Prescription drug formulary and benefit rules
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Governs coverage, tiering, prior authorization, step therapy, and quantity limits for prescription drugs and related supplies for Blue KC members as reflected in the drug benefit schedule and formulary lists. Affects Blue KC members, prescribing providers, and pharmacies.
No material clinical or coverage changes in this revision.
Coverage Criteria & Formulary Stance
High-level coverage stance
Coverage and member cost sharing are determined by the member certificate benefit schedule and formulary; certain items have special coverage rules or exception processes.
Special provisions
- Tier Exception Requests: If for medical reasons a contraceptive or HIV PrEP medication is not included on the Preventive Service list, a member may request an exception to waive otherwise applicable cost sharing; the member's doctor must complete and submit the request online at bluekc.com.
- Syringe and Needle Coverage: Syringes and needles are covered by prescription only, and only for members taking medications requiring injection; Techlite/Arkray supplies are covered at $0 and other syringe/needle products are covered at a non-preferred brand copay.
Refer to the formulary listing and detailed policy sections for per-product utilization controls (PA, QL, PV, ST) and exact coverage rules.
Tier Exception Requests for Contraceptives & HIV PrEP
Tier exceptions are available for select preventive medications.
Syringe and Needle Coverage
Coverage for syringes and needles is limited and subject to prescription requirements.
excerpt coverage annotations
Selected coverage-related annotations visible in this excerpt (partial):
Quantity limits (examples)
- Morphine sulfate oral tablet 30 mg — Limits Required = QL (3 EA per day).
- Buprenorphine sublingual formulations — Limits Required examples include QL (12 EA per 1 day) and QL (3 EA per 1 day).
- Linezolid oral tablet — Limits Required = QL (28 EA per 30 days).
- Memantine HCl ER — Limits Required = QL (1 EA per 1 day).
Prior authorization (examples)
- XIFAXAN ORAL TABLET 550 MG — marked as PA.
- EPIDIOLEX — Limits Required = PA.
Step therapy / PV flags
- NICOTROL / NICOTROL NS — Limits Required = ST (step therapy) indicated in listing.
- Certain smoking-cessation and contraceptive products — Limits Required = PV (verification/coverage flag) and may include QL annotations (e.g., nicotine products with QL (180 EA per 365 days)).
Sample coverage nodes from listed controls
Listings show drug-specific utilization controls; where PA is indicated, prior authorization is required before coverage.
Summary of controls in TOC
Formulary control indicators shown in the Table of Contents (indicative only; refer to the detailed policy sections for complete criteria):
Utilization control summary from table
Utilization controls shown in the list (examples):
Controls shown
- PA: Prior authorization required for listed drugs (examples in TOC include maraviroc and certain CGM devices marked PA).
- QL: Quantity limits specified with explicit limits and timeframes (examples include 'QL (1 EA per day)', 'QL (40 EA per 365 days)', 'QL (360 ML per 365 days)').
- ST: Step therapy required for select agents (e.g., JANUMET, JANUMET XR, JANUVIA, JENTADUETO and related entries indicate 'ST').
These are illustrative examples from the TOC; consult each detailed product section for the full criteria and documentation required for authorization or exception requests.
Formulary controls (index)
Formulary control indicators present in this excerpt (index entries and TOC fragments):
Coverage stance from table entries
Table entries indicate coverage status via utilization controls. Items shown with 'PA' or 'QL' imply coverage is subject to authorization or quantity limits.
Formulary limits and flags (excerpt)
Formulary entries and their associated limits/flags (excerpt):
ANY of the following
- GATTEX — Limits Required = PA (example of PA flag applied to gastrointestinal agent).
- LINZESS — Limits Required = ST; QL (1 EA per 1 day) (example of step therapy with quantity limit).
- Rabeprazole sodium oral tablet delayed — Limits Required = QL (1 EA per day) (example of QL for proton pump inhibitor).
These nodes are illustrative product-level entries extracted from the TOC; full coverage criteria and any clinical documentation requirements are defined in the detailed policy sections.
