CurrentPremera BluecrossPolicy N/A

Formulary drug list and coverage rules (Pharmacy & Specialty Drugs)

This document is the Premera Blue Cross formulary (drug list) describing covered generic, brand, and specialty drugs, the tier structure, utilization management restrictions (prior authorization, step therapy, quantity and age limits), and guidance for members and providers about how coverage applies under different plan types.

Policy Summary

PayerPremera Bluecross

PolicyFormulary drug list and coverage rules (Pharmacy & Specialty Drugs)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain required prior authorization and submit supporting clinical documentation when a drug line lists PA, QL, ST, SP, or other requirement flags.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+Distinct products listed in extract

PA/ST/QLUtilization restrictions present

variousQuantity limit examples

NPEntries marked NP

Coverage rules and formulary scope

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General formulary coverage

Coverage of a drug is determined by the member's benefit plan and may be subject to utilization management; listed drugs are covered only when benefit and utilization requirements are met.

General coverage conditions: Drug is covered when it appears on the plan formulary and the member meets the applicable benefit plan rules (eligibility, deductible, copay/coinsurance) and any utilization management requirements shown for the product (e.g., Prior Authorization, Step Therapy, Quantity Limit, Age Limit).

See the product's Requirements/Limits flags on the formulary for the exact controls required.

Formulary coverage flags

Each formulary product line includes a Drug Tier and one or more Requirements/Limits flags; coverage and any required provider actions depend on those flags.

Formulary flags and effect on coverage: Each listed product includes a Drug Tier and Requirements/Limits flags (examples used in the formulary: PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; AGE = Age Limit; SP = Specialty Pharmacy; NP = Nonpreferred; LA = Limited Access; OCh = other channel). Coverage is contingent on meeting the conditions indicated by these flags for the specific product.

Refer to the product line for exact combination of flags and any numeric limits (e.g., QL values).

When PA is present: If a product is flagged PA, the prescriber must obtain prior authorization from the plan before the drug will be covered; without an approved PA the claim may be denied.

PA definition and explanation: chunk 9.

When ST is present: If a product is flagged ST (step therapy), coverage requires trial and failure or contraindication to the specified preferred agent(s) before the requested drug will be approved.

Step therapy explanation: chunk 5 and chunk 9.

When QL is present: If a product is flagged QL, coverage is limited to the specified quantity and period (e.g., 84 mL per month for CAYSTON; 60 tablets per month for XIFAXAN); requests exceeding the QL require documentation or prior authorization and may be denied if not supported.

Examples of QL values appear in chunks 37 and 39; QL definition in chunk 9.

When AGE limits apply: If an AGE flag or age range is shown, the prescription is covered only when the member's age falls within the indicated FDA‑approved or plan‑specified age range.

Age limit examples and description: chunk 5 and chunk 9.

When SP, NP, LA, or OCh are present: SP indicates specialty pharmacy dispensing or specialty program routing; NP denotes nonpreferred formulary placement; LA indicates limited access/site‑of‑care controls; OCh denotes other channel controls. These flags may require specialty pharmacy dispensing or site‑of‑care restrictions and additional documentation or routing prior to coverage.

Definitions and specialty drug description: chunk 11 and chunk 36.

Certain drugs may be excluded from coverage under specific benefit plans or designated HCLV (High‑Cost Low‑Value) when a lower‑cost generic or therapeutic equivalent is available; this can result in a drug not being covered even if it appears on the formulary. Coverage for some classes or items is limited to specified age ranges or fill limits (examples include bowel prep coverage ages 45–75, breast cancer prevention drugs covered for persons aged ≥35, fluoride for ages 6 months–16 years). Some products are identified as LA (Limited Access) and may only be dispensed through an in‑network specialty channel.

Entries marked NP in the Requirements/Limits column reflect a nonpreferred formulary status (a placement or routing flag) rather than an absolute clinical exclusion; NP commonly appears alongside other flags such as PA, SP, or QL in the product lines and indicates nonpreferred placement that may affect member cost‑sharing or routing.

In the provided excerpts there are no explicit clinical exclusion statements (for example, wording that a product is categorically not covered for any clinical scenario). The listings focus on utilization controls (PA, QL, SP, NP, LA) without standalone exclusion text.

This segment of the formulary excerpt does not include explicit exclusions; product lines and class headings list requirement flags (e.g., ST, NP) and tiers but do not define absolute noncoverage criteria in the excerpt.

Within the cardiovascular, psychiatric and related sections there are numerous product entries with utilization flags and quantity or age limits, but the excerpt contains no standalone exclusion clauses. Coverage determinations in these sections are driven by the product’s listed Requirements/Limits rather than explicit exclusionary language.

