CurrentEmpire BluecrossPolicy N/A
Medicaid-Approved Preferred Drug List (PDL)
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A Medicaid Preferred Drug List governing coverage, prior authorization, quantity limits, specialty pharmacy and step therapy indicators for outpatient prescription drugs for members covered by Empire BlueCross Medicaid in North Carolina.
Policy Summary
PayerEmpire Bluecross
PolicyMedicaid-Approved Preferred Drug List (PDL)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateMay 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization when a product is annotated 'PA' before dispensing to avoid claim denial.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
2026-05-01policy effective date
NCapplicable state
PA, QL, SP, AL, DO, STcoverage flags used
Partialdocument segment
~200+drug entries shown
Coverage Criteria and Legend
Coverage flags and routing
Coverage and routing are determined by plan note flags assigned to each drug entry. When a product line includes one or more of the annotations below, the corresponding administrative action or routing applies.
Plan note conditions: Coverage/authorization status determined by notes: PA (prior authorization), QL (quantity limit), SP (specialty pharmacy), AL (age limit), DO (dispense/designation)
This segment lists which drugs have these flags but does not include the full clinical criteria for approvals; follow payer processes for PA and SP routing.
PA (Prior Authorization): Products annotated 'PA' require prior authorization before coverage; failure to obtain PA may result in claim denial or incorrect routing to non-specialty channels.
Submit supporting clinical documentation as required by the payer when requesting PA.
SP (Specialty Pharmacy routing): Products annotated 'SP' require specialty pharmacy handling or dispensing via the designated specialty channel.
Failure to route SP products through the specialty channel may cause denial or processing delays.
QL (Quantity Limit): Products annotated 'QL' are subject to quantity limits; requests exceeding the defined QL require documentation of medical necessity.
Numeric limits are product-specific and defined elsewhere; provide dosing and duration justification when requesting overrides.
AL (Age Limit): Products annotated 'AL' have age-based coverage restrictions; confirm member age meets the allowed range.
Age documentation should be included when required.
DO (Dispense/Designation): Products annotated 'DO' indicate plan-specific dispensing preferences or designations (e.g., formulary preferred or dispense-as-written instructions).
Follow dispense/designation instructions and any preferred-product edits during adjudication.
This section functions as a formulary legend: individual drug and formulation lines are listed alphabetically with plan note annotations that govern coverage and routing. Common annotations shown include PA (prior authorization), QL (quantity limit), OTC (over‑the‑counter) and other operational notes; coverage and authorization for a listed product is determined by the specific note(s) appearing next to that formulation.
No explicit clinical exclusion language appears in this fragment. Entries are limited to product names, formulations and short plan notes (e.g., PA, QL, OTC) that indicate utilization controls rather than full clinical exclusion criteria.
This excerpt does not contain detailed medical‑necessity criteria or the full authorization requirements for products annotated with utilization flags. The legend identifies which products carry flags (for example, PA or QL) but does not include the underlying clinical approval criteria.
Within this legend excerpt there are no explicit exclusions stated. Items are annotated with operational notes such as OTC, QL or PA, but the excerpt does not include statements designating any product as excluded from coverage.
No explicit exclusions are provided in this segment of the legend. Lines for supplies, devices and medications are annotated with payer notes (for example, OTC, QL, PA) but exclusionary language is not present in these chunks.
The excerpt is primarily a listing of products and formulations with short annotations. It does not present full coverage criteria or step‑by‑step medical necessity rules for the listed medications; instead it flags products that require further administrivia (e.g., PA) or that are subject to limits (QL).
This portion of the document is a legend‑only section: individual product lines are shown with plan notes (OTC, QL, PA, etc.). The listing style is product‑centric and does not contain the complete coverage criteria or approval workflows for those annotations.
The content here serves as a legend—items are identified and may carry notes such as PA, QL or AL. The legend itself does not include the step‑by‑step authorization instructions; individual entries may direct providers to seek further detail where a plan note is present.
This segment does not explicitly list any products as not medically necessary. The excerpt is informational and limited to product lines and their short plan notes rather than clinical determinations of non‑coverage.
