CurrentPremera BluecrossPolicy 052146

Metallic (M4) Formulary Drug List

A formulary drug list (Metallic M4) for specified Premera Bluecross plans listing covered generic, brand, specialty, and medical-benefit drugs, with associated tiers and utilization management restrictions (age limits, prior authorization, quantity limits, step therapy, limited access, ACA preventive designations, medical-benefit). This part (1 of 10) contains introductory policy text, coverage explanations, codes as drug names with strengths/forms, drug tiers, and stated requirements/limits for many anti-infective and antineoplastic agents.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Formulary Drug List

Policy CodePolicy 052146

Change TypeN/A

Effective Date052146 (05-25-2026)

Next Review Date

Key ActionProviders must verify member contract/benefit and refer to member booklet for plan-specific coverage and cost-sharing; inclusion on this list does not override member benefit rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this update.

~200Listed drug formulations in this part

ManyProducts with PA/QL/LA/ST flags

multipleDrugs listed in this part

multipleEntries with QL specified

many

Plans using Metallic M4 list

Coverage Summary

This document is the Metallic (M4) Formulary Drug List used for specified Premera Bluecross plans (see plan listing). The list of covered drugs (generic, brand and specialty) is developed and maintained by an independent Pharmacy & Therapeutics (P&T) Committee, which reviews drugs at least quarterly considering safety, effectiveness, and cost to determine placement and tier assignment. Drug entries show a Drug Tier (Tier 1 = Preferred Generic; Tier 2 = Preferred Brand; Tier 3 = Non-preferred; Tier 4 = Specialty; MB = Medical Benefit) and any utilization controls in the Requirements/Limits column. The formulary is updated throughout the year; members will be notified by letter and updates posted online if a drug is removed or moved to a higher cost-sharing tier.

ref":"b0_0"}]},{

ref":"b4_0","citations":["8","9","3"],"paragraphs":["Key terms used in this formulary include: PA (Prior Authorization) — prior approval required before coverage; QL (Quantity Limit) — a limit on the amount covered per prescription or time frame (examples shown such as 18 per 30 days for zolmitriptan and many per-30-day or per-year thresholds); ST (Step Therapy) — another drug must be tried first before coverage of the requested drug; LA (Limited Access) — some drugs must be filled at an in‑network specialty pharmacy or via a specified channel; MB (Medical Benefit) — drugs administered in clinic/infusion or billed under the medical benefit; ACA PV (Affordable Care Act Preventive Medication) — ACA preventive coverage when USPSTF criteria met (examples and age ranges provided in the ACA PV guidance); and OCh (Oral Chemotherapy) — designation indicating some oral chemo may be covered under the medical plan. The Requirements/Limits column next to each drug shows these flags and any numeric thresholds (e.g., QL (60 per 30 days), 900 MILLILITERS PER MONTH, etc.)."]},{

ref":"b5_0","citations":["5","2"],"paragraphs":["Q: Will the Formulary Drug List change? A: Yes. The formulary is updated throughout the year; if a drug is removed or moved to a higher cost sharing tier members will be notified by letter and changes are posted on the payer website’s 'Drug list Changes' page.","Q: How are drugs selected for the list? A: An independent Pharmacy & Therapeutics Committee of physicians, pharmacists and other providers reviews and selects drugs based on safety, effectiveness, and cost. The committee meets at least quarterly to review new drugs and updated evidence for existing drugs to determine placement on the formulary."]},{

ref":"b6_0","citations":["2","6","7"],"paragraphs":["The P&T Committee’s rationale centers on review of drug safety, effectiveness, and cost when considering inclusion and tier placement. The committee meets at least quarterly to review new market entrants and updated safety/effectiveness/cost information for existing drugs to keep the list current. Utilization management decisions (PA, QL, ST, LA, MB, ACA PV) are applied per-product as indicated in the Requirements/Limits column; numeric thresholds and limits are stated item-by-item (for example, multiple entries list QL thresholds such as 60 per 30 days, 120 per 30 days, or volume limits like 60 MILLILITERS PER MONTH). Providers and members should follow member booklet and plan procedures for PA submissions and for exceptions to QL/LA/ST controls."}]}

General Formulary Coverage Rules

Covered drugs appear on the formulary and may be subject to the following constraints:

Member contract & inclusion: Drug coverage is based on the member's coverage contract and member booklet; inclusion on this list indicates inclusion on the plan's formulary.
See member booklet for plan-specific coverage and cost-sharing.
Age Limits (AGE): Some drugs have Age Limits: prescription covered if patient age is within specified range.
Examples and explanation in formulary 'Are there any restrictions on my coverage?' section.
Prior Authorization (PA): Some drugs require Prior Authorization: provider must obtain prior approval before coverage; without approval drug may not be covered.
Definition and process described in the formulary and 'Drugs Requiring Approval' guidance.

Requirements & Limits (Per-item)

Requirements / Limits entries (per-item)

Each listed product includes a 'Requirements / Limits' field indicating utilization controls; examples below show the exact per-item constraints as stated in the formulary.

Per-item Requirements / Limits examples

AQNEURSA ORAL GRANULES IN PACKET 1 GRAM — Requirements / Limits = PA; QL (120 per 30 days).QL (120 per 30 days)
Also listed Drug Tier = 4 in source.
CYSTAGON ORAL CAPSULE 150 MG, 50 MG — Requirements / Limits = PA.
ELMIRON ORAL CAPSULE 100 MG — Requirements / Limits = PA.
VELPHORO ORAL TABLET, CHEWABLE 500 MG — Requirements / Limits = PA.

