052144_2026.pdf - OpenPayer

Coverage Summary

Metallic M1 Formulary Drug List (Partial — Part 1 of 10) — Provides the Metallic M1 formulary drug list used by specified Premera plans and summarizes how the list is developed and applied to member coverage. Coverage stance: mixed (some drugs covered on pharmacy tiers, others as MB medical-benefit). Common utilization controls include Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Limited Access (LA), Medical Benefit (MB), and ACA preventive (ACA PV) flags. This extraction covers Part 1 of 10 of the document.

Effective / Last review / Next review dates: none provided in this part of the source.

General Coverage Conditions and Restrictions — Formulary drugs may be subject to utilization controls including Age Limits, Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Limited Access (LA), Medical Benefit (MB), and ACA preventive (ACA PV). Age limits restrict coverage to specified patient ages; PA is required before coverage and drugs may not be covered without approval; QL limits amounts per prescription or time frame; ST requires trials of preferred alternatives; LA indicates specialty distribution/in-network specialty pharmacy requirements; MB denotes drugs covered under the medical benefit (clinic/infusion/home infusion). Providers may need to submit supporting clinical information per the payer's 'Drugs Requiring Approval' process.

Policy TitleMetallic M1 Formulary Drug List (Partial)

PayerPremera Bluecross

Policy StatusCURRENT

Document PartPart 1 of 10

Coverage stancemixed

General Coverage Conditions and Restrictions

Applicable Drugs & Coding Groups (excerpt)

PA Group (Prior Authorization)mixed

lenalidomide oral capsule 2.5 mg	lenalidomide 2.5 mg capsule
lenalidomide oral capsule 5 mg	lenalidomide 5 mg capsule
lenalidomide oral capsule 10 mg	lenalidomide 10 mg capsule
lenalidomide oral capsule 15 mg	lenalidomide 15 mg capsule
lenalidomide oral capsule 20 mg	lenalidomide 20 mg capsule
lenalidomide oral capsule 25 mg	lenalidomide 25 mg capsule
octreotide acetate injection solution 50 mcg/ml	octreotide acetate injection solution (various concentrations)
octreotide acetate injection syringe 100 mcg/ml	octreotide acetate injection syringe (various concentrations)
PIQRAY ORAL TABLET 200 MG	PIQRAY (alpelisib) oral tablet 200 mg/day
PIQRAY ORAL TABLET 250 MG	PIQRAY (alpelisib) oral tablet 250 mg/day

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QL Group (Quantity Limits)mixed

VIJOICE 50 MG GRANULES	VIJOICE oral granules 50 mg
VIJOICE 50/125 MG TABLET	VIJOICE tablets 50/125 mg
XTANDI 40 MG	XTANDI (enzalutamide) 40 mg capsule/tablet
XTANDI 80 MG	XTANDI (enzalutamide) 80 mg capsule/tablet
AIMOVIG AUTOINJECTOR 140 MG/ML	AIMOVIG autoinjector 140 mg/mL
AIMOVIG AUTOINJECTOR 70 MG/ML	AIMOVIG autoinjector 70 mg/mL
AJOVY AUTOINJECTOR 225 MG/1.5 ML	AJOVY auto-injector/syringe 225 mg/1.5 mL
EMGALITY 120 MG PEN	EMGALITY 120 mg pen/syringe
EMGALITY 300 MG SYRINGE	EMGALITY 300 mg syringe
NURTEC ODT 75 MG	NURTEC ODT disintegrating tablet 75 mg

1–10 of 18

1/2

LA Group (Limited Access / Specialty Pharmacy)mixed

acetaminophen-codeine combo	acetaminophen with codeine combination products (multiple strengths)
fentanyl transdermal patch	fentanyl transdermal patches (various mcg/hr strengths)
hydrocodone ER	hydrocodone extended-release capsules (various mg strengths)
hydrocodone-acetaminophen	hydrocodone-acetaminophen formulations (various strengths)
hydromorphone oral	hydromorphone oral formulations (liquid/tablet/ER)
methadone products	methadone oral formulations (various)
morphine oral	morphine oral solutions/tablets (various)
oxycodone products	oxycodone immediate and extended-release products
oxymorphone oral	oxymorphone oral tablet/ER
butalbital combination products	butalbital and certain combination analgesic products

1–10 of 13

1/2

ACA Group (Affordable Care Act Preventive / ACA PV)mixedCovered

fluoride oral drops 0.5 mg/ml	fluoride (sodium) oral drops 0.5 mg/mL
fluoride chewable 0.25 mg	fluoride oral tablet chewable 0.25 mg
fluoride chewable 0.5 mg	fluoride oral tablet chewable 0.5 mg
fluoride chewable 1 mg	fluoride oral tablet chewable 1 mg
smoking cessation aids	nicotine replacement products (covered per ACA PV rules)
statins	statin therapies (covered per ACA PV rules for eligible ages)

