CurrentFlorida BluePolicy 00026252

BlueMedicare Complete Rx formulary (Comprehensive Formulary) — Prescription drug coverage criteria

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This document governs the prescription drugs covered under the BlueMedicare Complete Rx (PDP) plan and describes coverage rules, restrictions, member rights, and how to use the formulary for plan enrollees and their prescribers.

Policy Summary

PayerFlorida Blue

PolicyBlueMedicare Complete Rx formulary (Comprehensive Formulary) — Prescription drug coverage criteria

Policy CodePolicy 00026252

Change TypeNo material change — routine update

Effective DateJan 1, 2026

Last ReviewOct 15, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' before submitting the claim to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

00026252Formulary ID

10/15/2025Last updated

31 daysTemporary supply

$35Insulin cap

72/24 hrsDecision timeframes

Coverage Criteria and Policy Rules

General coverage conditions

Covered when ALL of the following are met

Standard coverage conditions: Drug is listed on the formulary, is medically necessary, the prescription is filled at a BlueMedicare Complete Rx network pharmacy, and other plan rules are followed.

From formulary general coverage statement (BlueMedicare Complete Rx)

Temporary access during exception/transition

Covered temporarily when ALL of the following are met

Temporary supply provision: For drugs not on the formulary or with coverage restrictions, the plan will provide a one-time temporary 31-day supply (or refills up to a 31-day supply) while the member and prescriber pursue a coverage decision or formulary exception; applies during the first 90 days of membership or as a 31-day emergency supply for LTC admissions/discharges.31 days

One-time temporary supply; LTC admission/discharge override of refill-too-soon edits also applies

Policy Summary

PayerFlorida Blue

PolicyBlueMedicare Complete Rx formulary (Comprehensive Formulary) — Prescription drug coverage criteria

Policy CodePolicy 00026252

Change TypeNo material change — routine update

Effective DateJan 1, 2026

Last ReviewOct 15, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a drug is marked 'PA' before submitting the claim to avoid coverage denial.

SourceLink

On This Page

Formulary Codes, Tiers, and Quantity Rules

Formulary copay code referencesmixed

S615	Applies to Tiers 3,4 and 5 only; tier-specific copay/coinsurance structure described (examples in text)

Formulary drug linesNDC | mixed

hydrocodone-acetaminophen tab 5-325 mg	listed with QL (180 or 240 tablets/30 days) and tier entries
hydrocodone-acetaminophen tab 7.5-325 mg	listed with QL (180-240 tablets/30 days)
hydromorphone hcl liqd 7 mg/ml	QL (1440 mls/30 days)
hydromorphone hcl preservative free inj 10 mg/ml	BD (billing descriptor) stated
hydromorphone hcl tab 2 mg	Drug Tier = 4; QL (180 tablets/30 days)
hydromorphone hcl tab 4 mg	Drug Tier = 4; QL (180 tablets/30 days)
hydromorphone hcl tab 8 mg	Drug Tier = 4; QL (180 tablets/30 days)
ibuprofen tab 400 mg	QL (240 tablets/30 days)
ibuprofen tab 600 mg	QL (150 tablets/30 days)
ibuprofen tab 800 mg	QL (120 tablets/30 days)

1–10 of 57

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Formulary drug entries (selected examples)NDC | mixed

DIACOMIT stiripentol cap 250 mg	Drug Tier = 5; Requirements/Limits = PA (=65 yr) , QL (60 tablets/30 days).
DIACOMIT stiripentol cap 500 mg	Drug Tier = 5; Requirements/Limits = .
DIACOMIT stiripentol packet 250 mg	Drug Tier = 5; Requirements/Limits = .
EPIDIOLEX cannabidiol soln 100 mg/ml	Drug Tier = .; Requirements/Limits = PA.
FINTEPLA fenfluramine hcl oral soln 2.2 mg/ml	Requirements/Limits = PA, QL (360 mls/30 days).
FYCOMPA perampanel susp 0.5 mg/ml	Requirements/Limits = QL (2 bottles/28 days).
DIAZEPAM RECTAL GEL diazepam rectal gel delivery system 2.5 mg	Drug Tier = 4; Requirements/Limits = QL (5 twin pack(s)/30 days).
NAYZILAM midazolam nasal spray 5 mg/0.1 ml	Requirements/Limits = QL (10 bottles/30 days).
VALTOCO diazepam nasal spray (various doses)	Requirements/Limits = QL (5 twin pack(s)/30 days).
ZTALMY ganaxolone susp 50 mg/ml	Drug Tier = 5; Requirements/Limits = PA, QL (10 bottles/30 days).

