2025 Missouri ACA Prescription Drug List (HIX) — Small Group & Individual
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Provides the 2025 prescription drug formulary and related coverage rules for Blue KC Missouri ACA individual (non-standard) and small group (2-50) members, including tiering, prior authorization, step therapy, quantity limits, preventive drug indicators, and syringe/needle coverage.
No material clinical or coverage changes in this revision.
Formulary Coverage Criteria and Item Controls
Syringe and needle coverage rules
Covered when the following conditions are met:
ALL of the following
- Syringes and needles are covered by prescription only.
- Coverage is limited to members taking medications requiring injection.
- Techlite/Arkray supplies are covered at $0 cost; all other syringe/needle products are covered at a nonpreferred brand copay.
Tier exception and preventive drug coverage notes
Notes on preventive drug coverage and tier-exception process:
ALL of the following
- Members may request a tier exception to waive cost sharing for contraceptives or HIV PrEP medications not on the Preventive Service list; the member's physician must complete and submit the request online at bluekc.com.
- Tier exception requests are processed via online submission by the prescribing physician.
ALL of the following
- Preventive tobacco-cessation coverage: the plan provides two tobacco cessation attempts per year (including prescription and OTC medications) for a 90-day regimen when prescribed by an in-network provider.
- Preventive tobacco cessation medications may be covered at no cost under Routine Preventive Care; check member benefits for applicability.
Formulary coverage criteria by drug group
Formulary entries specify a Drug Category and Limits/Required actions which govern coverage and utilization management.
ALL of the following
- Nicotine cessation products: commonly Drug Category = 1; Limits/Required = PV; QL (180 EA per 365 days) or QL (180 ML per 365 days).
- Examples include bupropion hcl ER and multiple nicotine replacement products marked PV; QL (180 EA per 365 days).
ALL of the following
- Anticonvulsants and related agents: entries show varying Drug Category assignments and may list PA, ST, or QL (example: QL (2 EA per 1 fill)).
- BRIVIACT limits include ST; EPIDIOLEX listed with PA in the anticonvulsant section.
ALL of the following
- Drug Category codes used across the formulary include numeric categories 1–5 and LCG; Limits/Required indicates the applicable control(s) for each product.
Per-drug coverage controls appearing in this excerpt
Selected per-drug controls noted in the table-of-contents excerpt:
Formulary entries and limits
This fragment represents a table-of-contents-style listing where drug name, category, and Limits/Required are shown.
Per-product table entries specify drug category and any limits/requirements
Per-product table entries specify drug category and any limits/requirements (examples):
Coverage-related flags shown in the table for specific drugs
Coverage-related flags and quantity limits for selected drugs (examples):
Sample product control entries
Examples of product control entries from the biologics/toxicology sections:
Inline coverage flags and their meaning
Inline coverage flags used throughout the table-of-contents and their meanings:
Examples of control markers from the table-of-contents
Formulary control markers appearing in the TOC (partial examples):
Formulary entries and utilization controls
Formulary entries include drug name, drug category, and Limits/Required (may list PA, QL with specific limits, PV, or be blank).
ANY of the following
- Examples: ORENCIA prefilled syringes — PA; QL (0.15 ML per 1 day).
- BEYFORTUS intramuscular solution — PV; QL (2 ML per 300 days) or PV; QL (0.5 ML per 300 days).
- STELARA and similar immunomodulators — PA; QL with small ML-per-day measures specified.
listed_item_controls
Usage constraints and required actions are indicated alongside items in the table of contents:
ALL of the following
- Quantity limits examples: METHERGINE — QL (28 EA per 1 fill); CYSTADROPS — QL (0.72 ML per 1 day); BIMATOPROST — QL (0.1 ML per 1 day).
- Prior authorization examples: cyclosporine — PA; XIAFLEX — PA; ZOKINVY — PA; QL (4 EA per 1 day).
Partial coverage indicators and limits
Selected examples of limits and requirements from the drug table (partial):
Index-only - no coverage rules
Index entries — informational only; no coverage rules specified in these chunks.
Alphabetical/index listing of drugs referenced elsewhere; informational only
Alphabetical/index listing of drugs referenced elsewhere; informational only.
