CurrentPremera BluecrossPolicy N/A

Formulary Drug List

This document is a formulary drug list from Premera Blue Cross describing covered drugs, tiers (ACA Preventive 0, Generic 1, Preferred Brand 2, Non-Preferred Brand 3), and utilization management restrictions (PA, ST, QL, Age limits, SP, LA, VAC, EX). It lists many agents with Drug Tier and Requirements/Limits for this part of the multi-part formulary.

Policy Summary

PayerPremera Bluecross

PolicyFormulary Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for any drug marked 'PA' in the Requirements/Limits before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported for this formulary segment (has_material_change = false).

~250Document part drug lines (approx.)

manyEntries with Prior Authorization (PA)

multipleEntries with Quantity Limits (QL)

severalSpecialty / Limited Access (SP/LA)

severalExcluded (EX) tier entries

Coverage Summary

This part is a product listing with tiers and requirement flags; it does not itself contain detailed clinical medical necessity criteria. Coverage for a listed drug is governed by the formulary listing and any referenced utilization management restrictions.

General Formulary Utilization Management Restrictions

General Formulary Utilization Management Restrictions: Coverage for drugs listed on the formulary may be subject to one or more of the following utilization management restrictions. Where a formulary entry lists requirement flags, those flags invoke the corresponding restriction below.

ALL of the following

PA — Prior Authorization: Coverage requires prior approval from the plan. Without authorization, the drug may not be covered.
Provider or member must obtain approval before pharmacy fills.
ST — Step Therapy: Coverage requires trial and failure (or contraindication) of specified alternative drug(s) before coverage is granted for the listed agent.
Documentation of trials or intolerance may be requested.

Policy Summary

PayerPremera Bluecross

PolicyFormulary Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for any drug marked 'PA' in the Requirements/Limits before dispensing.

SourceLink

On This Page

Applicable Codes / Formulary Line Items

Formulary - Oncology / Specialty (mixed)mixedCovered

ZLYTREK ORAL CAPSULE 100 MG	ZLYTREK (entrectinib) oral capsule 100 mg
ZLYTREK ORAL CAPSULE 200 MG	ZLYTREK (entrectinib) oral capsule 200 mg
ROZLYTREK ORAL CAPSULE 100 MG	ROZLYTREK (entrectinib) oral capsule 100 mg - alternate name
ROZLYTREK ORAL CAPSULE 200 MG	ROZLYTREK (entrectinib) oral capsule 200 mg - alternate name
ROZLYTREK ORAL PELLETS IN PACKET 50 MG	ROZLYTREK oral pellets in packet 50 mg
RUBRACA ORAL TABLET 200 MG	RUBRACA (rucaparib) oral tablet 200 mg
RUBRACA ORAL TABLET 250 MG	RUBRACA (rucaparib) oral tablet 250 mg
RUBRACA ORAL TABLET 300 MG	RUBRACA (rucaparib) oral tablet 300 mg
RYDAPT ORAL CAPSULE 25 MG	RYDAPT (midostaurin) oral capsule 25 mg
SANDIMMUNE ORAL CAPSULE 100 MG	SANDIMMUNE (cyclosporine) oral capsule 100 mg

1–10 of 133

1/14

Formulary - Neurology / Epilepsy (mixed)mixedCovered

BANZEL ORAL SUSPENSION 40 MG/ML	BANZEL (rufinamide) oral suspension 40 mg/mL
BANZEL ORAL TABLET 200 MG	BANZEL oral tablet 200 mg
BANZEL ORAL TABLET 400 MG	BANZEL oral tablet 400 mg
BRIVIACT ORAL TABLET 10 MG	BRIVIACT (brivaracetam) oral tablet 10 mg
BRIVIACT ORAL TABLET 25 MG	BRIVIACT oral tablet 25 mg
BRIVIACT ORAL TABLET 50 MG	BRIVIACT oral tablet 50 mg
BRIVIACT ORAL TABLET 75 MG	BRIVIACT oral tablet 75 mg
BRIVIACT ORAL TABLET 100 MG	BRIVIACT oral tablet 100 mg
CARBAMAZEPINE VARIOUS FORMULATIONS	Carbamazepine (various formulations and strengths)
CLOBAMAZAM ORAL SUSPENSION/TABLET 2.5-20 MG	clobazam oral suspension/tablet 2.5-20 mg