1–10 of 12

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Formulary drug entries (partial)NDC|mixed

bupropion hcl tab er 12hr 200 mg	listed with QL (60 tablets/30 days)
bupropion hcl tab er 24hr 150 mg	listed with QL (90 tablets/30 days)
bupropion hcl tab er 24hr 300 mg	Drug Tier = 2; QL (30 tablets/30 days)
escitalopram oxalate tab 20 mg	Drug Tier = 2; QL (30 tablets/30 days)
EMSAM selegiline td patch 6 mg/24hr	Drug Tier = 5; Requirements/Limits = PA, QL (30 patches/30 days)
DRIZALMA SPRINKLE duloxetine 20 mg	Drug Tier = 4; QL (60 capsules/30 days)
TRINTELLIX vortioxetine hbr tab 5 mg	QL (30 tablets/30 days)
VENLAFAXINE BESYLATE ER 112.5 mg	Drug Tier = 4; QL (60 tablets/30 days)
ZURZUVAE zuranolone cap 20 mg	Drug Tier = 5; QL (28 capsules/365 days)
aprepitant capsule 40 mg	Drug Tier = 4; Requirements/Limits = BD

1–10 of 14

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Long-acting injectable product QLsmixed

INVEGA HAFYERA paliperidone palmitate er susp pref syr 1,092 mg/3.5ml	QL (1 kit/180 days)
INVEGA HAFYERA paliperidone palmitate er susp syr 1,560 mg/sml	QL (1 kit/180 days)
INVEGA SUSTENNA paliperidone palmitate er susp pref syr 39 mg/0.25ml	QL (1 kit/28 days)
INVEGA SUSTENNA paliperidone palmitate er susp syr 78 mg/0.5ml	QL (1 kit/28 days)
INVEGA TRINZA paliperidone palmitate er susp syr 273 mg/0.88ml	QL (1 kit/84 days)
PERSERIS risperidone subcutaneous for er susp prefilled syr 90 mg	QL (1 syringe/28 days)

Selected high-tier oral agentsmixed

COBENFY xanomeline tartrate-trospium chloride cap 50-20 mg	Drug Tier = 5; QL (60 capsules/30 days) PA,
NUPLAZID pimavanserin tartrate cap 34 mg (base equivalent)	Drug Tier = 5; QL (30 capsules/30 days); PA
LYBALVI olanzapine-samidorphan tab 5-10 mg	Drug Tier = 5; QL (30 tablets/30 days); PA (>=65 yr)

Clozapine formulationsmixed

clozapine orally disintegrating tab 100 mg	Drug Tier = 4; PA (>=65 yr); QL (270 tablets/30 days)
clozapine tab 100 mg	Drug Tier = 4; PA (>=65 yr); QL (270 tablets/30 days)
clozapine tab 200 mg	Drug Tier = 4; PA (>=65 yr); QL (120 tablets/30 days)

Antivirals (selected)mixed

abacavir sulfate soln 20 mg/ml (base equiv)	Drug Tier = 4; QL (960 mls/30 days)
abacavir sulfate tab 300 mg (base equiv)	Drug Tier = 4; QL (60 tablets/30 days)
acyclovir tab 800 mg	Drug Tier = 2

