CurrentBlue KCPolicy N/A
Blue KC Prescription Drug List (PDL) and Pharmacy Services Coverage Criteria
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Governs pharmacy benefit management for Blue KC HMO, PPO and EPO members with a prescription drug benefit, including PDL use, prior authorization, quantity limits, step therapy, specialty pharmacy processes and member/provider resources.
Policy Summary
PayerBlue KC
PolicyPrescription Drug List (PDL) and Pharmacy Services — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateEffective January 1, 2024
Next Review DateN/A
Key ActionSubmit an electronic prior authorization request when a drug is marked PA to obtain coverage.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
QuarterlyPDL committee meeting frequency
Optumdesignated specialty pharmacy
34 dayspecialty medication supply limit
44,000+network pharmacies nationwide
Coverage Criteria Summary
Some drug classes are not covered under standard pharmacy benefits unless the member adds a specific additional benefit rider. Examples called out in the formulary include fertility, birth control, impotency, and weight loss therapies; coverage depends on whether the applicable rider has been purchased for the member's plan.
Formulary drug tiers include plan-specific designations where certain tiers are explicitly marked as Not Covered. The tier legend shows multiple specialty and non-preferred brand tiers (for example PB-S, NPB-S) and indicates that coverage and copays vary by tier; some tiers in the legend are annotated as Not Covered for particular plan designs, so providers should confirm member benefit details in the member certificate or benefit summary before prescribing.
Certain formulary entries use flags such as ACA or M in the Restrictions column to denote program-specific designations or medical‑management modifiers. These markers appear alongside tier and restriction information (for example other entries in the index show mixed restriction annotations such as QL or PA together with program flags), and they should be interpreted in the context of the member's plan and the formulary legend.
Formulary Codes and Examples
Formulary restriction codesmixed
| PA | Prior Authorization required |
| M | Medical necessity / prescriber must meet clinical criteria |
| QL (0.1 ML per 1 day) | Quantity limit: 0.1 mL per 1 day |
Provider Requirements, Prior Authorization and Documentation
Prior Authorization
Prior Authorization Required
Prior authorization is required for many drugs listed in the formulary. Prior authorization (PA) must be obtained from Blue KC before the prescription can be filled for products marked “PA” in the Restrictions/Limits field — without an approved PA the plan may deny coverage.
- PA flags appear throughout the formulary (examples: ARIKAYCE; XIFAXAN 550 mg; EPIDIOLEX; FINTEPLA; many antineoplastics such as ALECENSA, ALUNBRIG; specialty antivirals like SOVALDI and EPCLUSA; biologics and specialty agents such as DUPIXENT, REPATHA, ADALIMUMAB products; specialty hormonal agents like ACTHAR, LUPRON; respiratory biologics such as NUCALA, FASENRA, TEZSPIRE).
- Specialty, oncology, antiviral, biologic, hormonal, genetic/enzymatic replacement, and many high-cost agents are frequently marked PA and commonly require prior authorization.
- Some antiviral and hepatitis/retroviral agents include PA and/or quantity limits (examples: SOVALDI, EPCLUSA, SELZENTRY).
- Many specialty biologics and injectable agents list both PA and quantity limits (QL) — e.g., DUPIXENT, REPATHA, ACTEMRA, ADALIMUMAB brands, HYRIMOZ, NUCALA, NUCALA formulations.
Step Therapy
Quantity Limits and Step Therapy
Quantity limits (QL) and step therapy (ST) are enforced where indicated. Requests that exceed QL or that do not follow ST requirements may be denied unless an approved PA or documented exception is provided.
- Numerous medications include QL entries (examples: REPATHA QL; SOVALDI QL per day; many opioid/analgesic formulations with per-day EA or ML limits).
- Step therapy (ST) is applied to select products (examples: SEYSARA, SOLOSEC, MOTPOLY XR, FANAPT, INVEGA HAFYERA, ADDERALL XR, JORNAY PM, METHYLIN oral solution, VYVANSE).
- Where entries list PA; QL or ST; QL the PA review will also assess requested quantity vs allowed quantity and applicable step edits.
Note
Submission Process and Specialty Pharmacy
Providers must submit an electronic prior authorization request via the Blue KC prior authorization form (Providers > Forms > Prior Authorizations for Medications). Specialty medications typically must be filled at the designated specialty pharmacy (Optum Specialty Pharmacy) when listed.
