therapies — coverage for these classes requires the applicable rider to be active on the member’s policy.
Syringes and needles are covered only by prescription and only for members using medications that require injection. Techlite/Arkray supplies are covered at $0 cost; other syringe/needle products are covered at a non-preferred brand copay. Requests for syringes/needles without a prescription or for non-injectable medication use are not eligible for coverage.
Drugs listed with utilization management flags may be denied if plan requirements are not met. Specifically, a drug can be considered not covered when prior authorization (PA) is required but approval is not obtained, when the requested use is not an FDA‑approved or plan‑recognized indication, or when a lower‑cost or clinically preferred alternative (step therapy) applies and those alternatives have not been tried or documented as inappropriate. Providers should submit prior authorization requests and supporting documentation via the Blue KC provider processes to avoid claim denials.
Formulary Codes and Indicators
| PA | Prior Authorization required |
| ST | Step Therapy required |
| QL | Quantity Limit (specific quantities often given) |
| M | Medical necessity review / managed |
| ACA | Additional clinical approval/code (as listed) |
Prior Authorization, Step Therapy, and Documentation
Prior authorization requirement
Prior Authorization Required: Blue KC requires prior authorization (PA) for many medications listed in this formulary. PA means the prescriber must obtain approval from Blue KC before the prescription will be covered; claims for drugs requiring PA may be denied if PA is not obtained. Prescribers should submit electronic prior authorization requests via the Blue KC provider portal (Providers > Forms > Prior Authorizations for Medications).
- Definition: PA = Prior Authorization — the plan requires approval before filling or the drug may not be covered.
- How to request: Submit an electronic prior authorization request via WWW.BlueKC.com > Providers > Forms > Prior Authorizations for Medications.
Prior authorization required for listed drugs
Prior authorization is required for numerous listed drugs across the formulary. Examples of PA‑marked products include select analgesics, specialty agents, oncology, MS therapies, and various high‑cost or safety‑sensitive medications. Many entries in the Table of Contents show the restriction marker "PA" next to the drug name indicating PA is required prior to coverage.
- Examples: fentanyl transdermal patches, hydrocodone ER formulations, several oncology oral agents (erlotinib, everolimus, imatinib), and specialty biologics (glatiramer, fingolimod) are PA‑marked in the formulary index.
- Diabetes injectables and GLP‑1 agents (e.g., TRULICITY, VICTOZA, SYMLINPEN) show PA markers in the diabetes section.
Prior authorization and quantity limits
Prior authorization and quantity limits: many drugs in the formulary require PA and/or have quantity limits (QL). When QL is present, the plan limits the amount dispensed per fill or per time period; when PA is present, authorization must be obtained even if quantity requested is within limits.
- Common QL examples: multiple opioid preparations list QL (EA per day or ML per day) alongside PA where applicable.
- Some specialty and oral oncology agents (e.g., erlotinib, everolimus) list PA plus a QL (e.g., 3 EA per 1 day or 1 EA per 1 day).
- PA and QL must both be adhered to — requests exceeding QL or without PA may be denied.
Prior authorization and restriction indicators
Restriction indicators: the formulary uses utilization management markers to indicate required actions. Common markers include PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), M (Maintenance), ACA (preventive/ACA), and OTC. Presence of these markers signals the need for additional provider action or documentation to secure coverage.
- PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; M = Maintenance; ACA = Affordable Care Act preventive designation.
- When a product is labeled with PA, ST, QL, or M, providers should expect potential denial or additional review unless requirements are met.
Prior authorization required for select agents
Prior authorization required for select agents and specialty/high‑cost drugs: many specialty agents, MS therapies, oncology drugs, genetic/enzyme disorder treatments, and certain pulmonary or rare‑disease medications are PA‑designated. Examples in the index include glatiramer acetate, fingolimod, teriflunomide, miglustat, tolvaptan, lenalidomide, and several octreotide and leuprolide products.
- MS therapies: dimethyl fumarate, glatiramer acetate, fingolimod, teriflunomide — PA and QL markers present.
- Genetic/enzyme and specialty drugs: miglustat, tolvaptan, lenalidomide — PA marked.
- Hormonal/injectable biologics: leuprolide acetate and octreotide products are PA‑designated.
Prior authorization required for PA‑marked medications
Prior authorization required for PA‑marked medications across categories (e.g., analgesics, CNS, respiratory, metabolic bone disease, pulmonary fibrosis agents, diabetes injectables). Review the formulary index for specific PA markers adjacent to drug entries; when PA appears, secure authorization before dispensing.
- Examples: certain extended‑release opioids, methylphenidate ER formulations, teriparatide, pirfenidone, and roflumilast are PA‑marked in the formulary.
- Diabetes GLP‑1 and injectable devices (listed with PA in diabetes section) require PA for coverage.
Prior authorization — not listed here / Not specified in this index
Prior authorization — not listed here / Prior authorization not specified in this index: this section of the document is primarily an index/listing of drugs and restriction markers. Some index entries reference page numbers or are abbreviated and do not include full authorization criteria in the index itself. For full PA clinical criteria and documentation instructions, consult the corresponding policy pages or the Blue KC prior authorization forms on the provider site.
- The index provides markers and page references only; it does not contain detailed PA clinical criteria or step‑by‑step documentation requirements.
