Value Plus Formulary — Prescription Drug Coverage and Utilization Management
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Governs coverage, utilization management, and pharmacy benefit administration for Capital BlueCross Value Plus formulary members, including prior authorization, step therapy, quantity limits, specialty drug distribution, and nonformulary exception processes. Affects providers, pharmacists, and members covered under Capital BlueCross prescription drug plans.
No material clinical or coverage changes in this revision.
Coverage rules and exclusions
Coverage rules
Covered when the following general conditions and utilization management requirements are met:
Providers may submit a nonformulary exception if medical necessity precedes P&T review.
Formulary uses a dot in the corresponding column to indicate commonly required PA, ST, or QLL.
Provider must submit the nonformulary consideration request per plan processes.
Some employers may purchase additional coverage or exclude classes; verify the member's Benefit Booklet.
Examples of contractual exclusions include: appetite suppressants / weight-loss drugs, anti-obesity agents (for example, Wegovy), drugs used for cosmetic purposes (e.g., wrinkle or hair‑loss treatments), erectile dysfunction drugs, non-self‑administered injectable drugs, certain vitamins (non‑prenatal), and products with OTC equivalents. Coverage for these categories can vary by employer-selected plan; members should consult their Benefits Booklet (Certificate of Coverage) for plan‑specific exclusions.
Prescription drugs that are not listed on the formulary are not covered by the plan unless an approved nonformulary (formulary exception) request is obtained. The provider must submit a nonformulary consideration (formulary exception) request on the member’s behalf to seek coverage for a non‑formulary product.
The provided formulary extract contains administrative flags (Tier, Specialty, Prior Authorization, Step Therapy, Quantity Level Limits, PHC, Limited Distribution) for many products, but these chunks do not include any separate or explicit "medical necessity" exclusion list. In other words, no discrete medical‑necessity exclusions are documented in these sections — the content is limited to formulary entries and administrative indicators.
Drugs that are not FDA‑approved and uses described as experimental or investigational (including off‑label) are not covered under the prescription drug benefit.
Formulary drug listings and sample entries
| PEGASYS | PEGASYS - peginterferon alfa-2a inj 180 mcg/ml (also listed as PEGASYS prefilled syr / soln - peginterferon alfa-2a) |
| PEGASYS prefilled syr | PEGASYS - peginterferon alfa-2a soln prefilled syr 180 mcg/0.5ml |
| PREZCOBIX | PREZCOBIX - darunavir-cobicistat tab 675-150 mg, 800-150 mg (darunavir formulations) |
| PREZISTA | PREZISTA - darunavir oral susp 100 mg/ml; PREZISTA - darunavir tab 75 mg, 150 mg (darunavir formulations) |
| PEGASYS | PEGASYS - peginterferon alfa-2a inj 180 mcg/ml (listed; prior authorization and limited distribution flags present in source) |
| PEGASYS prefilled syr | PEGASYS - peginterferon alfa-2a soln prefilled syr 180 mcg/0.5ml (listed separately in source) |
| PREZCOBIX | PREZCOBIX - darunavir-cobicistat tab 675-150 mg, 800-150 mg (listed; darunavir fixed-dose with cobicistat) |
| PREZISTA oral susp/tab | PREZISTA - darunavir oral susp 100 mg/ml; darunavir tablets 75 mg, 150 mg (oral suspension and tablet formulations included) |
| PREZCOBIX | PREZCOBIX - darunavir-cobicistat tab 675-150 mg, 800-150 mg (darunavir formulations consolidated) |
| PREZISTA | PREZISTA - darunavir oral susp 100 mg/ml; PREZISTA - darunavir tab 75 mg, 150 mg (suspension and tablet strengths) |
| PEGASYS | PEGASYS - peginterferon alfa-2a inj 180 mcg/ml; PEGASYS prefilled syr 180 mcg/0.5ml (both vial/injection and prefilled syringe presentations included) |
| PEGASYS_strength | 180 mcg/ml inj; 180 mcg/0.5ml prefilled syringe |
| PREZCOBIX_strength | darunavir-cobicistat 675-150 mg; 800-150 mg |
| PREZISTA_strength | darunavir oral suspension 100 mg/ml; tablets 75 mg, 150 mg |
| PREZCOBIX_combo | darunavir-cobicistat 675-150 mg, 800-150 mg |
| PEGASYS_presentation | peginterferon alfa-2a inj 180 mcg/ml; prefilled syr 180 mcg/0.5ml |
| PEGASYS_limited | PEGASYS entries in source include Limited Distribution and Prior Authorization flags |
| PREZCOBIX_limited | PREZCOBIX listed with tier BP and standard formulary attributes in source |
| PREZISTA_limited | PREZISTA listed with oral suspension and tablet forms; source shows standard formulary attributes |
| Context_REF1 | Section contains many grouped drug listing examples; PEGASYS and PREZCOBIX/PREZISTA consolidated into antiviral group for clarity |
Prior authorization, step therapy, quantity limits, and submission instructions
Prior authorization requirement
Prior Authorization (PA): Certain drugs listed in the formulary require prior authorization. When a PA indicator (•) is shown in the Prior Authorization column next to a drug, the provider must submit a PA request and obtain approval before the drug will be covered. Claims for flagged products may be denied if an approved PA is not on file. Limited distribution products may also be flagged and require special handling for fulfillment.
