CurrentBlue KCPolicy N/A

Kansas ACA Individual Standard Plan — Prescription Drug List (Formulary) — 2025

Lists covered prescription drugs, tiering, utilization management codes (PA, ST, QL), preventive drug indications, syringe/needle rules, and member exception pathway for contraceptives & PrEP for Kansas members.

Policy Summary

PayerBlue KC

PolicyKansas ACA Individual Standard Plan Prescription Drug List (Formulary) — 2025

Policy CodePolicy N/A

Change TypeNo material changes noted in this revision

Effective DateN/A

Next Review DateN/A

Key ActionPhysician must submit tier-exception requests online at bluekc.com to waive cost sharing for contraceptives or HIV PrEP when medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025plan year

10/14/2025document updated

PA, ST, QL, PVutilization flags

prescription-onlysyringes/needles

contraceptives & PrEPexception pathway

Part 2 of 15

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Formulary Coverage Rules and Examples

inv-01: Syringe/Needle Coverage

Covered when prescribed for members requiring injections; cost distinctions noted.

Syringes and needles require a prescription and are covered only for members taking medications that require injection.

Techlite/Arkray syringe and needle supplies are covered at $0 cost when prescribed.

All other syringe/needle products are covered at the non-preferred brand copay when prescribed.

inv-02: Tier Exception Requests for Contraceptives & PrEP

Exception pathway to waive cost sharing for contraceptives and HIV PrEP not listed as preventive.

Members may request a tier exception to waive applicable cost sharing for contraceptives or HIV PrEP medications that are not included on the Preventive Service list(s).

The member's physician must complete and submit the exception request online at bluekc.com.

inv-03: PA/ST/QL Usage in Formulary

Utilization management codes used in the formulary and how they appear in the tables.

PA (Prior Authorization): The plan requires prior approval for certain drugs; entries marked 'PA' in the Limits/Required column require authorization before coverage.

ST (Step Therapy): Entries marked 'ST' indicate a step-therapy requirement (member must try specified first-line drugs before alternatives).

QL (Quantity Limit): Entries marked 'QL' specify maximum quantities and timeframes (examples include EA per day, ML per day, day-supply per X days).

inv-04: Sample coverage entries from extract

Examples from the extract showing per-product coverage stance and flags.

XIFAXAN ORAL TABLET 550 MG is listed with 'PA' indicating prior authorization is required.

inv-05: Limits/Requirements flags (TOC level)

TOC-level summary of limits/requirement flags visible next to drug groups and products.

Entries in the table of contents show Limit/Required flags such as PA, QL, ST and PV adjacent to drug names (examples include itraconazole and voriconazole shown with 'PA').

Many specialty agents (e.g., AIMOVIG, EMGALITY, TAFINLAR, TAGRISSO) are shown with PA and/or QL in the Limits/Required column.

inv-06: Coverage stance for listed products

Coverage stance and utilization controls applied to listed drugs and devices in this excerpt.

Examples

Antipsychotics (e.g., asenapine, quetiapine) include quantity limits and in some cases step therapy.
Selected HCV agents (EPCLUSA, HARVONI, MAVYRET) are listed with PA and QL requirements.
CGM devices and components (e.g., DEXCOM G6/G7, GUARDIAN sensors/transmitters) are listed with 'PA' indicating prior authorization is required.

inv-07: Table-referenced coverage controls

Controls referenced in the table of contents with example products affected.

PA is indicated for multiple diabetes monitoring devices and certain injectable antidiabetics (e.g., DEXCOM G6/G7 receivers and sensors; liraglutide, MOUNJARO).

QL entries specify product-specific limits (examples: CONTOUR test strips QL 10 EA per 1 day; OZEMPIC QL expressed as ML per day).

ST is indicated for select diabetes agents (examples include GLYXAMBI, JARDIANCE listed with ST where noted).

inv-08: Examples of listed coverage indicators

How coverage indicators appear on individual biologic and specialty agents in the TOC.

REPATHA and REPATHA SURECLICK are listed with 'ST' and a QL (0.11 ML per 1 day) indicating step therapy and quantity limits apply.

inv-09: Partial formulary entries with authorization/limits

Partial formulary lines showing authorization and quantity-limit annotations.

Selected injectable and topical products are listed with PA and QL annotations (examples: EBGLYSS marked 'PA; QL (0.15 ML per 1 day)'; isotretinoin entries show 'PA; QL (0.01 ML per 1 day)' in this extract).

inv-10: Step therapy and quantity-limited agents

Examples where step therapy is specified for agents in this extract.

Prucalopride succinate and SYMPROIC are listed with 'ST' and QL (1 EA per 1 day), indicating step therapy plus quantity limits where applicable.

