CurrentPremera BluecrossPolicy N/A

formulary_drug_list_details

This document is a formulary drug list describing covered drugs, tiers (1-4), utilization management restrictions (PA, QL, ST, age limits, specialty, limited access, vaccine codes, oral chemo), and lists numerous anti-infective drugs with associated drug tiers and any requirements/limits. It is part 1 of 18 and contains introductory material, coverage/abbreviation explanations, and the anti-infectives, antifungals, antivirals, cephalosporins, macrolides, and miscellaneous anti-infectives sections.

Policy Summary

PayerPremera Bluecross

Policyformulary_drug_list_details

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must obtain prior authorization for drugs flagged 'PA' before the prescription will be covered.

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this update.

4Formulary tiers described

PA, QL, STUtilization management flags present

multiplePrior auth required (PA) occurrences

multipleAnti-infective entries (part)

oncology & neurologyTherapeutic focus

Formulary summary & scope

Coverage criteria & general rules

Covered when meeting plan contract and any utilization management restrictions listed next to drug name:

ALL of the following

Drug is included on the member's applicable formulary/drug list and the prescription is consistent with the member's benefit plan and coverage contract.
Any utilization management requirements shown in the Requirements/Limits column (for example: PA, QL, ST, LA, SP, OCh, OPT) have been satisfied prior to dispensing.
Coverage is subject to applicable member cost sharing, deductibles, and out-of-pocket maximums as described in the member booklet.
When a drug has age limits, the prescription is covered only if the patient's age falls within the specified age range.

Policy Summary

PayerPremera Bluecross

Policyformulary_drug_list_details

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must obtain prior authorization for drugs flagged 'PA' before the prescription will be covered.

On This Page

Certain drugs are covered in full when meeting ACA/age criteria:

ANY of the following

Bowel preparation agents (example: polyethylene glycol 3350 with electrolytes oral solution) — covered for persons 45 through 75 years; limited to 2 prescriptions per year.
Breast cancer prevention agents (tamoxifen, raloxifene, anastrozole, exemestane, letrozole, Soltamox liquid) — covered in full for persons 35 years or older when USPSTF/ACA criteria are met.
Fluoride — covered in full for persons 6 months through 16 years of age when meeting preventive coverage criteria.
Smoking cessation aids (example: nicotine patches) — covered in full for persons 18 years or older; limited to 180 days per year when meeting ACA/USPSTF criteria.
Statins (example: atorvastatin) — covered in full for persons 40 through 75 years when meeting USPSTF/ACA preventive criteria.

Each listed product includes associated Drug Tier and Requirements Limits indicating coverage constraints.

ANY of the following

Representative formulary entries include: ANCOBON (oral capsule) — Drug Tier 3; Requirements/Limits: see formulary (may include PA).
BREXAFEMME (oral tablet 150 mg) — Drug Tier 3; Requirements/Limits: PA; QL (24 per 180 days).
clotrimazole mucous membrane troche 10 mg — Drug Tier 1; Requirements/Limits: none listed.
NOXAFIL oral suspension/delayed release formulations — Drug Tier 3; Requirements/Limits: PA for certain strengths/forms.
ketoconazole oral tablet 200 mg — Drug Tier 1; Requirements/Limits: none listed.

Drug groups, tiers and requirement flags (selected excerpts)

Drug tiers (examples)mixed

Tier 1	Generic (lowest cost-sharing)
Tier 2	Preferred Brand
Tier 3	Non-Preferred Brand
Tier 4	Specialty (may require specialty pharmacy)

Utilization management abbreviationsmixed

PA	Prior Authorization - approval required before fill
QL	Quantity Limit - limits on amount covered per time period
ST	Step Therapy - require trial of preferred agent(s) first
LA	Limited Access - restricted distribution or specialty pharmacy required
SP	Specialty Pharmacy - may require fill at specialty pharmacy
VAC	Vaccine - vaccine coverage rules may apply
OCh	Oral Chemotherapy - may be covered under medical benefit
OPT	Optional Benefits - coverage varies by plan