- If an index entry lacks a PA marker, it does not guarantee absence of authorization requirements — check the main policy text or online PA guidelines.
Restriction codes indicate potential denial triggers
Restriction codes indicate potential denial triggers: presence of PA, ST, QL, or M next to a drug name may trigger a claim denial or additional review if the required prior authorization, step‑therapy trial, or documentation is not provided. Providers must follow the indicated UM flag to avoid coverage denials.
- Claims for PA‑flagged drugs will be denied if PA is not obtained.
- ST markers require documented trial/failure of lower‑step therapies or an approved exception via PA.
- Requests exceeding QL may be denied without appropriate justification.
Documentation and quantity adherence
Documentation and supporting clinical information: when PA, ST, QL, or other UM flags apply, providers should be prepared to submit supporting clinical documentation consistent with Blue KC policies (e.g., diagnosis, prior treatments, rationale for exception). Documentation supports review and can prevent delays or denials.
- Provide clinical rationale, relevant trial history, diagnostic information, and dosing/quantity requested when submitting PA.
- Specialty/MS agents and restricted drugs often require detailed documentation and may have QL or continuation criteria.
Step therapy presence and requirements
Step therapy presence and indicators: the formulary includes Step Therapy (ST) markers for select drug groups. ST requires trial of specified lower‑cost or preferred agents before coverage of a non‑preferred medication; if the prescriber believes the required step is inappropriate, a PA request with supporting documentation may be submitted.
- ST examples: diclofenac potassium (ST), certain antidepressants/antimigraine combinations, methylphenidate ER and some gabapentin/pregabalin ER formulations (ST markers present).
- If ST applies, submit documentation of trials and reasons for failure or intolerance of preferred agents when requesting an exception.
Policy Background
The Prescription Drug List (PDL) is developed and maintained by the Blue KC Medical and Pharmacy Management Committee, a local committee of physicians and pharmacists that reviews medications quarterly for safety, effectiveness, adverse events, comparative advantage, and cost. PDL status (tier placement, prior authorization, step therapy, and quantity limits) is assigned based on those reviews and post‑marketing information and informs coverage and utilization management decisions.
Key Terms and Abbreviations
Step Therapy Details
| Agent | Step therapy requirement |
|---|---|
| Agents marked 'ST' in the PDL (selected examples) | |
| Step therapy required per PDL — prescriber must try preferred/earlier‑line agents or submit prior authorization documenting failure/intolerance |
| Agent | Step therapy requirement |
|---|---|
| Diclofenac potassium (migraine) | |
| Marked 'ST' in formulary; step therapy applies before coverage of the listed product | |
| Indomethacin (oral formulations; rectal suppository) | |
| Select indomethacin formulations listed with 'ST' restriction; step therapy required per PDL |
| Agent | Step therapy requirement |
|---|---|
| Febuxostat | |
| Listed with 'ST' (and M) — step therapy requirement applies |
| Agent | Step therapy requirement |
|---|---|
| Topiramate ER (extended release 24-hour) | |
| Entry shows Restrictions = ST for topiramate ER — step therapy applies |
| Agent / product group | Step therapy requirement |
|---|---|
| Select migraine and antigout agents (e.g., diclofenac potassium, febuxostat) | |
| Marked 'ST' in the formulary — step therapy required before coverage of the listed agent | |
| Select oncology or specialty agents (examples in table entries show ST on some antidiabetic and antiepileptic combination products) | |
| When 'ST' appears for a product, step edits must be satisfied or prior authorization submitted documenting why alternatives are inappropriate |
| Rule | Notes |
|---|---|
| Step therapy applies to products labeled 'ST' in the PDL | |
| Prescribers must try required earlier‑line therapies or submit an electronic prior authorization request documenting failure/intolerance to obtain coverage |
| Agent(s) | Step therapy requirement |
|---|---|
| Methylphenidate ER (selected ER formulations) | |
| Some methylphenidate ER products listed with 'ST' — step therapy applies (try preferred product first) | |
| Imiquimod external cream 3.75%; pimecrolimus | |
| Imiquimod 3.75% and pimecrolimus are listed with 'ST' (pimecrolimus also has QL) — step therapy applies |
| Product | Step therapy requirement |
|---|---|
| Insulin pen needles (various brands/sizes) | |
| Listed with 'ST' (and M; OTC for some) — step therapy markers present for specified pen needles | |
| Ophthalmic agents (selected: bepotastine, bromfenac etc.) | |
| Some ophthalmic products show 'ST' restriction markers per the formulary — step therapy edits may apply prior to coverage |
| Agent | Step therapy requirement |
|---|---|
| Zileuton ER | |
| Listed with Restrictions = ST; M — step therapy applies to zileuton ER per formulary entry |
Quantity Limits (QL) by Product
Specialty Pharmacy and Site-of-Care Requirements
Use designated Specialty Pharmacy for specialty meds
Most specialty medications must be filled at the designated Specialty Pharmacy (Optum Specialty Pharmacy) and may be delivered to the physician's office or the patient's home; use the specialty pharmacy for dispensing specialty drugs.
- Optum Specialty Pharmacy Phone: 1-855-427-4682
- Specialty medications limited to a 34‑day supply
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