- PA indicated on the drug list by a dot (•) in the Prior Authorization column
- Claims for PA‑flagged drugs can be denied without an approved PA
- Limited Distribution status may affect where the drug can be dispensed
Prior authorization indicated on drug list
Providers must follow the PA process for drugs marked on the formulary. The formulary table includes columns showing administrative attributes (Tier, Specialty, Prior Authorization, Step Therapy, Quantity Level Limits, PHC, Limited Distribution). If a drug shows the PA indicator, submit a prior authorization request using the payer's PA form or electronic submission channel.
- Required formulary fields include: Drug Name, Tier, Specialty, Prior Authorization, Step Therapy, Quantity Level Limits, PHC, Limited Distribution
- Formulary table fields are present for each product to document UM attributes and fulfillment constraints
- Providers may submit PA or nonformulary exception requests on behalf of members
Prior Authorization requirement — examples
Examples of products marked requiring PA include specialty antivirals and selected oncology agents. The formulary shows many drug‑level examples (e.g., tobramycin nebulizer solutions, some HIV agents, hepatitis C direct‑acting antivirals, targeted oncology agents) with PA and/or Limited Distribution flags.
- Antivirals with PA flags: tobramycin nebu soln (Tobi/Bethkis), voriconazole (Vfend), select HIV agents (e.g., darunavir, delstrigo variants)
- Oncology examples with PA: bosutinib (BOSULIF), brigatinib (ALUNBRIG entries indicate specialty/PA in adjacent rows), TAGRISSO (osimertinib) shows PA indicators in some rows
- Limited Distribution examples are shown alongside PA (•) for select specialty drugs
Prior Authorization required for select antivirals
Selected antivirals (including sofosbuvir-containing hepatitis C therapies) are commonly subject to prior authorization and may have quantity limits documented. Examples in the formulary include GENVOYA, HARVONI, SOVALDI, SOFOSBUVIR/VELPATASVIR, and EPCLUSA; many of these are also marked specialty and/or limited distribution.
- GENVOYA — specialty and PA flagged in formulary entries
- HARVONI, SOVALDI, EPCLUSA — PA dot present on many formulations; quantity limits are indicated on selected formulations
- Sofosbuvir products often have both PA and Quantity Level Limits (QLL) entries
Prior Authorization fields present
PA fields are present across the formulary but not all entries include detailed PA criteria in this document. Presence of a PA flag indicates the operational requirement; providers should consult the payer's PA form or clinical criteria for the exact requirements.
- The document shows the Prior Authorization column for each drug but does not reproduce full clinical PA criteria here
- Where PA is indicated (•), follow payer PA form and guidance for documentation requirements
- Some entries include Limited Distribution and Quantity Level Limit markers in the same row as PA
Prior authorization required for marked drugs
Many drugs across therapeutic classes are marked for prior authorization; providers should submit PA requests for any product with the PA indicator to avoid coverage denial. Examples in the list include specialty antiretrovirals, antifungals, hepatitis C agents, and multiple oncology agents.
- Submit PA for flagged drugs such as tobramycin nebulizer solutions, voriconazole, various HIV agents, and specialty oncology medications
- Limited distribution products are often noted alongside PA and may restrict fulfillment to specific pharmacies
Denial triggers
Denial triggers: Claims may be denied for failure to obtain prior authorization, failure to meet step therapy requirements, or exceeding documented quantity level limits. The formulary notes these administrative controls and their potential impact on coverage.
- No approved PA when required may lead to denial of coverage for that claim
- Not attempting required step therapy (when a dot is present in the Step Therapy column) can be a basis for denial
- Dispensing beyond state controlled‑substance limits can shift the cost to the member per state law
Controlled substance dispensing limit
Controlled substances: State dispensing limits may restrict covered quantities for controlled substances. If a pharmacy dispenses a controlled substance in excess of the applicable state limit, the member may be responsible for the full cost with no benefits applied.