Drugs with Prior Authorization (PA)mixedCovered

APRETUDE INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE 600	Long-acting HIV pre-exposure prophylaxis injection
CABENUVA INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE 400 MG/2 ML - 600 MG/2 ML, 600 MG/3 ML - 900 MG/3 ML	Long-acting HIV treatment injection
BEYFORTUS INTRAMUSCULAR SYRINGE 100 MG/ML, 50 MG/0.5 ML	RSV monoclonal antibody
VIVJOA ORAL CAPSULE 150 MG	Cardiac medication (select indications)
SIRTURO ORAL TABLET 100 MG, 20 MG	Bedaquiline for resistant tuberculosis

Drugs with Quantity Limits (QL)mixedCovered

BREXAFEMME ORAL TABLET 150 MG	QL: 24 per 180 days (example)
PAXLOVID ORAL TABLETS, DOSE PACK 150 MG (10) - 100 MG (10)	Antiviral with specified course dosing; QL applies
TOBI INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML	Inhaled aminoglycoside; QL per benefit
TOBI PODHALER INHALATION CAPSULE, INHALATION DEVICE 28 MG	QL per benefit
ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML	May have QL/dispense limits

Drugs with Step Therapy (ST)mixedCovered

ORA VIG MUCO-ADHESIVE BUCCAL TABLET 50 MG	ST - requires trial of alternatives prior to approval
NOXAFIL ORAL SUSP, DELAYED RELEASE FOR RECON 300 MG	ST/PA in some indications
EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG	Hepatitis C regimens may require prior therapies or PA
HARVONI ORAL TABLET 45-200 MG, 90-400 MG	Hepatitis C regimen; step/PA rules possible

Drugs with Specialty (SP) / Limited Access (LA)mixedCovered

APRETUDE INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE 600	SP/LA - specialty administration and limited distribution
CABENUVA INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE 400 MG/2 ML - 600 MG/2 ML, 600 MG/3 ML - 900 MG/3 ML	SP/LA - specialty provider coordination required
BEYFORTUS INTRAMUSCULAR SYRINGE 100 MG/ML, 50 MG/0.5 ML	SP - administered in clinic
PAXLOVID ORAL TABLETS, DOSE PACK 150 MG (10) - 100 MG (10)	Oral antiviral; may be filled at retail but with QL/PA per plan
Biktarvy ORAL TABLET 30-120-15 MG, 50-200-25 MG	Antiretroviral regimen often managed through specialty pharmacy

Representative selected formulary entries (consolidated examples)mixed

ANCOBON ORAL CAPSULE 250 MG, 500 MG	Antimalarial/antiprotozoal agent
BREXAFEMME ORAL TABLET 150 MG	Antifungal for vulvovaginal indications; PA; QL 24/180 days
clotrimazole mucous membrane troche 10 mg	Antifungal - Tier 1
NOXAFIL ORAL SUSP, DELAYED RELEASE FOR RECON 300 MG	Posaconazole suspension - PA
ORA VIG MUCO-ADHESIVE BUCCAL TABLET 50 MG	Antifungal buccal tablet - ST
VIVJOA ORAL CAPSULE 150 MG	Cardiology agent - PA
APRETUDE INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE 600	Long-acting HIV prevention - SP/PA
CABENUVA INTRAMUSCULAR SUSPENSION, EXTENDED RELEASE (various strengths)	Long-acting HIV therapy - SP/PA
BARACLUDE ORAL SOLUTION 0.05 MG/ML	Antiviral for hepatitis B
BARACLUDE ORAL TABLET 0.5 MG, 1 MG	Antiviral for hepatitis B

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OpenPayer

formulary_drug_list_details

Formulary summary & scope

Coverage criteria & general rules

Key abbreviations and definitions

Drug groups, tiers and requirement flags (selected excerpts)

What providers must do

Quantity limits (examples) and notable thresholds

Selected formulary excerpts (anti-infectives & others)

Devices, diabetes supplies and DME highlights

Document changes & timeline