Coverage controls in table of contents
Listing of drugs with associated coverage-control flags; presence of PA/PV/QL implies managed coverage requiring authorization or limits.
Administrative controls (PA/PV/QL)
Administrative coverage controls shown in the Table of Contents entries
ANY of the following
- Prior Authorization (PA): noted for many products (examples: LUPRON DEPOT entries, octreotide acetate, SIGNIFOR) indicating PA is required before coverage is approved.
- Quantity Limits (QL): specific QL values appear alongside product entries (examples: SIGNIFOR = QL (2 ML per 1 day); OTEZLA = QL (2 EA per 1 day) and therapy pack limits).
- Prior Validation (PV): certain vaccines and contraceptives are marked PV (e.g., BEYFORTUS, ACTHIB, FLUARIX) indicating a prospective validation or verification workflow rather than standard PA.
Presence of these flags in the TOC signifies administrative controls; consult product-specific criteria for clinical or documentation requirements for authorization or validation.
coverage_flags_and_limit_rules
This section is a table-of-contents-style listing of drugs/devices with assigned categories and limit/authorization flags; specific coverage criteria are indicated by those flags and per-product QL values.
Drug Category codes categorize products but coverage status depends on Limits Required flags and underlying policy criteria.
Utilization controls (partial)
Utilization controls noted for specific drugs in the index (partial):
ANY of the following
- Cystic fibrosis agents: KALYDECO — Limits Required = PA; ORKAMBI — Limits Required = PA; QL values shown for ORKAMBI formulations (e.g., QL (2 EA per 1 day) and QL (112 EA per 28 days)).
- Pulmonary antihypertensives (e.g., ADEMPAS, ambrisentan, bosentan) — listed with PA and product-specific QL values (examples shown in TOC).
- Biologics and specialty agents (e.g., NUCALA) — Limits Required = PA and may include QL (per day) specifications for particular presentations.
These entries are partial TOC extracts; review the full product policy sections for clinical criteria, dosing and documentation needed for authorization or dispensing within QL limits.
Table of Contents — no coverage criteria in excerpt
No coverage criteria or decision nodes are present in this excerpt. Refer to the corresponding detailed sections (pages/indices referenced in the full document) for coverage rules.
Index entries
Table of contents entries (informational):
Accessibility and Language Services
Member rights and assistance information included in the document context.
Formulary Codes, Flags, and Quantity Limits
| PV | Available at $0 if Health Care Reform copay waiver is approved |
| PA | Prior Authorization required |
| ST | Step Therapy required |
| QL | Quantity Limit applies |
| No codes listed |
| QL | Quantity Limit (examples: QL (3 EA per day), QL (12 EA per 1 day), QL (2 EA per 1 day)) |
| PA | Prior Authorization required (examples: XIFAXAN 550 mg marked PA; EPIDIOLEX marked PA) |
| PV | Program/verification flag (appears with smoking cessation products) |
| ST | Step therapy requirement (appears for NICOTROL, NICOTROL NS) |
| QA | Quantity limits denoted as QL (example formats shown: 'QL (1 EA per 1 day)', 'QL (84 EA per 180 days)') |
| PA | Prior authorization required as indicated by 'Limitsl Required = PA' |
| ST | Step therapy required as indicated by 'Limitsl Required = ST' |
| Drug names and strengths as listed in the Table of Contents; no billing codes provided in this excerpt |
| ALECENSA | Listed in TOC with Limits Required = PA (no CPT/HCPCS/NDC provided in excerpt) |
| BOSULIF | Listed in TOC with Limits Required = PA (no CPT/HCPCS/NDC provided in excerpt) |
| CABOMETYX | Listed in TOC with Limits Required = PA (no CPT/HCPCS/NDC provided in excerpt) |
| PA | Prior Authorization required (as noted in Limitsl Required field) |