Formulary drug entries (no procedure codes present)mixed

No codes listed

Formulary Flags and Quantity Limitsmixed

QL (45 tablets/30 days)	Quantity limit for atorvastatin calcium 40 mg
QL (60 tablets/30 days)	Quantity limit for candesartan cilexetil 4/8/16 mg
PA	Prior authorization indicated for listed products (e.g., CORLANOR solution, ivabradine, KERENDIA)
QL (240 capsules/30 days)	Quantity limit for ENTRESTO sprinkle capsules
QL (30 tablets/30 days)	Quantity limit for ezetimibe 10 mg and many other tablet entries
QL (600 mls/30 days)	Quantity limit for CORLANOR oral solution

inv-24: Initial Coverage Supply — one-month (31-day) supply

Initial supply periodOne-month (31-day) supply

Applies toStandard initial coverage stage for retail & mail-order supplies

Reference in formularyInitial Coverage Stage — copayment/coinsurance amounts shown for 31-day supply

inv-25: Example Quantity Limits — examples such as 2700 mL/30 days; 360 tablets/30 days; 180 tablets/30 days; 15 patches/30 days

Example QL: large-volume liquid analgesics2700 mL/30 days (e.g., acetaminophen w/ codeine solution)

Example QL: high-count tablet limits360 tablets/30 days (e.g., some acetaminophen w/ codeine and oxycodone combinations)

Example QL: common tablet limits180 tablets/30 days (multiple opioid strengths such as hydrocodone-acetaminophen, hydromorphone tabs)

Example QL: patches15 patches/30 days (fentanyl transdermal patches)

Example QL: insulin/pen limits20 pens/30 days or 6 vials/30 days (insulin examples)

Example QL: specialty inhaled antibiotic28 vials/28 days (ARIKAYCE)

Example QL: EMGALITY presentations2 pens/30 days or 3 syringes/30 days depending on presentation

inv-26: Quantity Limits examples — e.g., QL (180 tablets/30 days), QL (90 tablets/30 days), QL (28 vials/28 days)

QL — 180 tablets/30 daysMultiple products (e.g., hydrocodone-acetaminophen formulations; hydromorphone tabs) listed with QL (180 tablets/30 days)

QL — 90 tablets/30 daysMorphine sulfate ER formulations: PA, QL (90 tablets/30 days)

QL — 28 vials/28 daysARIKAYCE amikacin sulfate liposome inhalation suspension: PA, QL (28 vials/28 days)

QL — 360 mLs/30 daysExamples for oral solutions (e.g., FINTEPLA) and other liquids noted as QL (360 mls/30 days)

QL — 2 pens/30 daysEMGALITY pen presentation: PA, QL (2 pens/30 days)

QL — 1 pen/28 daysOZEMPIC semaglutide pen: PA, QL (1 pen/28 days)

inv-27: Quantity Limits examples — examples include QL (60 tablets/30 days), QL (360 mls/30 days), QL (5 twin pack(s)/30 days), QL (10 bottles/30 days)

QL — 60 tablets/30 daysMany oral agents (e.g., celecoxib 50–200 mg, meloxicam 7.5 mg for some strengths) listed with QL (60 tablets/30 days)

QL — 360 mls/30 daysFINTEPLA fenfluramine oral solution listed with PA, QL (360 mls/30 days)

QL — 5 twin pack(s)/30 daysVALTOCO and diazepam nasal/rectal rescue delivery systems: QL (5 twin pack(s)/30 days)

QL — 10 bottles/30 daysNAYZILAM midazolam nasal spray: QL (10 bottles/30 days)

QL — 2 bottles/28 daysFYCOMPA perampanel suspension: QL (2 bottles/28 days)

inv-28: Common quantity limits — Examples: QL (30 tablets/30 days); QL (60 tablets/30 days); QL (600 mls/30 days)

Common QL — 30 tablets/30 daysMany tablets (e.g., escitalopram 20 mg, ezetimibe 10 mg, various cardiovascular/tablet entries) listed with QL (30 tablets/30 days)

Common QL — 60 tablets/30 daysMultiple products (e.g., bupropion ER, venlafaxine ER) show QL (60 tablets/30 days)

Common QL — 600 mls/30 daysLiquid formulations such as CORLANOR oral solution show large-volume QL (600 mls/30 days)

Common QL — 240 capsules/30 daysENTRESTO sprinkle capsules listed with QL (240 capsules/30 days)