- Medication Synchronization and proration guidance do not override state controlled substance dispensing limits
- Providers/pharmacies should confirm state dispensing limits before dispensing quantities that exceed typical limits
PA and quantity limits for sofosbuvir products
PA and quantity limits for sofosbuvir products are documented in the formulary. Several sofosbuvir‑containing agents are marked with PA and Quantity Level Limits; absence of an approved PA or exceeding QLLs may result in claim denial or member financial responsibility.
- SOVALDI and SOVALDI pellet/tab formulations show PA and QLL markers on certain rows
- HARVONI entries indicate PA and may include quantity limits for specific presentations
- Providers should submit PA requests and check QLLs when prescribing sofosbuvir‑containing regimens
No explicit prior authorization or denial rules provided
The document does not include explicit PA clinical criteria or step‑by‑step denial triggers for every listed drug within these chunks. Where PA/step therapy/QLL flags are blank, no explicit denial triggers are provided in this extract — consult the payer for product‑specific criteria.
- Many formulary rows show PA/Step Therapy fields but lack the detailed rule text in this excerpt
- Providers should not assume absence of a dot guarantees no UM program at the plan level — check specific plan materials
Limited Distribution may affect fulfillment
Limited Distribution: Some products are labeled Limited Distribution in the formulary, which may restrict which pharmacies can dispense them and affect fulfillment timelines. When Limited Distribution is indicated, providers and members may need to use a designated specialty pharmacy.
- Limited Distribution flag is shown in the formulary alongside PA and Specialty indicators
- Examples: APRETUDE, some hepatitis C and oncology agents, and select endocrine/specialty products
Nonformulary exception submission
Nonformulary exception submission: If a prescribed drug is not on the formulary, providers may submit a nonformulary consideration (formulary exception) request on behalf of the member. The P&T Committee reviews formulary status reconsiderations; requests concerning specific patients follow the dispute/appeal process.
- Providers may complete a Formulary Status Reconsiderations form or write a supporting letter to the P&T Committee
- Address for submission: Pharmacy Services, Capital Blue Cross P&T Committee, P.O. Box 773735, Harrisburg, PA 17177-3735
Submit Prior Authorization for flagged drugs
Submit Prior Authorization for flagged drugs: The formulary highlights examples of products requiring PA; providers should use the payer's PA form or electronic process to submit supporting clinical documentation to secure approval prior to dispensing.
- Examples of frequently PA‑flagged products: GENVOYA, HARVONI, SOVALDI, targeted oncology agents (TAGRISSO, TALZENNA), TRULICITY, selected glucagon/antidiabetic products
- Retrovir (zidovudine) and other ARV entries show PA fields in the formulary — verify plan‑specific PA requirements
Retrovir PA documentation
Retrovir PA documentation: The formulary includes Retrovir (zidovudine) entries with PA fields present. Even for older agents, check the PA column and submit documentation when a PA is indicated to avoid processing delays or denials.
- RETROVIR (zidovudine) cap and syrup entries are present in the formulary with PA column available
- Use payer PA form if the Prior Authorization column indicates a requirement
The document shows administrative attributes
Administrative attributes: The formulary records multiple administrative attributes per product (Tier, Specialty, Prior Authorization, Step Therapy, Quantity Level Limits, PHC, Limited Distribution). Some entries indicate Quantity Level Limits or PHC status, but numeric limits or full clinical criteria are not reproduced in these chunks.
- Required formulary fields visible: Drug Name, Tier, Specialty, Prior Authorization, Step Therapy, Quantity Level Limits, PHC, Limited Distribution
- Some rows show Quantity Level Limits and PHC markers without numeric limits included in this excerpt
Quantity/PHC documentation
Quantity/PHC documentation: The formulary marks Quantity Level Limits (QLL) and Preventive Healthcare (PHC) where applicable. Numeric QLL values and clinical thresholds are not visible in these chunks — check plan materials for specifics.
- Many product rows display a QLL marker (•) indicating limits apply; specific numeric limits are maintained in plan systems
- PHC markers (for PPACA‑mandated preventive coverage) are displayed where applicable
Step therapy indicated on drug list
Step Therapy: A Step Therapy column is present and, when marked with a dot (•), indicates the plan may require trials of specified alternatives before covering the requested drug. Most entries in this extract show no step therapy indication; where present, providers must follow the plan's step sequence.