Formulary Listings and Code Tables
Selected Formulary Products with PA/QL annotationsmixed
| OZEMPIC (0.25 OR 0.5 MG/DOSE) | Subcutaneous solution pen-injector — Notes = PA; QL |
| OZEMPIC (1 MG/DOSE) | Subcutaneous solution pen-injector — Notes = PA; QL |
| OZEMPIC (2 MG/DOSE) | Subcutaneous solution pen-injector — Notes = PA; QL |
| JANUMET ORAL TABLET | Notes = PA; QL |
| JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR | Notes = PA; QL |
| JANUVIA ORAL TABLET | Notes = PA; QL |
| liraglutide subcutaneous solution pen-injector | Reference = Victoza — Notes = PA; QL |
Antidepressants (examples)mixed
| escitalopram oxalate oral tablet | Reference = Lexapro |
| sertraline hcl oral tablet | Reference = Zoloft |
| venlafaxine hcl er oral capsule extended release 24 hour | Reference = Effexor XR — Notes = QL |
Drug products listed (no billing codes in segment)NDC
| NDC not provided | Document lists drug products and formulations but does not provide NDC values in this segment. |
Quantity limit presence — overview
Presence of QL annotationsMany products across therapeutic classes are annotated with 'QL' in the formulary legend indicating quantity limits apply
Numeric limits not shownThis document segment marks items with QL but does not provide the exact numeric quantity limits (per prescription or per month) within these chunks
Product types with QL flagsQL annotations appear on stimulants/ADHD agents, antidiabetics, specialty biologics, OTC antihistamines, supplies (lancets, syringes), and multiple other drug families
Quantity Limits — notation and missing numeric values
QL noted widelyQuantity limits (QL) are noted for many listed products in the legend but specific numeric limits are not included in this excerpt
Examples from legendQL appears next to antipsychotics (e.g., clozapine, risperidone), long-acting injectables, and other prescription lines in these chunks
Operational implicationClaims or prior authorization requests referencing QL should include documentation if requested quantity exceeds the plan's limit (exact limits defined elsewhere)
Provider Actions, Prior Authorization & Documentation
Prior Authorization
Prior Authorization Required
Prior authorization is required for any product annotated with PA in the formulary. Providers must obtain prior authorization before dispensing or billing PA‑designated medications or supplies; failure to secure PA may result in claim denial or noncoverage.
- Obtain PA prior to dispensing when the Notes field includes PA.
- Claims for PA items must include the authorization number or supporting documentation per Empire BlueCross processes.
Prior Authorization
PA Examples & Scope
Many high‑cost, specialty, and select products are marked PA, sometimes together with SP (specialty pharmacy) and/or QL (quantity limits). Examples include specialty biologics, injectable therapies, select oral agents, CGM devices and sensors, insulin delivery supplies, migraine biologics, and certain ophthalmic and nasal agents — these require PA and/or specialty routing as noted.
- Examples of PA‑marked prescription drugs and biologics: dapagliflozin‑containing agents, OZEMPIC, JANUMET, JANUVIA, liraglutide, DUPIXENT, REPATHA, ALYQ, ambrisentan, sildenafil (Revatio), tadalafil (PAH).
- Examples of PA‑marked specialty/high‑cost injectables: many biologics (e.g., DUPIXENT, XOLAIR, ARANESP, MVASI) and HAE therapies (HAEGARDA, TAKHZYRO, RUCONEST).
- Examples of PA‑marked migraine and neurology products: AIMOVIG, EMGALITY, NURTEC, various triptans when noted PA.
- Examples of PA‑marked ophthalmic and ENT agents: cyclosporine ophthalmic (Restasis), LASTACAFT, select ophthalmic anti‑infectives; selected nasal sprays such as FLONASE formulations annotated PA.
Prior Authorization
Prior Authorization for CGM Devices & Diabetes Supplies
Continuous glucose monitoring (CGM) systems and many diabetes supplies listed with PA require prior authorization and clinical justification. Examples include Dexcom G6/G7 receivers, sensors and transmitters; FreeStyle Libre readers and sensors; Omnipod starter kits and pods; and certain meter kits, insulin syringes and pen needles annotated PA.
- CGM devices/sensors noted PA: DEXCOM G6 receiver/sensor/transmitter; DEXCOM G7 receiver/sensor; FREESTYLE LIBRE 2/3 sensors and readers.
- Insulin delivery and supply examples: OMNIPOD kits/pods (PA; QL), meter kits annotated PA; insulin syringes and many pen needles annotated PA.
- Documentation should include patient diagnosis, prior therapies, and rationale for device selection.
Denial Risk
Utilization Management & Denial Risk
Utilization management flags (PA, QL, SP, AL, DO, ST) are operational controls that can trigger claim denials or require specific routing. Review Notes on each product and follow the payer’s PA and specialty pharmacy routing instructions.
- PA: prior authorization required; obtain approval before dispensing.
- QL: quantity limits — requests exceeding QL require justification.
- SP: specialty pharmacy — product may need to be dispensed via a specialty channel; claims filled outside required channel risk denial.
- AL/DO/ST: age limits, dose optimization, or step therapy requirements noted in class entries must be followed when present.