Age‑qualified PA/QL examplesSome entries include PA qualifiers (e.g., PA (>=65 yr)) alongside QLs; see clozapine, antipsychotics entries

inv-29: Quantity limits examples — e.g., QL (8 mls/28 days); QL (2 pens/30 days); QL (18 tablets/30 days)

QL — 8 mls/28 daysDihydroergotamine mesylate nasal spray: PA, QL (8 mls/28 days)

QL — 2 pens/30 daysEMGALITY pen presentation: PA, QL (2 pens/30 days)

QL — 18 tablets/30 daysSome triptan tablet formulations show QL (18 tablets/30 days)

Examples — pens/vials limitsInsulin pen/vial examples: QL (20 pens/30 days); QL (6 vials/30 days); QL (60 mls/30 days)

inv-30: Kit/Day supply limits for injectables — 1 kit/28 days, 1 kit/84 days, 1 kit/180 days

Kit/Day supply limits for LAI injectables1 kit/28 days, 1 kit/84 days, 1 kit/180 days (e.g., INVEGA SUSTENNA, INVEGA TRINZA, INVEGA HAFYERA)

Examples — 1 kit/180 daysINVEGA HAFYERA paliperidone palmitate er susp: QL (1 kit/180 days)

Examples — 1 kit/84 daysINVEGA TRINZA paliperidone palmitate er susp: QL (1 kit/84 days)

Examples — 1 kit/28 daysINVEGA SUSTENNA paliperidone palmitate er susp: QL (1 kit/28 days)

inv-31: Examples of quantity limits — e.g., 20 pens/30 days; 6 vials/30 days; 60 mls/30 days

Example QL — pens20 pens/30 days (HUMALOG KWIKPEN examples) and 4 pens/28 days (TRULICITY) shown

Example QL — vials6 vials/30 days (HUMALOG MIX 75/25 example) and 6 vials/30 days for insulin aspart listed

Example QL — liquid mLs60 mls/30 days shown for some insulin presentations (e.g., HUMALOG vial example)

Example QL — pens/vials summaryCounts vary by product presentation — pens, cartridges, vials and kits have product‑specific QLs

inv-32: Common quantity limits — examples include QL (30 tablets/30 days), QL (60 tablets/30 days), QL (4 pens/28 days), QL (1 pen/28 days)

Common QL — 30 tablets/30 daysNumerous oral tablets across therapeutic classes show QL (30 tablets/30 days)

Common QL — 60 tablets/30 daysMany products (e.g., atorvastatin 40 mg QL 45 tablets; other agents QL 60 tablets/30 days)

Common QL — pens/28 daysExamples include QL (4 pens/28 days) for TRULICITY and QL (1 pen/28 days) for OZEMPIC

Common QL — 1 pen/28 daysOZEMPIC semaglutide pen: PA, QL (1 pen/28 days)

inv-33: Quantity Limits examples — Examples include QL (30 tablets/30 days), QL (60 tablets/30 days), QL (240 capsules/30 days), QL (600 mls/30 days)

QL — 30 tablets/30 daysMany tablet entries across sections list QL (30 tablets/30 days)

QL — 60 tablets/30 daysMultiple entries list QL (60 tablets/30 days)

QL — 240 capsules/30 daysENTRESTO sprinkle capsules: QL (240 capsules/30 days)

QL — 600 mls/30 daysLarge-volume liquid example: CORLANOR oral solution: QL (600 mls/30 days)

Comprehensive examples preservedAnalgesics, antivirals, antipsychotics, injectables and specialty items have product‑specific QLs and PA flags as listed in the table

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for PA‑flagged drugs

Certain drugs and formulations listed in the formulary require prior authorization (PA) from the plan before the prescription can be filled; failure to obtain approval may result in the plan not covering the drug.

PA indicated in Requirements/Limits column must be obtained prior to dispensing.

Prior Authorization

Obtain PA for items marked 'PA' in the table

Drugs annotated with 'PA' in the Requirements/Limits column must have a prior authorization submitted and approved (examples include narcotic ER formulations, tramadol ER, and ARIKAYCE).

Verify PA for the exact product and formulation before claim submission.

