CurrentCapital BluecrossPolicy N/A

Capital Blue Cross Advantage Formulary

Advantage Formulary listing of covered prescription drugs, tier assignments, specialty designation, and utilization management indicators (Prior Authorization, Step Therapy, Quantity Level Limits, PHC, Limited Distribution). This fragment includes Anti‑Infective Agents (Penicillins/Cephalosporins/Macrolides) and supporting formulary development and program rules.

Policy Summary

PayerCapital Bluecross

PolicyCapital Blue Cross Advantage Formulary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests when the Prior Authorization column shows an indicator; verify step therapy, quantity limits, specialty dispensing and limited distribution status before prescribing.

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported in this brief.

Anti‑InfectivesTherapeutic class included (sample)

multipleProducts with PA/step/QLL/LD flags

AccredoSpecialty pharmacy

Jan 2026Document effective

N/APolicy number

Coverage summary & Applicability

Coverage considerations and Utilization Management applicability

Covered when ALL of the following are met:

ALL of the following

The drug is a prescription medication FDA-approved as evidenced by an NDA, ANDA, or BLA (or coverage is otherwise required by law or the member’s specific benefit contract).
The prescribing provider has submitted any required documentation (e.g., diagnosis, prior treatments, supporting medical records) when the drug is subject to Utilization Management (UM) requirements such as Prior Authorization, Step Therapy, or Quantity Limits.
Operational: documentation must support medical necessity for PA determinations.
If the drug is a specialty medication, it is dispensed through the plan’s specialty pharmacy (Accredo) when required by the plan, and limited distribution requirements are followed.

Policy Summary

PayerCapital Bluecross

PolicyCapital Blue Cross Advantage Formulary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 2026

Next Review DateN/A

On This Page

Utilization Management applicability

Prior Authorization (PA) may be required for specific drugs or indications; if required, the provider must obtain approval before the drug will be covered.
PA requirements are indicated in the formulary where commonly applied.
Step Therapy (ST) may apply — trial of specified preferred agents required before coverage of non-preferred products.
Failure to document trials may result in denial without PA override.
Quantity Limits (QL) may restrict the covered amount or dosing interval for certain agents (e.g., specialty drugs limited to 30-day supply).
Nonformulary exception process is available when a provider deems a non-formulary FDA-approved drug medically necessary prior to P&T review; submit nonformulary exception/PA requests with supporting information.

Formulary drug entries and code groups

AMOXICILLIN (TRIHYDRATE)NDCCovered

amoxicillin chew tab 125 mg	chewable tablet 125 mg
amoxicillin chew tab 250 mg	chewable tablet 250 mg
amoxicillin cap 250 mg	capsule 250 mg
amoxicillin cap 500 mg	capsule 500 mg
amoxicillin for susp 125 mg/5ml	oral suspension 125 mg/5 ml
amoxicillin for susp 200 mg/5ml	oral suspension 200 mg/5 ml
amoxicillin for susp 250 mg/5ml	oral suspension 250 mg/5 ml
amoxicillin for susp 400 mg/5ml	oral suspension 400 mg/5 ml
amoxicillin tab 500 mg	tablet 500 mg
amoxicillin tab 875 mg	tablet 875 mg

AMOXICILLIN/CLAVULANATE (AUGMENTIN)NDCCovered

amoxicillin & k clavulanate for susp 125-31.25 mg/5ml	oral suspension 125 mg/31.25 mg per 5 ml (Augmentin)
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml	oral suspension 200 mg/28.5 mg per 5 ml
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml	oral suspension 250 mg/62.5 mg per 5 ml (Augmentin)
amoxicillin & k clavulanate for susp 400-57 mg/5ml	oral suspension 400 mg/57 mg per 5 ml
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml	oral suspension 600 mg/42.9 mg per 5 ml (Augmentin ES-600)
amoxicillin & k clavulanate tab 250-125 mg	tablet 250 mg/125 mg
amoxicillin & k clavulanate tab 500-125 mg	tablet 500 mg/125 mg (Augmentin)
amoxicillin & k clavulanate tab 875-125 mg	tablet 875 mg/125 mg
AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg	extended-release tablet every 12 hours 1000 mg/62.5 mg

PENICILLINS & RELATEDNDCCovered

ampicillin cap 500 mg	capsule 500 mg
penicillin v potassium for soln 125 mg/5ml	oral solution 125 mg/5 ml
penicillin v potassium for soln 250 mg/5ml	oral solution 250 mg/5 ml
penicillin v potassium tab 250 mg	tablet 250 mg
penicillin v potassium tab 500 mg	tablet 500 mg
dicloxacillin sodium cap 250 mg	capsule 250 mg
dicloxacillin sodium cap 500 mg	capsule 500 mg