Documentation Required
Documentation Expectations & Submission
Documentation must accompany PA requests and claims for PA and SP items. Submit clinical justification, prior therapy history (when applicable), and any age/quantity evidence needed to support medical necessity. Quantity limit overrides require supporting documentation explaining need for quantities above the QL.
- When PA is indicated submit supporting clinical records, previous medication trials, and treatment rationale.
- For SP items include specialty‑pharmacy routing details and any required enrollment documentation.
- For AL/QL items document patient age and clinical reason when prescribing outside standard age/quantity limits.
Prior Authorization
Prior Authorization and Quantity Limits for Opioids
Controlled substances and opioid formulations frequently carry both PA and QL annotations. Providers must follow opioid PA processes and document prior treatments and justification to support medical necessity.
- Many opioid products (e.g., morphine ER, oxycodone formulations, tramadol combinations) are annotated PA; follow opioid prior authorization rules.
- Requests exceeding QL for controlled analgesics require clinical rationale and supporting records to reduce denial risk.
Step Therapy
Formulary Preference, Step Edits & Specialty Program Notes
Formulary preference notes (DO), step edits (ST), and specialty program indicators (SP) affect prior authorization and dispensing. Where step therapy or preferred‑product guidance exists, document attempted or contraindicated therapies if requesting non‑preferred products.
- DO: dose optimization or preferred dosing guidance — follow when applicable.
- ST: step therapy may require trial of preferred agents prior to authorization of non‑preferred drugs; document trials or contraindications.
- SP: specialty program requirements may mandate use of designated specialty pharmacy and adherence to program enrollment.
Note
OTC Prescription Note
OTC products listed with the OTC note may be covered only when prescribed; prescribers should indicate OTC on the prescription when coverage is sought. Some OTC items still carry QL or PA annotations — confirm Notes.
- When dispensing OTC medications via prescription, prescribers MUST indicate "OTC" on the prescription per payer instruction.
- OTC status does not remove PA or QL requirements if those flags are present for the specific item.
Key Abbreviations and Definitions
PA — Prior authorization
DefinitionPA = Prior authorization is required. Prior authorization is the process of obtaining approval of benefits before certain prescriptions are filled.
Operational noteItems marked 'PA' require submission of prior authorization documentation (clinical justification, prior therapy) before coverage will be granted.
Denial riskClaims for products annotated 'PA' may be denied if prior authorization is not obtained prior to dispensing.
QL — Quantity limits
DefinitionQL = Quantity limits; certain prescription medications have specific quantity limits per prescription or per month.
ScopeQL annotations appear across OTC and prescription items (e.g., antihistamines, supplies, specialty drugs) in the legend but numeric caps are not listed here.
Provider actionDocumentation should support medical necessity for quantities exceeding QL when submitting requests or appeals.
SP — Specialty Pharmacy
DefinitionSP = Specialty Pharmacy — medication is managed through a specialty pharmacy channel.
ExamplesSpecialty designation (SP) appears with many biologics and high-cost injectables in the legend (e.g., PEGASYS, DUPIXENT, ENSPRYNG).
Operational impactProducts labeled SP may require specialty-site dispensing and additional authorization/documentation processes.
ST — Step therapy
DefinitionST = Step therapy is required. You may need to use one medication before benefits for the use of another medication can be authorized.
Document noteThe legend uses 'ST' to indicate step therapy; specific step sequences and requirements are defined elsewhere in the policy document.
Provider actionPrescribers should document prior trials of required agents when submitting authorization requests for ST-marked drugs.
AL — Age Limit
DefinitionAL = Age Limit Restrictions — coverage may be limited to specified age groups as noted in the formulary legend.
Examples in legendAL annotations appear next to many pediatric/age-sensitive products (e.g., certain nasal sprays, contraceptives, antipsychotics).
DocumentationWhen AL applies, providers should include patient age in requests to support coverage determination.
DO — Dose optimization / designation
DefinitionDO = Dose Optimization Program / Designation — indicates dispenser or plan-specific dispense instruction or formulary designation.
Usage in legendDO appears alongside DO; QL notes for dosage-form or preferred dispensing (e.g., certain ER products and antipsychotics).
ImplicationDO may reflect a formulary-preferred product or dispensing edit; follow payer guidance when DO is shown.
PA — Prior Authorization (alternate reference)
Definition (alternate)PA = Prior Authorization — authorization required before coverage; items marked 'PA' need pre-approval from the payer.
Provider actionSubmit required clinical documentation (diagnosis, prior therapy) when requesting PA for listed products.
Operational riskFailure to obtain PA for PA-designated drugs may result in claim denial or noncoverage.
QL — Quantity Limit (alternate reference)
Definition (alternate)QL = Quantity Limit — restrictions on quantity or days' supply that the plan will cover for a given product.