LINZESS is listed with 'ST; QL (1 EA per 1 day)' demonstrating an ST requirement and a per-day quantity limit.

inv-11: Coverage annotations present

Common coverage annotations used and representative examples from specialty and contraceptive sections.

PA denotes prior authorization required for coverage (examples: CERDELGA, CHOLBAM, many specialty genetic disorder drugs).

QL denotes quantity limits with examples such as EVRYSDI QL (8 ML per 1 day) and GALAFOLD QL (0.5 EA per 1 day).

PV denotes preventive or preferred/variant designation used across contraceptive and vaccine listings (many contraceptives are flagged 'PV' and some include QL).

inv-12: Per-product coverage indicators (index)

Per-product TOC examples showing category numbers and limit/requirement flags.

Contraceptive products are frequently flagged 'PV' in the table of contents; some also include QL (examples: ANNOVERA PV; QL 1 EA per 350 days; certain products listed as PV with per-day limits).

Some reproductive/infertility agents (e.g., cetrotide, leuprolide depot, LUPRON DEPOT entries) are shown with PA in the Limits/Required column.

inv-13: Coverage listings and administrative controls (partial)

Partial listing of biologic/immune agents showing PA and quantity limits.

Many biologic and immunomodulator products are listed with 'PA' and numeric QL entries (examples: ADALIMUMAB-ADBM with PA; QL (0.08 EA per 1 day); ACTEMRA with PA; QL (0.13 ML per 1 day)).

Note: full coverage determination and clinical criteria are found in the detailed formulary pages referenced by these entries.

This segment is partial; full clinical criteria for PA/ST are not present in these extract chunks.

inv-14: Formulary entries with administrative constraints

Examples of entries that include administrative flags and quantity limits in ophthalmic, bone, and other categories.

Representative entries

PROLIA is listed with 'PA; QL (2 ML per 250 days)'.
CYSTADROPS is listed with QL (0.72 ML per 1 day).
Alendronate sodium entries show QL annotations (e.g., 0.15 EA per 1 day for certain presentations).

Many entries in these categories display a Drug Category number plus a Limits/Required field (PA, QL, or other flags); the extract does not include full clinical criteria or step pathways.

inv-15: Coverage stance entries

Summary of utilization controls and example drug groups in this document segment.

Groups and controls

Ophthalmic agents: multiple products list QL values (examples: RHOPRESSA QL 0.1 ML/day; bimatoprost QL 0.1 ML/day).
Otic agents: antibiotics and steroid combinations listed with Drug Category and some QL entries.
Respiratory and pulmonary agents: several high-cost agents require PA and many have QL (examples include NUCALA with PA indicated).
Sleep/wake agents: some entries indicate ST and/or QL (e.g., BELSOMRA listed with ST where noted).

An alphabetical index is provided separately; index segments in this extract do not include authorization details.

inv-16: Index-only — no coverage criteria

This index window contains only drug names and page/index pointers; no coverage criteria are present here.

Index entries list drug names and page references only; coverage determination (e.g., PA, ST, QL) must be taken from the detailed formulary pages referenced by these index entries.

inv-17: Index-only (no coverage rules)

Index-only excerpts—coverage rules are not included in these chunks.

These index excerpts contain drug names with reference numbers; they do not include Limits/Required flags or coverage criteria in this segment.

inv-18: Index-only segment; no coverage criteria

Alphabetical index segment without coverage details; reference to main formulary required for coverage determinations.

This segment is an alphabetical index of drug names; coverage details, utilization controls, and clinical criteria are not provided in these chunks and must be obtained from the main formulary sections referenced.

Formulary Flags, Codes, and Quantity Limits

Prior Authorization, Step Therapy, and Provider Guidance

Prior Authorization

Prior Authorization Required

PA: XIFAXAN ORAL TABLET 550 mg is listed as requiring prior authorization. Ensure PA is obtained before dispensing to avoid non-coverage.

Drug example: XIFAXAN 550 mg — Limits/Required = PA

Prior Authorization

CGRP & Migraine Agents — PA and Quantity Limits

Several CGRP and other migraine agents require prior authorization and have quantity limits. Examples include AIMOVIG, AJOVY, EMGALITY, NURTEC, QULIPTA, UBRELVY and dihydroergotamine formulations — most entries list PA and per-day QL values.

AIMOVIG (various presentations) — PA; QL (0.04–0.07 mL per day depending on presentation)
AJOVY — PA; QL (0.06 mL per day)
EMGALITY (prefilled syringe and auto-injector) — PA; QL (0.04–0.1 mL per day)
NURTEC — PA; QL (0.54 EA per day)
QULIPTA — PA; QL (1 EA per day)

Abbreviations and Formulary Terminology

Policy Summary

PayerBlue KC

PolicyKansas ACA Individual Standard Plan Prescription Drug List (Formulary) — 2025

Policy CodePolicy N/A

Change TypeNo material changes noted in this revision

Effective DateN/A

Next Review DateN/A

Key ActionPhysician must submit tier-exception requests online at bluekc.com to waive cost sharing for contraceptives or HIV PrEP when medically necessary.