Prior Authorization

Confirm PA applies to the exact formulation

Certain specific formulations and product presentations are marked 'PA' (for example, linezolid suspension and linezolid 600 mg tablets) — providers must obtain PA for those exact formulations.

Confirm NDC/formulation matches the PA‑flagged line when requesting authorization.

Prior Authorization

PA required for select products (formulation‑specific)

Some formulations (e.g., linezolid suspension; linezolid 600 mg tablets) and other select products are explicitly marked 'PA' in the Requirements/Limits column and require prior authorization prior to coverage.

Include product strength/formulation on the PA request to ensure correct review.

Prior Authorization

Prior authorization required for listed specialty agents (e.g., EPIDIOLEX, ZTALMY)

Several specialty agents are identified with 'PA' (examples include EPIDIOLEX cannabidiol solution and ZTALMY ganaxolone suspension); providers must submit prior authorization for these specialty/high‑tier drugs.

Specialty agents listed with PA will not be covered without an approved authorization.

Prior Authorization

PA required for selected specialty antifungals and agents

Certain high‑tier or specialty antifungals and specific formulations (for example, CRESEMBA, posaconazole, and voriconazole) are marked 'PA' and require prior authorization before coverage.

Submit clinical justification and intended formulation when requesting PA for antifungals.

Prior Authorization

Obtain PA for products annotated 'PA' in table

Products shown with 'PA' in the formulary table require prior authorization prior to coverage (providers must obtain PA as listed for each product).

Do not dispense PA‑flagged products without confirmed plan approval.

Prior Authorization

PA required for numerous formulary agents

Many listed drugs carry a PA requirement as noted in the Requirements/Limits column; providers must submit and secure prior authorization before coverage will be approved.

PA must be in place prior to claim submission to avoid denial.

Prior Authorization

Verify PA for specific therapy packs and strengths

Specific formulations (e.g., LENVIMA therapy packs, TAGRISSO 40 mg/80 mg) display PA in the Requirements/Limits column—verify and obtain PA for the exact NDC or pack prescribed.

Include therapy pack details or NDC when requesting authorization.

Prior Authorization

Obtain PA for listed PA‑marked drugs

Numerous listed drugs are marked 'PA' in the table; providers must obtain prior authorization before benefit coverage is approved for those drugs.

Check the Requirements/Limits column for PA flags before prescribing/dispensing.

Prior Authorization

PA required for many agents (including age‑based PA)

Many products require prior authorization and some include age‑based PA notes (e.g., 'PA (>=65 yr)'); providers must request PA as indicated and document member age when age‑based PA applies.

Provide member age in the PA request for age‑based PA entries.

Prior Authorization

PA required for flagged injectable and anxiolytic drugs

Products flagged 'PA' (examples include injectable ziprasidone vials and certain anxiolytic oral solutions) require prior authorization; do not assume coverage without PA approval.

Confirm PA status for injectable and anxiolytic formulations before administration or dispensing.

Prior Authorization

Obtain age‑based PA for entries marked 'PA (>=65 yr)'

Some products require age‑based prior authorization for members aged 65 years or older (many benzodiazepines, antipsychotics and related agents show 'PA (>=65 yr)'); providers must submit PA with age documentation where noted.

Include clinical rationale specific to older adults when requesting PA for age‑based entries.

Prior Authorization

PA applies to selected injectable and specialty products

Certain injectable and specialty products (e.g., TRULICITY, GRANIX, eltrombopag, PROCRIT/RETACRIT) are subject to prior authorization as shown in the table; obtain PA before initiating therapy.

Include indication, dose and administration site when submitting PA for injectables/specialty drugs.

Prior Authorization

PA required for cardiovascular and related agents annotated 'PA'

Products explicitly annotated with 'PA' (examples: CORLANOR oral solution, ivabradine tablets, KERENDIA) require prior authorization before coverage will be provided.

Requests lacking PA for these products may be denied; include product and quantity information on PA request.

Prior Authorization

REPATHA (evolocumab) requires PA

REPATHA SURECLICK evolocumab auto‑injector (140 mg/ml) is listed with 'PA' — prior authorization must be obtained before benefit coverage.

