Value Formulary (2026) — Prescription Drug List and Utilization Management
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Defines the Capital Blue Cross 2026 Value Formulary for prescription drugs, including formulary tiers, specialty drug handling, utilization management (prior authorization, step therapy, quantity limits), and processes for exceptions and reconsideration; applies to members and providers under Capital Blue Cross plans governed by this formulary.
No material clinical or coverage changes in this revision.
Formulary Coverage & Exclusions
Formulary Coverage and Utilization Management
Covered when ALL of the following plan- and formulary-level conditions are met:
Source: Coverage considerations (FDA approval) and Nonformulary exception process.
Check member's Certificate of Coverage and plan materials before prescribing.
See Additional coverage considerations.
Refer to prescription drug plan materials for plan‑specific UM requirements.
See Utilization management (Quantity Level Limits).
Contact Accredo or member services for limited distribution instructions.
Exclusions are plan- and contract-specific. Examples noted in the formulary materials include exclusions for drugs used for cosmetic purposes, appetite suppressants, erectile dysfunction drugs, non–self‑administered injectable drugs, experimental or investigational (including off‑label) use, certain vitamins (non‑prenatal), and products with OTC equivalents. Members should consult their Certificate of Coverage for the final determination of whether a given product is excluded under their plan.
The provided formulary segments in this excerpt do not include explicit exclusion statements; they are product listings used for billing and coverage reference. Absence of an exclusion statement in these chunks does not guarantee coverage — coverage remains subject to the member's plan benefits and any utilization management rules indicated elsewhere in the formulary.
This catalog-style excerpt lists vaccine and antineoplastic products and does not state explicit coverage exclusions for the items shown. Use the formulary columns and the member’s Certificate of Coverage to determine applicable utilization management or coverage limitations for listed products.
The antineoplastic product listing in this chunk enumerates therapy packs and formulations but does not include specific exclusion language. Coverage determinations for oncology agents are governed by plan benefits and any utilization management requirements indicated in the formulary.
This segment contains endocrine and corticosteroid product listings (including fludrocortisone and hydrocortisone) without explicit exclusion statements. Providers should reference plan documents and formulary utilization indicators for coverage and dispensing instructions.
Listings for testosterone transdermal gels and related formulations are presented here without explicit exclusion language. Coverage of androgen preparations is subject to plan benefit rules and any utilization management indicators shown in the formulary.
Diabetes therapy agents such as sitagliptin (JANUVIA) and metformin combinations are listed in this excerpt. No explicit coverage exclusions are stated in this portion; coverage and any quantity or prior authorization limits are determined by the member’s plan and the formulary columns.
Insulin product presentations (e.g., LYUMJEV pen formats) are enumerated without exclusion statements. Specialty distribution, supply limits, and any utilization management requirements should be confirmed via the formulary columns and the member’s Certificate of Coverage.
This section lists specialty metabolic agents (e.g., sapropterin/Kuvan and sodium phenylbutyrate/Buphenyl) as product entries. The excerpt does not include explicit exclusions; coverage and any restricted distribution or prior authorization requirements are determined by plan rules.
Repeated listings of digoxin oral solution are provided here as product entries without an explicit coverage stance in the excerpt. Determinations of coverage, supply limits, and any utilization management are controlled by the member’s benefit plan and the formulary indicators.
The product listings in these chunks do not include any statements designating items as "not medically necessary." Where such determinations apply, they would be reflected in the member’s benefit documentation or separate medical policy language.
There are no explicit “not medically necessary” determinations present in these vaccine and oncology listing excerpts. Clinical coverage determinations are made according to product labeling, utilization management rules, and the member’s Certificate of Coverage.
No "not medically necessary" statements appear in this antineoplastic agent listing. Coverage for oncology drugs depends on plan benefits and any applicable prior authorization or other utilization management requirements.
The testosterone and related endocrine product entries in this excerpt do not include determinations that they are "not medically necessary." Coverage is governed by plan rules and any indicated utilization management criteria.
