Metallic (M4) Formulary Drug List

Coverage Summary

General formulary coverage rules and restrictions

Drugs are covered per plan contract and may be subject to the following restrictions; coverage applies when applicable conditions are met:

Coverage basis: Drug coverage is based on the member's coverage contract and member booklet; inclusion on the formulary indicates coverage subject to plan rules.
Prior Authorization (PA): Some drugs require prior authorization (PA) before coverage; providers must obtain PA when 'Requirements / Limits = PA' is indicated.
See 'Drugs Requiring Approval' webpage for PA process.
Quantity Limits (QL): Some drugs have quantity limits specified as units per time period (e.g., 60 per 30 days, 120 per 30 days, 1 per 365 days); prescriptions exceeding listed QL may not be covered.
Examples and specific QL values are given per drug in the list.
Step Therapy (ST): Some drugs have step therapy requirements: member must try required drug(s) first (ST) before coverage of an alternative drug will be allowed.
ST-coded products listed in the formulary require documented prior steps.
Age limits (AGE): Some drugs are limited to specified ages (AGE) per FDA indications; coverage applies when the patient is within the allowed age range.
Age restrictions shown in Requirements/Limits column where present.
Limited Access (LA): Some drugs are Limited Access (LA) and may require dispensing at a specialty in-network pharmacy or have restricted distribution; LA items often require provider coordination.
LA indicates specialty distribution or restricted handling.
Medical Benefit (MB): Some drugs are covered under the medical benefit (MB) — usually clinic/infusion-administered products — rather than the pharmacy benefit.
MB-designated items list site-of-care considerations.

Drug coverage requirements summary

Each listed drug has associated Requirements / Limits codes which indicate coverage constraints:

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How to use codes: Providers must obtain PA where 'PA' is indicated; claims are processed against listed QL values and step therapy edits; LA/MB designations change dispensing or benefit pathway.

See 'Drugs Requiring Approval' page and member booklet for operational details.

Scope: Formulary drug list for Premera Blue Cross Metallic (M4) plans (excludes American Indian/Alaskan Native eligible plans with zero cost shares). Effective date: 2026-05-01. The list includes covered generic, brand, specialty and medical-benefit drugs with tier assignments and utilization management restrictions. Formulary maintenance: the independent Pharmacy and Therapeutics Committee meets at least quarterly and the list is updated throughout the year; members are notified of removals or tier changes and upcoming changes are posted on the plan website.

Definitions & Background

The formulary is developed by an independent Pharmacy and Therapeutics Committee of physicians, pharmacists and other healthcare providers that reviews drugs for safety, effectiveness and cost; the committee meets at least quarterly to review new drugs and update placements on the list.

Term	Definition
PA
Prior Authorization - requirement to get approval prior to filling.
QL
Quantity Limit - limit on amount covered per prescription or time frame.
ST
Step Therapy - requirement to try specified drugs first.
AGE
Age limit - coverage limited to specified ages.
LA
Limited Access - may require specialty pharmacy or restricted distribution.
MB
Medical Benefit - drug covered under medical benefit (clinic/infusion).
ACA PV
Affordable Care Act Preventive Medication - no cost when USPSTF A or B applies and other listed preventive coverage rules.
ACA
Affordable Care Act preventive or related designation (as used in formulary context)
Och
Oncology designation

Provider Actions & Operational Requirements

Prior Authorization

Prior Authorization Required

Obtain prior authorization when required. Many drugs on this formulary require prior authorization (PA) before we will cover them. Prior authorization is required for certain high-cost, specialty, limited access (LA), medical-benefit (MB) and oncology-designated (OCh) products. Providers must submit clinical information to support medical necessity when requesting PA. See the 'Drugs Requiring Approval' page for full PA submission instructions.

Prior authorization required for select specialty and high-cost agents (examples: EPCLUSA, HARVONI, TRIKAFTA, TYVASO) when indicated by the formulary.
Prior authorization may be required for specified biologics and high‑tier agents.
PA required for listed products designated LA, LA/MB, or OCh on the drug list.

