CurrentCapital BluecrossPolicy N/A

Capital Blue Cross 5-Tier Classic Formulary (Drug List) - Medicare Part D

This document describes the Medicare Part D formulary (drug list) used by Capital Blue Cross for the 5-Tier Classic plan, including coverage rules, restrictions (prior authorization, quantity limits, step therapy), exception processes, and how members/providers can find drugs and contact the plan. It affects plan members, prescribers, pharmacies, and providers administering prescription benefits.

Policy Summary

PayerCapital Bluecross

Policy5-Tier Classic Formulary (Medicare Part D)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' before dispensing to avoid denial of coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5-Tierformulary tier structure name

01/01/2026formulary current as of

30 daysnotice period for mid-year non-maintenance changes

72 hrsstandard exception decision timeframe

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.

expedited decision timeframe

Formulary Coverage and Rules

Formulary Coverage and Member Options

General coverage rules and member options

Formulary coverage prerequisites: The plan generally covers drugs listed on the formulary when the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules (e.g., prior authorization, quantity limits, step therapy) are followed.

from chunks 1 and 10

If drug not on formulary: Member may request a list of covered alternative drugs or request an exception for coverage of a non‑formulary drug; a temporary 30‑day supply may be provided while an exception is pursued.30-day temporary supply

from chunk 11 and 3

Mid-year changes policy: The plan may make immediate changes when adding generics or certain biosimilars and will notify members; for other mid‑year changes (removals, new restrictions, tier moves) affected members will receive at least 30 days' notice or may receive a 30‑day supply at refill.30 days notice

from chunks 2 and 3

Formulary administrative controls

Coverage is subject to the product-specific RequirementsILimits field shown for each formulary item.

Formulary coverage conditions: Coverage for a listed drug is subject to the Drug Tier and the Requirements/Limits shown for that product (examples: QL = quantity limits; PA = prior authorization). If PA is indicated, prior authorization must be obtained before coverage; if QL is indicated, dispensing is limited to the listed quantity and timeframe.

Administrative controls only; see formulary Requirements/Limits entries for product-specific rules.

If a manufacturer withdraws a drug from sale or the FDA determines a drug has been withdrawn for safety or effectiveness reasons, the plan may immediately remove the drug from the formulary and will provide notice to affected members. For other mid‑year formulary changes (for example, removing a brand when a generic is added or replacing an original biologic when a biosimilar is added), the plan will notify affected members at least 30 days before the change or provide a one‑time 30‑day supply at refill with notice.

This excerpt does not present specific medical exclusions. The formulary entries shown are organized by drug and list a Drug Tier and the product‑specific Requirements/Limits (for example, QL or PA) rather than discrete clinical exclusion rules.

Within the provided table segments there are no explicit coverage or exclusion criteria described. Instead, the table lists drug formulations with their assigned Drug Tier and any Requirements/Limits (e.g., QL or PA) for each entry; determination of coverage vs exclusion is based on those product‑level annotations and plan rules rather than an explicit exclusion list in this excerpt.

When a drug is removed from the formulary for reasons other than generic or biosimilar substitution (for example, voluntary market withdrawal or an FDA safety determination), the plan may discontinue coverage immediately and will follow notice procedures described above. Members or prescribers may request an exception to continue coverage during the notice period.

The excerpt does not include any statements labeling products as 'not medically necessary.' Coverage actions in this segment are expressed as formulary tier assignments and administrative controls such as PA or QL, and no explicit not medically necessary determinations are provided here.

