Prescription Drug Formulary and Utilization Management
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This document governs the Capital Blue Cross Elite Full Formulary: which drugs are covered, tier placement, and utilization management (prior authorization, step therapy, quantity limits) for members and providers under Capital Blue Cross plans.
No material clinical or coverage changes in this revision.
Formulary Coverage & Exclusions
Formulary Coverage and Utilization Management
Covered when plan terms and utilization management criteria are met.
supported by document
PA noted with dot in formulary
Step therapy noted with dot in formulary
QLL indicated with dot in formulary; specialty drugs limited to 30-day supply
Nonformulary exception available; unapproved drugs not covered
Coverage exclusions include drugs that are not FDA-approved, products indicated for cosmetic purposes (for example, agents for hair growth or wrinkle treatment), and categories that some plans exclude such as erectile dysfunction or certain weight-loss/anti-obesity agents. Prescription products with available OTC equivalents may also be excluded. The policy notes that some drugs not approved for self-administration may be covered under the medical benefit rather than the pharmacy benefit.
This abbreviation key section provides mappings between short tokens and full product lines and does not itself state coverage determinations, utilization management rules, or exclusions.
The material in this segment is an abbreviation/drug mapping used for reference within the formulary tables; it does not contain coverage decision language or criteria.
This abbreviation key block lists vaccine product name mappings and related shorthand identifiers; it does not specify coverage criteria, exclusions, or medical necessity rules.
Drugs characterized as experimental, investigational, or not FDA-approved are explicitly stated as not covered by the prescription drug benefit.
The abbreviation key content in this portion does not include any statements declaring products to be not medically necessary.
Drug Name / Abbreviation Mappings
| erythromycin ethylsuccinate for susp 400 mg/sml (Eryped 400) | Listed as Drug Name / repeated in abbreviation key |
| erythromycin tab delayed release 250 mg; 333 mg; 500 mg | Listed in abbreviation mappings |
| ciprofloxacin hcl tab 750 mg (base equiv) | Listed as Drug Name |
| levofloxacin oral soln 25 mg/ml; levofloxacin tab 250 mg; 500 mg; 750 mg | Listed as Drug Name |
| moxifloxacin hcl tab 400 mg (base equiv) | Listed as Drug Name |
| fidaxomicin tab 200 mg (Dificid) | Listed as Drug Name |
| OFLOXACIN ofloxacin tab 300 mg; ofloxacin tab 400 mg | Listed as Drug Name |
| demeclocycline hcl tab 150 mg; 300 mg | Listed in TETRACYCLINES group |
| AMINOGLYCOSIDES | Category header present |
| doxycycline hyclate cap 50 mg; 100 mg (Vibramycin) | Listed as Drug Name |
| DELSTRIGO | doravirine-lamivudine-tenofovir df tab 100-300-300 mg |
| EPCLUSA | sofosbuvir-velpatasvir pellet pack 150-37.5 mg; 200-50 mg |
| DESCOVY | emtricitabine-tenofovir alafenamide fumarate tab 120-15 mg |
| DOVATO | dolutegravir sodium-lamivudine tab 50-300 mg (base eq) |
| TRUVADA | emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg; 133-200 mg; 167-250 mg |
| ISENTRESS | raltegravir potassium various formulations |
| ENTECAVIR | entecavir tab 0.5 mg; 1 mg (Baraclude) |
| KALETRA | lopinavir-ritonavir soln 400-100 mg/ml (80-20 mg/ml) |
| PREZISTA | darunavir oral susp 100 mg/ml |
| PREVYMIS | letermovir tab 240 mg |
| LIVTENCITY | maribavir tab 200 mg |
| PREZCOBIX | darunavir-cobicistat tab 675-150 mg, 800-150 mg |
| PREZISTA | darunavir oral susp 100 mg/ml |
| MAVYRET | glecaprevir-pibrentasvir pellet pack 50-20 mg; tab 100-40 mg |
| RELENZA DISKHALER | zanamivir aerosol powder breath activated 5 mg/act |
| SOVALDI | sofosbuvir pellet pack 150 mg, 200 mg; tab 200 mg; 400 mg |
| STRIBILD | elvitegravir-cobicistat-emtricitabine-tenofovir DF tab |