REPATHA SURECLICK also shows a quantity limit (QL 6 pens/28 days) that must be respected or justified.

Step Therapy

Step therapy applies when ST is indicated

Step therapy (ST) may require the prescriber to document that a specified first‑line drug was tried and found ineffective or not tolerated before the plan will cover an alternative drug; step therapy applies when 'ST' is indicated in the Requirements/Limits column.

When ST is indicated, include prior therapy details in the authorization or exception request.

Note

Step‑therapy sequences not specified in this excerpt

No explicit step therapy sequences or failure criteria are detailed in this formulary excerpt; the table focuses on PA and QL flags rather than step‑by‑step ST rules.

If step therapy is relevant, follow the plan's ST guidance and document trials of first‑line agents when requesting exceptions.

Note

Documentation Required

Prescriber supporting statement required for exceptions; decision timeframes

Exception requests require the prescriber’s supporting statement explaining the medical reason for the formulary exception; standard decisions are generally made within 72 hours and expedited decisions within 24 hours when applicable.

Include clinical rationale, prior therapies tried, and any relevant diagnostics in the exception request.

Documentation Required

Provide site‑of‑care and clinical info for limited distribution/BD drugs

When a drug is limited distribution or marked 'BD', providers or pharmacies may need to supply site‑of‑care information or additional clinical details to determine coverage and dispense location.

Contact Member Services or consult the Pharmacy Directory for limited distribution access instructions.

Documentation Required

Document PA/QL/ST fields from the formulary table on requests

Formulary table entries include Requirements/Limits fields (PA, QL, ST, age qualifiers) that must be met and documented when requesting coverage or submitting claims for the listed products.

Supply diagnosis, prior therapy, product strength/formulation, quantity and member age (when age‑based PA applies) with PA requests.

Documentation Required

Include clinical justification and quantity details for PA/QL requests

Providers must provide documentation to support prior authorization requests for PA‑flagged medications (examples include diagnosis and prior therapy); quantity limits (QL) must also be documented or justified if exceeded.

When QL applies, include requested quantity and intended days’ supply in the authorization.

Note

Prior Authorization

EPIDIOLEX requires prior authorization

EPIDIOLEX cannabidiol solution is listed with 'PA' in the Requirements/Limits column; providers must obtain prior authorization to avoid coverage denial.

Include indication and prior treatment history when requesting PA for EPIDIOLEX.

Prior Authorization

ZTALMY requires PA and is subject to QL

ZTALMY ganaxolone suspension is listed with both 'PA' and a quantity limit (QL 10 bottles/30 days); providers must obtain PA and ensure requested quantity does not exceed the stated QL.

PA approval and adherence to QL are required to avoid claim denial for ZTALMY.

Note

Denial Risk

Denial risk if PA not obtained or QL exceeded

Requests exceeding specified quantity limits (QL) or lacking required prior authorization (PA) may be denied; when PA or QL flags are present on the formulary line, submit authorization or an exception prior to fill to avoid denial.

Check the product’s QL (e.g., 30 tablets/30 days, pen/vial limits) and request PA for exceptions before dispensing.

Denial Risk

Denial triggers: missing PA or age‑based PA not documented

Requests for products marked 'PA' or 'QL' (including age‑based PA such as 'PA (>=65 yr)') may be denied if prior authorization is not obtained or quantity limits are exceeded; include member age on requests when age qualifiers apply.

Age‑based PA entries (e.g., many antipsychotics, benzodiazepines) require age documentation on PA requests.

Note

Definitions, Background and Policy Context

This formulary lists covered Medicare Part D drugs including brand, generic, biological products and biosimilars, organized by therapeutic condition and alphabetically. Each listed product shows a Drug Tier and any utilization controls (for example, PA or specific QL values) that govern coverage and member cost‑sharing under the BlueMedicare Complete Rx plan.

inv-98: Generic drugs — definition and cost implication

Generic drugs — definitionFDA-approved drugs having the same active ingredient as brand-name drugs; generally equivalent in effect and usually less costly.