MB / MB-designated (Medical Benefit) Groupmixed

REPATHA injection	REPATHA (evolocumab) listed entries (injectable)
SKYRIZI SUBCUTANEOUS SYRINGE 150 MG/ML	SKYRIZI subcutaneous syringe 150 mg/mL
STEQEYMA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML	STEQEYMA subcutaneous syringe 45 mg/0.5 mL
STEQEYMA SUBCUTANEOUS SYRINGE 90 MG/ML	STEQEYMA subcutaneous syringe 90 mg/mL
TREMFYA ONE-PRESS 100 MG/ML	TREMFYA one-press subcutaneous auto-injector 100 mg/mL
TREMFYA PEN INDUCTION PK 200 MG/2 ML	TREMFYA pen induction pack (2-pen) 200 mg/2 mL
TREMFYA PEN 100 MG/ML	TREMFYA pen subcutaneous pen injector 100 mg/mL
TREMFYA PEN 200 MG/2 ML	TREMFYA pen subcutaneous pen injector 200 mg/2 mL
TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML	TREMFYA subcutaneous syringe 100 mg/mL
TREMFYA SUBCUTANEOUS SYRINGE 200 MG/2 ML	TREMFYA subcutaneous syringe 200 mg/2 mL

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Provider Actions & Requirements

Prior Authorization

Prior Authorization required for specified drugs

Prior authorization (PA) is required for a number of specified drugs, including many specialty, oncology, biologic, limited access (LA) and medical-benefit (MB) products. Providers should request PA using Premera's PA/LA submission workflows on the payer website. Examples of drugs that commonly require prior authorization include, but are not limited to:

EPCLUSA
HARVONI
SOVALDI
XIFAXAN
Oncology agents (oral and infused)
Biologics (e.g., CABLIVI, REPATHA)
Dermatologic biologics (e.g., TALTZ, TREMFYA, DUPIXENT, SKYRIZI, YESINTEK)
STEQEYMA
CYSTAGON
ELMIRON
VELPHORO
AQNEURSA
Selected specialty agents and limited access products

Definitions & FAQs

Glossary — key terms used in the formulary:

PA (Prior Authorization): required before coverage; without prior approval the drug may not be covered.

QL (Quantity Limit): a limit on the amount of a drug covered per prescription or within a defined timeframe (examples listed per drug).

ST (Step Therapy): requires trial of specified alternative(s) before coverage of the requested drug.

LA (Limited Access): drug may only be filled at an in‑network specialty pharmacy or requires restricted distribution/special handling.

MB (Medical Benefit): drugs administered in clinic/infusion or via home infusion and billed to the medical benefit rather than pharmacy.

ACA PV (Affordable Care Act Preventive): preventive medications covered in full when USPSTF criteria are met; may include age/frequency limits.

Och: oncology designation indicating oral chemotherapy or oncology channel for distribution/coverage.

Will the Formulary change? — Yes. The list is updated throughout the year; members are notified if a drug is removed or moved to a higher cost‑sharing tier and changes are posted on the payer website.

How is the list developed? — The list is developed by an independent Pharmacy and Therapeutics Committee of clinicians that reviews safety, effectiveness, and cost at least quarterly.

Quantity Limits & Thresholds (examples)

Product	Quantity limit	Notes
abacavir tablet	60 per 30 days	Listed as QL (60 per 30 days).
lamivudine solution	900 mL per month	Listed as 900 MILLILITERS PER MONTH for oral solution.
JAKAFI	60 per 30 days	Listed as QL (60 per 30 days).
lapatinib	180 per 30 days	Listed as QL (180 per 30 days).
LYNPARZA	120 per 30 days	Listed as QL (120 per 30 days).
SKYRIZI	1 per 84 days	Listed with QL (1 per 84 days).
epinephrine auto-injector	4 per 30 days	Listed QL (4 per 30 days) for auto-injectors.
PAXLOVID	40 per 90 days	Listed as QL (40 per 90 days).
SANTYL topical ointment	6 grams per month	Listed limit: 6 GRAMS PER MONTH.
AQNEURSA granules	120 per 30 days	Listed as PA; QL (120 per 30 days).

Clinical Evidence & Notes

Clinical evidence: no discrete clinical-trial metrics were extracted in this part. Formulary placement and restrictions are determined by the Pharmacy & Therapeutics committee's review of safety, effectiveness, and cost rather than by specific trial metrics included here.

Revision History

noteLatest

No dated revision entries in this extraction; use full document change log if available.