The multiple sclerosis and specialty drug listings show extensive use of utilization controls (e.g., PA; SP; LA; QL) but the excerpt does not include explicit medical‑necessity or exclusion statements for individual products; authorization and dispensing controls are used to manage access.

There are no explicit Not Medically Necessary (NMN) determinations stated in the excerpted product lines; instead the document applies utilization controls (PA, QL, ST, NP, SP, LA) to govern coverage and require provider documentation where appropriate.

Utilization controls are specified on a per‑product basis across the formulary. Common controls include PA (Prior Authorization), ST (Step Therapy), SP (Specialty Pharmacy), NP (Nonpreferred), LA (Limited Access), and QL (Quantity Limit). Quantity limits are shown as concrete thresholds for many products (examples: Cayston QL = 84 mL per month; Xifaxan QL = 60 tablets per month; topical/other entries with QL (1 per 30 days)).

Coverage that falls outside the specific limits noted in the formulary (for example age limits, quantity limits, or ACA preventive medication criteria) may be considered at the plan’s discretion and could be denied; the document notes that coverage outside specified limits is governed by the applicable benefit contract and plan rules.

As used in the formulary listings, the NP flag denotes a nonpreferred placement (a formulary tier or routing designation). NP is shown on multiple product lines and is distinct from flags that mandate prior authorization or specialty dispensing.

The excerpted material does not present explicit Not Medically Necessary (NMN) declarations for specific products. Product lines instead list requirement flags and tiers; where coverage exceptions are applicable, providers are expected to follow the PA/QL/ST processes to document medical necessity.

Product listings and coding references

Quantity limit codesmixed

QL (60 Capsules per month)	Quantity limit examples shown for hydrocodone and hydromorphone products
QL (90 Tablets per month)	Quantity limit examples shown for morphine and oxycodone extended-release products
QL (120 Tablets per month)	Quantity limit example for morphine extended-release and oxycodone high-dose products

Utilization requirement codesmixed

PA	Prior authorization (appears on many product lines)
ST	Step therapy (appears on several NSAID and other products)
SP	Special program/site of service prior auth indicator (appears for some products)
ACA	Appears for aspirin low-dose items (coverage/benefit code)

Selected products with utilization controlsmixed

TECFIDERA 120 mg / 240 mg	Tecfidera oral capsule delayed release; quantity limits and PA indicated
VUMERITY 231 mg	Vumerity oral capsule delayed release; PA and QL (120 per fill) noted
REBIF titration pack	Rebif titration pack subcutaneous; PA; SP; LA indicated
HEMANGEOL 4.28 mg/mL	Hemangeol oral solution; PA; SP; NP
KERENDIA 10/20/40 mg	Kerendia oral tablet; PA; QL (varies by strength); NP

Cardiovascular / Hypertension / Lipid agentsmixed

various antihypertensives & lipid-lowering agents

Extensive list of ACE inhibitors, ARBs, beta-blockers, calcium channel blockers, diuretics, antiarrhythmics and statins with varied requirement flags as listed in the formulary (see product lines for details)

inv-20: Age limits (examples)

Bowel prep (example)Covered for persons between 45 and 75 years old

Breast cancer prevention agentsCovered in full for persons 35 years or older (e.g., tamoxifen, raloxifene, anastrozole, exemestane)

FluorideCovered in full for persons 6 months through 16 years old

Smoking cessation aidsCovered in full for persons 18 years or older; limited to 180 days per year

Statins (example: atorvastatin)Covered in full for persons 40 through 75 years old

inv-21: Quantity limits examples

CaystonQL (84 Milliliters per month / 84 per 30 days)

Xifaxan (200 mg, 550 mg)QL (60 Tablets per month / 60 per 30 days)

Ivermectin / STROMECTOLQL (20 Tablets per month / 20 per 30 days)

inv-22: Example Quantity Limits

Common small-molecule caps/tabletsExamples include QL (30 Tablets per month) and QL (33 Capsules per month)

Higher monthly capsExamples include QL (120 per 30 days) as shown for select agents

Formulation-dependent QLsSome oral oncology and specialty drugs list QL per pack or per year instead of per month

inv-23: Common quantity limits

QL 120/30 daysMultiple anticonvulsant and chronic therapy examples list QL 120 per 30 days

QL 150/30 daysListed for some anticonvulsant or specialty formulations

QL 240/30 daysShown as an upper-monthly quantity for several chronic oral agents

inv-24: Common quantity limits — 8,10,16,18,30,60,120,240 examples

8 units per monthExample: injectable/rescue migraine therapies QL (8 per month)

18 tablets per monthOral triptan formulations commonly limited to QL (18 per 30 days)

30–240 units per monthRange examples include 30, 60, 120, 240 units per month for various products

inv-25: Quantity Limits examples — 60/90/120 per month examples

60 per monthExamples: some opioid and capsule formulations show QL 60 per 30 days