SubstitutionGeneric drugs usually can be substituted for the brand-name drug at the pharmacy without needing a new prescription, depending on state laws.

Cost implicationTypically lower cost to members compared with brand-name products.

inv-99: Original biological products and biosimilars — definition and note on interchangeability

Original biologic vs biosimilarBiological products are complex drugs; biosimilars are highly similar alternatives to original biological products.

Interchangeability noteSome biosimilars are interchangeable and may be substituted for the original biological product at the pharmacy without a new prescription depending on state law.

Cost implicationBiosimilars may cost less than the original biological product.

inv-100: Limited distribution drug — definition and asterisk notation

Limited distribution drug — definitionDrugs indicated with an asterisk that may be available only at select pharmacies; access may require contacting Member Services or Pharmacy Directory.

Access implicationMay limit where the drug can be dispensed (site-of-care restriction).

Provider actionContact Member Services or consult Pharmacy Directory for site-specific access information.

inv-101: High Risk Medication (HRM) — definition and age-related advisory

High Risk Medication (HRM) — definitionMedications that may be unsafe in patients greater than 65 years; marked with '#'.

AdvisoryAlternatives may be available in lower copay tiers; discuss with prescriber if appropriate.

LabelingHRM flagged items are identified in the formulary symbol key.

inv-102: Split fill — definition and purpose for high-cost meds

Split fill — definitionAllows a 2-week partial fill (partial supply) for certain high-cost medications to reduce out-of-pocket cost if therapy is discontinued early.

PurposePermits dispensing a 2-week supply initially rather than a full month to limit member cost exposure for new high-cost therapies.

IndicationMarked with 't' symbol in the formulary where applicable.

inv-103: QL — Quantity Limits definition and examples

Quantity Limits (QL) — definitionMaximum quantity allowed per specified time period (e.g., QL (180 tablets/30 days)).

ExamplesShown inline with product rows such as QL (30 tablets/30 days), QL (2 bottles/28 days), QL (6 pens/28 days).

Provider implicationPrescriptions must not exceed the listed QL or a prior authorization/exception is required.

inv-104: PA — Prior Authorization definition

Prior Authorization (PA) — definitionInsurer approval required before coverage; drugs marked 'PA' require prior authorization to be obtained before the prescription is filled.

Age qualifiersSome PA entries include age qualifiers (e.g., PA (>=65 yr)).

ConsequenceClaims submitted without required PA may be denied or delayed.

inv-105: Drug Tier — Formulary tier designation explanation

Drug Tier — explanationFormulary tier designation indicating cost-sharing or coverage category (tiers 1-6).

Tier mappingTiers referenced across the formulary (e.g., Tier 2 = generics; Tier 5 = specialty drugs).

Member impactTier determines copay/coinsurance for initial one-month (31-day) supply.

inv-106: Requirements/Limits — field in formulary table indicating utilization management controls

Requirements/Limits field — meaningIndicates utilization management controls applied to a product (e.g., PA, QL, ST, BD).

Where shownDisplayed in the formulary 'Requirements/Limits' column adjacent to each product/strength.

Provider actionProviders must follow documented requirements when submitting prescriptions or PA requests.

inv-107: PA — Prior Authorization definition (table-specific)

PA (table-specific)Marked 'PA' in the Requirements/Limits column to indicate prior authorization required for that product.

Age qualifiers possibleTable entries may include age-based PA notes (e.g., PA (>=65 yr)).

DocumentationPA requests should include diagnosis and supporting clinical information per plan process.

inv-108: QL — Quantity Limit (table-specific)

QL (table-specific)Shown as QL (quantity/period) next to product rows (e.g., QL (5 twin pack(s)/30 days)).

Unit typesMay specify tablets, capsules, pens, vials, bottles, kits, patches or mLs with a days-based period.

EnforcementDispensed quantity must not exceed the listed QL without prior authorization or exception.

inv-109: QL — Quantity Limit examples (alternate chunks)

QL examples (alternate)Examples in table include QL (2 bottles/30 days), QL (60 tablets/30 days), QL (10 bottles/30 days).

Specific product examplesBRIVIACT oral solution QL (2 bottles/30 days); ZTALMY QL (10 bottles/30 days).