Coding, Code Tables and Annotations

NDC/CPT/HCPCS not provided in this segmentmixed

No codes listed

NDC/Coding not provided in this excerptmixed

No codes listed

Formulary drug entries (partial)NDC|proprietary

TIVICAY dolutegravir sodium tab 50 mg	Drug name and strength as listed
TRIUMEQ abacavir-dolutegravir-lamivudine tab 600-50-300 mg	Drug name and strength as listed
VOSEVI sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg	Drug name and strength; RequirementsILimits = PA
MOUNJARO tirzepatide soln auto-injector	Drug name and formulation; RequirementsILimits = PA, QL (4 pens/28 days)

Sample listed drugs with requirementsmixed

VIBERZI	eluxadoline tab 75 mg, 100 mg — Requirements/Limits = PA, QL (60 tablets/30 days)
VOWST	fecal microbiota spores, live-brpk caps — Requirements/Limits = PA, QL (12 capsules/56 days)
XERMELO	telotristat ethyl tab 250 mg — Requirements/Limits = PA, QL (90 tablets/30 days)
XIFAXAN	rifaximin tab 550 mg — Requirements/Limits = PA, QL (90 tablets/30 days)

Additional specialty drugsmixed

PYRUKYND	mitapivat sulfate tab 5 mg, 20 mg, 50 mg — RequirementsILimits = PA, QL (56 tablets/28 days)
ATTRUBY	acoramidis hcl tab pack 356 mg (712 mg twice daily) — RequirementsILimits = PA, QL (112 tablets/28 days)
REZDIFFRA	resmetirom tab 60/80/100 mg — RequirementsILimits = PA, QL (30 tablets/30 days for specified strengths)

Urology and related agentsmixed

ZENPEP	pancrelipase dr cap (multiple strengths) — Drug Tier = 3, Requirements/Limits = .
GEMTESA	vibegron tab 75 mg — Requirements/Limits = QL (30 tablets/30 days)
MYRBETRIQ	mirabegron granules or tab ER — Requirements/Limits include QL (3 bottles/28 days or 30 tablets/30 days)

Quantity limits examples

QL (films)60 films/30 days (e.g., BELBUCA buccal film)

QL (patches)15 patches/30 days (e.g., fentanyl transdermal patch)

QL (vials)28 vials/28 days (e.g., ARIKAYCE)

QL (tablets - high count)360 tablets/30 days (example for some opioid formulations)

QL (mLs)2700 mls/30 days (example for certain liquid formulations)

Prior Authorization, Step Therapy, Documentation and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed in the formulary. Providers must obtain PA before dispensing or filing a claim for drugs marked “PA” in the Requirements/Limits column. Claims for PA-designated drugs may be denied if approval is not obtained in advance.

Failure to obtain PA may result in non-coverage or claim denial.
PA decisions are typically made per the plan's process — prescribers must submit supporting clinical information.

Prior Authorization

Drugs Requiring Prior Authorization

Examples of drugs that require prior authorization include (but are not limited to): BELBUCA, fentanyl patches, multiple lidocaine products (patches/ointments/viscous), ARIKAYCE, VOSEVI, MOUNJARO, OZEMPIC, many specialty oncology and biologic agents, and numerous high-cost specialty medications identified in the formulary. Review the Requirements/Limits column for the PA flag on each product.

Specialty biologics and many migraine agents (AIMOVIG, EMGALITY, etc.) show PA and QL.

Step Therapy Controls and Notes

Policy point	Summary / plan action
Step therapy (general)
Plan may require members to try specified first-line (preferred) drugs before covering alternative agents; prescriber may request an exception. (See formulary lookup for product-specific ST flags.)

Formulary key flag	Implication
ST (Step Therapy)
Some drugs are designated 'ST' in the formulary key indicating step therapy may apply; specific step sequences/edits are not listed in this excerpt and must be checked on the full formulary or prior authorization resources.

Observation	Note
Tiering present (1-5)
Drugs are assigned to tiers (1–5) which may affect member cost-sharing and the financial pathway of therapy; the document does not provide an explicit algorithm tying tier to step sequence—use formulary entries to infer pathway.

Product annotations	Implication for step/controls
Requirements/Limits (PA, QL)
Some products list Quantity Limits (QL) and may have tier-specific prior authorization (PA); although these indicate utilization controls, no explicit step therapy algorithm is provided in the excerpt.