90 per monthExamples: morphine ER pellets and other formulations with QL 90 per 30 days

120 per monthExamples: morphine ER tablets and select high-dose ER products with QL 120 per 30 days

inv-26: Quantity limits examples

Sodium oxybate (XYREM)QL (3 Bottles per month)

SPRAVATO nasal sprayRequirements = PA; SP; NP; QL (4 per 30 days)

SUNOSI / SUNOSTSUNOSI QL (30 per 30 days); SUNOST QL (60 per 30 days)

inv-27: Quantity limits examples — 4 per 30 days; 60 per 30 days

DUPIXENTQL (4 per 30 days)

Example 60 per 30 daysMultiple cardiovascular and anticoagulant products (e.g., rivaroxaban/Xarelto) list QL (60 per 30 days)

4 per 30 days (other biologics)Shown for certain injectable/topical pens and biologics in dermatology section

inv-28: DUPIXENT quantity limit example (4 per 30 days)

DUPIXENT quantity capQL (4 per 30 days)

Associated requirementsRequirements listed alongside DUPIXENT include PA; SP; LA in product line

Formulations coveredBoth DUPIXENT pen and syringe entries list the same QL (4 per 30 days)

inv-29: DUPIXENT quantity limit (alternate entry)

DUPIXENT (alternate entry)Requirements Limits = PA; SP; LA; QL (4 per 30 days)

PresentationListed for both pen and syringe presentations with identical QL

Routing/controlsFlagged with specialty/site-of-care indicators (SP; LA) alongside QL

inv-30: SOFDRA quantity limit example (1 per 30 days)

SOFDRA topical gel with pump 12.45%Requirements Limits = NP; QL (1 per 30 days) — listed as 1 unit per 30 days

FlaggingEntry shows NP and QL flags in dermatology/topical therapy section

Dispensing periodQuantity limit specified as 1 per 30 days consistent with product packing

Prior authorization, step therapy, quantity limits — what providers must do

Prior Authorization

Obtain prior authorization when PA is listed

Prior authorization (PA) is required for drugs listed with the PA flag; providers must obtain payer approval before the prescription will be covered.

If a drug line shows 'PA' in Requirements/Limits, submit a prior authorization request and obtain approval prior to dispensing.

Prior Authorization

Request PA for listed antiviral/anti‑infectives

Select antiviral and anti‑infective products are marked 'PA' (often with SP or LA); providers must request prior authorization for coverage of these agents.

Examples: EPCLUSA, HARVONI, MAVYRET, SOFOSBUVIR‑VELPATASVIR show PA (often with SP and LA).

Prior Authorization

PA required for listed anti‑infectives

Many products in the miscellaneous anti‑infectives list are designated 'PA'; obtain prior authorization before prescribing these PA‑flagged agents.

Examples: ALINIA, ARIKAYCE, BETHKIS, CAYSTON show Requirements = PA.

Prior Authorization

Obtain PA for oral antineoplastics/immunosuppressants

Oral antineoplastic and immunosuppressant agents frequently require prior authorization (and often specialty routing); providers must submit PA for these agents.

Examples: many oral oncology agents list 'PA; SP; OCh; LA' in Requirements/Limits.

Prior Authorization

Follow per‑drug PA requirements

Many drugs across the formulary carry a PA flag; providers must follow the Requirements/Limits column and obtain prior authorization where indicated.

Coverage is contingent on meeting utilization management flags shown per drug line (PA, QL, ST, etc.).

Billing Rule

Route through specialty channels when SP/OCh/LA flagged

Some agents require specialty pharmacy (SP) routing or other channel/site controls in addition to prior authorization; providers must route prescriptions per those flags.

SP indicates specialty pharmacy dispensing; LA or OCh indicate limited access or other channel restrictions—follow payer routing instructions.

Prior Authorization

PA required for many neurology/antiepileptic meds

Neurology and antiepileptic medications are frequently marked PA; prescribers should obtain prior authorization for these CNS agents when PA is listed.

Examples: KEPPRA, LAMICTAL, VIMPAT have PA specified on their product lines.

Prior Authorization

Obtain PA for specific formulations and follow QL

Some products specify PA for particular formulations or formulations have separate QL; submit PA and adhere to formulation‑specific quantity limits (e.g., VIMPAT oral solution/tablets).

VIMPAT oral solution: Requirements = PA; QL (6 Bottles per month).
VIMPAT tablets: Requirements = PA; QL (varies by strength).

Prior Authorization

PA required for PA‑flagged dopamine/migraine/neurology drugs

Products marked with 'PA' require prior authorization before coverage; this includes multiple dopamine, migraine, and neurology therapies listed with PA.

Examples: GOCOVRI, INBRIJA, EMGALITY are shown with PA in Requirements/Limits.

