Children's Health Insurance Program (CHIP) Drug Formulary — Coverage Criteria
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This document is the Capital Blue Cross CHIP drug formulary describing covered prescription and specialty drugs, utilization management programs, and guidance for providers and members in Pennsylvania covered under CHIP.
No material clinical or coverage changes in this revision.
Coverage Criteria and Exclusions
The formulary notes that some drugs may be contractually excluded from coverage depending on the member's prescription drug plan. Examples of contractual exclusions explicitly listed include: appetite suppressants (weight loss), anti‑obesity agents (for example, Wegovy), erectile dysfunction drugs, non self‑administered injectable drugs, experimental or investigational uses (including off‑label use), and vitamins that are not considered preventive drugs. Members and providers should verify coverage against the member's Benefits Booklet (Certificate of Coverage) because inclusion in the formulary listing alone is not a guarantee of coverage or payment.
The content in this segment is a formulary product listing (for example, multiple penicillin and related anti‑infective entries). There are no explicit coverage exclusions or medical‑necessity criteria stated within these chunks; the text presents drug names, strengths, and internal formulary markers only.
This portion of the document contains product listings (including zidovudine and multiple antimalarial entries). The extract does not specify any contractual exclusions or explicit coverage limitations — it is limited to listing drug products and formulations.
The vaccine and pediatric vaccine product lines shown in this excerpt are presented as formulary entries (e.g., Moderna, Novavax, ROTATEQ). There are no explicit exclusions described in these chunks; the listings indicate covered product descriptors without stating exclusionary rules.
This segment lists combined oral contraceptive formulations (including levonorgestrel & ethinyl estradiol 91‑day products) and related entries. The text does not include explicit contractual exclusions or statements denying coverage for these products in these chunks.
The insulin and insulin‑pen product listings (for example, INSULIN ASPART FLEXPEN and other pen injector entries) are presented as formulary items. There are no explicit coverage exclusions stated in this product listing segment.
This portion contains cardiovascular and antihypertensive drug listings (e.g., lisinopril, ramipril, various diuretics). The extract provides product and strength information only and does not state any contractual exclusions.
The antiviral/antiretroviral listings in this segment (for example, nevirapine/Viramune and related entries) do not include any statements that medications are not medically necessary. The extract is a formulary listing without NMN declarations.
The vaccine product descriptors shown here (including COVID‑19 and rotavirus vaccines) do not contain any language declaring products not medically necessary. The entries are descriptive formulary listings only.
The contraceptive and progestin product listings (for example, VELIVET and medroxyprogesterone acetate) in this extract do not include explicit not medically necessary statements; they are presented as formulary entries.
Formulary entries for lipid‑lowering agents and bile acid sequestrants (for example, cholestyramine) appear in these chunks. There are no statements in this extract identifying any listed medications as not medically necessary.
Formulary Codes and Mappings
| GN | Formulary status code appearing next to multiple products (e.g., fluconazole suspension, itraconazole, acyclovir susp) |
| BP | Formulary status code appearing next to multiple products (e.g., fluconazole, voriconazole, ledipasvir-sofosbuvir) |
| GPI | Formulary status code appearing next to several products (e.g., terbinafine, acyclovir cap) |
| SP | Formulary status code appearing next to some antiviral agents (e.g., voriconazole, abacavir sulfate) |
| BN | Formulary status code appearing next to certain products (e.g., abacavir-lamivudine, lamivudine) |
| IGN | Formulary status code appearing with some lamivudine/epivir entries |
| PAXLOVID nirmatrelvir tab 6 X 150 mg ritonavir tab 5 x 100 mg pak | Formulary product listing |
| PAXLOVID nirmatrelvir tab 10 X 150 BPI mg & ritonavir tab 10 x 100 mg pak | Formulary product listing |
| PAXLOVID nirmatrelvir tab 20 X 150/BP mg & ritonavir tab 10 x 100 mg pak | Formulary product listing |
| nevirapine tab er 24hr 400 mg Viramune Xr | Formulary product listing |
| nevirapine tab 200 mg Viramune | Formulary product listing |
| ODEFSEY emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg | Formulary product listing |
| oseltamivir phosphate cap 30 mg/45 mg/75 mg Tamiflu | Formulary product listing |
| PEGASYS peginterferon alfa-2a inj 180 mcg/ml | Formulary product listing |
| VOSEVI sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg | Formulary product listing |
| zidovudine cap 100 mg Retrovir | Formulary product listing |
| zidovudine syrup 10 mg/ml Retrovir | Formulary product listing |
| zidovudine tab 300 mg | Formulary product listing |
| fosfomycin tromethamine | Listed under ANTIMALARIALS heading in this section (formatting artifact) |
| atovaquone-proguanil hcl tab (Malarone) | Formulary product listing |
| chloroquine phosphate tab 250 mg and 500 mg | Formulary product listing |
| COARTEM artemether-lumefantrine tab 20-120 mg | Formulary product listing |
| hydroxychloroquine sulfate tab (Plaquenil) | Formulary product listing |
| mefloquine hcl tab 250 mg | Formulary product listing |
| primaquine phosphate tab 26.3 mg (15 mg base) | Formulary product listing |
| albendazole tab 200 mg Albenza | Formulary product listing |
| mebendazole chew tab 100 mg EMVERM | Formulary product listing |