This diabetes agent listing does not contain "not medically necessary" language. Coverage and any applicable limits or prior authorization requirements should be verified through the formulary columns and the member’s benefit documents.
Insulin product listings in this excerpt do not include explicit "not medically necessary" statements. Any determination of medical necessity will follow plan criteria and utilization management policies.
The anti‑infective product listings in these chunks do not state any "not medically necessary" decisions. Clinical appropriateness and coverage are determined by product labeling, formulary placement, and the member’s Certificate of Coverage.
Formulary listing segments that are purely product inventories generally do not include explicit "not medically necessary" language. Any such determinations would be contained in separate policy statements or benefit documentation.
Drug Listings and Code Tables
| flucytosine cap 250 mg; 500 mg | flucytosine (Ancobon) |
| griseofulvin microsize susp 125 mg/ml | griseofulvin microsize suspension 125 mg/mL |
| griseofulvin microsize tab 500 mg | griseofulvin microsize tablet 500 mg |
| ketoconazole tab 200 mg | ketoconazole 200 mg tablet |
| nystatin tab 500000 unit | nystatin 500,000 unit tablet |
| terbinafine hcl tab 250 mg | terbinafine 250 mg tablet |
| voriconazole tab 50 mg; 200 mg | voriconazole (Vfend) 50 mg and 200 mg tablets |
| abacavir sulfate tab 300 mg | abacavir sulfate 300 mg tablet (Ziagen) |
| emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg | Truvada (emtricitabine + TDF) |
| acyclovir cap 200 mg | acyclovir 200 mg capsule |
| acyclovir susp 200 mg/ml | acyclovir suspension 200 mg/mL (Zovirax) |
| EPCLUSA sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg | Epclusa (sofosbuvir-velpatasvir) |
| APRETUDE cabotegravir im extended release susp 600 | Apretude 600 mg IM suspension |
| atazanavir sulfate cap 150 mg; 200 mg; 300 mg | atazanavir (Reyataz) capsules |
| HARVONI ledipasvir-sofosbuvir tab 45-200 mg; 90-400 mg | Harvoni (ledipasvir-sofosbuvir) |
| COMPLERA emtricitabine-rilpivirine-tenofovir df tab | Complera fixed-dose combination |
| darunavir tab 600 mg; 800 mg | darunavir (Prezista) |
| ISENTRESS raltegravir packet / tab | Isentress formulations (chewable 25 mg, 100 mg; packet 100 mg; tab 400 mg) |
| DELSTRIGO doravirine-lamivudine-tenofovir df tab | Delstrigo fixed-dose combination |
| LAGEVRIO molnupiravir cap 200 mg | Molnupiravir (Lagevrio) 200 mg capsules |
| lamivudine oral soln 10 mg/ml (Epivir) | lamivudine oral solution 10 mg/mL |
| lamivudine tab 100 mg (Epivir HBV) | lamivudine 100 mg tablet for HBV |
| LEDIPASVIRISOFOSBUVIR ledipasvir-sofosbuvir tab 90-400 mg | Ledipasvir-sofosbuvir |
| lopinavir-ritonavir tab 100-25 mg; 200-50 mg (Kaletra) | lopinavir/ritonavir formulations |
| maraviroc tab 150 mg; 300 mg (Selzentry) | maraviroc tablets |
| TIVICAY dolutegravir sodium tab 50 mg | Dolutegravir (Tivicay) 50 mg tablet |
| ODEFSEY emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg | Odefsey fixed-dose combination |
| COMIRNATY 2025-26 | covid-19 mRNA vaccine tris - Pfizer, various age formulations (30 mcg/0.3ml; 10 mcg/0.3ml for 5-11y) |
| GARDASIL 9 | human papillomavirus (HPV) 9-valent recombinant vaccine |
| HAVRIX / VAQTA / RECOMBIVAX HB / ENGERIX-B / HEPLISAV-B | Hepatitis A and B vaccine formulations listed with concentrations and prefilled syringes |