Migraine biologics	Formulary controls noted
AIMOVIG (erenumab)
Listed with Requirements/Limits = PA and QL (e.g., 2 pens/30 days or 1 pen/30 days depending on strength) indicating utilization management prior to ongoing coverage.

Drug	Formulary control
MOUNJARO (tirzepatide auto-injector)
Requirements/Limits = PA and QL (4 pens/28 days) — prior authorization required; no explicit step sequence provided in this excerpt.

Specialty injectable	Formulary controls
REPATHA (evolocumab) prefilled syringe / auto-injector
Requirements/Limits = PA, QL (6 syringes/28 days or 6 pens/28 days) — prior authorization and quantity limits indicated, suggesting utilization controls though no step algorithm is shown.

General observation	Implication
PA annotations for specialty agents
Many specialty/high-cost agents in the formulary are annotated with 'PA' (prior authorization) and often with QL; these annotations indicate additional utilization management, but explicit step therapy sequences are not specified in this extract.

Quantity Limit Examples and Specifics

Losartan 25 mg example quantity limit

ExampleLosartan 25 mg — QL 60 tablets/30 days

ContextShown as an illustrative QL in the formulary explanatory text

UseApplied per prescription / adjudication as specified in Requirements/Limits

BELBUCA — QL

DrugBELBUCA (buprenorphine buccal film)

Quantity limit60 films/30 days

RequirementPA indicated

Place of Service Considerations

Note

Definitions and Formulary Key

Generic drugs — definition

DefinitionGeneric drugs = FDA-approved products with the same active ingredient as brand-name drugs; generally therapeutically equivalent and usually less costly.

SubstitutionGeneric drugs usually can be substituted for brand without a new prescription depending on state law.

ContextExplained in the formulary definitions section

Original biological products and biosimilars

DefinitionOriginal biological products and biosimilars: biologics are complex drugs; biosimilars are similar alternatives and some may be interchangeable depending on state law.

Substitution noteInterchangeable biosimilars may be substituted at the pharmacy without a new prescription subject to state law.

Biosimilar Policy Notes

Note

Biological products and biosimilars are discussed in the formulary. The plan may add biosimilars (including interchangeable biosimilars) and replace or move original biological products on the formulary; whether a biosimilar may be substituted for the reference product depends on its interchangeability status and applicable state law. The formulary groups biologic and biosimilar products by therapeutic area and notes tiering and any Requirements/Limits that apply.

Policy Summary

PayerCapital Bluecross

Policy5-Tier Classic Formulary (Medicare Part D)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' before dispensing to avoid denial of coverage.

SourceLink

On This Page

Example Quantity Limit — EMSAM

DrugEMSAM (selegiline) transdermal patch 6/9/12 mg/24hr

RequirementPA + QL

Quantity limit30 patches/30 days

Zuranolone quantity limit

DrugZURZUVAE (zuranolone) capsules 20 mg

Quantity limit28 capsules/365 days (20 mg)

Alternate strength14 capsules/365 days (30 mg)

NURTEC quantity limit

DrugNURTEC (rimegepant) 75 mg disintegrating tab

RequirementPA + QL

Quantity limit16 tablets/30 days

Example quantity limits — assorted

TRIUMEQQL (30 tablets/30 days)

MOUNJARO (pens)QL (4 pens/28 days)

RYBELSUSQL (30 tablets/30 days)

Quantity limits examples — assorted

Example A60 tablets/30 days (e.g., VIBERZI)

Example B12 capsules/56 days (e.g., VOWST)

Example C56 tablets/28 days (e.g., COMETRIQ kits)

Many oncology agents and orphan therapies show PA with specific QL entries.

Prior Authorization

Prior Authorization and Quantity Limits for Specialty Agents

Some specialty agents require both prior authorization and quantity limits (PA + QL). For these products, providers must obtain PA and ensure dispensed quantities do not exceed the listed QL. Examples: ARIKAYCE (PA, QL 28 vials/28 days), REPATHA (PA, QL 6 syringes/28 days), and many oncology and specialty oral/IV agents.