CEPHALOSPORINSNDCCovered

CEFACLOR - cefaclor cap 250 mg	capsule 250 mg
CEFACLOR - cefaclor cap 500 mg	capsule 500 mg
CEFACLOR - cefaclor for susp 250 mg/5ml	oral suspension 250 mg/5 ml
CEFACLOR ER - cefaclor monohydrate tab er 12hr 500 mg	extended-release tablet 500 mg
CEFADROXIL - cefadroxil tab 1 gm	tablet 1 g
cefadroxil cap 500 mg	capsule 500 mg
cefadroxil for susp 250 mg/5ml	oral suspension 250 mg/5 ml
cefadroxil for susp 500 mg/5ml	oral suspension 500 mg/5 ml
cefdinir cap 300 mg	capsule 300 mg
cefdinir for susp 125 mg/5ml	oral suspension 125 mg/5 ml

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MACROLIDES & LINCOSAMIDESNDCCovered

azithromycin for susp 100 mg/5ml	oral suspension 100 mg/5 ml (Zithromax)
azithromycin for susp 200 mg/5ml	oral suspension 200 mg/5 ml (Zithromax)
azithromycin tab 150 mg	tablet 150 mg (Zithromax)
azithromycin tab 250 mg	tablet 250 mg (Zithromax)
azithromycin tab 500 mg	tablet 500 mg (Zithromax)
azithromycin tab 600 mg	tablet 600 mg (Zithromax)
clarithromycin for susp 125 mg	oral suspension 125 mg
clarithromycin tab er 24hr 500 mg	extended-release tablet 500 mg
clarithromycin tab 250 mg	tablet 250 mg (Biaxin)
clarithromycin tab 500 mg	tablet 500 mg (Biaxin)

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FIDAXOMICINNDCCovered

DIFICID - fidaxomicin for susp 40 mg/ml	oral suspension 40 mg/ml
DIFICID - fidaxomicin tab 200 mg	tablet 200 mg
fidaxomicin tab 200 mg	tablet 200 mg (Dificid)

TETRACYCLINES & SARECYCLINENDCCovered

tetracycline hcl cap	tetracycline HCl capsules (various strengths)
SEYSARA - sarecycline hcl tab 60 mg	tablet 60 mg (base equivalent)
SEYSARA - sarecycline hcl tab 100 mg	tablet 100 mg (base equivalent)
SEYSARA - sarecycline hcl tab 150 mg	tablet 150 mg (base equivalent)

FLUOROQUINOLONES & OTHER ORALSNDCCovered

CIPRO	ciprofloxacin oral (suspension, tablets)
levofloxacin	levofloxacin oral (solution, tablets)
moxifloxacin	moxifloxacin tablets
OFLOXACIN	ofloxacin oral formulations

AMINOGLYCOSIDES & INHALED TOBRAMYCIN GROUPNDCCovered

AMINOGLYCOSIDES group	class-level aminoglycosides
ARIKAYCE	amikacin liposome inhalation suspension (Arikayce)
BETHKIS	tobramycin inhalation solution (Bethkis)
KITABIS PAK	tobramycin inhalation solution kit (Kitabis Pak)
TOBI	tobramycin inhalation solution (Tobi)
TOBI PODHALER - tobramycin inhal cap 28 mg	tobramycin inhalation capsules 28 mg (Tobi Podhaler)
TOBRAMYCIN (generic)	tobramycin generic formulations
tobramycin nebu soln 300 mg/5ml	nebulization solution 300 mg/5 ml

AMINOGLYCOSIDE ORAL/OTHERNDCCovered

neomycin sulfate tab

neomycin sulfate tablets

ANTIFUNGALSNDCCovered

fluconazole tab 50 mg	tablet 50 mg
fluconazole tab 100 mg	tablet 100 mg
fluconazole tab 150 mg	tablet 150 mg
fluconazole tab 200 mg	tablet 200 mg
griseofulvin microsize susp 125 mg/5ml	oral suspension 125 mg/5 ml
griseofulvin ultramicrosize tab 125 mg	tablet 125 mg (ultramicrosize)
griseofulvin ultramicrosize tab 250 mg	tablet 250 mg (ultramicrosize)
itraconazole cap 100 mg	capsule 100 mg (Sporanox)
itraconazole oral soln 10 mg/ml	oral solution 10 mg/ml (Sporanox)
ketoconazole tab 200 mg	tablet 200 mg

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ANTIVIRALS & HEPATITIS/OTHER ANTIVIRALSNDCCovered

ANTIVIRALS (class-level header)	class-level header
abacavir sulfate soln 20 mg/ml	oral solution 20 mg/ml (Ziagen)
abacavir sulfate tab 300 mg	tablet 300 mg (Ziagen)
abacavir sulfate-lamivudine tab 600-300 mg	combination tablet (Epzicom)
acyclovir cap 200 mg	capsule 200 mg (Zovirax)
acyclovir susp 200 mg/5ml	oral suspension 200 mg/5 ml
acyclovir tab 400 mg	tablet 400 mg
acyclovir tab 800 mg	tablet 800 mg
adefovir dipivoxil tab 10 mg	tablet 10 mg (Hepsera)
emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg	Complera combination tablet