| TIVICAY | dolutegravir sodium tab 50 mg; PD oral susp 5 mg |
| TRIUMEQ | abacavir-dolutegravir-lamivudine tab 600-50-300 mg |
| TYBOST | cobicistat tab 150 mg |
| valacyclovir | valacyclovir hcl tab 500 mg; 1 g (Valtrex) |
| valganciclovir | valganciclovir hcl for soln 50 mg/ml; tab 450 mg (Valcyte) |
| VEMLIDY | tenofovir alafenamide fumarate tab 25 mg |
| Valtrex | valacyclovir hcl tab 1 gm (Valtrex) |
| Valcyte | valganciclovir hcl for soln 50 mg/mL (base equiv) and tab 450 mg (base equiv) (Valcyte) |
| KRINTAFEL | tafenoquine succinate tab 150 mg |
| VEMLIDY | tenofovir alafenamide fumarate tab 25 mg |
| VIREAD | tenofovir disoproxil fumarate oral powder 40 mg/g and tab 150 mg, 200 mg |
| VOSEVI | sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg |
| XOFLUZA | baloxavir marboxil tab therapy pack 1 40 mg |
| BENZNIDAZOLE | benznidazole tab 12.5 mg; 100 mg |
| VIRACEPT | nelfinavir mesylate tab 250 mg, 625 mg |
| CAYSTON | aztreonam lysine for inhalation solution 75 mg |
| No codes listed |
| SHINGRIX | zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml |
| PNEUMOVAX 23 | pneumococcal vaccine polyvalent soln syr pref |
| PREVNAR 20 | pneumococcal 20-valent conjugate vaccine susp syr 0.5 ml |
| RECOMBIVAX HB | hepatitis b vaccine (recombinant) susp |
| ROTATEQ | rotavirus vaccine, live oral pentavalent soln |
| TRUMENBA | meningococcal group B vac (recomb) im susp prefilled syr |
| BOOSTRIX | tet-diph-acell pertuss ad pref syr |
| GRASTEK | timothy grass pollen allergen ext sl tab 2800 bau |
| ODACTRA | dust mite mixed ext sl tab 12 sq-hdm |
| ORALAIR | grass mixed pollen ext sl tab 300 ir |
| RAGWITEK | short ragweed pollen allergen extract sl tab 12 amb a 1-U |
| BOSULIF | bosutinib cap/tab (multiple strengths listed) |
| BRAFTOVI | encorafenib cap 75 mg |
| BRUKINSA | zanubrutinib cap 80 mg |
| CABOMETYX | cabozantinib S-malate tab (various strengths) |
| COPIKTRA | duvelisib cap 15 mg; 25 mg |
| AUGTYRO | repotrectinib cap 40 mg; 160 mg |
| ALECENSA | alectinib (mg base equivalent) listed |
| ALUNBRIG | brigatinib tab (30 mg; 90 mg; 180 mg) and initiation pack |
| COMETRIQ | cabozantinib s-mal cap kit |
| ALUNBRIG | brigatinib tab 30 mg; 90 mg; 180 mg |
| COMETRIQ | cabozantinib s-mal cap x 80 mg & 3 x 20 mg (140 dose) kit |
| AUGTYRO | repotrectinib cap 40 mg; 160 mg |
| COPIKTRA | duvelisib cap 15 mg; 25 mg |
| AVMAPKI FAKZYNJA CO-PACK | avutometinib cap 0.8 mg & defactinib tab 200 mg therapy |
| AYVAKIT | avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg |
| COTELLIC | cobimetinib fumarate tab 20 mg (base equivalent) |
| BALVERSA | erdafitinib tab 3 mg, 4 mg, 5 mg |
| BESREMI | ropeginterferon alfa-2b soln prefilled syr 500 mcg/ml |
| cyclophosphamide | tab 50 mg; cap 25 mg |
| methotrexate sodium inj 50 mg/2ml (25 mg/ml), 250 mg/10ml | methotrexate sodium injection formulations listed in abbreviation key |
| methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) | preservative-free methotrexate injection formulation listed |
| methotrexate sodium tab 2.5 mg (base equiv) | oral methotrexate tablet strength |
| PIQRAY alpelisib tab 200 mg/300 mg | alpelisib tablet pack daily dose entries |
| QINLOCK ripretinib tab 50 mg | ripretinib tablet strength |
| TALZENNA talazoparib tosylate tab 40 mg, 80 mg; cap 0.1 mg, 0.25 mg, 0.35 mg, 0.5 mg | talazoparib strengths and formulations |
Authorization, Step Therapy & Submission Notes
Prior Authorization Required
Your prescription drug plan requires prior authorization (PA) for certain drugs. If PA is commonly required for a drug listed in this formulary, it will be noted with an indicator in the Prior Authorization column next to that drug. Failure to obtain required prior authorization may result in the drug not being covered. Some plans may require PA for additional drugs beyond those noted here; providers and members should refer to the member's specific prescription plan materials and Benefit Booklet (Certificate of Coverage) for details.