ScopeQL annotations apply to many therapeutic classes, including cardiovascular agents, contraceptives, and supplies as shown in the legend.
DocumentationRequests exceeding QL should include medical necessity rationale and supporting documentation per payer instructions.
DO — Drug of Choice / formulary-preferred (inventory)
DefinitionDO = Drug of Choice / formulary-preferred — indicates a formulary preferred product or one subject to specific edits.
Operational noteDO annotations can signal preferred agents that may be required before non‑preferred agents are authorized.
Example usageDO appears with certain antidepressants, cardiovascular agents, and antipsychotics in the legend to indicate preference or edits.
SP — Specialty (inventory reference)
DefinitionSP = Specialty — product designated as specialty drug, often requiring specialty pharmacy handling and additional authorization steps.
ExamplesMany biologics and hematopoietic agents (e.g., DUPIXENT, HAEGARDA, ARANESP) are annotated 'SP' in the legend.
Routing implicationSpecialty (SP) items may require dispensing via designated specialty pharmacies and associated documentation/processes.
OTC — Over-the-counter
DefinitionOTC = Over-the-counter — product available without a prescription; when dispensed via prescription, prescribers should indicate 'OTC' on the script.
Formulary usageOTC appears for many antacids, analgesics, antihistamines, supplies and prenatal vitamins in the legend (often with QL).
Provider actionIndicate OTC on prescription if dispensing an OTC product through the pharmacy benefit; QL may still apply.
Prior Authorization required (short)
Short notePA — Prior authorization required before coverage for items marked 'PA'.
ActionObtain PA per payer process to avoid denial.
ReferenceSee legend for items annotated 'PA' which list this requirement next to product names.
Quantity Limit (short)
Short noteQL — Quantity limit applies to items annotated 'QL' in the legend.
ImplicationExact numeric limits are not provided in this excerpt; consult the plan's quantity limit tables for specifics.
Provider actionDocument and justify quantities exceeding QL when requested.
OTC — Over-the-counter (short)
Short noteOTC — Over-the-counter; product available without prescription but listed for payer reference.
NoteOTC entries in the legend may still carry QL annotations.
Provider actionIndicate OTC on prescriptions if dispensing OTC items through benefit coverage.
DO — Dispense as written / dispensing note
DefinitionDO — Dispense as written / directional note indicating payer-specific dispensing instruction or designation.
UsageDO appears next to several drugs (e.g., antipsychotics, antidepressants) to indicate dispensing or preference guidance.
ImplicationFollow payer dispense instructions when 'DO' is indicated to ensure proper adjudication.
SP — Specialty product (short)
Short noteSP — Specialty product designation; specialty handling and authorization often required.
ExamplesHAEGARDA, UDENYCA and other specialty injectables are annotated SP in the legend.
Operational impactSpecialty designation may require use of designated specialty pharmacies and additional documentation.
Formulary note abbreviations (compound)
Compound legendPA = Prior Authorization; QL = Quantity Limit; OTC = Over-the-counter; DO = Designated/Dispense note; AL = Age Limit; SP = Specialty; ST = Step therapy.
Usage guidanceThese abbreviations in the legend indicate the operational controls that apply to each listed product and guide provider documentation and routing.
Document referenceSee the formulary legend entries for per-product annotations; specific PA/QL criteria are defined elsewhere in the policy.
PA — Prior Authorization (duplicate)
PA (duplicate)Prior Authorization — coverage requires pre-approval from the payer for items marked 'PA'.
ImplicationObtain PA before dispensing to avoid denial; submit clinical justification per payer requirements.
ReferenceLegend defines PA and shows PA annotations next to multiple products throughout the formulary.
QL — Quantity Limit (duplicate)
QL (duplicate)Quantity Limit — restrictions on the amount of drug that will be covered; many products in the legend carry QL notes.
Where seenQL shown across classes including cardiovascular agents, contraceptives, and cephalosporins in the legend.
Next stepsRefer to plan-specific quantity limit tables or prior authorization criteria to determine numeric limits.
SP — Specialty Pharmacy (duplicate)
SP (duplicate)Specialty Pharmacy — specialty product designation indicates specialty handling and potential routing to specialty pharmacies.
ExamplesBiologics and high-cost injectables in the legend (HAEGARDA, TAKHZYRO) show SP annotations.
ActionFollow specialty drug processes when SP is indicated to ensure proper dispensing and coverage.
DO — Dispense override / directional note (inventory)
DO (inventory)DO — Designation/Dispense instruction appears as a formulary note indicating dispense preference or override direction.
ContextUsed with several antipsychotics and other classes to indicate specific dispensing or preference logic.