ARIKAYCE: PA, QL (28 vials/28 days).
REPATHA: PA, QL (6 syringes/28 days).
Oncology agents frequently list PA with per-30-day QLs (see formulary entries).

Prior Authorization

Linezolid Prior Authorization

Linezolid products may require prior authorization depending on formulation. The formulary flags oral suspension (linezolid for susp 100 mg/mL) with PA; IV/other formulations may also have PA depending on the entry — check the Requirements/Limits for the specific formulation.

Linezolid oral suspension 100 mg/mL: Requirements/Limits = PA.
Confirm PA requirement for IV formulations on the formulary row before dispensing.

Prior Authorization

Prior Authorization Required for Some Drugs

Certain non-specialty drugs and topical/analgesic products also carry PA or QL requirements (for example, lidocaine patches/ointments and some analgesic formulations). Providers must follow the formulary annotations and obtain PA where indicated.

Lidocaine patch 5%: PA, QL (90 patches/30 days).
Lidocaine ointment/viscous solutions: some entries show PA and QL — verify per row.

Prior Authorization

PA Required Where Marked

Where the formulary lists PA next to a product, providers must request and receive prior authorization before dispensing. Examples include SIVEXTRO tablet formulation, many antipsychotics with age-based PA, and testosterone injectable/gel products.

SIVEXTRO tablets: Requirements/Limits = PA.
Antipsychotics (multiple entries): PA often triggered for members >=65 years.
Testosterone injections and topical gels: multiple entries show PA (and QL).

Prior Authorization

Prior Authorization and Quantity Limits

Prior authorization and quantity limits are commonly paired for many formulary entries. Providers should both obtain PA (when required) and ensure units dispensed fall within the QL. Requests exceeding QL or lacking PA documentation are subject to denial.

Fidaxomicin (DIFICID) suspension/tab: QL limits (1 bottle/10 days; 20 tabs/10 days).
Vancomycin capsules: QL 120/30 days (125 mg), 240/30 days (250 mg).
Testosterone products: multiple PA + QL entries (e.g., gels with pump/bottle limits).

Prior Authorization

PA for Omnipod Devices

Durable diabetes devices and disposable pump kits (Omnipod products) require prior authorization. PA is shown for Omnipod kits and pods, and QL entries specify kit and pod limits (for example, 1 kit/720 days; 15 pods/30 days).

OMNIPOD DASH PDM KIT (Gen 4): PA, QL (1 kit/720 days).
OMNIPOD DASH PODS (Gen 4): PA, QL (15 pods/30 days).

Prior Authorization

PA for Select GLP-1 Injectables

Many GLP-1 injectables and other weight/diabetes agents require PA and often have a QL. Examples include OZEMPIC (PA, QL 1 pen/28 days) and MOUNJARO (PA, QL 4 pens/28 days).

OZEMPIC semaglutide pens: Requirements/Limits = PA, QL (1 pen/28 days).
MOUNJARO tirzepatide: Requirements/Limits = PA, QL (4 pens/28 days).

Documentation Required

Formulary Requirement Annotations

The formulary uses Requirement/Limits annotations (PA, QL, ST, BD, #) adjacent to each drug entry. Providers must consult these annotations for coverage rules and follow the Requirements/Limits shown when prescribing and dispensing.

PA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy; BD = Part B/Part D determination; # = High Risk Medication.
Follow the Requirements/Limits column on each formulary row before filling.

Prior Authorization

Age-Based Prior Authorization Triggers

Some products have age-based PA triggers (for example, several antipsychotics and certain CNS agents indicate PA for members >=65 years). When age-based PA applies, include the member age and clinical rationale in the PA submission.

Examples: chlorpromazine and other agents note PA (>=65 yr).
Provide clinical justification if requesting PA exceptions for age-based restrictions.