- Submission: Use BlueKC.com Providers > Forms > Prior Authorizations for Medications to submit electronic PA requests.
- Specialty pharmacy: Specialty prescriptions identified in the formulary are filled via Optum Specialty Pharmacy (Phone: 1-855-427-4682).
- If step therapy (ST) is indicated, the provider must document prior trials of required agents or request PA to bypass ST with clinical justification.
Documentation Required
Documentation Expectations for PA, ST and QL
Documentation must accompany PA or exception requests and should address diagnosis, prior treatment trials (for ST), rationale for requested dose/quantity, and relevant clinical records. When formulary entries include restriction codes (PA, QL, ST, M) provide supporting documentation to avoid delays or denials.
- Provide diagnosis and chart notes demonstrating medical necessity.
- For ST: document prior use and response to required agents, or provide clinical rationale for exception.
- For QL: indicate intended dosing schedule and total quantity requested; match request to allowable QL (e.g., QL (1 EA per 1 day), QL (0.11 ML per 1 day), etc.).
- For biologics/specialty injectables include weight, dosing interval, and supporting lab or imaging results when relevant.
Denial Risk
Denial Risk and Enforcement
Failure to obtain required prior authorization, exceed quantity limits, or comply with step therapy/medical management edits may result in claim denials or noncoverage.
- Denial triggers include: missing PA for PA-marked drugs; requests exceeding QL; failure to meet ST requirements.
- Many high-cost specialty, oncology, antiviral, hormonal, and biologic agents are routinely denied without PA (examples across the formulary: ALECENSA, ALUNBRIG, SOVALDI, EPCLUSA, DUPIXENT, REPATHA, ACTHAR, many TNF-inhibitors and other biologics).
- Medical management (M) flags indicate additional utilization review and may require medical benefit review in addition to PA.
Formulary Governance and Maintenance
The Prescription Drug List (PDL) is maintained and reviewed by Blue KC's Medical and Pharmacy Management Committee, which is composed of practicing physicians and pharmacists who meet regularly (quarterly) to evaluate medications for safety, effectiveness, adverse events, therapeutic advantages over existing agents, and cost. Specialty drugs — which often require special ordering, handling or clinical monitoring — are included on the PDL but may have additional coverage rules (e.g., prior authorization, quantity limits, or site‑of‑care considerations).
Key Terms and Abbreviations
inv-77: Generic equivalent / alternative
Generic equivalent vs alternativeA generic equivalent contains the same active ingredient and works the same as the brand; a generic alternative may not have the same active ingredient but works similarly.
Maintenance drugA medication used to treat a chronic condition approved for long-term use; Blue KC uses Medi-Span to determine maintenance drug status.
Specialty drug / Specialty PharmacyMedications requiring special ordering, handling, clinical monitoring, or customer service; Specialty Pharmacy provides dedicated services and coordinates shipment and billing.
Specialty supply limitSpecialty medications are limited to a 34‑day supply (specialty med supply day limit = 34 days).
inv-78: Maintenance drug
Maintenance drug definitionMedication used to treat a chronic condition and approved for long-term use; Medi-Span used to determine status.
Implication for fillsMaintenance drugs may be eligible for multi-month fills per benefit rules.
Benefit classificationMarked with 'M' in Restrictions/legend to indicate maintenance status in many entries.
inv-79: Specialty drug / Specialty Pharmacy
Specialty drug definitionMedications requiring special ordering, handling, clinical monitoring, or customer service often dispensed by Specialty Pharmacy.
Specialty Pharmacy servicesProvides patient care coordinator, clinical staff support, refill reminders, overnight shipping and billing coordination.
Supply limitSpecialty medications are limited to a 34‑day supply.
inv-80: Specialty Pharmacy
Specialty Pharmacy (site of care)A pharmacy that provides specialized care and services for patients with complex chronic health conditions and dispenses specialty medications; includes patient care coordinator and clinical staff support.
Delivery optionsMedications can be delivered to physician office or patient home; shipments are coordinated and sent overnight.
No additional cost servicesServices such as supplies to administer medication and care management are provided at no additional cost.
inv-81: PA
PA — Prior AuthorizationThe plan requires approval before filling certain drugs; without approval the plan may not cover the drug.
QL — Quantity LimitThe plan limits the amount of drug that will be covered for certain drugs.
ST — Step TherapyThe plan may require trying specified drugs first before covering another drug.
inv-82: QL
QL definitionQuantity Limit: the plan limits the amount of the drug that we will cover.