Applicable Codes & Drug List (partial)

Listed Drugs with Tier and Requirements (partial list in this part)mixed

griseofulvin ultramicrosize oral tablet 125 mg	Drug Tier = 3. Requirements / Limits = .
griseofulvin ultramicrosize oral tablet 250 mg	Drug Tier = 3. Requirements / Limits = .
posaconazole oral suspension 200 mg/5 ml (40 mg/ml)	Drug Tier = 3. Requirements / Limits = .
posaconazole oral tablet, delayed release (dr/ec) 100 mg	Drug Tier = 3. Requirements / Limits = .
voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)	Drug Tier = 3. Requirements / Limits = .
acyclovir oral suspension 200 mg/5 ml	Drug Tier = 1. Requirements / Limits = .
acyclovir oral tablet 400 mg	Drug Tier = 1. Requirements / Limits = .
acyclovir oral tablet 800 mg	Drug Tier = 1. Requirements / Limits = .
adefovir oral tablet 10 mg	Drug Tier = 1. Requirements / Limits = .
amantadine hcl oral capsule 100 mg	Drug Tier = 1. Requirements / Limits = .

1–10 of 80

1/8

Provider Requirements & Billing Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for many listed products and select biologics and oral agents. Providers must request prior authorization where noted on the drug list; without approval the drug may not be covered.

Prior Authorization required where noted on the formulary/drug list
Prior authorization required for many biologics and select oral agents
Prior authorization required for PA-designated drugs and for specified/selected products and agents
PA + LA required for growth hormones and interferons

Billing Rule

Medical Benefit Drugs

Some drugs are covered under the medical benefit rather than the pharmacy benefit. These medical benefit (MB) drugs are typically administered in a clinic, infusion center, or via home infusion and may have separate billing rules.

Revision History

2026-05-25effectiveLatest

Policy effective; current formulary extract (part 1 of 10)

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Formulary Drug List

Policy CodePolicy 052146

Change TypeN/A

Effective Date052146 (05-25-2026)

Next Review Date

Key ActionProviders must verify member contract/benefit and refer to member booklet for plan-specific coverage and cost-sharing; inclusion on this list does not override member benefit rules.

SourceLink

On This Page

Quantity Limits (QL): Quantity Limits: quantity limited per prescription or time frame (examples given such as 18 per 30 days for zolmitriptan).

Specific QL thresholds are listed per-product in the Requirements / Limits column.

Step Therapy (ST): Step Therapy: another drug must be tried first before this drug will be covered.

ST explanation and examples are in the 'Are there any restrictions on my coverage?' section.

ACCRUFER ORAL CAPSULE 30 MG — Requirements / Limits = PA.

AQNEURSA tier/QL note: AQNEURSA entry also shows Drug Tier = 4 and QL (120 per 30 days).QL (120 per 30 days)

mirabegron ST: mirabegron oral tablet extended release 24 hr 25 mg, 50 mg — Requirements / Limits = ST.

Exact wording from product listing.

fluoride / ACA: fluoride (sodium) oral drops/tablets and certain multivitamin fluoride products — Requirements / Limits = ACA.

ACA preventive designation shown in product entries.

Medical Benefit drugs (MB) — covered under medical not pharmacy benefit
Check member booklet for medical vs pharmacy coverage specifics
Examples in list denoted as 'MB' (medical benefit)

Step Therapy

Step Therapy Requirements

Step therapy requirements apply to select agents. Providers must document trials of required first-line agents before coverage will be approved for step-therapy-designated drugs.

Step therapy enforced for select agents (ST applies where noted)
Step therapy applies — try required alternative(s) before approval
Step therapy requirements and enforced exceptions must be documented

Billing Rule

Limited Access (LA) / Specialty Pharmacy

Limited Access (LA) drugs may be restricted to an in-network specialty pharmacy or be subject to limited distribution. These products often require special handling, provider coordination, or patient education.

Limited Access (LA) specialty pharmacy fill required where noted
Limited distribution / LA designation — fill only at designated in-network specialty pharmacy
Limited/LA or ACA flags require documentation of site-of-care or special program enrollment

Documentation Required

Quantity Limits Enforcement

Quantity limits (QL) are enforced for many drugs. Providers should ensure prescriptions and claims adhere to the specified limits; documentation may be required to support overrides.

Quantity limits enforcement is active — QL specified on formulary
Quantity limits (QL) specified (e.g., AQNEURSA has a defined quantity limit)
Quantity-limit documentation required to request exceptions or higher quantities
Quantity limits enforced for multiple agents listed on the formulary

Billing Rule

Site-of-Care / Specialty Designation

Site-of-care and specialty designations affect where and how a drug is provided. Oral chemotherapy (OCh) and other specialty-designated items may be covered under medical benefit depending on plan language.

Site-of-care / specialty designation (LA / OCh) noted on the drug list
Oral Chemo (OCh) designation — certain oral chemotherapy drugs may be covered under medical benefit
Limited distribution or site-of-care restrictions require following member booklet and specialty pharmacy processes

Documentation Required

Documentation Requirements

Documentation is required for prior authorization, limited-access (LA) or ACA-designated fills, quantity-limit exceptions, and step-therapy exceptions. Providers should follow the member booklet and the 'Drugs Requiring Approval' page for submission requirements.

Limited/LA or ACA flags require documentation
Quantity-limit documentation required for QL overrides
Follow member booklet and 'Drugs Requiring Approval' web page for required documentation and submission process