| QL | Quantity Limit (example: 'QL (1 EA per day)' or 'QL (40 EA per 365 days)') |
| ST | Step Therapy required (noted as 'ST' in Limitsl Required) |
| No billing or procedure codes provided in this excerpt; entries are formulary drug names, categories, and utilization controls. |
| 1-4 | Drug Category levels shown in the table (e.g., 1, 2, 3, 4) used to classify drugs |
| PA; QL | Examples: SKYRIZI, SPEVIGO, STELARA entries show PA; QL values in TOC (no billing codes in excerpt) |
| Multiple strengths and formulations of levothyroxine and related thyroid products are listed (strengths enumerated); no procedure codes provided in excerpt |
| levo-t / levothyroxine / unithroid / levoxyl | Various oral tablet strengths enumerated in TOC (no CPT/HCPCS/NDC codes in excerpt) |
| QL examples | Quantity limits annotated in TOC (examples: QL (55 EA per 365 days) for OTEZLA therapy pack; QL (1 EA per 1 day) for RINVOQ) |
| PV | PV noted for many vaccines in TOC (e.g., FLUARIX, FLUCELVAX) |
| QL | Quantity Limit — value specified per product (e.g., QL (0.1 ML per 1 day), QL (18 ML per 1 day)) |
| PA | Prior Authorization required for some products (e.g., XIAFLEX, PULMOZYME, KALYDECO) |
| PV | Coverage/verification flag used on several items (e.g., condoms, diaphragms, PARAGARD) |
| ST | Step therapy flag present for select products (e.g., zileuton er = ST) |
| QL (2 EA per 1 day) | Quantity limit for ORKAMBI oral packet 75-94 mg |
| QL (112 EA per 28 (days) | Quantity limit for ORKAMBI oral tablet |
| QL (3 EA per 1 day) | Quantity limit for ADEMPAS |
| This section is a listing of drug names and product variants; no specific billing or diagnosis codes provided in these chunks. |
| No billing or procedure codes present in these chunks; content is a TOC of drug/product names and page/index references |
Provider Requirements, Prior Authorization & Step Therapy
Provider Requirements — Prior Authorization, Step Therapy & Quantity Limits
PA = Prior Authorization: The Plan requires prior authorization for many listed drugs, devices and supplies. Lack of prior authorization may result in noncoverage. PV = Prior Validation/Verification: Items marked PV require coverage verification (examples include certain vaccines, contraceptives, and OTC devices). ST = Step Therapy: The Plan may require trial of specified first‑line agents before covering alternatives. QL = Quantity Limit: The Plan limits the amount and/or frequency of coverage for specified products.
- PA examples (partial): XIFAXAN; many Molecular Target Inhibitors (ALECENSA, BOSULIF, CABOMETYX, CAPRELSA, COMETRIQ, COTELLIC, dasatinib, ERIVEDGE, etc.); specialty biologics (REPATHA, DUPIXENT, NUCALA, NUCALA presentations, ILARIS, ACTEMRA, BENLYSTA, GAMMAGARD, HIZENTRA, etc.); selected antiemetics and antiinfectives; select pulmonary antihypertensives (ADEMPAS, TYVASO, VENTAVIS, sildenafil/tadalafil for PAH); cystic fibrosis agents (KALYDECO, ORKAMBI); selected oncology and orphan agents (XIAFLEX, ZOKINVY).
- PV examples (partial): nicotine replacement products and many contraceptive/barrier items (PARAGARD = PV; WIDE‑SEAL DIAPHRAGMS = PV); BEYFORTUS presentations (PV; QL); various laxative OTC items flagged PV with annual fill limits.
- ST examples (partial): Certain dermatologic and specialty topical products and some neurology/other agents are noted with ST flags in the Table of Contents.
- QL examples: A wide range of drugs and devices include specific quantity limits such as: aprepitant capsules (QL per 30 days), ondansetron oral solution QL (4 mL/day), granisetron QL, terbinatine oral QL (84 EA per 180 days), CONTOUR/TEST STRIPS QL (10 EA per day), many CGRP migraine therapies with per‑day/per‑dose QLs, NUCALA QL (0.11 mL per day or other presentations), REPATHA QL (0.11–0.13 mL per day), SIGNIFOR QL (2 mL per day), BEYFORTUS QL (per 300 days), ADEMPAS QL (3 EA per day), TYVASO/VENTAVIS QLs, and numerous others.