Time-period basisQLs are specified per time period (e.g., EA per day, ML per 28 days, EA per 365 days).
Claims/PA impactExceeding QL may trigger denial or need for prior authorization documentation.
inv-83: ST
ST definitionStep Therapy: the plan may require trying certain drugs first before covering another drug.
Provider actionProviders must document why earlier step agents are inappropriate when requesting bypass via PA.
Common usageST appears in Restrictions for multiple agents (see formulary entries).
inv-84: Restriction codes used
PA — Prior AuthorizationPrior authorization required (PA) — listed in Restrictions/Limits for many biologic and specialty products.
QL — Quantity LimitQuantity Limit (QL) — maximum allowed quantity per specified time period (e.g., 0.17 ML per 1 day).
ST — Step TherapyStep Therapy (ST) — requirement to try preferred alternatives first where noted.
M — Medical modifierM indicates medical benefit or may require medical justification in Restrictions legend.
inv-88: PA
PA listed in restrictionsPA indicates pre-approval required before coverage for the listed presentation.
QL listed in restrictionsQL indicates the maximum allowed quantity per time period (EA per day, ML per day, EA per 365 days).
ST listed in restrictionsST indicates step therapy edits apply for the product.
inv-89: QL
QL — Quantity LimitQuantity Limit — maximum allowed quantity over specified time frame (e.g., QL (0.17 ML per 1 day)).
Examples in biologicsDUPIXENT entries show QL expressed in ML per day (0.17 ML, 0.29 ML).
Impact on claimsClaims exceeding QL require documentation or may be denied if QL not met/authorized.
inv-87: NPB / PB-S / G-S / PB
NPB / PB-S / G-S / PB — Tier codesFormulary uses multiple tier/plan flags (e.g., NPB = Non-preferred Brand, PB-S = Preferred Brand Specialty, G-S = Generic Specialty, PB = Preferred Brand).
Tier affects coverage/managementTier designations indicate benefit tiering and often correlate with PA/QL requirements.
Refer to formulary legendExact tier definitions and member cost-sharing are in the benefit schedule/legend.
Step Therapy Details
| Coverage action | Notes / provider action |
|---|---|
| Step therapy required where specified | |
| If an agent is flagged 'ST' the plan requires trying specified preferred drugs first; providers must submit a prior authorization to bypass steps and document why earlier agents are inappropriate |
| Policy statement | Source detail |
|---|---|
| The plan may require trying specified drugs first (Step Therapy) before covering alternative agents | |
| ST (Step Therapy) means the plan requires trial of listed preferred drugs; prior authorization is required if earlier drugs are inappropriate |
| Product | Restriction |
|---|---|
| MOTPOLY XR | |
| Restrictions: ST (step therapy) |
| Product | Restriction / notes |
|---|---|
| DESVENLAFAXINE ER | |
| Restrictions: ST; M; QL (1 EA per day) — subject to step therapy edits |
| Therapy / product group | Restriction |
|---|---|
| Migraine biologics (e.g., EMGALITY, AIMOVIG, AJOVY) | |
| Restrictions: PA; M; QL and some presentations flagged with ST — prior steps may be required |
| Product | Restriction |
|---|---|
| FANAPT | |
| Restrictions: ST; QL (2 EA per 1 day) — step therapy applies |
| Product | Restriction |
|---|---|
| FANAPT | |
| Restrictions: ST (step therapy required prior to coverage) |
| Product | Restriction |
|---|---|
| INVEGA HAFYERA | |
| Restrictions: ST (step therapy applies) |
| Product(s) | Restriction / QL |
|---|---|
| ADDERALL XR | |
| Restrictions: ST; QL (2 EA per 1 day) — step therapy required prior to coverage |
| Product group | Restriction |
|---|---|
| Stimulant and methylphenidate formulations (various ER/solution products) | |
| Restrictions: Many formulations list ST and QL as applicable — step therapy required where indicated |
| Product examples | Restriction |
|---|---|
| EUCRISA; IMIQUIMOD (3.75%/pump); ZILXI | |
| Restrictions: ST noted for select products — step therapy may be required prior to coverage |
| Observation | Implication |
|---|---|
| ST annotations present for multiple products in the listing | |
| Indicates plan requires trying preferred agents first; prior authorization may be needed to override steps |
| Product category | Flags / restrictions |
|---|---|
| Contraceptive and hormonal products | |
| Restrictions include M, ACA, and ST flags in various entries — may indicate medication management, ACA-mandated coverage, or step therapy requirements |
| Product | Restriction |
|---|---|
| EPIPEN 2-PAK | |
| Restrictions: ST (step therapy) — follow applicable plan step edits |
| Example products | Restriction |
|---|---|
| EPIPEN 2-PAK; SYMBICORT; BELSOMRA; DAYVIGO | |
| Restrictions: Flagged ST in listings — step therapy applies to these drugs where indicated |
Quantity Limit Details
inv-113: Specialty medications
Specialty device day-limitDEXCOM G6 RECEIVER: QL (1 EA per 273 days)
Sensor daily allocationDEXCOM G6 SENSOR: QL (0.1 EA per 1 day)
PA requirement for devicesDEXCOM devices listed with PA and QL in Restrictions (PA; QL entries)
inv-114: multiple (see table entries)
Multiple QL examples presentMany specific per-fill or per-day QL values appear across analgesic and related sections (e.g., QL (2 EA per 1 day); QL (1 EA per 1 day); mL/day limits).
