CurrentPremera BluecrossPolicy 052148_2025

Formulary / Open (A1) and Preferred (A2) Drug List (Part 1)

Part 1 of Premera Blue Cross formulary drug list describing how to use the drug list, formulary development process, coverage abbreviations, tier definitions (A1/A2), utilization management restrictions (PA, QL, ST, SP, HCLV, LA), ACA preventive items, specialty pharmacy rules, and an extensive listing of drugs with tiers and requirements/limits for each product in this section.

Policy Summary

PayerPremera Bluecross

PolicyFormulary / Open (A1) and Preferred (A2) Drug List (Part 1)

Policy CodePolicy 052148_2025

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization (PA) before dispensing any drug row marked 'PA'; claims may be denied without approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — has_material_change=false in the brief.

200+Drugs listed in this part (approx.)

PA/QL/ST/SP/LACommon utilization restrictions

A1/A2Formulary lists covered

manyPA-flagged entries

numerousNon-preferred (NP) entries

Coverage Summary

Provider Actions & Utilization Management

Note

Applicable Codes and Formulary Entries

Listed Drugs and Tiers (anti-infectives, antifungals, antivirals, antibiotics)mixed

ANCOBON ORAL CAPSULE 250 MG	Tier 2; Requirements: NP
ANCOBON ORAL CAPSULE 500 MG	Tier 2; Requirements: NP
BREXAFEMME ORAL TABLET 150 MG	Tier 2; Requirements: PA; QL (24 Tablets per 180 days); NP
clotrimazole mucous membrane troche 10 mg	Tier 1
CRESEMBA ORAL CAPSULE 186 MG	Tier 2; Requirements: PA
CRESEMBA ORAL CAPSULE 74.5 MG	Tier 2; Requirements: PA
DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML	Tier 2; Requirements: NP
fluconazole oral suspension for reconstitution 10 mg/ml	Tier 1
fluconazole oral suspension for reconstitution 40 mg/ml	Tier 1
fluconazole oral tablet 50 mg	Tier 1

1–10 of 38

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Policy Summary

PayerPremera Bluecross

PolicyFormulary / Open (A1) and Preferred (A2) Drug List (Part 1)

Policy CodePolicy 052148_2025

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization (PA) before dispensing any drug row marked 'PA'; claims may be denied without approval.

SourceLink

On This Page

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General Coverage Restrictions

General Coverage Restrictions and Utilization Management

Covered drugs may have specific utilization management restrictions and limits. These restrictions—listed in the Requirements/Limits column of the formulary—may include age limits, prior authorization, quantity limits, step therapy, and other special requirements. Where multiple restrictions apply, any one may affect coverage (operator = any). When a restriction applies, the prescribing provider may need to supply additional clinical information before the drug will be covered.

Age Limits: Some drugs are limited to certain ages consistent with FDA indications or clinical guidance. Coverage is contingent on the patient meeting the specified age range.

Prior Authorization (PA): Some drugs require prior authorization before coverage. Without prior approval, the drug may not be covered.

Quantity Limits (QL): The plan may limit the amount of a drug covered per prescription or within a defined time frame (for example, X units per 30 days).

Step Therapy (ST): Some drugs require trial of one or more specified agents first. The drug will be covered only if prior required agents are ineffective, not tolerated, or contraindicated.

Other Special Requirements for Coverage: Additional conditions may apply (for example, specialty pharmacy fill requirements, prior documentation of diagnosis, or site-of-care restrictions).

Open (A1) / Preferred (A2) Formulary Rules

The Open (A1) and Preferred (A2) formulary designations determine which drug list applies to your plan and how medical deductibles and cost sharing apply. The following rules apply to routing and member cost responsibilities. All of the following must be considered when determining member cost-share and routing (operator = all).

If you are enrolled in a high-deductible health plan (HSA-eligible), reference the Open (A1) drug list. For covered drugs under A1, medical deductible applies; after the deductible is met, applicable coinsurance applies until the out-of-pocket maximum is reached.

If you are enrolled in a PPO plan, reference the Preferred (A2) drug list.

Drugs on both A1 and A2 are assigned to tiers: Generic (Tier 1) and Brand (Tier 2). Member cost share is based on tier, plan design, and whether deductibles or out-of-pocket maximums have been met.

Formulary routing guidance (plan-specific): check member ID card and plan documents to confirm whether A1 or A2 list applies; contact customer service at 800-722-1471 (TTY:711) for plan routing questions.

Formulary product entries and Requirements/Limits

Formulary product entries include the drug name, Drug Tier, and Requirements/Limits. The Requirements/Limits field will fully represent utilization management applied to that product (consolidated, not duplicated).

Each formulary product row identifies Drug Tier (e.g., 1 = Generic, 2 = Brand) and any applicable abbreviations (PA, QL, ST, AGE, NP, HCLV, LA, SP, OCh, OPT) in the Requirements/Limits column.

Examples of Requirements/Limits used in formulary entries: PA (Prior Authorization required); QL (Quantity Limit — e.g., 24 per 180 days); AGE (age range specified in the formulary); ST (Step Therapy required); NP (Not Preferred or requires non-preferred routing as defined by plan); HCLV (High-Cost Low Value — lower-cost alternatives required where available); LA (Limited Access — specialty pharmacy or limited distribution); SP (Specialty Pharmacy dispensing required); OCh (Oral Chemotherapy — may be subject to medical benefit rules); OPT (Optional/Excluded benefit categories such as ED, fertility, weight management where plan-specific exclusions apply).

When a product’s Requirements/Limits shows multiple restrictions, all listed restrictions apply as specified (do not assume any are optional). For example, an entry reading "PA; QL (24 per 180 days)" requires prior authorization and imposes the stated quantity limit.

Provider/Billing note: Prescribers must supply clinical justification and documentation for PA and other special requirements where requested. Failure to supply requested information may result in claim denial or non-coverage.

OpenPayer

Formulary / Open (A1) and Preferred (A2) Drug List (Part 1)

Coverage Summary

Provider Actions & Utilization Management

Applicable Codes and Formulary Entries

General Coverage Restrictions

Formulary Product Entries (sampled highlights)