Provider implicationAdhere to DO notes to avoid dispensing conflicts at claim adjudication.
AL — Alternate label / limitation (inventory)
AL (inventory reference)AL — Alternate label / Age Limit or limitation indicating coverage restrictions or labeling considerations for certain products.
Where usedAL appears next to antipsychotics, pediatric formulations, and various OTC items in the legend.
ActionDocument patient age or labeling details when AL applies to support coverage decisions.
QL — Quantity Limit (additional reference)
QL (additional)Quantity limit annotations are applied to many supply items (lancets, pen needles, syringes) and related devices; numeric caps not provided in this excerpt.
ExampleLancets and lancing devices show 'OTC; QL' across multiple entries in the legend.
Provider noteSupplies marked QL may have monthly or yearly limits defined elsewhere; include quantity justification when requesting overrides.
PA — Prior Authorization (additional reference)
PA (additional)Prior authorization — approval required before the plan will cover the drug or item when 'PA' is annotated.
ExamplesPA appears for many specialty injectables, CGM devices, and selected branded products in the legend.
Provider actionSubmit required clinical documentation per payer PA instructions to obtain coverage.
SP — Step Therapy / specialty mapping
SP mappingSP used in inventory mapping indicates step/specialty program handling; some antiviral and PAH agents are annotated 'PA; SP; QL'.
ImplicationSP mapping may trigger specialty pharmacy routing and additional authorization steps.
ExampleAgents like ambrisentan and tadalafil (PAH) show PA; SP; QL in the legend.
AL — Age Limit (inventory mapping)
AL mappingAL indicates age limits in inventory mapping and appears alongside many contraceptives, pediatric formulations and OTC items.
Operational noteProviders should confirm patient age when submitting claims or PA requests for AL-marked products.
Example entriesContraceptives in the legend frequently show AL; QL annotations.
OTC — Over-the-counter (inventory mapping)
OTC mappingOTC marking in inventory mapping denotes products available without prescription (many PPIs, antacids, prenatal vitamins) but still listed for benefit context.
ExamplesMultiple omeprazole/esomeprazole/lansoprazole lines are shown as OTC in the legend.
ImplicationEven when OTC, some products carry QL annotations and may require documentation for coverage amounts.
DO — Designation (inventory mapping)
DO mappingDO designation in inventory mapping signals a formulary designation or dispense preference (may indicate formulary-preferred agents or dispense instructions).
UsageAppears with multiple CNS and cardiovascular agents to indicate plan-specific dispensing logic.
Provider actionFollow DO guidance when present to align with adjudication rules.
QL — Quantity Limit (inventory reference)
QL (inventory)Quantity limits are annotated throughout inventory listings (including supplies and devices); numeric limits are not included in these inventory chunks.
ExampleCGM sensors/receivers (Dexcom, FreeStyle Libre) and Omnipod kits are shown with PA; QL annotations.
Next stepsRefer to the plan's specific quantity limit tables or PA criteria for numeric thresholds and exception processes.
PA — Prior Authorization (inventory reference)
PA (inventory)PA annotation in inventory indicates prior authorization required for coverage of the listed product or device.
ExamplesMany specialty and high-cost items in the inventory show PA; SP; QL (e.g., AVONEX, BETASERON, ENSPRYNG).
Provider guidanceSubmit PA per payer instructions with clinical justification to obtain authorization prior to dispensing.
OTC — Over-the-counter (additional inventory)
OTC (additional inventory)Some inventory items are designated OTC yet also carry QL or PA flags (e.g., certain pen needles or supplies shown as OTC; QL).
ImplicationOTC designation does not always remove utilization controls; check legend for QL/PA alongside OTC entries.
ExampleSelected supply and device listings show 'PA; OTC; QL' or similar combined notes.
SP — Specialty product designation (additional inventory)
SP (product)Specialty product designation identifies items managed through specialty pharmacy channels and often paired with PA and QL.
ExamplesHAEGARDA, KALBITOR, RUCONEST and other hematologic/specialty agents are annotated PA; SP; QL.
Operational noteSpecialty designation may require specific site-of-care or dispensing arrangements.
PA — Prior Authorization (supply items reference)
PA (supply items)Some supply items (e.g., certain insulin syringes, Omnipod kits) are annotated 'PA' indicating prior authorization required before coverage.
QL (supply items)Supply items frequently include 'QL' indicating quantity limits on lancets, pen needles and related consumables.
OTC (supply items)Many supply items are also marked OTC while still showing QL annotations in the inventory legend.
QL — Quantity limit (supply items reference)
QL (supply)Quantity limits apply to pen needles, lancets, insulin syringes and related supplies (noted as QL in the legend); numeric caps not present in these chunks.