| ivermectin tab 3 mg Stromectol | Formulary product listing |
| vancomycin hcl cap 125 mg | Formulary product listing under ANTI-INFECTIVE AGENTS MISC. |
| No codes listed |
| Medrol dosepak | methylprednisolone therapy pack 4 mg (21) |
| POMALYST | pomalidomide cap |
| SOLTAMOX | tamoxifen citrate oral solution 10 mg/mL |
| Nexavar | sorafenib tosylate tab 200 mg |
| temozolomide | temozolomide cap 5 mg |
| Fareston | toremifene citrate tab 60 mg |
| PREDNISONE INTENSOL | prednisone concentrate 5 mg/mL |
| prednisone therapy pack | prednisone tablet therapy packs (multiple strengths/counts) |
| TREXALL | methotrexate sodium tab 5 mg / 7.5 mg |
| CONTRACEPTIVES | multiple combined hormonal contraceptive products listed |
| METHITEST | methyltestosterone tab 10 mg |
| danazol | danazol cap 50/100/200 mg |
| testosterone cypionate | testosterone cypionate IM inj 200 mg/mL (Depo-testosterone) |
| Androgel | testosterone topical gel (various strengths) |
| Various estradiol and combination estrogen products | estradiol gels, patches, and combination oral estrogen-progestin formulations (multiple brands/strengths) |
| levonorgestrel & ethinyl estradiol | multiple 28/84/91-day formulations and brands |
| levonorgestrel tab 1.5 mg | levonorgestrel one‑dose emergency contraception |
| No codes listed |
| No codes listed |
| No codes listed |
Provider Actions, Prior Authorization, Step Therapy, Quantity Limits
Prior Authorization Required
Prior authorization may be required for certain drugs listed in the formulary. When the Prior Authorization (PA) column indicates an indicator (dot) next to a drug, the provider must submit a PA request and obtain approval before the drug will be covered. Some plans may require PA on additional drugs beyond those noted in this document; refer to the member's specific prescription drug plan materials for full details.
- Prior Authorization required when indicated — obtain authorization when the Prior Auth column indicates.
- Prior Authorization not specified in this segment — many formulary entries in this excerpt list only drug names, strengths, and status codes without explicit PA indicators.
- Prior Authorization not specified in these chunks — portions of the listing show product names/presentations only; no PA rules present.
- Prior Authorization not specified in this extract — entries are formulary categorizations without explicit PA requirements.
- UM indicators may trigger denial — if utilization management conditions (PA, Step Therapy, Quantity Limits) shown in the UM columns are not met, coverage may be denied.
- None specified in these chunks. — Several chunks contain only product listings and do not specify provider steps for authorization or documentation.
- No explicit authorization or PA/denial triggers present — many lines present drug names and tiers without operational PA instructions.
- Not specified in this excerpt — the chunked section contains product names and presentations but lacks authorization or submission steps.
- This excerpt contains product names and presentations; no authorization or documentation requirements are specified here.
- No authorization or documentation required specified — where PA is commonly required it will be noted with an indicator in the Prior Authorization column; otherwise this excerpt shows listings only.
- This excerpt contains drug listing lines and formulary classifications; provider action is limited to checking the UM columns for indicators.
- This chunked section contains product names and strengths only; follow plan materials and UM columns to determine PA/Step Therapy/Quantity Limit applicability.
- This section is a listing of formulary drugs — providers should consult the Prior Authorization, Step Therapy, and Quantity Level Limits columns and the member's prescription drug plan documents for any required actions.
- Follow Step Therapy when indicated — if a dot appears in the Step Therapy column, pharmacy and providers must follow the plan's step edits before coverage is available.
- No step therapy rules present in these chunks — many entries show drug names and tiers but do not include step therapy detail in the excerpt.
- No step therapy rules are stated in this excerpt — consult full plan materials or the UM columns for program applicability.
Definitions and Abbreviations
Step Therapy Rules
| Step therapy — explanation |
|---|
| Step Therapy (ST): Your prescription plan may include a step therapy program. This means you may need to try another proven, cost‑effective drug before coverage is available for the requested drug. When step therapy commonly applies to a drug in this formulary it is indicated with a dot in the Step Therapy column next to that drug. Refer to your prescription drug plan materials for details about step requirements that may apply to your specific benefits. |
Quantity Level Limits (QLL)
Site-of-Care and Benefit Assignment
Infusion/medical benefit — non–self‑administered injectables
Injectable drugs that are not routinely self‑administered may be covered under the medical benefit rather than the prescription drug plan; some medical injectables are available through Accredo (Capital Blue Cross' specialty medical injectable provider).
- Contact Accredo at 833-721-1626 (TTY: 711) or fax 888-302-1028 for distribution and billing information.
Background and Context
Specialty drugs are described as therapies used to treat complex conditions (for example, hepatitis, multiple sclerosis, rheumatoid arthritis) and may be oral or injectable and sometimes self‑administered. The formulary indicates specialty distribution channels and review by the Pharmacy & Therapeutics Committee; for some specialty products, distribution is through a designated specialty pharmacy (Accredo). Providers should reference the formulary and Benefits Booklet for coverage determination and any utilization management that may apply.
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