| FLUAD / FLUARIX | 2025-2026 influenza vaccine formulations (adjuvanted and split virus preparations) |
| JYNNEOS | smallpox & monkeypox vaccine, live non-replicating, 0.5 ml |
| M-M-R II / PRIORIX | measles-mumps-rubella virus vaccines |
| MENVEO / TRUMENBA / PENBRAYA | meningococcal vaccines (A,C,Y,W-135 and B formulations) |
| VARIVAX | varicella virus vaccine live for injection |
| MRESVIA | RSV mRNA pre-f vaccine (50 mcg/0.5 ml) |
| NOVAVAX / MODERNA / SPIKEVAX | additional COVID-19 vaccine products (Novavax subunit, Moderna formulations) |
| IBRANCE | palbociclib tablets (75 mg, 100 mg, 125 mg) |
| COTELLIC | cobimetinib fumarate tablets 20 mg |
| ALECENSA | alectinib HCl capsules 150 mg |
| LENVIMA (multiple daily dose packs) | lenvatinib capsule therapy packs (4 mg, 8 mg, 10 mg, 12 mg, 18 mg, 20 mg, 24 mg daily dose packs) |
| POMALYST | pomalidomide capsules (2.3 mg, 3 mg, 4 mg) |
| METHOTREXATE SODIUM | injectable methotrexate sodium 50 mg/2 mL and oral formulations |
| IMATINIB (Gleevec) | imatinib mesylate tablets (100 mg, 400 mg) |
| HYDROXYUREA | hydroxyurea capsules 500 mg |
| SOLTAMOX | tamoxifen citrate oral solution 10 mg/mL |
| ERIVEDGE / IBRANCE / POMALYST / etc. | additional antineoplastic agents listed by name and formulation |
| lenvatinib 18 mg | LENVIMA 18 MG DAILY DOSE lenvatinib cap therapy pack (10 mg & 2 x 4 mg) |
| lenvatinib 20 mg | LENVIMA 20 MG DAILY DOSE lenvatinib cap therapy pack (2 x 10 mg) |
| lenvatinib 24 mg | LENVIMA 24 MG DAILY DOSE lenvatinib cap therapy pack (2 x 10 mg & 4 mg) |
| talazoparib | TALZENNA talazoparib tosylate cap 0.1 mg; 0.25 mg; 0.35 mg; 0.5 mg; 0.75 mg |
| tamoxifen | tamoxifen citrate tab 10 mg; 20 mg (SOLTAMOX mentioned) |
| nilotinib | TASIGNA nilotinib hcl cap 50 mg; 150 mg; 200 mg |
| crizotinib | XALKORI crizotinib cap 200 mg; 250 mg |
| temozolomide | temozolomide cap 5 mg |
| toremifene | toremifene citrate tab 60 mg (Fareston) |
| methotrexate | TREXALL methotrexate sodium tab 5 mg; 7.5 mg; 10 mg |
| idelalisib | ZYDELIG idelalisib tab 100 mg; 150 mg |
| prednisone/prednisolone/methylprednisolone/dexamethasone | Multiple corticosteroid oral and solution formulations (prednisone, prednisolone, methylprednisolone, dexamethasone) in various strengths and pack types |
| testosterone formulations | Multiple testosterone formulations: gels (Androgel), injections (cypionate, enanthate), TD gels in various strengths |
| fludrocortisone/hydrocortisone | fludrocortisone acetate tab 0.1 mg; hydrocortisone tab 5 mg; 10 mg; 20 mg |
| tamoxifen oral solution | SOLTAMOX tamoxifen citrate oral soln 10 mg/ml |
| tretinoin | tretinoin cap 10 mg |
| treatment combinations | Various supportive/simultaneous listings (e.g., corticosteroids listed among antineoplastic agents) |
| No codes listed |
| JANUVIA 25 mg, 50 mg, 100 mg | sitagliptin formulations listed (base equivalent) |
| metformin HCl tab 5-500 mg, 5-1000 mg, 12.5-500 mg, 12.5-1000 mg | metformin combination/strength listings |
| JARDIANCE 10 mg, 25 mg | empagliflozin tablets |
| SYNJARDY XR (empagliflozin-metformin ER) 5-1000 mg; 10-1000 mg; 12.5-1000 mg | combination empagliflozin/metformin extended release |
| liraglutide soln pen-injector 18 mg/3 mL (Victoza) | GLP-1 receptor agonist |
| TRULICITY dulaglutide soln auto-injector 0.75 mg/0.5 mL | GLP-1 receptor agonist |