1–10 of 24

1/3

Formulary - Migraine, Movement Disorders, Parkinson's & Related (mixed)mixedCovered

AIMOVIG	AIMOVIG (erenumab) migraine agent - multiple presentations
AJOVY	AJOVY (fremanezumab) migraine agent
EMGALITY	EMGALITY (galcanezumab) migraine agent
NURTEC	NURTEC (rimegepant) oral/tablet formulations
REYVOW 100 MG	REYVOW (lasmiditan) 100 mg
REYVOW 50 MG	REYVOW 50 mg
UBRELVY 100 MG	UBRELVY (ubrogepant) 100 mg
UBRELVY 50 MG	UBRELVY 50 mg
APOKYN/APOMORPHINE SUBCUTANEOUS CARTRIDGE 10 MG/ML	Apokyn apomorphine subcutaneous cartridge 10 mg/mL
INBRIJA INHALATION CAPSULE 42 MG	INBRIJA inhalation capsules 42 mg

1–10 of 22

1/3

Formulary - Triptans / Acute Migraine (mixed)mixedCovered

RIZATRIPTAN FORMS	Rizatriptan oral tablet/ODT/other forms
SUMATRIPTAN FORMS	Sumatriptan oral/injectable/nasal forms
TOSYMRA	TOSYMRA sumatriptan formulation
ZEMBRACE	ZEMBRACE (zolmitriptan) nasal powder
ZOLMITRIPTAN FORMS	Zolmitriptan oral/tablet/nasal formulations
SUMATRIPTAN-NAPROXEN 85-500 MG	Combination sumatriptan-naproxen 85/500 mg
UBRELVY 100/50 MG	UBRELVY (ubrogepant) 100/50 mg entries

Formulary - Opioid Overdose & Rescue (mixed)mixedCovered

NARCAN 4 MG SPRAY	Narcan (naloxone) 4 mg spray
KLOXXADO 8 MG SPRAY	KLOXXADO naloxone 8 mg spray
REXTOVY 4 MG SPRAY	REXTOVY rescue spray 4 mg

Formulary - Respiratory & Inhaled Therapies (mixed)mixedCovered

INCRUSE ELLIPTA 62.5 MCG	INCRUSE ELLIPTA inhalation 62.5 mcg/actuation
TIROSLINT/OTHER RESPIRATORY	Selected respiratory agents including bronchodilators and steroids
PULMICORT INHALATION SUSPENSION 0.25/0.5/1 MG/2 ML	Pulmicort inhalation suspension for nebulization

Formulary - Insulins & Diabetes Supplies (mixed)mixedCovered

ADMELOG SOLOSTAR U-100	Admelog SoloStar U-100 insulin pen 100 units/mL
AFREZZA INHALATION CARTRIDGE	Afrezza inhalation cartridges with inhaler
CONTINUOUS GLUCOSE MONITORS & STRIPS	Multiple CGM and blood glucose meter test strip products listed

Formulary - Vaccines & Preventive (mixed)mixedCovered

FLUAD 2025-2026	FLUAD 2025-2026 vaccine
GARDASIL 9	GARDASIL 9 HPV vaccine
COVID & SEASONAL VACCINES	Selected seasonal and COVID vaccines

Formulary - Topical / Dermatology (mixed)mixedCovered

ZORYVE TOPICAL CREAM 0.15%	ZORYVE topical cream 0.15%
ZORYVE TOPICAL CREAM 0.3%	ZORYVE topical cream 0.3%
ZORYVE TOPICAL FOAM 0.3%	ZORYVE topical foam 0.3%
OPZELURA TOPICAL CREAM 1.5%	Opzelura topical cream 1.5%
QBREXZA TOPICAL TOWELETTE 2.4%	QBREXZA topical towelette 2.4%