Prior Authorization

Secure PA for PA‑flagged assorted products

Various assorted products are marked 'PA' across the formulary; providers must secure prior authorization for those listed items prior to dispensing.

See individual drug lines for PA designation and any accompanying QL or SP flags.

Prior Authorization

Obtain PA for listed opioid/CNS examples

Numerous products (including certain opioid and opioid‑related therapies) are designated 'PA' in the Requirements/Limits column and require prior authorization before coverage.

Examples include NUCYNTA ER and certain buprenorphine formulations shown with PA or QL.

Prior Authorization

PA required for many CNS agents

Many central nervous system (CNS) agents across the list are marked 'PA'; providers must obtain prior authorization where noted to avoid noncoverage.

Examples: SODIUM OXYBATE and other CNS agents require PA per their product entries.

Prior Authorization

Lumryz requires PA and has QL/annual kit limits

Lumryz and its starter pack require prior authorization and have specific quantity limits (30 packets per month; starter pack 1 kit per year); submit PA and ensure QL adherence.

Lumryz: Requirements = PA; QL (30 Packets per month); Lumryz Starter Pack: Requirements = PA; QL (1 Kit per year).

Prior Authorization

Obtain PA for specialty/selected agents

Many specialty and selected agents (e.g., PROVIGIL, SODIUM OXYBATE, SPRAVATO, multiple MS agents) are marked PA and require prior authorization before coverage.

Examples: SODIUM OXYBATE (PA; QL; SP), SPRAVATO (PA; SP; QL), and numerous MS agents list PA and SP flags.

Prior Authorization

PA required for Tecfidera, Vumerity, Hemangeol

Selected products such as Tecfidera, Vumerity, and Hemangeol are labeled 'PA' (many with QL or SP); providers must request prior authorization and follow any quantity limits.

Tecfidera: Requirements = PA; QL (14 capsules per year or QL 60 per 30 days depending on formulation).
Vumerity: Requirements = PA; QL (120 Capsules per fill).
Hemangeol: Requirements = PA; SP; NP.

Prior Authorization

Request PA for select pulmonary and injectable agents

Certain pulmonary and specialty products (e.g., ORENITRAM, UPTRAVI) and high‑cost injectables (ALHEMO, HEMLIBRA) are marked PA; obtain prior authorization prior to dispensing.

Examples: ORENITRAM and UPTRAVI dose packs: PA; SP; ALHEMO and HEMLIBRA: PA with QL noted for HEMLIBRA (2 per 30 days).

Prior Authorization

PA required for PA‑marked PROMACTA formulations

Some products listed with 'PA' require prior authorization for specific formulations (for example PROMACTA entries show PA and QL); obtain PA per product line.

PROMACTA examples show Requirements = PA; QL (30 per 30 days) for some strengths.

Prior Authorization

Obtain PA for many biologic/topical agents

Numerous biologic and topical agents (e.g., SILIQ, SKYRIZI, STELARA, SPEVIGO) list 'PA' and often SP/LA flags; providers must obtain prior authorization and follow specialty routing as indicated.

Examples: SILIQ, SKYRIZI, SPEVIGO show Requirements = PA; SP; NP; LA.

Step Therapy

Document required trials for step therapy (ST)

Step therapy (ST) is required where the ST flag appears; providers must ensure specified alternative therapy trials are documented before the requested drug will be covered.

If a drug line shows 'ST', document trial and failure or intolerance to preferred agent(s) per the plan prior to coverage.

Step Therapy

Follow ST/SP flags for select antivirals

Some high‑cost or specialty antiviral products use SP/ST flags indicating step edits or specialty program edits apply; follow the Requirements/Limits entry for step therapy instructions.

Hepatitis C direct‑acting antivirals frequently show PA; SP; LA and may have step/route requirements.

Step Therapy

Adhere to step therapy for select tetracyclines

Certain tetracycline‑class products are marked 'ST'; providers must comply with step therapy edits when prescribing these agents.

Examples: AVIDOXY, DORYX, ORACEA and related branded tetracyclines list Requirements = ST; NP.

Note

ST sequences not specified here — follow PA/plan rules

The document does not provide step therapy sequences in this excerpt; where ST is present, the ST flag is the trigger and PA/QL remain primary controls.

Providers should reference the plan's specific prior authorization/step therapy policy for detailed step sequences.

Note

Follow displayed flags when step therapy details are absent

Some entries only display requirement flags without step detail; providers should follow the per‑drug flags (PA, ST, SP, QL) shown and submit required authorizations/documentation.

Absence of a step sequence in this excerpt means submit PA or follow ST flag as indicated by the payer.

Billing Rule

Use SP routing for SP‑flagged products

SP flags may indicate management via the specialty pharmacy program and/or step edits for certain high‑cost agents; route prescriptions through the specialty pharmacy when SP is shown.