SourceLink

On This Page

UBRELVY — PA; QL (0.54 EA per day)

Dihydroergotamine mesylate injection — PA; QL (0.86 mL per day)

Prior Authorization

Oncology Agents — Prior Authorization

Many oncology (antineoplastic and targeted) therapies require prior authorization; several also have quantity limits. Examples include TAFINLAR, TAGRISSO, TASIGNA, TUKYSA, TURALIO, VENCLEXTA, XALKORI, ZELBORAF, ZYDELIG, ZYKADIA and multiple others.

TAFINLAR — Limits/Required = PA
TAGRISSO 40 mg & 80 mg — PA; 40 mg entry includes QL (1 EA per day)
VENCLEXTA (and starting pack) — PA
XALKORI — PA
Multiple other listed antineoplastics — PA

Prior Authorization

CGM Devices and Components — Prior Authorization

Certain continuous glucose monitoring (CGM) devices and components require prior authorization. This includes Dexcom G6 and G7 receivers, sensors and transmitters, as well as Guardian sensors and transmitters.

DEXCOM G6 Receiver, Sensor, Transmitter — Limits/Required = PA
DEXCOM G7 Receiver, 15-day Sensor — Limits/Required = PA
GUARDIAN 4 Glucose Sensor, Guardian 4 Transmitter, Guardian Link 3 Transmitter — Limits/Required = PA

Note

Authorization Indicators in Formulary

The formulary uses several authorization indicators: PA = Prior Authorization required; ST = Step Therapy required; QL = Quantity Limit; PV = Preferred/Variant (including preventive/$0 designations). Review the Limits/Required column for the applicable flags on each product.

PA — prior authorization required before coverage
ST — step therapy required; alternate agents may be required first
QL — quantity limits, often shown as amount per day/period
PV — preferred/variant; may indicate preventive or $0 copay when applicable

Note

Contraceptives & Hormonal Agents — PV and Quantity Limits

Contraceptives and hormonal agents in the formulary are often marked PV (preferred/variant); some products include quantity limits or PA for specific formulations (for example, ANNOVERA marked PV with QL; select IUDs/implants marked PV).

Many combined oral contraceptives — Limits/Required = PV
ANNOVERA — PV; QL (1 EA per 350 days)
CRINONE vaginal gel 8% — Limits/Required = QL (0.6 GM per day)
Medroxyprogesterone acetate intramuscular (DEPO-SUBQ PROVERA 104) — QL (0.02 mL per day)

Prior Authorization

Prior Authorization Required — Multiple Drugs

Numerous additional drugs across therapeutic classes show Prior Authorization in the Limits/Required column — examples span specialty, orphan, injectables, and high-cost therapies. Check the formulary listing for PA flags before prescribing or dispensing.

Leuprolide acetate injection and multiple LUPRON DEPOT presentations — Limits/Required = PA
Specialty biologics and enzyme replacement therapies (examples listed throughout) — Limits/Required = PA
Many immunomodulators and infused/subcutaneous biologics — Limits/Required = PA; often with QL

Prior Authorization

Selected Prior Authorization Examples

The listing includes many specific PA examples across categories (e.g., cystic fibrosis agents, pulmonary and specialty respiratory drugs, biologics). Review the Limits/Required column for product-specific prior authorization requirements and quantity limits.

KALYDECO — Limits/Required = PA
ORKAMBI (various presentations) — PA; some entries include QL
PULMOZYME — PA

Step Therapy

Step Therapy — Examples

Step therapy is used for select products. Example: BELSOMRA (suvorexant) and certain antipsychotics require step therapy before coverage; other agents (e.g., some antidiabetics and migraine adjuncts) also show ST flags.

BELSOMRA — Limits/Required = ST; QL (1 EA per day)
FANAPT and FANAPT titration packs — Limits/Required = ST; QLs specified
GLYXAMBI, JARDIANCE — ST indicated for select antidiabetic agents

Note

Drug Index — Reference Only (no authorization details in index)

The formulary includes an alphabetical drug index and multiple index sections that list drug names with page references but do not provide authorization details within the index. Use the index to locate the detailed formulary entries where Limits/Required flags appear.

Index entries (e.g., abacavir sulfate, abigale, ABILIFY MAINTENA, abiraterone acetate, etc.) provide page references only
Refer from index to formulary entries to view PA/ST/QL/PV annotations