- Step Therapy field is present for products but detailed sequence steps are not included in these chunks
- Many formulary entries show no step therapy (mostly blank), but some specialty or oncology agents indicate step requirements
Definitions and policy background
Specialty drugs are prescription therapies used to treat complex or chronic conditions (for example, hepatitis, multiple sclerosis, and rheumatoid arthritis). They may be oral or injectable, are often self‑administered, and may require distribution through a participating specialty pharmacy (e.g., Accredo). Specialty products are commonly subject to utilization management such as Prior Authorization, Step Therapy, and Quantity Level Limits, and the plan typically limits specialty supplies to a 30‑day standard fill.
Step therapy applicability
| Summary |
|---|
| Step therapy applies where noted in the formulary; products subject to step therapy are identified by a dot in the Step Therapy column of the drug list. |
| Drug / Product | Step Therapy |
|---|---|
| Formulary drug list — per‑drug Step Therapy column indicates applicability; if a dot is present the step therapy program applies to that product. | |
| Follow the plan's step therapy program as indicated in the Step Therapy column; refer to member-specific plan materials for program details. |
| Example products | Step Therapy |
|---|---|
| Multiple aminoglycoside and related entries (e.g., tobramycin nebulized solutions: Tobi/Bethkis) — Step Therapy = . (no step therapy documented for most presentations) | |
| Voriconazole (suspension and tablets) — Step Therapy = . (most listed rows show no step therapy) |
| Product | Step Therapy note |
|---|---|
| HARVONI (ledipasvir-sofosbuvir) pellet pack/tab — Step Therapy = . for most rows, but other UM flags (PA, QLL) present | |
| Lamivudine oral solution / lamivudine 100 mg (HBV) — select rows show Step Therapy = • indicating a step therapy marker for certain presentations |
| Scope | Observation |
|---|---|
| Vaccine and antiviral product lines include a Step Therapy field for each item but the majority of entries in these segments are blank (Step Therapy = .) | |
| Step Therapy field exists as an administrative column across many products but is largely unpopulated in these chunks |
| Pediatric vaccine | Step Therapy |
|---|---|
| COVID-19 mRNA vaccine (Moderna) — pediatric 6 mo–11 yr presentations show Step Therapy = • in some rows (marker present) though no detailed step requirements are provided in these chunks. |
| Product examples | Step Therapy |
|---|---|
| Multiple oncology and specialty agents list a Step Therapy field; where a bullet (•) is shown the formulary indicates step therapy applies to that presentation. | |
| Bexarotene (Targretin) entries include Step Therapy markers in some rows (•) while many other product rows remain blank. |
| Oncology / specialty product | Step Therapy |
|---|---|
| Sorafenib (Nexavar), sunitinib, and other oncology agents show Step Therapy flags in the formulary table (dots in Step Therapy column where present). | |
| TAFINLAR (dabrafenib) listings show Step Therapy markers (•) for certain presentations in these chunks. |
| Antidiabetic / glucagon product | Step Therapy |
|---|---|
| GLYXAMBI — Step Therapy = • in at least one listed presentation (marker indicates step therapy applies). | |
| GVOKE (glucagon auto-injector) and related glucagon kit entries show Step Therapy markers on select rows (•) in the formulary extract. |
| Member requirement | Implication |
|---|---|
| Where a bullet (•) appears in the Step Therapy column, the member must have met the applicable step therapy requirement before coverage is available. | |
| Formulary rows with Step Therapy = • should prompt prior verification of prior therapy alternatives per plan step therapy programs to avoid claim denials. |
| Insulin product | Step Therapy |
|---|---|
| Most listed insulins (intermediate and basal examples such as HUMULIN N, NOVOLIN N, premixed products) show Step Therapy = . (blank) in these excerpts — step therapy is not documented for the majority of entries. | |
| A small number of insulin presentations include step therapy markers where specifically noted; otherwise Step Therapy fields are generally empty. |
Quantity level limits and related flags
Specialty pharmacy and site of service rules
Check site-of-care and billing for limited distribution/infusion drugs
Limited distribution specialty drugs may require site-specific coverage or billing under the medical benefit (for non–self-administered injectables); providers should verify site-of-care billing rules and coordinate with the specialty pharmacy.
- Contact Accredo for specialty distribution and billing instructions
- Verify whether a drug is billed under prescription or medical benefit
Fill specialty drugs at participating specialty pharmacies
Specialty drugs indicated in the formulary must be filled at participating specialty pharmacies in the network; providers and members may be directed to use Accredo for specialty dispensing.
- Accredo is the plan's designated specialty pharmacy
- Call 833.721.1626 or fax 888.302.1028 for service setup
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