Examples: SABRIL and other specialty agents show SP; providers should dispense via in‑network specialty pharmacy if required.

Step Therapy

TOSYMRA requires step therapy

TOSYMRA is listed with an ST flag; providers must follow step therapy requirements where ST is indicated for this product.

TOSYMRA: Requirements = PA; ST; QL (18 Units per month).

Step Therapy

Meet ST requirements for select NSAIDs/combos

Select NSAIDs and combination analgesics are marked 'ST'; ensure step therapy requirements are met prior to coverage for those products.

Examples: FLECTOR patch, fenoprofen, and other NSAIDs list Requirements = ST; NP.

Step Therapy

Step therapy applies to examples like FLECTOR, LICART, LODINE

Some analgesic products (FLECTOR, LICART, LODINE) and others are designated ST; providers must document trial of preferred therapies per step therapy before coverage.

FLECTOR patch: Requirements = ST; NP. LODINE 400 mg entries indicate ST in Requirements.

Step Therapy

ST applies to select psychiatric agents

Certain antidepressants and related agents are marked ST in the list; providers must follow step therapy editing for those psychiatric medications.

Examples: Desvenlafaxine ER, Effexor XR, Latuda, Lexapro appear with ST or PA+ST designations.

Step Therapy

Document prior therapy for ST‑flagged psychiatric meds

The formulary marks some psychiatric medications with ST; ensure required prior trials are documented when prescribing these agents.

Examples: PAXIL CR, PRISTIQ, QUETIAPINE 150 mg are listed with Requirements = ST; NP.

Step Therapy

ST applies to certain cardiovascular/antihypertensive drugs

Step therapy flags are applied to select cardiovascular/antihypertensive agents; providers must comply with ST requirements where shown.

Examples: ACCUPRIL, ALTACE, EXFORGE HCT show ST flags in Requirements/Limits.

Step Therapy

Check ST flags on branded products

Branded products may carry ST flags; check the Requirements/Limits column for ST before prescribing branded agents to ensure step therapy compliance.

Lotensin HCT and other branded combinations are examples of items with ST flags.

Step Therapy

ST indicated for NIACOR and PRAMOSONE examples

Some entries (e.g., NIACOR, PRAMOSONE) are specifically marked 'ST'; providers must follow step therapy rules for these products prior to coverage.

PRAMOSONE topical products: Requirements = ST; NP.

Step Therapy

Step therapy required for select topical agents

Multiple topical acne and corticosteroid products list 'ST' in Requirements/Limits; providers should document failure of preferred topical therapies before coverage.

Examples: ADAPALENE topical products, ACZONE, ABSORICA are marked ST; NP.

Documentation Required

Submit clinical information to support restricted drugs

When utilization controls apply (PA, QL, ST, age limits), providers must submit clinical information to support coverage requests, including indication and relevant clinical history.

The formulary states providers may need to provide additional information when restrictions are present; contact customer service or use the 'Drugs Requiring Approval' page for process details.

Documentation Required

Document adherence to QL (example LIVTENCITY)

Quantity limits (QL) shown for products require documentation and adherence; for drugs with specific QL (e.g., LIVTENCITY QL 160 per 30 days) ensure dispensing matches authorized quantity.

LIVTENCITY: Requirements = PA; SP; NP; QL (160 per 30 days).
Prescriptions exceeding QL require documentation or PA for override.

Documentation Required

Provide documentation for QL overrides (CAYSTON, XIFAXAN)

Prescriptions that exceed quantity limits (e.g., CAYSTON 84 mL/month; XIFAXAN 60 tablets/month) will require documentation or prior authorization to support the increased quantity.

CAYSTON: QL (84 Milliliters per month).
XIFAXAN: QL (60 Tablets per month).

Documentation Required

Adhere to product QLs or submit supporting documentation

Quantity limits are specified for many products (examples include QL 30 per month, 120 per 30 days, 240 per 30 days); providers must ensure prescriptions adhere to listed QLs or supply documentation for medical necessity.

Examples in the antineoplastic and anticonvulsant sections show varying QLs that must be followed.

Billing Rule

Limit prescriptions to listed QL unless authorized

When a product line includes a QL, prescriptions must be limited to the listed quantity per timeframe unless an authorization/override is obtained and documented.

Claims exceeding the QL will require documentation to establish medical necessity for the additional quantity.

Documentation Required

Provide supporting documentation for PA/SP/NP/LA flags

Products flagged with PA, SP, NP, LA, or QL require submission of supporting documentation for prior authorization or specialty program enrollment; providers must include clinical rationale and dosing/quantity details.

Follow payer instructions for specialty routing and PA documentation when PA; SP; LA flags appear on the drug line.

Documentation Required

Document indication and quantity for migraine biologics/rescue meds

For migraine biologics and rescue therapies flagged with PA and QL, prescribers should document the indication and the quantity requested to support the authorization.