Period unitsSome QLs use 28-day periods for kits or specific packs (e.g., kit/28 days).

inv-110: PA — Prior Authorization definition with age qualifiers

PA with age qualifiersPA entries may include age qualifiers such as 'PA (>=65 yr)' indicating age‑based authorization requirements.

Table shorthandThe table uses abbreviations (PA, QL, BD) that imply required actions for coverage.

Provider implicationClaims for age-qualified items need member age documented on claim or PA request.

inv-111: BD — Table BD designation (meaning not fully defined in fragment)

BD — table designation'BD' appears in the table for some items (e.g., antiemetics); it indicates drugs that may be covered under Medicare Part B or Part D depending on circumstance and often requires prior authorization to determine coverage.

ActionAdditional information (site of care, use) may be requested to determine Part B vs Part D coverage.

Provider noteProviders should supply necessary documentation when BD is indicated to establish correct benefit coverage.

inv-112: Table abbreviation key — PA = Prior Authorization; QL = Quantity Limit

Table abbreviation keyPA = Prior Authorization; QL = Quantity Limit

Other abbreviationsBD = may be covered under Part B or Part D; ST = Step Therapy

UsageSee column headings for these abbreviations; they indicate utilization management controls applied to each product.

Note

Step Therapy Notes and Application

Step therapy requirement	Source summary
Must try specified first-line drugs before coverage of alternate drug is approved
Step therapy may require trying specified first-line drugs before the plan will cover an alternative for the same condition; if the first-line drug fails, the alternate may be covered

When ST applies	Source summary
Step therapy applies when ST is indicated in the Requirements/Limits column of the formulary table
The formulary uses 'ST' (Step Therapy) in the Requirements/Limits field to denote when the requirement applies

Specified sequences present?	Source summary
No explicit step therapy sequences or step-fail rules are specified in the provided excerpt
The table focuses on Drug Tier, PA, QL and other annotations; explicit ST sequences are not detailed in these chunks

Antiemetic BD/step rules	Source summary
Some antiemetic entries are designated 'BD' (benefit designation) in the Requirements/Limits column
No explicit step‑failure or step‑through rules for antiemetics are provided in this fragment

Oncology agents — step therapy	Source summary
Many oncology agents list Prior Authorization (PA) and Quantity Limits (QL) in Requirements/Limits
Step therapy specifics or sequences for oncology agents are not present in these chunks

PA for older patients	Source summary
Prior authorization is required for certain formulations when the member is age 65 years or older (PA (>=65 yr))
Multiple product lines (e.g., antipsychotics, clozapine, aripiprazole formulations) show PA (>=65 yr) as an additional utilization control

Higher-tier products and ST	Source summary
Some products are assigned higher formulary tiers (e.g., Tier 5) and may require Prior Authorization (PA) before coverage
No explicit step therapy sequence linking lower-tier to higher-tier products is provided in the excerpt

Step therapy presence	Source summary
Step therapy requirements are not specified for the items shown in this excerpt
Formulary entries in these chunks emphasize PA, QL and tiering rather than ST sequences

MOUNJARO coverage flags	Source summary
MOUNJARO (tirzepatide) pen formulations are listed with Prior Authorization (PA) for certain strengths
Quantity Limit shown for selected MOUNJARO pen strengths: QL (4 pens/28 days)

Specialty products and UM enforcement	Source summary
Some specialty products (e.g., KERENDIA, ivabradine, REPATHA evolocumab) are flagged with PA and QL in the Requirements/Limits column
PA and QL flags on specialty/ high‑tier products indicate utilization management controls that may be enforced (prior authorization and quantity limits)

BlueMedicare Complete Rx formulary (Comprehensive Formulary) — Prescription drug coverage criteria

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Coverage Criteria and Policy Rules

Formulary Codes, Tiers, and Quantity Rules

Provider Requirements, Prior Authorization, and Documentation

Definitions, Background and Policy Context

Quantity Limits (QL) by Product and Formulation

Step Therapy Notes and Application

Pharmacy and Distribution Notes

Biosimilars and Interchangeability