| FIASP FLEXTOUCH 100 unit/mL | insulin aspart (with niacinamide) pen-injector |
| FIASP PENFILL 100 unit/mL | insulin aspart cartridge (with niacinamide) |
| NOVOLOG 100 unit/mL | insulin aspart solution |
| HUMALOG 100 unit/mL (KwikPen, Junior KwikPen, Tempo Pen) | insulin lispro presentations |
| HUMULIN R U-500 500 unit/mL | concentrated insulin regular |
| INSULIN ASPART FLEXPEN 100 unit/mL | insulin aspart pen-injector |
| INSULIN ASPART PENFILL 100 unit/mL | insulin aspart cartridge |
| NOVOLIN R 100 unit/mL | insulin regular (human) |
| INSULIN LISPRO 100 unit/mL | insulin lispro solution |
| LYUMJEV 100 unit/mL (and KwikPen 200/100 presentations) | insulin lispro-aabc product and pen forms |
| insulin lispro-aabc soln pen-injector 200 | LYUMJEV KWIKPEN insulin lispro-aabc solution pen-injector (200 units/mL) — listed |
| insulin lispro prot & lispro sus pen-inj 100 unitlml (75-25) | HUMALOG MIX 75/25 KWIKPEN — insulin lispro protamine & lispro suspension pen-injector 100 units/mL (75/25) |
| insulin nph (human) (isophane) inj 100 unitlml | HUMULIN N insulin NPH injectable 100 units/mL |
| NOVOLIN N FLEXPEN insulin nph | NOVOLIN N FLEXPEN insulin NPH suspension pen-injector 100 units/mL |
| NOVOLIN 70/30 insulin nph isophane & regular human inj 100 unitlml (70-30) | NOVOLIN 70/30 premixed insulin 100 units/mL (70/30) |
| liothyronine sodium tab 25 mcg; 50 mcg | Liothyronine sodium (Cytomel) tablets 25 mcg and 50 mcg |
| methimazole tab 5 mg; 10 mg | Methimazole (Tapazole) tablets 5 mg and 10 mg |
| NP THYROID 15/30/120 thyroid tab | NP Thyroid compounded/desiccated thyroid tablets in multiple strengths (15 mg, 30 mg, 120 mg) |
| 5.8 mg | OMNITROPE somatropin solution cartridge 5 mg/1.5ml, 10 |
| 10 mg/1.ml | OMNITROPE somatropin solution cartridge 10 mg/1.ml (various references) |
| 10 mg; 20 mg; 30 mg | isosorbide dinitrate tab strengths |
| 30 mg; 60 mg; 120 mg | isosorbide mononitrate tab ER 24hr strengths |
| 0.3 mg; 0.4 mg; 0.6 mg | nitroglycerin sublingual tablet (Nitrostat) strengths |
| 0.4 mg/spray (400 mcg/spray) | nitroglycerin topical solution/spray (Nitrolingual) |
| 0.1 mg/hr; 0.2 mg/hr; 0.4 mg/hr | nitroglycerin transdermal patch 24hr strengths (Nitro-Dur) |
| 500 mg; 1000 mg | ranolazine ER tablet 12hr 500 mg; 1000 mg |
| 25 mg; 50 mg; 100 mg; 400 mg | atenolol and other beta blocker tablet strengths referenced |
| 100 mg; 500 mg | sapropterin dihydrochloride powder packet 100 mg, 500 mg (Kuvan) |
| 100 mg tablet | sapropterin dihydrochloride tablet (Kuvan) |
| 3 g | sodium phenylbutyrate oral powder 3 g/teaspoonful |
| 10000 unit | PREGNYL chorionic gonadotropin for IM injection 10000 unit |
| sapropterin dihydrochloride tab 100 mg (Kuvan) — product name repeated |
| powder 3 g/teaspoonful (Buphenyl) — sodium phenylbutyrate oral powder |
| digoxin oral soln 0.05 mg/mL (Digoxin) |
| various cardiovascular agents: carvedilol tabs, labetalol, metoprolol succinate ER (Toprol XL) — product names listed |
Prior Authorization, Step Therapy, Quantity Limits & Reconsideration
Prior authorization may be required for some drugs
Some drugs listed in the formulary may require prior authorization; when PA is commonly required it is denoted by a dot in the Prior Authorization column adjacent to the drug entry. Providers must submit a prior authorization request for those drugs before coverage will be provided under the member's prescription drug plan.