Documentation Required

Quantity Limit Documentation and Examples

Quantity limits are documented on many formulary rows and must be observed. Documentation supporting the quantity dispensed should be available with the PA request (when applicable). Examples: fidaxomicin QL, vancomycin capsule QLs, and many chronic therapy medications with per-30-day caps.

DIFICID (fidaxomicin) suspension: QL (1 bottle/10 days); tablets: QL (20 tablets/10 days).
Vancomycin HCl capsules: 125 mg QL (120 capsules/30 days); 250 mg QL (240 capsules/30 days).
Ensure documentation supports quantities when submitting PA or when dispensing near QL thresholds.

Step Therapy

Step Therapy Requirement and Flags

Step therapy (ST) may apply to certain drugs (flagged 'ST' in the formulary key). The extract does not list many specific ST sequences; where ST applies the prescriber must follow the plan's step requirements or submit an exception request with supporting documentation.

ST is indicated by 'ST' in the Requirements/Limits column — check the formulary row.
If requesting an exception to step therapy, prescribers must provide medical rationale and supporting clinical records.

Documentation Required

Exception Request Documentation

Exception requests require the prescriber to provide medical reasons and supporting documentation. The plan will generally decide within standard timeframes: 72 hours for standard reviews and 24 hours for expedited requests when waiting could seriously harm the member. Lack of adequate supporting information may lead to denial.

Prescriber must explain why alternatives or restrictions are not appropriate.
Expedited (fast) decisions: plan must decide within 24 hours when criteria for urgency are met; otherwise, standard decision within 72 hours.

Documentation Required

Documentation for BD Drugs

Some formulary entries are BD-designated (may be covered under Medicare Part B or Part D depending on place-of-service or drug use). For BD drugs, additional documentation may be required to determine coverage (e.g., place of service, infusion setting). Providers should include place-of-service and use information when requesting coverage determinations.

BD entries identify drugs where Part B/Part D coverage depends on circumstance.
Include infusion/clinic location and clinical indication in submissions for BD drugs.

Fentanyl transdermal patch — QL

DrugFentanyl transdermal patch (various mcg/hr strengths)

Quantity limit15 patches/30 days

RequirementPA indicated

ARIKAYCE — QL

DrugARIKAYCE (amikacin liposome inhalation suspension)

Quantity limit28 vials/28 days

RequirementPA indicated

ARIKAYCE (amikacin liposome inhalation suspension)

DrugARIKAYCE (amikacin liposome inhalation suspension)

Quantity limit28 vials/28 days

NoteListed with PA in Requirements/Limits

fidaxomicin (DIFICID) suspension — QL

Drugfidaxomicin (DIFICID) suspension 40 mg/mL

Quantity limitQL (1 bottle/10 days)

IndicationApplies to suspension course duration

fidaxomicin tablets — QL

Drugfidaxomicin (DIFICID) tablets 200 mg

Quantity limitQL (20 tablets/10 days)

ContextCourse-based QL for treatment duration

vancomycin oral capsules 125 mg — QL

Drugvancomycin HCl oral capsules 125 mg

Quantity limit120 capsules/30 days

NoteListed in Requirements/Limits for dispensing/adjudication

vancomycin oral capsules 250 mg — QL

Drugvancomycin HCl oral capsules 250 mg

Quantity limit240 capsules/30 days

NoteHigher-strength packaging QL listed

vancomycin HCl cap 125 mg — QL

Drugvancomycin HCl cap 125 mg

Quantity limit120 (capsules)/30 days

ContextSame QL shown for vancomycin 125 mg entries

vancomycin HCl cap 250 mg — QL

Drugvancomycin HCl cap 250 mg

Quantity limit240 (capsules)/30 days

ContextRefer to Requirements/Limits for dispensing rules

BRIVIACT oral solution — QL

DrugBRIVIACT (brivaracetam) oral solution 10 mg/mL

Quantity limit2 bottles/30 days

FormulationsSolution listed separately from tablets

BRIVIACT tablets — QL

DrugBRIVIACT tablets (multiple strengths)