Member rights and available services for language and disability assistance
Accessibility and non-discrimination information for members:
Formulary Codes, Quantity Limits, and Examples
| PA | Prior Authorization |
| ST | Step Therapy |
| QL | Quantity Limit |
| PV | Preventive (may be $0) |
| QL (2 EA per 1 day) | Quantity limit example for bupropion hcl er (sr) |
| QL (3 EA per 1 day) | Quantity limit example for certain drugs listed in document |
| QL | Quantity Limit — example formats: '1 EA per 1 day', '4 EA per 30 days', '84 day supply per 180 days'. |
| PA | Prior Authorization required |
| ST | Step Therapy required |
| LCG | Local Coverage Group or similar internal code |
| QL | Quantity Limit (examples: 'QL (1 EA per 1 day)', 'QL (3 EA per 1 day)') |
| PA | Prior Authorization required (PA) noted for specific products |
| ST | Step Therapy required (ST) for specific products |
| QL | Quantity Limit (examples shown: e.g., 'QL (1 EA per 1 day)', 'QL (10 EA per 1 day)', 'QL (0.3 ML per 1 day)') |
| PA | Prior Authorization required |
| ST | Step Therapy |
| LCG | Limited Coverage Group / formulary designation (context-specific) |
| No CPT/HCPCS/ICD codes present in this excerpt; entries are drug names, categories, and limits. |
| PA | Prior Authorization required |
| QL | Quantity Limit (per day or per period), examples provided in parentheses |
| ST | Step Therapy |
| LCG | Limited Coverage Guidance |
| PV | Potentially a plan/vendor-specific designation (PV) used in limits |
| PA | Prior Authorization required |
| QL | Quantity Limit (with specification) |
| ST | Step Therapy |
| PV | Provider Verification / Pharmacy Verification |
| LCG | Limited Coverage Group / category code shown in list |
| 1-5, LCG, named categories | Internal drug category identifiers used in the formulary listing (e.g., 1, 2, 3, 4, 5, LCG, named categories like Hormonal Agents). |
| No codes listed |
| Drug Category = 1|2|3|4|5|LCG | Category assignments appear throughout (examples: Drug Category = 3, 2, 1, 4, 5, LCG). |
| Alphabetical drug index entries (partial) — demonstrates which drugs are included in this portion of the formulary/index. |
| No codes listed |
| Multiple product names and kit references listed (no standardized codes present in this excerpt). |
Quantity Limit Examples and Common Values
Authorization, Step Therapy, and Provider Verification Requirements
Prior Authorization required
PA = Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs; without approval the plan may not cover the drug.
Tier exception requests for contraceptives & PrEP
To request a tier exception to waive cost sharing for contraceptives or HIV PrEP not on the Preventive Service list, the member's physician must complete and submit the online tier‑exception request at bluekc.com.
- Applies to contraceptives and HIV PrEP preventive medications
- Physician must submit request online at bluekc.com
Formulary limits / requirement flags
Formulary entries use Limits/Required flags — PV (prior verification), QL (quantity limit), ST (step therapy), and PA (prior authorization) — to indicate utilization controls that may apply to a drug.
- PV indicates plan/pharmacy verification or preventive designation
- QL denotes numeric quantity limits (e.g., per day or per 365 days)
- ST denotes step therapy requirements
- PA denotes prior authorization is required
PA indicated on formulary drug list
Multiple products in the drug list are marked with 'PA', indicating prior authorization is required for coverage (examples include dronabinol and many high‑cost specialty agents listed throughout the TOC).
- Dronabinol — Limits/Required = PA (see therapy adjuncts)
- Specialty/genetic drugs (e.g., CERDELGA, CHOLBAM) — Limits/Required = PA
- Cystic fibrosis agents (e.g., KALYDECO, ORKAMBI) — Limits/Required = PA
Quantity limits (QL) defined on entries
Quantity limits (QL) are specified for many products and are shown as numeric constraints (examples in the formulary include per‑day or per‑period values such as QL (2 EA per 1 day), QL (4 EA per 30 days), and annual limits like QL (180 EA per 365 days)).
- Examples: QL (2 EA per 1 day); QL (4 EA per 30 days); QL (180 EA per 365 days)
- Some supplies show fill‑frequency constraints (e.g., QL 2 fill per 365 days)
Follow Limits/Required indicators in formulary table
Formulary table entries include utilization controls such as PA (prior authorization), ST (step therapy), and PV (pharmacy/provider verification) next to product names — providers must follow these indicated authorization actions for affected agents.
- PV may denote vaccine/program or preventive designation requiring verification
- ST indicates a required trial of preferred agents before coverage of non‑preferred agents
- PA indicates prior authorization must be obtained before fill
PA required for CGM devices and sensors
Continuous glucose monitoring devices and related transmitters/sensors (examples: DEXCOM G6/G7 devices and GUARDIAN sensors/transmitters) are flagged 'PA' in the formulary; obtain prior authorization before ordering/dispensing these devices.
- DEXCOM G6 Receiver/Sensor/Transmitter — Limits/Required = PA
- DEXCOM G7 devices and sensors — Limits/Required = PA
- GUARDIAN 4 Sensor/Transmitter — Limits/Required = PA
PA required for blood/hematology and biologic agents
High‑cost biologics and hematology/blood formation agents are designated with 'PA' in the formulary; providers must secure prior authorization for these agents before administration or dispense.
- Examples: ARANESP, NEULASTA, PROMACTA, NEULASTA ONPRO — Limits/Required = PA
- Many immunomodulators and specialty injectables (e.g., ORENCIA, ACTEMRA) have PA and QL flags
Authorization and QL indicators present in TOC
The Table of Contents shows PA, ST and QL indicators alongside many drug entries (for example, ENTRESTO entries show QL; REPATHA shows ST and QL; multiple MS agents are marked PA). Review the TOC flags to determine required prior authorization, step therapy, or quantity limits for a given product.