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ANTIPARASITIC/ANTIMALARIALS & MISC INFECTIOUS DISEASENDCCovered

chloroquine phosphate tab 500 mg	chloroquine phosphate tablet 500 mg
valacyclovir hcl tab 500 mg	valacyclovir tablet 500 mg (Valtrex)
mebendazole chew tab 100 mg	mebendazole chewable tablet 100 mg (Emverm)
praziquantel tab 600 mg	praziquantel tablet 600 mg
ivermectin tab 3 mg	ivermectin tablet 3 mg (Stromectol)
atovaquone susp 750 mg/5 ml	atovaquone suspension 750 mg/5 ml (Mepron)
tafenoquine succinate tab 150 mg	tafenoquine tablet 150 mg (Krintafel)
atovaquone-proguanil hcl tab 62.5-25 mg	Malarone 62.5 mg/25 mg
atovaquone-proguanil hcl tab 250-100 mg	Malarone 250 mg/100 mg
mefloquine hcl tab 250 mg	mefloquine tablet 250 mg

OTHER NOTABLE ANTIMICROBIALS & UTI AGENTSNDCCovered

clindamycin hcl cap 75 mg	clindamycin capsule 75 mg (Cleocin)
vancomycin hcl for oral soln 25 mg/ml	oral solution 25 mg/ml (Firvanq)
vancomycin hcl for oral soln 50 mg/ml	oral solution 50 mg/ml
vancomycin hcl cap 125 mg	capsule 125 mg (Vancocin)
vancomycin hcl cap 250 mg	capsule 250 mg (Vancocin)
fosfomycin tromethamine powd pack 3 gm	powder packet 3 g (Monurol)
nitrofurantoin monohydrate macrocrystalline cap 100 mg	cap 100 mg (Macrobid)
nitrofurantoin macrocrystalline cap 25 mg	cap 25 mg (Macrodantin)
nitrofurantoin macrocrystalline cap 50 mg	cap 50 mg (Macrodantin)

STOREFRONT VACCINES & PUBLIC HEALTHNDCCovered

ENGERIX-B hepatitis B vaccine susp 20 mcg/ml	Engerix-B suspension 20 mcg/ml
FLUAD 2025-2026 influenza vaccine	Fluad seasonal influenza 2025-2026
AFLURIA 2025-2026	Afluria seasonal influenza 2025-2026
COMIRNATY 2025-26 variants	Comirnaty COVID-19 vaccine 2025-26 variants
GARDASIL 9	Gardasil 9 HPV vaccine
PNEUMOVAX 23	Pneumovax 23 pneumococcal vaccine
PREVNAR 20	Prevnar 20 pneumococcal conjugate vaccine
SHINGRIX	Shingrix herpes zoster vaccine
VARIVAX	Varivax varicella vaccine

SELECTED MISCELLANEOUS INFECTIOUS DISEASE AGENTS & OTHERSNDCCovered

linezolid tab 600 mg	linezolid tablet 600 mg (Zyvox)
linezolid susp 100 mg/5ml	oral suspension 100 mg/5 ml (Zyvox)
rifaximin tab 200 mg	rifaximin tablet 200 mg (Xifaxan)
rifaximin tab 550 mg	rifaximin tablet 550 mg (Xifaxan)
metronidazole tab 250 mg	metronidazole tablet 250 mg (Flagyl)
metronidazole tab 500 mg	metronidazole tablet 500 mg (Flagyl)
tedizolid phosphate tab 200 mg	tedizolid phosphate tablet 200 mg (Sivextro)
sulfamethoxazole-trimethoprim susp 200-40 mg/5 ml	oral suspension 200 mg/40 mg per 5 ml
sulfamethoxazole-trimethoprim tab 400-80 mg	tablet 400 mg/80 mg (Bactrim)
sulfamethoxazole-trimethoprim tab 800-160 mg	tablet 800 mg/160 mg (Bactrim DS)

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ANTIBIOTIC BRANDS/KEY TRADE NAMES (INDEX)mixed

AUGMENTIN	amoxicillin-clavulanate preparations listed above
AUGMENTIN ES-600	amoxicillin-clavulanate 600-42.9 mg/5 ml suspension and related ES formulations
ZITHROMAX	azithromycin formulations listed above
ZITHROMAX TRI-PAK	azithromycin 500 mg tri-pack
BAXDELA	delafloxacin oral formulations
BETHKIS	tobramycin inhalation solution (Bethkis)
TOBI PODHALER	tobramycin inhalation capsules 28 mg
TOBI PODHALER - duplicated	Zithromax Tri-Pak and Seysara also indexed

ADDITIONAL INDEX ENTRIESmixed

PAXLOVID	nirmatrelvir-ritonavir (indexed)
RIBAVIRIN	ribavirin formulations
VALGANCICLOVIR HCL soln 50 mg/ml	Valganciclovir oral solution 50 mg/ml (Valcyte)
VALGANCICLOVIR HCL tab 450 mg	Valganciclovir tablet 450 mg (Valcyte)
BENZNIDAZOLE tab 12.5 mg	benznidazole tablet 12.5 mg
FOSFOMYCIN tromethamine powd pack 3 gm	Monurol

OpenPayer

Capital Blue Cross Advantage Formulary

Coverage summary & Applicability

Utilization management & provider requirements

Formulary drug entries and code groups

Initial therapy criteria

Examples: products that may require PA / Step Therapy / Limited Distribution

Applicable codes and product groups

Revision history