Opioid QLsExamples include QL (4 EA per 1 day) and QL (1.6 ML per 1 day) for various opioid formulations.
High-volume per‑fill QLsSome products show large per‑fill volume limits (e.g., 98 ML per 1 day entries for select oral solutions).
inv-115: buprenorphine hcl sublingual tablet 2 mg
buprenorphine 2 mg QLbuprenorphine hcl sublingual tablet 2 mg — QL (12 EA per 1 day)
buprenorphine 8 mg QLbuprenorphine hcl sublingual tablet 8 mg — QL (3 EA per 1 day)
buprenorphine-naloxone film QLbuprenorphine-naloxone sublingual film 12-3 mg — QL (2 EA per 1 day)
inv-116: buprenorphine hcl sublingual tablet 8 mg
buprenorphine 8 mg tablet QLbuprenorphine hcl sublingual tablet 8 mg — QL (3 EA per 1 day)
Tier listingListed in Anti-Addiction section; QL applied per day for abuse‑liability management.
Related formulationsMultiple buprenorphine/naloxone formulations have differing QLs (2–12 EA per day depending on strength/formulation).
inv-117: buprenorphine-naloxone sublingual film 12-3 mg
buprenorphine-naloxone film 12-3 mg QLQL (2 EA per 1 day)
SUBOXONE film 12-3 mgSUBOXONE SUBLINGUAL FILM 12-3 MG listed with QL (2 EA per 1 day) in the table of contents.
Other film strengthsOther buprenorphine-naloxone film strengths have QLs ranging from 3–12 EA per 1 day depending on strength.
inv-118: SUBOXONE SUBLINGUAL FILM 2-0.5 MG
SUBOXONE 2-0.5 mg QLSUBOXONE SUBLINGUAL FILM 2-0.5 MG — QL (12 EA per 1 day)
Section listingAppears in Anti-Addiction/Substance Abuse Treatment Agents section.
Related strengthsMultiple SUBOXONE strengths shown with proportional QLs (e.g., 6 EA, 3 EA per day for higher strengths).
inv-119: dabigatran etexilate mesylate
Dabigatran QLdabigatran etexilate mesylate — QL (2 EA per day)
PRADAXA listingPRADAXA ORAL CAPSULE — QL (2 EA per day) (same class listing)
Formulary contextAnticoagulant section indicates QLs to control supply and safety.
inv-120: PRADAXA ORAL CAPSULE
PRADAXA QLPRADAXA ORAL CAPSULE — QL (2 EA per day)
Therapeutic classListed under anticoagulants with QL to limit daily supply.
ImplicationClaims exceeding two capsules/day will trigger QM/authorization review.
inv-122: VALTOCO NASAL LIQUID 10 MG/0.1ML
VALTOCO numeric (table)VALTOCO NASAL LIQUID 10 MG/0.1ML — numeric QL value shown as 0.34 (EA per day)
VALTOCO therapy pack numericVALTOCO NASAL LIQUID THERAPY PACK 10 — numeric QL value shown as 0.67 (EA per day)
AIMOVIG numeric examplesAIMOVIG entries show QL values 0.04 ML and 0.07 ML per day in adjacent biologics listing.
inv-123: VALTOCO NASAL LIQUID THERAPY PACK 10
VALTOCO therapy pack (table)VALTOCO NASAL LIQUID THERAPY PACK 10 — numeric QL value 0.67 per day
Related entriesListed in same table region as other rescue/biologic products with per‑day numeric QLs.
