CurrentCapital BluecrossPolicy N/A

Prescription Drug Formulary and Utilization Management

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.

Policy Summary

PayerCapital Bluecross

PolicyPrescription Drug Formulary and Utilization Management

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when required; failure to obtain PA may result in noncoverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyformulary updates

30-dayspecialty supply limit

Accredospecialty pharmacy

20+drug lines shown

antibioticsprimary class represented

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Formulary Coverage and Utilization Management

Covered when plan terms and utilization management criteria are met.

Formulary and regulatory requirements: Drug must be FDA-approved (NDA, ANDA, or BLA) and be covered under the member's specific plan terms; group-specific benefits or legal requirements (e.g., preventive benefits) may supersede this policy.

supported by document

Prior authorization: If the formulary indicates prior authorization is required for the drug (noted with a dot in the prior authorization column), the provider must obtain prior authorization before the drug will be covered.

PA noted with dot in formulary

Step therapy: If the formulary indicates the drug is subject to step therapy (noted with a dot in the step therapy column), the member must trial and fail the required alternative(s) before coverage of the requested drug is available.

Step therapy noted with dot in formulary

Quantity limits: When a drug has a quantity level limit (noted with a dot in the QLL column), coverage is limited to the specified quantity or time period; quantities beyond the limit may be the member's financial responsibility.

QLL indicated with dot in formulary; specialty drugs limited to 30-day supply

Nonformulary / exception process: If a drug is not listed on the formulary or is not yet FDA-approved, the provider may submit a nonformulary exception request supporting medical necessity for coverage consideration.

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

Formulary Drug Name / Abbreviation mappingsmixed

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

1–10 of 37

1/4

Drug name tokens in abbreviation keymixed

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)

Additional drug tokensmixed

TRUVADA	emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg; 133-200 mg; 167-250 mg
ISENTRESS	raltegravir potassium various formulations

Further drug tokensmixed

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

Drug name entries (sample)NDC

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

Additional drug name entriesNDC

SOVALDI	sofosbuvir pellet pack 150 mg, 200 mg; tab 200 mg; 400 mg
STRIBILD	elvitegravir-cobicistat-emtricitabine-tenofovir DF tab

HIV-related drug name entriesNDC

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

Antiviral entriesNDC

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

Drug name entries from abbreviation keyNDC|mixed

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

1–10 of 20

1/2

Vaccine product names listed (no explicit CPT/HCPCS codes present in these chunks)mixed

No codes listed

Biologicals / Vaccinesmixed

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

Allergen immunotherapy oral tabletsmixed

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

Antineoplastics / Oncology oral agentsmixed

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

Abbreviation to Drug Name Mappingsmixed

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

1–10 of 39

1/4

Drug name mappings (examples)NDC|mixed

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

Additional drug mappingsNDC|mixed

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

strengths/packaging examples

Examples of tablet strengths30 mg; 90 mg; 180 mg (e.g., brigatinib ALUNBRIG)

Examples of oral solution / suspension strengths10 mg/mL; 25 mg/mL; 200 mg/5 mL; 400 mg/mL (e.g., itraconazole oral soln 10 mg/mL; levofloxacin soln 25 mg/mL; acyclovir susp 200 mg/mL; itraconazole delayed-release packets)

Examples of capsule / tablet strengths for anti-infectives50 mg; 100 mg; 150 mg; 200 mg; 250 mg; 300 mg; 400 mg; 500 mg; 750 mg

Examples of pack / packet presentationspellet packs and packet formulations (e.g., sofosbuvir-velpatasvir pellet packs 150-37.5 mg; 200-50 mg; posaconazole DR suspension packets)

Examples of injectable / prefilled syringe concentrations50 mg/2 mL (25 mg/mL); 500 mcg/mL (ropeginterferon prefilled syringes); 0.5 mL syringes for vaccines

Authorization, Step Therapy & Submission Notes

Prior Authorization

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.

Note

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

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).

Documentation Required

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.

Note

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

Specialty drugs — definition and distribution notes

DefinitionSpecialty drugs: medications used to treat complex conditions (e.g., hepatitis, multiple sclerosis, rheumatoid arthritis) that may be oral or injectable and are distributed through the plan's specialty pharmacy provider (Accredo).

DistributionSpecialty drugs are distributed through the plan's specialty pharmacy (Accredo); some are limited distribution and available only from select pharmacies.

Supply limitSpecialty drugs are limited to a 30-day supply (plan standard).

P&T Committee — definition

DefinitionP&T Committee: Pharmacy and Therapeutics Committee composed of providers and pharmacists that reviews FDA-regulated prescription drugs for safety, efficacy, and tier placement; meets at least annually and reviews new FDA approvals.

Abbreviation key — common shorthand tokens

mgmilligram

mlmilliliter

tab_tablets

susp_suspension

capcapsules

Abbreviation key mapping (GN, GP, GPI, BP) to drug entries

GNGeneric name or generic formulation label used to map generic drug entries (example: erythromycin tab delayed release 250 mg; 333 mg; 500 mg).