Quantity limit60 tablets/30 days

RequirementListed with QL in Requirements/Limits

VALTOCO nasal spray — QL

DrugVALTOCO (diazepam) nasal spray — various doses

Quantity limit5 twin pack(s)/30 days

NoteQL applies across listed dose presentations

EMSAM selegiline transdermal patch — QL

DrugEMSAM (selegiline) transdermal patch 6/9/12 mg/24hr

Quantity limit30 patches/30 days

RequirementPA indicated

escitalopram oxalate solution — QL

Drugescitalopram oxalate solution 5 mg/mL

Quantity limit600 mls/30 days

ContextSolution formulation QL shown separately from tablets

TRINTELLIX — QL

DrugTRINTELLIX (vortioxetine)

Quantity limit30 tablets/30 days

NoteListed with QL in Requirements/Limits

ZURZUVAE zuranolone cap 20 mg — QL

DrugZURZUVAE (zuranolone) cap 20 mg

Quantity limit28 capsules/365 days

Alternate strength30 mg listed separately with QL 14 capsules/365 days

NURTEC rimegepant — QL

DrugNURTEC (rimegepant) disintegrating tab 75 mg

Quantity limit16 tablets/30 days

RequirementPA indicated

BRUKINSA zanubrutinib 160 mg — QL

DrugBRUKINSA (zanubrutinib) 160 mg tablets

Quantity limit60 tablets/30 days

RequirementPA indicated

CALQUENCE acalabrutinib 100 mg — QL

DrugCALQUENCE (acalabrutinib) 100 mg tablets

Quantity limit60 tablets/30 days

RequirementPA indicated

KOSELUGO selumetinib 10 mg — QL

DrugKOSELUGO (selumetinib) 10 mg capsules

Quantity limit240 capsules/30 days

RequirementPA indicated

LUMAKRAS sotorasib 120 mg — QL

DrugLUMAKRAS (sotorasib) 120 mg tablets

Quantity limit240 tablets/30 days

RequirementPA indicated

POMALYST pomalidomide — QL

DrugPOMALYST (pomalidomide) capsules

Quantity limit21 capsules/28 days

RequirementPA indicated

ROZLYTREK entrectinib 100 mg — QL

DrugROZLYTREK (entrectinib) 100 mg caps

Quantity limit150 capsules/30 days

RequirementPA indicated

ROZLYTREK entrectinib 200 mg — QL

DrugROZLYTREK (entrectinib) 200 mg caps

Quantity limit90 capsules/30 days

RequirementPA indicated

TUKYSA tucatinib 50 mg — QL

DrugTUKYSA (tucatinib) 50 mg

Quantity limit300 tablets/30 days

RequirementPA indicated

VITRAKVI larotrectinib 25 mg — QL

DrugVITRAKVI (larotrectinib) 25 mg

Quantity limit180 capsules/30 days

RequirementPA indicated

XALKORI crizotinib 150 mg — QL

DrugXALKORI (crizotinib) 150 mg caps

Quantity limit180 capsules/30 days

RequirementPA indicated

VENCLEXTA STARTING PACK — QL

DrugVENCLEXTA STARTING PACK (venetoclax) starter pack

Quantity limit1 pack (42 tablets)/28 days

RequirementPA may apply

Multiple — assorted per-entry QL examples

Multiple entriesQuantity limits vary per drug entry (examples include kit frequencies, tablets per 30 days, vials per 30 days, mLs per 30 days)

InstructionSee each formulary line for the specific QL per product

Examples1 kit/180 days; kit/28 days; 1 syringe/28 days; 30 tablets/30 days; 84 days; 90 vials/30 days; 540 mls/30 days

TRIUMEQ — QL

DrugTRIUMEQ (abacavir-dolutegravir-lamivudine)

Quantity limitQL (30 tablets/30 days)