ExamplesTRUEPLUS, ULTICARE and similar supply brands are annotated with PA/OTC/QL combinations in the legend.
Provider actionWhen requesting quantities above typical use, include rationale and any required documentation for QL exceptions.
OTC — Over-the-counter (supply items reference)
PA (supply) duplicatePA annotation appears for CGM components (Dexcom G6/G7, FreeStyle Libre readers/sensors) and some meter kits, indicating prior authorization is required.
QL (supply) duplicateCGM sensors and related components also show QL annotations in the legend.
Operational noteClaims for CGM devices should include PA documentation to prevent denial; numeric QL thresholds are specified elsewhere.
SP — Specialty (legend reference)
SP (legend)SP — Specialty drug designation used in legend to indicate specialty handling and routing requirements.
ExamplesSP is used with immunomodulators and transplant-related agents (e.g., cyclosporine, mycophenolate) in the legend.
ImplicationSP items may require specialty pharmacy dispensing and additional PA documentation.
OTC — Over-the-counter (supply reference)
OTC (supplies)OTC — many lancets, lancing devices and related consumables are designated OTC while QL still applies.
ExamplesASSURE, DIATHRIVE, GNP and other lancet brands are annotated 'OTC; QL' across supply listings.
Provider guidanceEven OTC-listed supplies may have quantity limits; verify plan QL rules when ordering in bulk or frequently.
PA — Prior authorization (supply items reference)
PA (supply legend)PA appears on selected supply/device lines (e.g., certain pen needles, insulin syringes, TRUEPLUS items) indicating prior authorization may be required.
QL (supply legend)Supply lines commonly also show QL indicating coverage limits for consumables and devices.
ActionSubmit PA and quantity justification per payer processes for device/supply requests that exceed typical usage.
QL — Quantity limit (supply items reference)
QL (supply) repeatQuantity limits noted for various supplies and OTC items (QL annotations present; numeric limits not provided here).
ExamplesTRUEPLUS pen needles/lancets and many OTC consumables show QL in the legend.
Provider noteRefer to the payer's detailed QL tables or PA criteria to determine numeric thresholds and exception processes.
PA — Prior authorization (legend reference)
PA (legend) duplicatePA — Prior authorization required; used for certain specialty or high-cost agents listed in the legend.
ExamplesAVONEX, BETASERON, REBIF and other specialty injectables show 'PA; SP; QL' designations.
Operational impactObtain PA and route via specialty pharmacy where indicated to ensure coverage and proper site-of-care handling.
OTC — Over-the-counter (legend additional)
OTC (legend additional)OTC appears extensively in the legend for antacids, PPIs, prenatal vitamins and other consumer products; many OTC items also include QL notes.
ExampleZEGERID OTC and multiple omeprazole/esomeprazole/lansoprazole lines are shown OTC; some OTC lines include QL.
Provider actionWhen prescribing an OTC product through the pharmacy benefit, indicate 'OTC' on the prescription per legend instructions.
PA / QL / AL — compound legend reference
Compound legend notePA / QL / AL — common combined annotations in the legend indicating prior authorization, quantity limits, and age limits may all apply to a product.
ExamplesVaccines and some vaginal/contraceptive products show combinations like AL; QL or PA; QL in the legend.
ImplicationCheck all applicable legend flags (PA, QL, AL, SP, DO, ST) when evaluating coverage or submitting authorizations.