- CGRP migraine therapies: AIMOVIG, AJOVY, EMGALITY, NURTEC and others appear with PA and/or QL flags (examples: AIMOVIG PA; QL per day, AJOVY PA; QL, NURTEC PA; QL).
- Durable medical devices and continuous glucose monitoring (CGM): Multiple device entries are marked PA under Limits/Required — examples include DEXCOM G6/G7 receiver, sensor and transmitter (PA), GUARDIAN sensors/transmitters (PA), and select insulin pump/CGM pods and kits. Prior authorization is required for many DME/CGM components.
- Table of Contents indicators: The Table of Contents repeatedly annotates Limit requirements for many entries (PA, PV, ST, QL). Providers should consult the formulary TOC for specific flags per product and formulation.
- Specific product examples (partial): • Ondansetron oral solution QL (4 mL/day). • Aprepitant oral capsule QL (1–4 EA per 30 days depending on strength). • Metyrosine: PA; QL (16 EA per day). • VYNDAMAX: PA; QL (1 EA per day). • REPATHA and REPATHA PUSHTRONEX: PA; QL (0.11–0.13 mL per day). • DUPIXENT, SKYRIZI: PA; QL (per‑day mL limits). • KALYDECO, ORKAMBI: PA; ORKAMBI QL examples (2 EA per day; 112 EA per 28 days listed).
- Pulmonary antihypertensives: Agents such as ADEMPAS, TYVASO (multiple kit/refill designations), VENTAVIS, TRACLEER, treprostinil, sildenafil/tadalafil for PAH are annotated PA and often include explicit QLs (EA or mL per day).
- Biologic examples: NUCALA products, ACTEMRA, BENLYSTA, ILARIS and multiple immunoglobulin products (GAMMAGARD, GAMUNEX‑C, HIZENTRA) are designated PA; many include QLs (mL or EA per day or per period).
- Contraceptives and verification flags: Several contraceptive devices and barrier products (PARAGARD, WIDE‑SEAL DIAPHRAGMS, IUDs like MIRENA) are marked PV indicating coverage verification rather than PA in some cases.
- Coverage action for providers: Prior authorization or verification must be requested before dispensing/servicing PA/PV flagged items. For products with QL or ST flags, submit clinical justification and documentation of prior trials or dosing history as required by the Plan.
- Accessibility & Language Services: Blue KC provides non‑discrimination and language access services, including qualified interpreters and written materials in alternative formats. For language assistance call 1‑844‑395‑7126.
Table of Contents — Limits/Required Flags
The Table of Contents includes many entries annotated with Limits/Required flags (PA, PV, ST, QL). Use the TOC as a quick reference to identify which product formulations and devices require prior authorization, verification, step therapy, or are subject to quantity limits.
- TOC examples: • Molecular Target Inhibitors section lists many drugs with Limits/Required = PA (ALECENSA, BOSULIF, CABOMETYX, CAPRELSA, COMETRIQ, COTELLIC, dasatinib, ERIVEDGE, etc.). • CGRP migraine therapy entries show PA and QL flags for AIMOVIG, AJOVY, EMGALITY and others. • Device/CGM entries (DEXCOM G6/G7, GUARDIAN sensors/transmitters) are marked PA in the TOC. • Multiple biologics, immunoglobulins and specialty injectables show PA; QL annotations in the TOC (ACTEMRA, ILARIS, NUCALA, GAMMAGARD, etc.).
Provider Submission Requirements
When submitting prior authorization requests include: drug/device name, NDC or product identifier, dosing regimen, duration, relevant prior therapy trials (for ST), and supporting clinical documentation. For items marked PV, include coverage verification details per payer instructions.
- If a product is PA: do not dispense until authorization is approved to avoid noncoverage. • For ST: document failure, intolerance, or contraindication to required first‑line agents. • For QL: indicate medical necessity for quantities beyond standard limits when applicable. • For DME/CGM: include device order, device-specific model/part numbers, and clinical justification.
Key Definitions & Formulary Flags
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