Examples: EMGALITY is PA; NURTEC ODT has PA; QL (8 Tablets per month).

Documentation Required

Submit required documentation for PA/QL requests

When PA or QL flags are present, providers are expected to follow prior authorization and quantity‑limit processes and submit necessary documentation as part of the request.

Many product entries include PA or QL which trigger requirements for documentation or authorization prior to coverage.

Documentation Required

Include days supply/quantity when requesting QL exceptions

The formulary provides QL examples (e.g., 20 Tablets per 5 days; 60 Tablets per month); providers must include quantity/days‑supply details when requesting overrides or PA.

Include days supply and quantity in PA submissions to demonstrate need beyond listed QL.

Denial Risk

Exceeding QL requires documentation to prevent denial

Claims submitted for quantities exceeding stated QLs will require documentation supporting medical necessity or prior authorization to avoid denial.

Examples: Many products list QL (30 per 30 days); exceeding this without PA/documentation may result in denial.

Documentation Required

Follow PA and specialty routing processes as flagged

Providers must follow the payer's prior authorization and specialty routing processes when PA, SP, NP, LA, or ST flags are present on a drug line; failure to do so can affect coverage.

The document instructs prescribers to follow the payer's PA and QL processes for items labeled PA and QL; SP/LA indicate specialty routing.

Documentation Required

Document justification for requests exceeding explicit QLs

When a QL is explicitly stated (e.g., '4 per 30 days'), providers must document justification to support requests for quantities above the stated limit.

DUPIXENT example: QL (4 per 30 days) — documentation needed for requests beyond this limit.

Billing Rule

Adhere to requirement flags for routing and authorization

Requirement flags (PA, SP, NP, QL, LA, ACA, ST) determine routing, authorization, and coverage; providers must document and submit authorization requests consistent with these flags.

These flags indicate utilization controls and required actions—follow the plan's processes per product line.

Documentation Required

Document requirement flags and clinical details on requests

Prescribers should document requirement flags on PA/SP/QL/ST requests and include clinical details to support approval as indicated by the formulary entries.

The formulary marks many products with requirement flags — include these in authorization submissions.

Documentation Required

DUPIXENT: follow PA/SP/QL (4 per 30 days)

DUPIXENT is listed with a quantity limit of 4 per 30 days; providers must request authorization and document need for any quantity beyond the stated QL.

DUPIXENT: Requirements = PA; SP; LA; QL (4 per 30 days).

Denial Risk

Risk of noncoverage if PA not obtained

Failure to obtain required prior authorization may result in the drug not being covered; obtain and document approval before dispensing PA‑flagged products.

The coverage abbreviations explicitly state that without prior authorization the drug may not be covered.

Denial Risk

PA missing may cause denial for PA‑listed items

Requests for products listed with 'PA' may be denied if prior authorization is not obtained; submit PA requests proactively to avoid denials.

The product listings show many antiviral and other agents with Requirements = PA.

Denial Risk

Expect utilization review for flagged drugs

Claims may be denied or require intervention when drugs are marked with PA, NP, SP, or have quantity limits; ensure authorization and routing meet the flags shown on the drug line.

Products marked with PA/NP/SP/QL are triggers for utilization review and possible denial if requirements are unmet.

Denial Risk

Noncompliance with PA/SP can lead to denial or extra handling

If PA, SP, or other specialty requirements are not followed for listed drugs, claims may be denied or require additional handling; follow the Requirements/Limits instructions on each product line.

Specialty pharmacy or limited access flags often accompany PA and require adherence to payer routing to avoid denials.

Denial Risk

Missing PA for PA‑flagged products triggers denial risk

A missing PA for PA‑flagged products (examples shown in the list) is an explicit trigger for denial; obtain payer approval before dispensing to avoid claim rejection.

Examples in the neurology and movement disorder sections (GOCOVRI, INBRIJA) list PA; lack of approved PA may result in denial.

Denial Risk

QL exceedance can trigger denial or edits

Exceeding quantity limits (QL) stated in the formulary (monthly or per fill) can trigger denials or step edits; check QL values and request authorization for higher quantities.

Common QL examples include 8, 18, 30, 60, 120, 240 units per timeframe; exceeding these without PA/documentation risks denial.

Note

Anticipate utilization review for PA/QL/ST/SP flags

Product lines showing PA, QL, ST, SP or NP will trigger utilization review; providers should anticipate prior authorization and documentation requests for these items.

Examples across the formulary show these flags commonly and act as triggers for utilization management.

Denial Risk

Claims may be denied if PA/ST/QL/SP requirements unmet

When products are listed with PA, ST, QL or SP, claims submitted without meeting those program requirements may be denied or returned for additional documentation.