Step Therapy Indicators and Notes
| Reference | Summary |
|---|---|
| inv-131 | |
| ST flag indicates step therapy is required for some agents; specific step sequences are not listed in this legend excerpt. |
| Reference | Summary |
|---|---|
| inv-132 | |
| Entries annotated with DO may indicate formulary-preferred products or dose/dispense edits and could be used to implement step edits or preferred-agent requirements. |
| Reference | Summary |
|---|---|
| inv-133 | |
| Some antidiabetic agents and GLP-1 agonists (examples: dapagliflozin-containing products, OZEMPIC, liraglutide) are marked PA and may be subject to step edits elsewhere in the policy. |
| Reference | Summary |
|---|---|
| inv-134 | |
| Long-acting injectable antipsychotics and some specialty psychotropics are annotated with PA and AL/QL which may imply administrative step or monitoring requirements prior to approval. |
| Reference | Summary |
|---|---|
| inv-135 | |
| Some products include DO and AL annotations suggesting dispensing or step requirements; explicit step-therapy sequences are not provided in this excerpt. |
| Reference | Summary |
|---|---|
| inv-136 | |
| Step therapy is required for specific pulmonary arterial hypertension agents and select branded products (entries marked PA; SP; QL indicate step/authorization expectations). |
| Reference | Summary |
|---|---|
| inv-137 | |
| No explicit step therapy rules are listed in this segment; only annotations such as PA, QL, SP are present in the legend portion. |
| Reference | Summary |
|---|---|
| inv-138 | |
| No explicit step therapy entries appear in this excerpt; the legend provides annotations but does not define step logic here. |
| Reference | Summary |
|---|---|
| inv-139 | |
| This legend portion does not list step therapy requirements; entries are annotated (PA, QL, OTC) but no step sequences are specified. |
| Reference | Summary |
|---|---|
| inv-140 | |
| No explicit step therapy steps specified in this excerpt; some items are flagged SP (specialty) indicating special handling rather than defined step sequences. |
| Reference | Summary |
|---|---|
| inv-141 | |
| No explicit step-therapy sequences listed in these chunks; riluzole and other entries are noted PA; SP which may imply specialty handling rather than formal step requirements in this legend. |
| Reference | Summary |
|---|---|
| inv-142 | |
| Some specialty agents are annotated 'PA; SP; QL' which implies specialty pharmacy dispensing and prior authorization steps are required for coverage though detailed step sequences are not provided here. |
| Reference | Summary |
|---|---|
| inv-143 | |
| No step therapy is specified in this legend portion; if step rules exist they are defined elsewhere in the policy document rather than in this excerpt. |
Quantity Limits (QL) Notes
Various stimulants and ADHD agents — QL noted
Stimulants / ADHD agentsVarious stimulants and ADHD agents (e.g., amphetamine-dextroamphetamine, dexmethylphenidate) are annotated with QL in the legend; specific numeric limits are not provided here.
ExamplesEntries show Notes = DO; AL; QL or PA; QL for different formulations, indicating QL applies across strengths and forms.
Provider implicationPrescribers should expect quantity limits on ADHD agents and consult plan-specific QL tables if larger quantities are needed.
Selected biologics (adalimumab biosimilars) — QL noted
Adalimumab biosimilarsSelected biologics (adalimumab biosimilars such as Hadlima, Amjevita) are annotated 'PA; SP; QL' in the legend, indicating PA and QL apply.
ImplicationBiosimilars designated SP/PA/QL require specialty pharmacy handling and prior authorization; numeric QL thresholds are defined elsewhere.
DocumentationSubmit specialty authorization documentation per payer requirements for biosimilar biologics.
Multiple listed products — QL applied where noted
Multiple products with QLSeveral listed products across classes are marked with 'QL' in the legend; numeric quantity limits are not included in this document excerpt.
Classes affectedQL appears in CNS, cardiovascular, anti-infective, antidiabetic, and other classes in the legend.
Next stepConsult the plan's full quantity limit tables or contact the payer for specific numeric limits per product.
Multiple listed products — QL annotations present
QL annotations presentMultiple product lines in the legend carry QL annotations; the excerpt lists QL flags adjacent to drug/formulation lines without numeric limits.
ExamplesAntipsychotics, antidepressants and long-acting injectables in this portion display AL; DO; QL or PA; QL notes.
Provider noteWhere QL is indicated, providers should be prepared to justify quantities beyond standard dispensing through PA or supporting documentation.
OTC antihistamine oral formulations — OTC designation; QL present
OTC antihistaminesOTC oral antihistamine formulations (cetirizine, loratadine, diphenhydramine, fexofenadine) are marked OTC and frequently include QL annotations in the legend.
ImplicationEven OTC allergy products listed on the formulary may be subject to quantity limits; check plan QL guidance for supply limits.
Provider actionIndicate OTC on prescriptions for OTC allergy products when dispensing through the pharmacy benefit and document quantities as needed.
REPATHA (prefilled syringe / SureClick) — PA; QL
REPATHAREPATHA (subcutaneous solution prefilled syringe / SureClick auto-injector) is annotated 'PA; QL' in the legend indicating prior authorization and quantity limits apply.
Operational noteREPATHA requires PA and is subject to QL; providers should follow specialty/PA processes for biologic dosing and dispensing.
DocumentationSubmit clinical justification and dosing regimen when requesting PA for REPATHA per payer requirements.
Multiple listed — QL flags present
QL flags across listingsNumerous listed products include QL flags in the legend; the excerpt does not supply numeric QL values within these lines.
Example product groupsOTC, prescription, supplies and specialty injectables frequently carry QL indicators across the formulary excerpts.
Provider adviceFor precise quantity thresholds, consult the payer's detailed QL tables or contact pharmacy services.
Multiple listed products (cardiovascular, contraceptives) — QL noted
Cardiovascular and contraceptivesMultiple cardiovascular agents and many contraceptive products in the legend are annotated with QL; numeric limits are not shown here.