- PA requirement indicated by a dot in the Prior Authorization column when commonly applied
- Provider must submit a PA request and obtain approval before the drug will be covered
PA indicated per drug in formulary columns
Prior Authorization applicability is shown per drug by an entry in the Prior Authorization column; presence of that indicator means the plan's UM prior authorization requirement applies and the provider must follow the PA process described by the plan.
- Check the Prior Authorization column for an indicator next to the drug
- If indicated, follow the plan's PA submission process prior to dispensing
No prior authorization details in this listing segment
This excerpt does not specify any specific prior authorization requirements for the products shown. The content in these chunks is a product listing and does not provide PA criteria or affected billing codes.
- No drug-specific PA details are provided in this listing segment
- Refer to the formulary columns or the member's plan materials for PA requirements
Formulary listing — PA not specified here
The document fragment is a formulary product listing and does not state prior authorization requirements for the listed products. Providers should consult the formulary columns or the member's plan materials for UM indicators.
- Formulary listing only; PA requirements not specified here
- Use the Prior Authorization column in the full formulary to determine PA needs
PA not specified for vaccines/antineoplastics in this excerpt
No explicit prior authorization requirements or affected billing codes are specified in this excerpt; the content is a formulary listing of vaccines and antineoplastic agents and their presentations only.
- Vaccine and oncology product listings without PA mapping in this fragment
- Check full formulary columns for PA indicators
PA not specified; codes not listed here
This segment lists drug names, formulations, and strengths but does not specify which HCPCS/CPT/NDC codes require prior authorization. Providers should refer to the plan's UM resources for PA code mappings.
- Drug entries shown without associated PA code requirements
- Consult plan materials for PA coding and submission instructions
No PA rules in this formulary fragment
Prior authorization requirements are not stated in this excerpt; the text is a formulary-style list of products and formulations and does not provide PA rules.
- No PA rules presented in this fragment
- Use the Prior Authorization column or plan documents for PA guidance
PA not specified in this section
No explicit prior authorization requirements are stated in these chunks; the content is a medication listing and strengths without PA mapping.
- Providers should not assume PA is or is not required based on this listing alone
- Verify UM indicators in the formulary columns or member plan
PA not listed for these products
No prior authorization statements are present in this portion; the text lists drug names and strengths only. Providers must check the Prior Authorization column or member-specific benefits for PA requirements.
- Listing shows products but no PA criteria here
- Confirm PA via formulary columns or Benefit Booklet
Product listing — PA not specified
This section is a product/formulation listing and does not state specific prior authorization requirements. Providers should consult the full formulary columns and the member's Certificate of Coverage for PA applicability.
- No PA criteria included in this listing
- Use plan-specific materials to confirm PA needs
PA not specified in this fragment
No explicit prior authorization requirements are stated in this document fragment; the content is a formulary/product listing without PA mapping. Verify PA requirements through the formulary columns or specific plan materials.