TierTier 5

TIVICAY — QL variations

DrugTIVICAY (dolutegravir) 50 mg

Quantity limitQL (30 tablets/30 days) or QL (60 tablets/30 days) depending on listing

TierTier 5

MOUNJARO — QL

DrugMOUNJARO (tirzepatide) auto-injector

Quantity limitQL (4 pens/28 days)

RequirementPA indicated

LYUMJEV pens — QL

DrugLYUMJEV pens (insulin lispro-aabc)

Quantity limit20 pens/30 days

Alternate packaging6 vials/30 days listed for some presentations

NOVOLOG vials — QL

ProductNOVOLOG (insulin aspart) vials

Quantity limit6 vials/30 days

ContextInsulin vial QL examples shown in formulary

OMNIPOD DASH INTRO KIT — QL

ProductOMNIPOD DASH INTRO KIT

Quantity limit1 kit/720 days

RequirementPA indicated

OMNIPOD pods — QL

ProductOMNIPOD pods

Quantity limit15 pods/30 days

RequirementPA indicated for kits; pods listed with QL

OZEMPIC pens — QL

DrugOZEMPIC (semaglutide) pens

Quantity limit1 pen/28 days

RequirementPA indicated

MOUNJARO pens — QL

ProductMOUNJARO pens

Quantity limit4 pens/28 days

RequirementPA indicated

RYBELSUS tablets — QL

DrugRYBELSUS (semaglutide) tablets

Quantity limit30 tablets/30 days

RequirementPA indicated

Pegfilgrastim syringes — example QL

Product classPegfilgrastim syringes (examples)

Quantity limit30 syringes (example list) — frequency varies by product

RequirementPA often indicated for biosimilars/specialty products

atorvastatin 10/20/40 mg — QL

Drugatorvastatin 10/20/40 mg formulations

Quantity limit45 tablets/30 days

Higher strength80 mg QL = 30 tablets/30 days

atorvastatin 80 mg — QL

Drugatorvastatin 80 mg

Quantity limit30 tablets/30 days

ContextStrength-specific QL listed in formulary

candesartan cilexetil — QL

Drugcandesartan cilexetil (selected strengths)

Quantity limit60 tablets/30 days

ContextApplies to listed strengths as shown

REPATHA — QL

DrugREPATHA (evolocumab) prefilled syringes/pens

Quantity limit6 syringes/pens/28 days

RequirementPA indicated

ENTRESTO (sprinkle caps) — QL

DrugENTRESTO (sprinkle capsules)

Quantity limit240 capsules/30 days

ContextSprinkle capsule presentation QL specified

rosuvastatin (5-20 mg) — QL

Drugrosuvastatin (5-20 mg)

Quantity limit45 tablets/30 days

Higher strength40 mg QL = 30 tablets/30 days

telmisartan-amlodipine / valsartan — QL

Drugtelmisartan-amlodipine (listed strengths)

Quantity limit30 tablets/30 days

Valsartan examplevalsartan 40/80/160 — 60 tablets/30 days

valsartan (selected strengths) — QL

Drugvalsartan (40/80/160 mg)

Quantity limit60 tablets/30 days

Alternate strengthvalsartan 320 mg — QL 30 tablets/30 days

AUSTEDO — QL range

DrugAUSTEDO (deutetrabenazine)

Quantity limit60-120 tablets/30 days depending on strength

RequirementPA may apply

INGREZZA — QL

DrugINGREZZA (valbenazine)

Quantity limit30 capsules/30 days

RequirementPA indicated for some presentations

fluorouracil cream 5% — QL

Productfluorouracil cream 5%

Quantity limit40 grams/30 days

FormulationTopical cream QL specified by grams

VIBERZI — QL

DrugVIBERZI (eluxadoline)

Quantity limit60 tablets/30 days

RequirementPA indicated

VOWST — QL

DrugVOWST (fecal microbiota spores, live)

Quantity limit12 capsules/56 days

RequirementPA indicated

PYRUKYND — QL

DrugPYRUKYND (mitapivat)