Providers should ensure prior trials (ST), approved PAs, or QL documentation accompany claims to avoid denials.

Note

Policy background and governance

The formulary drug list is developed and maintained by an independent Pharmacy & Therapeutics (P&T) Committee that evaluates safety, effectiveness and cost when determining drug placement, tiering, and utilization management controls. Specialty drugs are generally subject to enhanced management, including specialty pharmacy routing and additional documentation requirements.

Definitions and abbreviations

inv-96: Tier definitions — Tier 1 = generics, Tier 2 = brands (low importance)

Tier 1Generally denotes generic drugs

Tier 2Generally denotes brand drugs

Tier placementTier assignments appear next to product lines to indicate member cost-sharing level

inv-97: Abbreviations — PA, QL, ST, AGE, SP defined (low importance)

PAPrior Authorization

QLQuantity Limit

STStep Therapy

AGEAge Limit

SPSpecialty Pharmacy

inv-98: PA definition — Prior Authorization (low)

PAPrior Authorization — you (or your physician) must obtain authorization from the plan before filling the prescription; without approval the drug may not be covered

ContextPA appears frequently in the Requirements/Limits column for many specialty and high-cost drugs

Provider actionProviders must submit required documentation to support PA requests as noted in plan guidance

inv-99: QL definition — Quantity Limit (low)

QLQuantity Limit — a maximum amount of drug covered per prescription or within a specified time frame (examples shown as '30 per 30 days', '84 mL per month', '60 per 30 days')

EnforcementClaims exceeding QL require documentation or prior authorization per the formulary entries

Common periodsQLs are commonly expressed per 30 days, per month, per year, or per pack as shown in entries

inv-100: NP definition — NP flag context (low)

NPNonpreferred — product designated as nonpreferred on the formulary (may imply higher cost-sharing or additional requirements)

Usage in listNP appears frequently next to product lines indicating formulary placement rather than absolute exclusion

Provider implicationNP entries may still require PA or other flags depending on the product line

inv-101: SP definition — Step Therapy / Specialty (low)

SPSpecialty Pharmacy — indicates specialty drug management and dispensing through a specialty channel; often limited to a one-month supply

Site-of-careSP may be paired with LA (limited access) to indicate restricted distribution or site-specific requirements

Associated flagsProducts flagged SP commonly also show PA and QL in Requirements/Limits

Step therapy rules and affected products

Rule	Notes / Example products
Step therapy requires that a member try specified alternative drugs first before the requested drug will be covered.	Described generally in the formulary; see examples below where products are flagged 'ST' or 'SP'.

Product / Flag	Requirement
EPCLUSA	Requirements = PA; SP; LA (SP indicates step/specialty edits may apply)
HARVONI	Requirements = PA; SP; LA (SP indicates step/specialty edits may apply)
SOFOSBUVIR-VELPATASVIR (SOVALDI / VOSEVI entries)	Requirements = PA; SP; NP; LA (SP shown for several HCV direct-acting antivirals)
XOFLUZA	Requirements = QL (2 per year); NP — listed among antiviral products with utilization flags

Tetracycline product	Listed requirement/flag
AVIDOXY (DK kit / oral tablet)	Requirements Limits = ST; NP
DORYX (DR/EC formulations)	Requirements Limits = ST; NP
EMROSI / ORACEA / minocycline extended-release examples	Requirements Limits = ST; NP (multiple tetracyclines listed with ST)

Statement	Source note
No explicit step therapy sequences or clinical step-by-step algorithms are provided in the excerpt.	The formulary lists ST/SP flags per product but does not define required prior-step drugs or sequences in these chunks.

Example product	SP / LA meaning in context
SABRIL (vigabatrin) entries	Requirements = PA; SP; NP; LA — SP or LA indicate specialty or limited-access routing prior to approval
VIGABATRIN / VIGAFYDE entries	Requirements = PA; SP; LA — flagged for specialty management / limited access

Product	Requirement flags
TOSYMRA nasal spray	Requirements Limits = PA; ST; QL (18 Units per month); NP — includes 'ST' indicating step therapy

NSAID / related product	Requirement / Flag
ARTHROTEC / ARTHROTEC 50/75	Requirements Limits = ST; NP (examples of NSAID-class items with ST)
DICLOFENAC (submicronized) / FLECTOR patch	Requirements Limits = ST; NP (FLECTOR patch specifically listed with ST)
INDOCIN / NAPROSYN / MELOXICAM formulations	Multiple entries show ST or NP for certain formulations (ST noted for some products)

Example product	Listed requirement
FLECTOR transdermal patch 1.3%	Requirements Limits = ST; NP
LICART / diclofenac-misoprostol combinations (diclofenac-misoprostol)	Some diclofenac-misoprostol entries shown; diclofenac products listed with ST in multiple lines
LODINE (etodolac) & MELOXICAM oral suspension	Etodolac and meloxicam entries appear among NSAIDs with ST noted for some formulations (meloxicam suspension Requirements = ST)

