drug_list_document
Partial extract (part 1 of 18) of Premera Bluecross drug list describing formulary organization, utilization management abbreviations (PA, ST, Q/QL, SP, LA, NP, ACA PV), and an alphabetical listing of covered drugs with tiers and requirement/limit flags. Governs coverage categorization, prior authorization, quantity limits, step therapy, specialty pharmacy and limited access designations; providers must follow member booklet for plan-specific cost sharing and benefit details.
No material clinical or coverage changes reported in this extract of the formulary.
Formulary coverage overview
This document contains the list of covered drugs for Premera Bluecross and summarizes how coverage, tiering, and utilization management are applied. Covered drugs will be subject to your plan’s cost-sharing (deductible, coinsurance/copay, and out-of-pocket maximum) and any applicable utilization management requirements described on the drug list. Tiering: Generic = Tier 1 (lower cost share); Brand = Tier 2. Utilization management types: Prior Authorization (PA) — approval required before coverage; Quantity Limits (Q/QL) — limits on amount or frequency; Step Therapy (ST) — required trial of specified medications first; Specialty Pharmacy (SP) — certain drugs limited to specialty pharmacy with additional support; Limited Access (LA) — required dispensing at specific in-network pharmacy.
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