Provider noteTherapy-pack QL differs from single‑unit QL — check product-level entry when submitting claims.
inv-124: AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML
AIMOVIG auto‑injector QLAIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML — QL (0.04 ML per 1 day)
AIMOVIG (other) QLAIMOVIG (other presentation) — QL (0.07 ML per 1 day)
Restriction flagsEntries include PA; M; QL for migraine biologics where indicated.
inv-126: ALUNBRIG ORAL TABLET THERAPY PACK
ALUNBRIG therapy pack QLALUNBRIG ORAL TABLET THERAPY PACK — QL (30 EA per 365 days)
ALUNBRIG tablet QLALUNBRIG ORAL TABLET 30 MG — QL (4 EA per 1 day)
PA indicatorALUNBRIG entries marked PA alongside QL in oncologic section.
inv-128: IMBRUVICA ORAL CAPSULE 140 MG
IMBRUVICA 140 mg QLIMBRUVICA ORAL CAPSULE 140 MG — QL (3 EA per 1 day)
IMBRUVICA other strengths70 mg listed with QL (1 EA per 1 day); multiple presentations marked PA; QL.
Oncology drug managementMany oncologic agents carry PA and QL restrictions to manage utilization.
inv-129: clozapine oral tablet 100 mg
clozapine 100 mg QLclozapine oral tablet 100 mg — QL (9 EA per 1 day)
Clozapine other strengthsMultiple clozapine strengths show QLs ranging 3–9 EA per day depending on formulation.
Section contextListed under Antipsychotics with QL to control dispensing frequency.
inv-130: aripiprazole oral solution
aripiprazole solution QLaripiprazole oral solution — QL (25 ML per 1 day)
Tablet QL comparisonAripiprazole oral tablet QL (1 EA per 1 day) — solution has an ML-based QL.
Claims noteFormulation-specific QLs require checking exact NDC/presentation on claim.
inv-131: BARACLUDE ORAL SOLUTION
BARACLUDE oral solution QLBARACLUDE ORAL SOLUTION — QL (630 ML per 30 days)
Formulation-specific limitLarge-volume antiviral oral solution given a monthly ML limit in the formulary.
PA/Ql flagsListed with QL and NPB tiering in antiviral section.
inv-132: SOVALDI oral packet/tablet
SOVALDI packet/tablet QLSOVALDI oral packet/tablet — QL (1–2 EA per 1 day) depending on formulation
PA requirementSOVALDI entries marked PA alongside QL in antiviral section.
Formulation dependencePacket vs tablet formulation drives daily EA allowance.
inv-133: PAXLOVID (150/100 & 300/100)
PAXLOVID dosing QLPAXLOVID (150/100) — QL (4 EA per 1 day); PAXLOVID (300/100) — QL (6 EA per 1 day)
Formulation-specific QLDifferent pack strengths have distinct per-day EA QLs.
SectionListed in antiviral / COVID-19 therapy entries with explicit per-day caps.
inv-134: FABHALTA
FABHALTA QLFABHALTA — QL (2 EA per 1 day)
PA statusListed with PA where applicable in blood products/modifiers section.
Therapeutic groupingAppears under Blood Products and Modifiers with utilization controls.
inv-135: CORLANOR ORAL SOLUTION
CORLANOR oral solution QLCORLANOR ORAL SOLUTION — QL (15 ML per 1 day)
PA/M flagsCORLANOR listed with PA; M; QL in cardiovascular section.
Claims implicationDaily ML limit enforced for solution vs tablet presentations.
inv-136: REPATHA SURECLICK
REPATHA SURECLICK QLREPATHA SURECLICK — QL (0.11 ML per 1 day)
REPATHA family QLsREPATHA PUSHTRONEX (0.13 ML per 1 day); REPATHA SURECLICK (0.11 ML per 1 day)
PA requirementREPATHA entries include PA alongside QL in formulary.
inv-137: dextroamphetamine sulfate oral solution
Dextroamphetamine solution QLdextroamphetamine sulfate oral solution — QL (60 ML per 1 day)
ADDERALL tablet QLADDERALL ORAL TABLET 10–20 mg — QL (3 EA per 1 day)
ER capsule examplesdextroamphetamine sulfate ER 10 mg — QL (1 EA per 1 day); 15 mg — QL (4 EA per 1 day)
inv-138: ADDERALL ORAL TABLET 10-20 mg
ADDERALL tablet QLADDERALL ORAL TABLET 10–20 mg — QL (3 EA per 1 day)
Step therapy flagADDERALL XR is listed with ST; QL (2 EA per 1 day) in other contexts.