Psychotropic product	Requirement / Flag
Desvenlafaxine ER, Effexor XR	Requirements Limits = ST; NP (examples of antidepressants listed with ST)
Drizalma; Latuda; Lexapro	Entries include ST flags for selected products (Drizalma, Latuda, Lexapro show ST in listings)
Fanapt; Fetzima; others	Multiple antidepressant/antipsychotic agents listed with ST where shown

Antidepressant / Antipsychotic product	Listed requirement
PAXIL CR	Requirements Limits = ST; NP
PRISTIQ	Requirements Limits = ST; NP
QUETIAPINE 150 mg	Requirements Limits = ST; NP — quetiapine 150 mg listed with ST

Cardiovascular / Antihypertensive product	Requirement / Flag
ACCPRIL (ACE inhibitor)	Requirements Limits = ST; NP (example ACE inhibitor listed with ST)
ALTACE (ramipril)	Requirements Limits = ST; NP (listed with ST)
EXFORGE HCT / combination agents	Requirements Limits = ST; NP (combination antihypertensives shown with ST)

Branded product	Step therapy flag
ARTHROTEC (brand NSAID) entries	Requirements Limits = ST; NP — branded products shown with ST flags
EMROSI / AVIDOXY branded tetracyclines	Requirements Limits = ST; NP — branded tetracycline-class products flagged ST
TOSYMRA (nasal spray) — branded migraine product	Requirements Limits = PA; ST; QL — specifically includes ST flag

Topical / Other product	Requirement / Flag
PRAMOSONE topical cream / lotion / ointment	Requirements Limits = ST; NP (listed with ST for topical corticosteroid entries)
PYZCHIVA auto-injector	Requirements Limits = PA; SP; NP — specialty/topical biologic with utilization flags
ENSTILAR topical foam	Requirements Limits = PA (example topical with utilization controls)

Topical acne / corticosteroid product	Step therapy flag
ABSORICA / ABSORICA LD (oral isotretinoin) and acne topicals	Requirements Limits = ST; NP — acne therapies listed with ST
ACZONE topical gel; adapalene topical formulations	Requirements Limits = ST; NP — multiple topical acne preparations flagged ST
AKLIEF, ALTRENO, ACANYA, adapalene-benzoyl peroxide combinations	Requirements Limits = ST; NP — various topical acne and corticosteroid preparations listed with ST

Quantity limits and per-product caps

Specialty pharmacy, infusion, and limited-distribution controls

Billing Rule

Dispense specialty drugs via in‑network specialty pharmacy

Specialty drugs may be required to be filled at an in‑network specialty pharmacy or be distributed through limited distribution channels; providers must route per the SP/LA flags.

The formulary notes specialty drugs are generally used for complex conditions and may require enhanced support and limited dispensing.

Billing Rule

Follow LA/SP site‑of‑care distribution restrictions

LA and SP flags indicate site‑of‑care or specialty distribution restrictions (e.g., certain hepatitis C and specialty agents); follow listed routing and site requirements when submitting requests.

Examples: hepatitis C DAAs frequently show PA; SP; LA and require specialty/site specific handling.

Prior Authorization

Obtain PA and site approval where PA; SP indicated

Some products include 'PA; SP' indicating both prior authorization and site‑specific prior authorization (infusion or specialty center) are required; obtain both PA and any site approvals stated.

Example: ZILBRYSQ shows Requirements = PA; SP indicating site‑specific prior authorization.

Billing Rule

Use specialty pharmacy processes for SP‑designated agents

Many specialty agents are designated SP—these require specialty pharmacy management and may need prior authorization submitted through specialty channels.

Examples: MS agents, sodium oxybate, SPRAVATO and others list SP in Requirements/Limits.

Billing Rule

Route injectable/subcutaneous specialty agents via SP

Injectable/subcutaneous specialty agents are often designated SP and may be limited to specialty pharmacy dispensing; follow the SP flag for site and dispensing channel instructions.

Examples: HEMLIBRA, ALHEMO, HYMPAVZI are listed with PA; SP; LA where applicable.

Billing Rule

Follow SP/infusion controls for biologic agents

Numerous biologic injectables list SP indicating specialty pharmacy or infusion‑site controls; ensure prescriptions are routed and authorized per the SP designation to avoid denial.

Examples: SILIQ, SKYRIZI, SPEVIGO, STELARA entries include PA; SP; NP flags.

Policy Summary

PayerPremera Bluecross

PolicyFormulary drug list and coverage rules (Pharmacy & Specialty Drugs)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain required prior authorization and submit supporting clinical documentation when a drug line lists PA, QL, ST, SP, or other requirement flags.

SourceLink

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