- ENTRESTO — QL examples shown
- REPATHA / REPATHA SURECLICK — ST; QL (0.11 ML per 1 day)
- Several MS agents — PA and QL noted
PA plus quantity limits on select biologics
Some products listed in the TOC explicitly combine prior authorization and quantity limits (e.g., DUPIXENT and TALTZ show PA and QL); secure authorization and adhere to the stated QL when prescribing or dispensing these agents.
- DUPIXENT prefills — Limits/Required = PA; QL (per day values shown)
- TALTZ prefilled syringes — Limits/Required = PA; QL (per day values shown)
Step therapy (ST) entries — follow trial requirements
Some agents are subject to Step Therapy (ST) or LCG designations in the formulary; follow step‑therapy requirements (trial of preferred agents) before submitting for non‑preferred product coverage.
- Examples: pimecrolimus — Limits/Required = ST
- LINZESS — Limits/Required = ST; QL (1 EA per 1 day)
PA for specialty/genetic enzyme disorder drugs
Several specialty and genetic/enzyme disorder therapies are marked 'PA' in the list (e.g., CERDELGA, CHOLBAM, EVRYSDI); providers must request prior authorization for these therapies before treatment.
- CERDELGA, CHOLBAM — Limits/Required = PA
- EVRYSDI ORAL SOLUTION — Limits/Required = PA; QL (8 ML per 1 day)
Observe QL and fill‑frequency constraints
The formulary lists quantity limits and fill frequency constraints for many products (examples: QL (1 EA per 1 day); QL (8000 ML per 365 days); QL (2 fill per 365 days)). Ensure prescribed quantities and refill timing comply with the stated QL.
- Many laxative and electrolyte preparations show PV plus QL (e.g., gavilyte-c QL 8000 ML per 365 days)
- Some products restrict fills per 365‑day period (e.g., 2 fill per 365 days)
PA required for select specialty/injectable therapies
Numerous specialty and injectable therapies are listed with Limits/Required = PA (examples include LUPRON DEPOT‑PED and octreotide formulations); obtain prior authorization per the formulary before administration or billing.
- LUPRON DEPOT‑PED (3‑month and 6‑month) — Limits/Required = PA
- Octreotide acetate injections/subcutaneous — Limits/Required = PA
Pharmacy verification (PV) and QL for contraceptives
Many oral contraceptives and related products show PV (pharmacy verification) and may include QL; pharmacies/providers must perform the indicated verification and adhere to quantity rules when dispensing contraceptives.
- Numerous contraceptive products list Limits/Required = PV
- Selected contraceptives also include QL (e.g., 1 EA per 1 day)
General prior authorization requirement
Across the formulary many listed drugs include 'PA' in the Limits/Required field indicating prior authorization is required for coverage. Providers should check the TOC entry for PA flags before prescribing.
- PA is used broadly across therapeutic classes to control access to specific drugs
- If PA is not obtained the plan may deny coverage
PV designation for vaccines/devices (verification)
Some vaccines and devices are marked 'PV', indicating program or vaccine‑specific processing or pharmacy/provider verification is required prior to dispensing; follow PV processing instructions where indicated.
- BEYFORTUS intramuscular syringes show PV with QL examples
- PV flags appear on vaccine/device entries in the TOC
Prior authorization example — cyclosporine
Example: cyclosporine appears in the formulary with Limits/Required = PA; prior authorization must be obtained for coverage of cyclosporine as indicated.
- Cyclopsorine listed with Limits/Required = PA in the TOC
Quantity limits noted (examples)
Multiple items include Limits/Required = QL indicating quantity limits apply (examples: METHERGINE QL (28 EA per 1 fill); CYSTADROPS QL (0.72 ML per 1 day)). Prescribers must follow these QL values when authorizing therapy.
- METHERGINE — QL (28 EA per 1 fill)
- CYSTADROPS — QL (0.72 ML per 1 day)
Additional PA indicators — partial list
The formulary includes many additional PA examples in limits/required fields (partial list includes KALYDECO, ORKAMBI, ADEMPAS, ambrisentan, bosentan) — confirm PA requirements for these agents before prescribing or billing.
- KALYDECO — Limits/Required = PA
- ORKAMBI — Limits/Required = PA; QL shown
- ADEMPAS — Limits/Required = PA; QL (3 EA per 1 day)
Drug index is informational (no authorization rules)
The alphabetical drug and device index is informational only and does not contain coverage or authorization rules; use the TOC entries to identify PA, ST, PV, or QL requirements for specific products.
- Index entries list product names and page references
- Authorization flags are shown in the TOC, not the index
Use drug index for reference; confirm rules in TOC
The drug index pages list product names for reference; they do not replace the Table of Contents where Limits/Required flags (PA, QL, ST, PV) are indicated — check the TOC for authorization and quantity rules.
- Index provides quick lookup of drug names
- Authorization and QL flags must be confirmed in the TOC entries
Drug Index Listing — reference only
The continuation of the drug index reiterates that index listings are for reference only and do not show prior authorization or quantity‑limit rules — always consult the TOC entries for required authorizations and limits.
- Index spans multiple chunks/pages; no Limits/Required data in index entries
- TOC entries contain the operational flags to follow
Formulary Abbreviations and Key Terms
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