Last updatedFormulary shows 'Last Updated Date: 05/30/2024' near ADHD entries.
inv-139: dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg
DEXTRO ER 10 mg QLdextroamphetamine sulfate ER 24‑hour 10 mg — QL (1 EA per 1 day)
DEXTRO ER 15 mg QLdextroamphetamine sulfate ER 24‑hour 15 mg — QL (4 EA per 1 day)
Multiple ER strengthsER strengths list distinct per‑day QLs to control daily total exposure.
inv-141: METHYLIN ORAL SOLUTION 10 MG/5ML
METHYLIN solution QLMETHYLIN ORAL SOLUTION 10 MG/5 ML — QL (30 ML per 1 day)
METHYLIN other concentrationMETHYLIN ORAL SOLUTION 5 MG/5 ML — QL (60 ML per 1 day)
ST flagMETHYLIN entries include ST; QL in ADHD section.
inv-142: MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 X 0.25 MG
MAYZENT starter pack QLMAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 x 0.25 mg — QL (24 EA per 365 days)
PA indicatorStarter packs are listed with PA; QL in MS therapies section.
Alternate pack sizes7‑count starter pack shows QL (14 EA per 365 days) where listed.
inv-143: DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 MG/1.14ML
DUPIXENT pen QLDUPIXENT SUBCUTANEOUS SOLUTION PEN‑INJECTOR 200 mg/1.14 mL — QL (0.17 ML per 1 day)
DUPIXENT 300 mg QLDUPIXENT pen or syringe 300 mg/2 mL — QL (0.29 ML per 1 day)
PA requirementDUPIXENT presentations marked PA; QL in formulary entries.
inv-146: DEXCOM G6 RECEIVER
DEXCOM G6 receiver QLDEXCOM G6 RECEIVER — QL (1 EA per 273 days)
DEXCOM G6 sensor QLDEXCOM G6 SENSOR — QL (0.1 EA per 1 day)
Device PA flagDEXCOM devices listed with PA; QL in device/monitoring kit section.
inv-147: DEXCOM G6 SENSOR
DEXCOM G6 sensor daily QLDEXCOM G6 SENSOR — QL (0.1 EA per 1 day)
Receiver cadenceReceiver QL expressed per 273 days (1 EA per 273 days) to limit replacements.
PA requirementBoth sensor and receiver entries show PA alongside QL in the table.
inv-148: SAMSCA / tolvaptan
SAMSCA / tolvaptan QLSAMSCA / tolvaptan — QL (2 EA per 1 day)
EVRYSDI QLEVRYSDI — QL (8 ML per 1 day)
GALAFOLD QLGALAFOLD — QL (0.5 EA per 1 day)
inv-149: EVRYSDI
EVRYSDI daily QLEVRYSDI — QL (8 ML per 1 day)
PA statusEVRYSDI listed with PA; QL in Genetic/Enzyme Disorder section.
Dose monitoringHigh per‑day ML limit — provider documentation expected for dosing.
inv-150: GALAFOLD
GALAFOLD QLGALAFOLD — QL (0.5 EA per 1 day)
PA indicatorGALAFOLD listed with PA; QL in genetic disorder agents.
Supply controlPer‑day EA limit used to control use of enzyme‑targeted therapies.
inv-151: ELIGARD SUBCUTANEOUS KIT 30 MG
ELIGARD kit daily QLELIGARD SUBCUTANEOUS KIT 30 MG — QL (0.009 EA per 1 day)
FIRMAGON annual QLFIRMAGON (240 mg dose) — QL (2 EA per 365 days)
TRELSTAR mixject examplesTRELSTAR MIXJECT items show small EA-per-day QLs (0.012, 0.006, 0.036 EA per day)
inv-153: ORILISSA ORAL TABLET 150 MG
ORILISSA 150 mg QLORILISSA ORAL TABLET 150 MG — QL (1 EA per 1 day)
ORILISSA 200 mg QLORILISSA ORAL TABLET 200 MG — QL (2 EA per 1 day)
PA flagORILISSA entries marked PA; QL in hormonal agents section.
inv-155: TRELSTAR MIXJECT items
TRELSTAR MIXJECT QL examplesTRELSTAR MIXJECT — QL values shown as 0.012 EA/day; 0.006 EA/day; 0.036 EA/day for different strengths
PA requirementTRELSTAR entries carry PA alongside QL in hormonal/injectable section.