- Prior Authorization (PA) required for certain drugs — providers must submit a PA request for coverage prior to dispensing when indicated.
- Drugs requiring PA are marked in the Prior Authorization column in the formulary or search results.
- Failure to obtain PA when required may result in non-coverage of the drug.
Informational — Abbreviation Mappings
This section primarily lists abbreviation mappings and drug-name/key entries. It is informational only and does not specify additional provider actions, documentation requirements, or step therapy rules beyond indicating where UM program indicators (Prior Authorization, Step Therapy, Quantity Limits) will appear in the formulary columns.
- Section content = abbreviation key and drug listing examples.
- No provider documentation or submission procedures are specified in this abbreviation/key section.
- This section lists abbreviation keys and mapping examples (dosage forms, codes such as GP, GN, BP, BN, NC, specialty markers).
Step Therapy — No Specific Rules in This Section
Step therapy (ST) may apply to certain drugs in the prescription drug plan and, when commonly required for drugs, will be noted with an indicator in the Step Therapy column next to those drugs. However, no step therapy rules or step-therapy-specific provider actions are detailed in this abbreviation/key excerpt.
- Step Therapy (ST) is described generally: members may need to try a proven, cost-effective alternative before coverage of the requested drug is available.
- No specific step therapy rules, pathways, or prior step requirements are provided in this section.
- If a drug is subject to step therapy it will be indicated in the formulary (Step Therapy column).
Nonformulary Exception — Provider Action
Nonformulary drugs are not covered unless approved through the nonformulary consideration (formulary exception) process. Providers may submit a nonformulary consideration request on a member's behalf. This informational excerpt does not include the submission form, criteria, or documentation details for nonformulary exception requests.
- Providers can submit nonformulary (formulary exception) requests for members.
- This section does not provide the procedural steps, forms, or required clinical documentation for exception requests — refer to the member's prescription plan materials for procedure details.
No Additional Provider Actions Specified in This Section
No additional provider actions, documentation requirements, authorization procedures, or denial criteria are specified within these abbreviation-key chunks beyond the general notes above. For operational details (how to submit PA or exception requests, required clinical documentation, and any plan-specific UM rules), providers should consult the member's prescription plan materials or contact the plan's pharmacy benefit manager.
- This section contains abbreviation mappings and drug name entries only — no PA submission steps, required forms, or denial triggers are provided here.
- Refer to the plan's UM materials or PBM (Prime Therapeutics on behalf of Capital Blue Cross) for specific authorization submission instructions and documentation requirements.
Abbreviations & Key Terms
Supply Limits & Specialty Drug Supply
Administration & Billing Notes
Bill non–self-administered injectables to medical benefit / contact Accredo
Injectable drugs that are not routinely self-administered may be billed under the member's medical benefit; Accredo can provide select medical injectable drugs and can be contacted for distribution and billing information.
- Contact Accredo at 833.721.1626 (TTY: 711) or fax 888.302.1028 for information on service and billing.
- Self-administered injectable drugs are usually covered under the prescription benefit; non–self-administered injectables may be medical benefit.
Policy Background
Specialty drugs treat complex conditions (for example, hepatitis, multiple sclerosis, and rheumatoid arthritis) and may be oral or injectable. Distribution and management of specialty therapies are administered through the plan’s specialty pharmacy (Accredo) for many products; some specialty agents are designated as limited distribution and must be obtained from specific pharmacies. Standard supply expectations note a 30-day specialty supply with maintenance drug options commonly available as 30- or 90-day supplies. Providers should prescribe formulary agents when appropriate and may submit a nonformulary (formulary exception) request if a formulary alternative is not suitable. Utilization management programs such as prior authorization, step therapy, and quantity level limits (QLL) apply where indicated on the formulary.
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