- Listing does not identify PA-applicable codes
- Confirm PA via the Prior Authorization column or Benefit Booklet
PA not specified for listed products
This segment enumerates drug names and formulations but does not specify prior authorization requirements. Providers must check the formulary columns or contact plan administrators to determine PA obligations.
- No PA mapping included here
- Contact Prime Therapeutics/Capital Blue Cross or review full formulary columns for PA
PA not specified in this section
No prior authorization requirements are stated in these chunks; the content is product/formulation names and classifications without PA instructions. Providers should consult plan-specific UM resources to confirm PA needs.
- Listing only; no PA criteria present
- Verify PA via formulary columns or member's plan
No PA requirement indicated in this fragment
No prior authorization requirement is specified in this fragment. The listing repeats product entries but does not indicate applicable PA processes; check the formulary columns or plan materials for PA indicators.
- Repeated product listings without PA indicators here
- Refer to the Prior Authorization column or Benefit Booklet for requirements
PA not specified in this section
No prior authorization requirements are specified in these pages; content is limited to drug names and formulations. Providers should verify PA via the formulary columns or the member's Certificate of Coverage.
- Formulary entries only; no PA rules listed
- Confirm PA with plan materials or specialty pharmacy when applicable
Step therapy may apply to some drugs
Some drugs may be subject to step therapy; when step therapy is commonly required it is indicated by a dot in the Step Therapy column next to the drug. Providers must follow the plan's step therapy requirements when the indicator is present.
- Step therapy indicated by a dot in the Step Therapy column when commonly applied
- Provider must document trial/failure of required preferred agents per plan before obtaining coverage
Step therapy indicated per formulary entry
Step Therapy is indicated per drug by an entry in the Step Therapy column; presence of that indicator means the plan may require a trial of preferred or cost‑effective agents before covering the requested drug.
- Check the Step Therapy column for an indicator next to the drug
- If present, document trials of required alternatives before requesting coverage
No step therapy details in this listing
No step therapy rules are stated in these chunks. The content is a product listing and does not provide step therapy criteria or required prior trials.
- Listing segment only; no step therapy details provided
- Consult formulary columns or plan materials for step therapy applicability
Step therapy not specified in this segment
This fragment does not include step therapy rules. Providers should rely on the Step Therapy column in the complete formulary or the member's plan documents to determine whether step therapy applies.
- No step therapy criteria included here
- Verify step requirements via the Step Therapy column or plan materials
No step therapy rules in this fragment
No step therapy rules are present in these chunks; content is product listings and presentation details. Check the Step Therapy column in the full formulary for any program indicators.
- Vaccine/antineoplastic listings without step therapy mapping here
- Confirm step therapy through formulary columns or plan contact
Step therapy not stated here
No step therapy rules are provided in these chunks. Providers should not assume step therapy requirements from this listing and must check the formulary columns or plan materials for step therapy indicators.
- Product listing does not include step therapy criteria
- Use plan-specific UM resources to confirm step therapy
No step therapy requirements in this section
No step therapy requirements are specified in these chunks. The document segments are drug listings without step therapy mapping; refer to the formulary columns or plan documentation for step therapy details.
- No step therapy criteria shown in these listings
- Confirm step therapy via the Step Therapy column in the full formulary
Step therapy not indicated for these entries
No step therapy rules are specified in this fragment. Providers should consult the Step Therapy column or the member's plan materials for any required prior trials before coverage.
- Insulin and diabetes product listings here do not include step therapy details
- Check formulary columns for step therapy indicators
No step therapy described in this fragment
No step therapy rules are described in these chunks. The product listings in this fragment lack step therapy mapping; verify step therapy applicability via the full formulary columns.
- Thyroid and endocrine listings without step therapy info here
- Confirm step therapy via plan materials when needed
Step therapy not specified in this fragment
No step therapy requirements are specified in this fragment. Providers must consult the formulary Step Therapy column or their prescription drug plan materials for any applicable requirements.