ImplicationContraceptives frequently show AL and QL — age and quantity restrictions may both apply depending on the product.
Provider stepVerify age and quantity rules when prescribing contraceptives with AL/QL flags to ensure coverage compliance.
Multiple OTC and prescription products — QL indicated
OTC and Rx with QLBoth OTC and prescription products across the legend carry QL annotations; specific numeric QL values are not provided in this segment.
ExamplesDermatologics, PPIs, and other classes show OTC; QL or PA; QL notes in the legend excerpts.
RecommendationConsult the full policy/Q L tables for numeric limits or PA criteria when managing utilization or authorizations.
Multiple OTC and prescription products — QL flagged
OTC and Rx QL notesMultiple OTC and prescription entries in this portion of the legend are flagged with QL; numeric limits are not included in these lines.
Affected classesUrology, gout agents, hematologic kits and other classes show QL annotations in the legend.
Next stepRefer to the payer's quantity limit resources for exact thresholds and exception procedures.
Various lancets, syringes, supplies — QL noted
Diabetes supplies QLLancets, lancing devices, pen needles, insulin syringes and CGM components are annotated with QL in the legend; exact numeric limits are not shown here.
ExamplesASSURE, DIATHRIVE, DROPLET and other supply brands show 'OTC; QL' across entries.
Provider actionCheck the plan's supply quantity rules for limits and document medical necessity for quantities beyond typical use.
Multiple lancet and accessory items — QL noted
Lancet/accessory QLMultiple lancet and accessory items are annotated 'OTC; QL' indicating quantity limits apply to these supply lines.
ExamplesDevice starter packs and lancet packs show QL across the legend entries.
Operational noteProviders ordering frequent or bulk supplies should confirm QL thresholds with the payer to avoid coverage denials.
AIMOVIG, EMGALITY, NURTEC — QL noted
Migraine biologics and QLAIMOVIG, EMGALITY and NURTEC are annotated with PA and/or QL in the legend indicating utilization controls apply to these migraine therapies.
ImplicationPrior authorization is required for PA-marked migraine biologics and quantity limits apply per plan guidance.
Provider actionSubmit PA with clinical justification and dosing schedule for these migraine products; confirm numeric QL thresholds elsewhere.
Various OTC prenatal and multivitamins — QL noted
OTC prenatal/multivitamins QLVarious OTC prenatal and multivitamins are listed with OTC and QL annotations in the legend; numeric quantity limits are not provided here.
ExamplesClassic prenatal, CVS prenatal gummy, and multiple prenatal formulations show 'OTC; QL' notes.
Provider guidanceDocument patient need and age where relevant when requesting quantities that exceed typical supply limits.
Selected nasal and ophthalmic OTC products — QL indicated
Nasal/ophthalmic OTC QLSelected nasal and ophthalmic OTC products are annotated QL in the legend without numeric QL values provided in this excerpt.
ExamplesFlonase, other nasal sprays and multiple lubricating eye drops show combinations of PA/OTC/QL or OTC; QL annotations.
Provider noteWhen dispensing OTC nasal/ophthalmic products via prescription, indicate OTC and confirm any applicable QL rules for coverage.
Multiple listed products — QL annotation present
Miscellaneous QL annotationsMany additional listed products across classes carry QL annotations in the legend; numeric limits are not included within these lines.
Classes notedOphthalmic, otic, dermatologic, respiratory agents and others show QL flags in the legend excerpts.
ActionRefer to detailed plan resources for numeric QL values and exception processes when required.
ZEGERID OTC; OXYTROL; COMIRNATY — QL indicated
Selected OTC/Rx examples with QLZEGERID OTC, OXYTROL FOR WOMEN and COMIRNATY vaccine entries are indicated with 'QL' in the legend (numeric QL values not shown here).
ImplicationEven vaccine and OTC capsule entries can carry QL annotations; consult the plan's quantity rules for dose/series limits.
Provider actionFor vaccines and special OTC items annotated AL/QL or QL, include patient age and rationale when requesting quantities beyond typical schedules.
Site of Care and Specialty Administration
Note
Background and Scope
This document is a Medicaid Preferred Drug List organized by therapeutic class and alphabetized within class. It displays individual products and formulations with plan flags (for example, PA, QL, OTC, SP, AL, DO) that indicate prior authorization, quantity limits, specialty pharmacy routing, age limits or dispense instructions which determine coverage processing and provider actions.
Policy Summary
PayerEmpire Bluecross
PolicyMedicaid-Approved Preferred Drug List (PDL)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateMay 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization when a product is annotated 'PA' before dispensing to avoid claim denial.
SourceLink
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