CurrentCapital BluecrossPolicy N/A

2026 Exclusive Full DRUG LIST (Formulary)

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Capital Blue Cross Exclusive Full Formulary listing covered prescription drugs, tier placement, specialty designation, and utilization management indicators (prior authorization, step therapy, quantity limits, limited distribution) for fully insured individual and employer group plans in Pennsylvania.

Policy Summary

PayerCapital Bluecross

Policy2026 Exclusive Full DRUG LIST (Formulary)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a drug's Prior Authorization column shows an indicator (dot), the provider must submit a prior authorization request for coverage approval before the drug will be covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief (has_material_change=false).

multipleTherapeutic classes

~150+Drug entries (approx.)

multiplePA flagged items

multipleLimited Distribution items

70+Vaccine entries

Coverage Summary

General Formulary Coverage Criteria

This fragment of the Capital Blue Cross 2026 Exclusive Full Drug List (Formulary) summarizes the formulary coverage stance and scope for the plan. It describes what the formulary covers and the plan-level boundaries for covered prescription drugs.

Covered when ALL of the following are met:

AND

The drug is a prescription medication that is FDA‑approved (NDA, ANDA, or BLA) OR coverage is required by law or specific group benefit (for example, PPACA preventive drugs).

AND

The drug is included on the Capital Blue Cross Exclusive Full Formulary or a nonformulary exception is approved.

AND

For specialty agents, distribution is via the plan's designated specialty pharmacy (Accredo) and any limited distribution restrictions are satisfied.

AND

Utilization management requirements (prior authorization, step therapy, quantity limits) are met when applicable.

OR (coverage exceptions):

Medically necessary nonformulary drugs may be covered if an approved nonformulary exception is granted by the plan following submission by the provider.

Leaf nodes (operational notes):

Prior Authorization: Some drugs require provider submission and plan approval before coverage; noted in the formulary with a dot in the PA column where commonly required.

Step Therapy: Some drugs require trials of specified alternatives before coverage of the requested drug is approved.

Limited Distribution: If a drug is identified as limited distribution, the member may be required to obtain it from specific pharmacies designated by the manufacturer or plan (members/providers may need to contact Accredo or member services).

Quantity/Duration Limits: Coverage may be subject to limits on days supply or quantity (eg, specialty drugs limited to 30‑day supply).

Applicable Codes / Formulary Code Groups

Provider Actions & Administrative Requirements

Note

Formulary Criteria (Operational Notes)

Quantity / Threshold Notes

Revision History

Policy Summary

PayerCapital Bluecross

Policy2026 Exclusive Full DRUG LIST (Formulary)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a drug's Prior Authorization column shows an indicator (dot), the provider must submit a prior authorization request for coverage approval before the drug will be covered.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCapital BluecrossPolicy N/A

2026 Exclusive Full DRUG LIST (Formulary)

Customize your policy alerts

Sign up for all Capital Bluecross policy alerts

Know when Capital Bluecross releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCapital Bluecross

Policy2026 Exclusive Full DRUG LIST (Formulary)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a drug's Prior Authorization column shows an indicator (dot), the provider must submit a prior authorization request for coverage approval before the drug will be covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief (has_material_change=false).

multipleTherapeutic classes

~150+Drug entries (approx.)

multiplePA flagged items

multipleLimited Distribution items

70+Vaccine entries

Coverage Summary

General Formulary Coverage Criteria

Covered when ALL of the following are met:

AND

The drug is a prescription medication that is FDA‑approved (NDA, ANDA, or BLA) OR coverage is required by law or specific group benefit (for example, PPACA preventive drugs).

AND

The drug is included on the Capital Blue Cross Exclusive Full Formulary or a nonformulary exception is approved.

AND

For specialty agents, distribution is via the plan's designated specialty pharmacy (Accredo) and any limited distribution restrictions are satisfied.

AND

Utilization management requirements (prior authorization, step therapy, quantity limits) are met when applicable.

OR (coverage exceptions):

Medically necessary nonformulary drugs may be covered if an approved nonformulary exception is granted by the plan following submission by the provider.

Leaf nodes (operational notes):

Prior Authorization: Some drugs require provider submission and plan approval before coverage; noted in the formulary with a dot in the PA column where commonly required.

Step Therapy: Some drugs require trials of specified alternatives before coverage of the requested drug is approved.

Quantity/Duration Limits: Coverage may be subject to limits on days supply or quantity (eg, specialty drugs limited to 30‑day supply).

Applicable Codes / Formulary Code Groups

Provider Actions & Administrative Requirements

Note

Formulary Criteria (Operational Notes)

Quantity / Threshold Notes

Revision History

Policy Summary

PayerCapital Bluecross

Policy2026 Exclusive Full DRUG LIST (Formulary)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a drug's Prior Authorization column shows an indicator (dot), the provider must submit a prior authorization request for coverage approval before the drug will be covered.

SourceLink

On This Page