- Specialty metabolic and other agents listed without step therapy mapping
- Refer to plan-specific UM resources for step therapy
No step therapy rules in this section
No step therapy requirements are specified in these pages; content is product listings repeated across the formulary. Providers should check the Step Therapy column or member plan materials to determine if step therapy applies.
- Repeated product listings without step therapy indicators here
- Confirm step therapy via the formulary's Step Therapy column
Request formulary tier reconsideration / appeals
Providers may request a formulary tier reconsideration by completing a Formulary Status Reconsiderations form or by sending a letter describing the drug's significant advantages; the P&T Committee will review requests and communicate results, and patient‑specific requests must follow the dispute and appeal process.
- Complete the Formulary Status Reconsiderations form or submit a detailed letter to the P&T Committee
- P&T Committee will review and communicate outcomes; patient-specific reviews follow the dispute/appeal process
Use formulary columns to determine UM and dispensing
Prescribers and pharmacists should use the formulary columns (Prior Authorization; Step Therapy; Quantity Level Limits; Limited Distribution) to determine required utilization management actions and where the drug must be dispensed.
- Check the Prior Authorization, Step Therapy, Quantity Level Limits, and Limited Distribution columns for UM and dispensing instructions
- If an indicator is present, follow the corresponding UM or limited distribution requirements
Reference product presentation for coding/documentation
This segment contains product names, formulations, and presentation details (e.g., dose, volume, prefilled syringe) that providers should reference when coding and documenting vaccine or antineoplastic drug administration, but it does not provide explicit documentation requirements.
- Use the listed product formulation and presentation details for accurate coding and documentation
- No specific documentation forms or fields are specified in these chunks
Formulary listing does not guarantee coverage — PA may cause denial
Coverage of a drug is not guaranteed by its listing in the formulary; prior authorization may be required and lack of approval will result in denial of coverage.
- A formulary listing alone does not ensure coverage or payment
- If PA is required and not approved, the claim may be denied
UM indicators may trigger claim denials if unmet
If an indicator for Prior Authorization, Step Therapy, or Quantity Limits is present in the formulary columns, utilization management programs may apply and claims lacking required UM may be denied. Providers must follow UM requirements indicated in the formulary columns.
- Presence of UM indicators in the formulary columns signals applicable UM programs
- Claims submitted without required UM (e.g., PA approval) may be denied
Step Therapy Rules & Indicators
| Step therapy overview |
|---|
| Step therapy may require trying a proven, cost‑effective alternative prior to coverage of the requested drug; if commonly required it is indicated with a dot in the Step Therapy column next to the drug. |
| Step therapy indicator |
|---|
| Presence of an indicator in the Step Therapy column of the formulary denotes the plan may require trials of preferred agents before coverage of the listed drug. |
Quantity Limits & Dispensing Constraints
Site of Care and Medical Benefit Notes
Confirm site-of-care and medical benefit billing for certain injectables
Some non-self-administered injectable drugs may be covered under the member's medical benefit and distributed through Accredo; providers should confirm site-of-care coverage (infusion center, hospital outpatient, or office) and billing pathways with the plan.
- Non–self-administered injectables may be billed to medical benefit rather than pharmacy
- Accredo may assist with distribution and billing for select medical injectables; contact 833.721.1626 or fax 888.302.1028 for service
Terminology and Abbreviations
Policy Background
Specialty drugs are used to treat complex, chronic, or rare conditions such as hepatitis, multiple sclerosis, and rheumatoid arthritis and may be oral or injectable and self‑administered or provider‑administered. Specialty medications are typically distributed through the plan’s designated specialty pharmacy (Accredo) and may be subject to limited distribution, requiring dispensing from specified pharmacies. Coverage is determined by FDA approval status and the member’s Certificate of Coverage; utilization management tools such as prior authorization, step therapy, and quantity level limits may apply.
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