Documentation Required

Provide Clinical Information for Restricted Drugs

Applicable Codes & Drug Examples

Tier definitions (informational)mixed

Tier 1	Preferred Generic
Tier 2	Preferred Brand
Tier 3	Non-preferred
Tier 4	Specialty / Medical Benefit (MB)

Examples: Drugs with PA (Prior Authorization)NDC

PAXLOVID ORAL TABLETS, DOSE PACK	NDC listed examples — prior authorization may apply
BIKTARVY ORAL TABLET	Antiretroviral — prior authorization
IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG	Oral oncology — PA likely
INLYTA ORAL TABLET 1 MG, 5 MG	Kinase inhibitor — PA
JAKAFI ORAL TABLET (5-25 MG strengths)	Janus kinase inhibitor — PA
KISQALI ORAL TABLET (200-600 MG/DAY)	CDK4/6 inhibitor — PA
LENALIDOMIDE (REVLIMID) ORAL CAPSULE (multiple strengths)	Immunomodulatory — PA and REMS
LENVIMA ORAL CAPSULE (multiple dosing regimens)	Multi-kinase inhibitor — PA
LUKCEZUE ORCL?	(placeholder)

Examples: Drugs with QL (Quantity Limits)NDC

cefuroxime axetil oral tablet 250 mg, 500 mg	Antibiotic — quantity limits per course
letrozole oral tablet 2.5 mg	Breast cancer prevention/therapy — QL may apply
tamoxifen oral tablet 10 mg, 20 mg	Breast cancer prevention/therapy — QL
metformin oral tablet	Example generic with standard QL rules

Examples: LA/MB (Limited Access / Medical Benefit)mixed

Gleostine ORAL CAPSULE 10 MG, 40 MG, 100 MG	Oral chemotherapy — may be covered under medical benefit (MB) or limited access
lomustine oral capsule 10 mg, 40 mg, 100 mg	Oral chemotherapy — MB or LA
MATULANE ORAL CAPSULE 50 MG	Procarbazine — oral chemo MB
LEUKERAN ORAL TABLET 2 MG	Chlorambucil — oral chemo MB
LYSODREN ORAL TABLET 500 MG	Mitotane — oral chemo MB
TRETINOIN (ANTINEOPLASTIC) ORAL CAPSULE 10 MG	Oral retinoid for oncology — MB

Medical Benefit drugs (examples)mixed

octreotide acetate injection forms	Injectable somatostatin analog — typically medical benefit
SIMULECT INTRAVENOUS RECON SOLN 10 MG, 20 MG	Induction immunosuppressant — medical benefit
epoprostenol intravenous recon soln 0.5 mg, 1.5 mg	Pulmonary hypertension infusion — MB
SC/IV biologics (e.g., ENTYVIO PEN SUBCUTANEOUS PEN 108 MG/0.68 ML)	Examples of medical/administration benefit items

Products with ST (Step Therapy)NDC

MEKINIST ORAL (SOLUTION & TABLETS)	MEK inhibitor — step therapy may apply
MEKTOVI ORAL TABLET 15 MG	BRAF/MEK combination agent — ST possible
TAGRISSO ORAL TABLET 40 MG, 80 MG	EGFR inhibitor — ST criteria
TAFINLAR (capsule/tablet) 10-75 MG	BRAF inhibitor — ST for combination use

ACA-designated products (preventive)mixedCovered

tamoxifen oral tablet 10 mg, 20 mg	Breast cancer prevention — ACA preventive coverage when criteria met
letrozole oral tablet 2.5 mg	Breast cancer prevention in specified ages per ACA guidance
fluoride oral formulations	Pediatric preventive fluoride coverage per ACA/USPSTF guidance

Other major categorized drugs — oncology & targeted agentsNDC

KOMZIFTI ORAL CAPSULE 200 MG	Kinase inhibitor — coverage with criteria
lapatinib oral tablet 250 mg	HER2 inhibitor — oncology
LAZCLUZE ORAL TABLET 80 MG, 240 MG	Targeted oncology therapy — coverage with management
lenalidomide oral capsule (multiple strengths)	See REVLIMID — REMS and PA
letrozole oral tablet 2.5 mg	Aromatase inhibitor
MEKTOVI ORAL TABLET 15 MG	MAPK pathway inhibitor
nilotinib hcl oral capsule (50-200 mg)	BCR-ABL inhibitor
NINLARO ORAL CAPSULE (2.3-4 MG)	Proteasome inhibitor — specialty
ORSERDU ORAL TABLET 86 MG, 345 MG	Prostate cancer therapy — specialty
pazopanib oral tablet 200 mg	VEGF inhibitor

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Hematology / immunomodulatorsNDC

lenalidomide oral capsule (multiple strengths)	REVLIMID — REMS, PA
pomalidomide oral capsule (1-4 MG)	POMALYST — REMS, PA
THALOMID ORAL CAPSULE 50 MG, 100 MG	Thalidomide — REMS, PA
mercaptopurine oral tablet 50 mg	Antimetabolite — coverage with limits
methotrexate sodium injection/solution and oral tablet 2.5 mg	Disease-modifying — dosing/PA rules
mycophenolate mofetil/sodium oral forms	Immunosuppressant — monitoring
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg	Immunosuppressant — therapeutic monitoring