Formulary - Hormones & Endocrine (mixed)mixedCovered

ANDROGEL TRANSDERMAL GEL METERED-DOSE PUMP 20.25 MG/1.25 GRAM	Androgel transdermal gel metered pump 20.25 mg/1.25 g
TESTIM TRANSDERMAL GEL 50 MG/5 GRAM	Testim transdermal gel 50 mg/5 g
LEVOTHYROXINE VARIANTS	Levothyroxine oral capsule/tablet multiple strengths

Formulary - GI, Bowel Prep & Hepatology (mixed)mixedCovered

PEG 3350 ELECTROLYTE PREPS	Polyethylene glycol 3350 electrolyte oral powder (various brands)
MOVIPREP / PLENVU / SUTAB	Bowel prep kits (MoviPrep, Plenvu, SUTAB)
VIVAGUARD / OTHER GI PRODUCTS	Selected GI agents and specialty products

Formulary - Ophthalmology (mixed)mixedCovered

EYLEA INTRAVITREAL SOLUTION 2 MG/0.05 ML	EYLEA intravitreal solution 2 mg/0.05 mL
LUCENTIS INTRAVITREAL SYRINGE 0.3/0.5 MG/0.05 ML	LUCENTIS intravitreal syringes 0.3 and 0.5 mg/0.05 mL
XIIDRA OPHTHALMIC 5%	Xiidra ophthalmic drops 5%

Formulary - Cardiovascular, Antihypertensives & Lipids (mixed)mixedCovered

ATORVASTATIN / STATINS	Multiple statin products including atorvastatin, rosuvastatin
JOURNAVX 50 MG	Journavx 50 mg
ANTIHYPERTENSIVE AGENTS	Multiple ACE/ARB, beta-blocker entries

Formulary - Renal / Electrolyte Modifiers (mixed)mixedCovered

VELTASSA ORAL POWDER IN PACKET 8.4/16.8 GRAM	Veltassa oral powder in packet
LOKELMA ORAL POWDER IN PACKET 5 GRAM	Lokelma oral powder in packet 5 gram

Formulary - Urology & BPH (mixed)mixedCovered

MYRBETRIQ VARIANTS	Myrbetriq formulations
GEMTESA ORAL TABLET 75 MG	GEMTESA 75 mg

Formulary - Specialty Biologics & Injectables (mixed)mixedCovered

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML	Stelara subcutaneous syringe 45 mg/0.5 mL
TREMFYA ONE-PRESS AUTO-INJECTOR 100 MG/ML	Tremfya one-press auto-injector 100 mg/mL
DUPIXENT PEN 200 MG/1.14 ML	Dupixent pen 200 mg/1.14 mL and 300 mg/2 mL
SKYRIZI WEARABLE INJECTOR 180 MG/1.2 ML	Skyrizi wearable injector 180 mg/1.2 mL

Formulary - Topical Analgesics & Patches (mixed)mixedCovered

FLECTOR PATCH	Flector topical patch
Diclofenac topical pump/drops	Diclofenac topical pump and eye drops entries

Formulary - Miscellaneous & OTC (mixed)mixedCovered

ASPIRIN 81 MG VARIANTS	Aspirin 81 mg (various brands, chewable, delayed release)
NARCAN / RESCUE AGENTS	Naloxone products listed elsewhere

Index / Catch-All - Remaining Catalog Items (mixed)mixed

REMAINING INDEXED DRUGS

Comprehensive index includes remaining drugs and formulations referenced in document (e.g., many antipsychotics, antidepressants, antivirals, antibiotics, endocrine, dermatology, ophthalmic, respiratory, GI, renal, oncology agents not exhaustively listed above).

OpenPayer

Formulary Drug List

Coverage Summary

Drug-specific Coverage Entries (examples)

Utilization Management Flags & Definitions

Applicable Codes / Formulary Line Items

Provider Actions & Operational Requirements

Quantity Limits (thresholds) — Selected Examples

Revision History