Administration settingInjected depot products imply clinic administration or infusion‑center setting.
inv-156: ACTEMRA ACTPEN / ACTEMRA SUBCUTANEOUS
ACTEMRA QLACTEMRA ACTPEN / ACTEMRA SUBCUTANEOUS — QL (0.13 ML per 1 day)
ADALIMUMAB kit QLADALIMUMAB-ADBM (2 PEN) AUTO‑INJECTOR KIT 40 MG/0.4 ML — QL (0.15 EA per 1 day)
AMJEVITA QLAMJEVITA SOLUTION AUTO‑INJECTOR 40 MG/0.8 ML — QL (0.12 ML per day)
inv-159: CIMZIA
CIMZIA QLCIMZIA — QL (0.08 EA per day)
ENBREL QLENBREL entries — QL (0.15 ML per day)
HUMIRA QL rangeHUMIRA presentations — QL range 0.08–0.15 EA per day depending on presentation
inv-163: HUMIRA-PSORIASISIUVEIT STARTER
HUMIRA‑psoriasis starter QLHUMIRA‑PSORIASISIUVEIT STARTER — QL (3 EA per 365 days)
HYRIMOZ per‑day QLHYRIMOZ SOLUTION AUTO‑INJECTOR 40 MG/0.4 ML — QL (0.06 ML per 1 day)
HYRIMOZ presentation rangeHYRIMOZ presentations show 0.01–0.06 ML / 0.03–0.06 EA depending on formulation
inv-165: RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML
RASUVO 20 mg QL (28 days)RASUVO SUBCUTANEOUS SOLUTION AUTO‑INJECTOR 20 MG/0.4 ML — QL (1.68 ML per 28 days)
OTEZLA annual QLOTEZLA ORAL TABLET THERAPY PACK — QL (55 EA per 365 days)
Multiple strength entriesRASUVO also listed with QLs of 0.84, 1.12, 1.4 ML per 28 days for other strengths.
inv-167: STELARA SUBCUTANEOUS SOLUTION
STELARA QLSTELARA SUBCUTANEOUS SOLUTION — QL (0.009 ML per 1 day)
PA flagSTELARA entries include PA alongside QL in biologics section.
Dose unitsQLs for biologics commonly expressed in ML per day.
inv-168: KERENDIA
KERENDIA QLKERENDIA — QL (1 EA per 1 day)
methergine per fillmethergine / methylergonovine maleate oral — QL (28 EA per 1 fill)
ContextListed in miscellaneous and hormonal sections with explicit per‑day or per‑fill caps.
inv-170: guaifenesin-codeine / HYCODAN / hydrocodone solutions
Guaifenesin-codeine solution QLguaifenesin‑codeine / HYCODAN / hydrocodone solutions — QL (240 ML per 1 fill)
Promethazine-codeine similar QLpromethazine‑codeine oral solution — QL (240 ML per 1 fill)
High‑volume per‑fill controlLarge per‑fill ML caps used to control total dispensed liquid opioids/combination solutions.
inv-171: Multiple (see list)
Mixed examples summaryVaried QLs across respiratory and specialty sections: e.g., QL (0.27 GM per 1 day); QL (2 EA per 1 day); QL (4 ML per 1 day); QL (90 EA per 30 days)
Formulation-dependent unitsQL units vary by product (EA, ML, GM) and period (per day, per 30 days, per 365 days).
Provider actionVerify product‑level QL and include appropriate documentation if requesting override/PA.
inv-172: TOBI PODHALER
TOBI PODHALER QLTOBI PODHALER — QL (224 EA per 40 days)
Period-specific limitUnique 40‑day QL period applied to this inhaled antibiotic presentation.
SectionListed under respiratory/cystic fibrosis therapies with explicit multi‑day QL.
Specialty Medication Delivery and Administration Sites
Note
Note
Note
Policy Summary
PayerBlue KC
PolicyPrescription Drug List (PDL) and Pharmacy Services — Coverage Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateEffective January 1, 2024
Next Review DateN/A
Key ActionSubmit an electronic prior authorization request when a drug is marked PA to obtain coverage.
SourceLink
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