BPBrand Preferred / Brand-related label used for brand product entries (example: DELSTRIGO doravirine-lamivudine-tenofovir df tab 100-300-300 mg marked BP).

GPIGroup product identifier used in abbreviation mappings for specific formulations or packs (seen across antiretroviral and other groups).

Abbreviation key mapping shorthand tokens to full drug names and dosage forms

DELSTRIGOdoravirine–lamivudine–tenofovir DF tablet 100-300-300 mg (brand entry) — tab presentation

DESCOVYemtricitabine–tenofovir alafenamide fumarate tablet 120-15 mg (and other strengths) — tab presentation

TRUVADAemtricitabine–tenofovir disoproxil fumarate tablet various strength packs (e.g., 100-150 mg; 133-200 mg; 167-250 mg) — tab presentation

Abbreviation key — shorthand labels associated with formulations

BNBrand non-preferred / Brand notation used in abbreviation mappings (appears with some entries).

BPBrand preferred notation used in abbreviation mappings (appears with patented brand entries).

GNGeneric notation used to indicate generic formulations in mappings; often used for multiple strengths/formulations.

Abbreviation key — mapping tokens to full drug names with dosage forms and strengths

ALUNBRIGbrigatinib tablets — 30 mg; 90 mg; 180 mg (tab)

COMETRIQcabozantinib S-malate capsule/kit (example pack: 1 x 80 mg & 3 x 20 mg) — cap

METHOTREXATE SODIUMmethotrexate sodium injection formulations — 50 mg/2 mL (25 mg/mL); 250 mg/10 mL; preservative-free 1000 mg/40 mL listed

Abbreviation key (vaccine products) — product name, formulation, dose/presentation

COMIRNATY 2025-26COVID-19 mRNA vaccine (Pfizer) — im suspension prefilled syringe 30 mcg/0.3 mL

GARDASIL 9human papillomavirus (HPV) 9‑valent recombinant vaccine — im suspension

PREVNAR 20pneumococcal 20‑valent conjugate vaccine — suspension syringe 0.5 mL

Abbreviation key mapping short labels to full drug/vaccine product names and presentation

CAPVAXIVEpneumococcal 21‑valent conjugate vaccine — solution syringe 0.5 mL

FLUZONE HIGH‑DOSE 2025-26influenza vaccine split high‑dose — suspension syringe 0.5 mL

MODERNA COVID‑19 VACCINEmRNA COVID‑19 vaccine (Moderna) — multiple presentations noted (prefilled syringes)

Abbreviation key — example mapping (selected oncology agents)

ALUNBRIGbrigatinib tablet — 30 mg; 90 mg; 180 mg; initiation pack available

AUGTYROrepotrectinib capsule — 40 mg; 160 mg

COPIKTRAduvelisib capsule — 15 mg; 25 mg

Abbreviation key / Drug mapping — example oncology oral agents

KISQALIribociclib succinate tablets — pack/daily-dose entries (e.g., 200 mg daily dose pack referenced)

JAYPIRCApirtobrutinib tablets — 50 mg; 100 mg

LENVIMAlenvatinib capsules — therapy packs referenced for various daily doses

Abbreviation key mapping to full drug names, formulations, strengths, brand names

XALKORIcrizotinib capsules — 200 mg; 250 mg

TAFINLARdabrafenib mesylate tablets/for oral suspension — 10 mg and other tablet strengths

TALZENNAtalazoparib tosylate tablets — 40 mg; 80 mg

Abbreviation key mapping brand/generic names to dosage forms and strengths

Vancomycin (Vancocin/Firvanq)oral solution and oral formulations — example listed (Vancocin)

Fosfomycinfosfomycin tromethamine powder pack 3 g (single‑dose pack)

Albendazole (Albenza)albendazole tablet 200 mg — antiparasitic example in key

Abbreviation key mapping shorthand codes to full product names for hormonal therapies

Estrogen-progestin combined formulationsdesogestrel & ethinyl estradiol tablets (e.g., 0.15 mg/30 mcg) and drospirenone‑ethinyl estradiol‑levomefolate (Beyaz) — oral tablets

Medroxyprogesterone acetate (Depo‑Provera)IM suspension prefilled syringe 150 mg/mL — contraceptive injectable presentation

Testosterone formulationstestosterone cypionate IM injection 100 mg/mL and 200 mg/mL; transdermal gels and solutions (examples listed)

Abbreviation key mapping shorthand entries to drug names and formulations

Erythromycinerythromycin ethylsuccinate suspension 400 mg/mL; delayed‑release tablets 250 mg, 333 mg, 500 mg

Itraconazoleitraconazole oral solution 10 mg/mL; itraconazole capsule 100 mg (Sporanox)

Ketoconazoleketoconazole tablets 200 mg

OpenPayer

Prescription Drug Formulary and Utilization Management

Formulary Coverage & Exclusions

Drug Name / Abbreviation Mappings

Authorization, Step Therapy & Submission Notes

Abbreviations & Key Terms

Supply Limits & Specialty Drug Supply

Administration & Billing Notes

Policy Background