Quantity limit56 tablets/28 days

RequirementPA indicated

testosterone td gels — assorted QL examples

Product classtestosterone transdermal gels (various products)

Quantity limit examples30 packets/30 days; 90 packets/30 days; 60 units/30 days; 2 pump bottles/30 days; 4 pump bottles/30 days

RequirementPA indicated for several formulations

ContextSee formulary/biosimilar preference statements

Dosage form abbreviations

abbreviationmg = milligram; ml = milliliter; mcg = microgram

formtab = tablet; cap = capsule; susp = suspension; soln = solution

otherpf = preservative-free; pak = pack; td = transdermal

Tier legend

Tier 1Preferred Generic

Tier 2Generic

Tier 3Preferred Brand

Tier 4Non-Preferred Brand

Tier 5Specialty Drugs

Formulary annotations (PA / QL / ST)

PAPrior Authorization — requires approval from the plan before the drug is covered

QLQuantity Limit — maximum quantity allowed per time period as shown in Requirements/Limits

STStep Therapy — required trial of preferred drug(s) before coverage of alternatives

QL — Quantity Limit definition

DefinitionQL — Quantity Limit: limit on the quantity of a drug allowed per time period as shown in the Requirements/Limits column (e.g., QL (30 tablets/30 days)).

PurposeUsed to control dispensing frequency and dose amounts for safety, cost, or utilization reasons.

ApplicationNumerical limits vary by drug and formulation; see each formulary entry for specifics.

PA — Prior Authorization definition

DefinitionPA — Prior Authorization: approval required from the plan before the drug is covered; claims may be denied without PA.

When usedMarked 'PA' in the Requirements/Limits column for specific products.

ConsequenceFailure to obtain PA may result in the plan not covering the drug or claim denial.

BD designation note

BDBD — designation for drugs that may be covered under Medicare Part B or Part D depending on circumstances; may require place-of-service information

UseShown in the formulary key to indicate coverage determination considerations

ActionProviders may need to supply additional documentation to determine Part B vs Part D coverage

Table abbreviations

SymbolsPA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy

HeadersFormulary table columns include drug name, strength/form, Drug Tier, and Requirements/Limits

NotesSee beginning of the formulary table for full abbreviation key

QL — quantity limit (reiteration)

ReiterationQL — Quantity Limit as used in Requirements/Limits column (e.g., QL (30 tablets/30 days)).

ImplicationDispensing and claims must honor the numeric limit specified.

ReferenceSee each formulary line for product-specific QL values.

PA — prior authorization (reiteration)

ReiterationPA — Prior Authorization — requires plan approval before coverage; listed in Requirements/Limits when applicable.

Provider actionObtain PA prior to dispensing when 'PA' is indicated to avoid claim denial.

TimingSee plan contact/process for PA submission and decision timeframes.

Drug Tier — definition

DefinitionDrug Tier = Formulary tier assignment indicating member cost-sharing level (1-5)

RangeTier 1 = Preferred Generic ... Tier 5 = Specialty Drugs

UseTier impacts member cost-sharing and utilization management

QL (alternate mention)

Alternate mentionQL — Quantity Limit appears throughout Requirements/Limits column to restrict quantity per timeframe

Provider actionPharmacies must adjudicate claims against QL values; prescribers may need to request exceptions for larger quantities

ExamplesSee formulary entries for numeric QL values per product

PA (alternate mention)

Alternate mentionPA — Prior Authorization appears in Requirements/Limits column for many products

Provider actionPrescribers must submit clinical documentation to support PA requests; lack of support may result in denial

ConsequenceClaims may be denied if PA not obtained when required

PA / QL — table abbreviations

AbbreviationsPA = Prior Authorization; QL = Quantity Limit — as used in the Requirements/Limits column

PurposeThese abbreviations indicate utilization management controls adjacent to each drug listing

ActionProviders must follow the Requirements/Limits shown for each product