Neurology / antiseizure medicationsNDC

clobazam oral suspension/tablet	Benzodiazepine for seizures — coverage rules
clonazepam (multiple forms)	Seizure/Anxiety — controlled med rules
diazepam rectal kit	Rescue kit — coverage
DILANTIN ORAL CAPSULE 30 MG	Phenytoin — antiseizure
divalproex (various forms)	Anticonvulsant/mania — QL/PA as applicable
gabapentin (capsules, solution, tablets)	Neuropathic pain/seizures
lamotrigine (various forms)	Antiseizure — pediatric dosing noted
levetiracetam (solutions & tablets)	Antiseizure — includes IV/PO forms
NAYZILAM NASAL SPRAY 5 MG/SPRAY	Benzodiazepine nasal spray for seizure clusters
VALTOCO & NAYZILAM nasal sprays	Rescue therapies — coverage details

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Pain, opioid and controlled substancesNDC

acetaminophen-codeine (various forms)	Opioid combination analgesics — controlled prescribing rules
buprenorphine (sublingual, transdermal)	Opioid use disorder and pain — specialized coverage
butalbital-containing products	Limitations due to abuse potential
fentanyl transdermal patch (various mcg/hr)	Opioid patch — controlled prescribing
hydrocodone ER capsules	Extended-release opioid — PA/QL rules
hydromorphone, morphine, oxycodone (many forms)	Opioids — monitoring and limits
methadone products	Opioid treatment and pain — specific coverage pathways
oxymorphone (IR & ER)	High-risk opioids — limits
buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg	OUD treatment formulations

CNS stimulants & wakefulness agentsNDC

lisdexamfetamine oral capsule 10-70 mg	ADHD stimulant — QL/PA as applicable
SUNOSI ORAL TABLET 75 MG	Solriamfetol — excessive daytime sleepiness
SUNOSI ORAL TABLET 150 MG	Higher strength solriamfetol

Multiple sclerosis & neurology specialty agentsNDC

dimethyl fumarate oral capsule, dr/ec 120 mg - 240 mg	MS therapy — specialty
glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml	MS injectables — specialty/PA
PLEGRIDY and REBIF presentations	Interferon formulations listed with multiple syringe/pen strengths
teriflunomide oral tablet 7 mg, 14 mg	MS oral therapy
VUMERITY ORAL CAPSULE 231 MG DR/EC	Diroximel fumarate — specialty

Biologics, injectables & vaccines (examples)mixed

CIMZIA SUBCUTANEOUS SYRINGE KIT 200 MG/ML	Biologic — specialty benefit
ENTYVIO PEN SUBCUTANEOUS PEN 108 MG/0.68 ML	IBD biologic — injectable specialty
INFLECTRA INTRAVENOUS RECON SOLN 100 MG	Infliximab biosimilar — medical benefit
TENIVAC, TICOVAC, TRUMENBA, VAXELIS, VARIVAX, VAQTA, VAXNEUVANCE	Vaccine presentations included per schedule

Endocrine, metabolic, and thyroid therapiesNDC

ARMOUR THYROID ORAL TABLET (15-300 MG)	Thyroid replacement — multiple strengths
donepezil, galantamine, memantine, rivastigmine	Cognitive agents for dementia

Gastroenterology, motility & supportive agentsNDC

LINZESS ORAL CAPSULE (72,145,290 MCG)	Irritable bowel syndrome/constipation agent
MOVANTIK ORAL TABLET 12.5 MG, 25 MG	OIC treatment — specialty
PRUCALOPRIDE ORAL TABLET 1 MG, 2 MG	Chronic constipation agent

Respiratory & inhaled therapies (examples)NDC

TYVASO DPI inhalation cartridge	Inhaled prostacyclin for pulmonary hypertension
TRELEGY ELLIPTA	Combination inhaled COPD/asthma therapy

Cardiology & antiarrhythmicsNDC

flecainide oral tablet 50/100/150 mg	Antiarrhythmic
mexiletine oral capsule 150/200/250 mg	Ventricular arrhythmia agent
pacerone oral tablet 100 mg, 200 mg	Amiodarone — specialty monitoring

Diabetes and GLP-1/GIP agentsNDC

TRIJARDY XR ORAL TABLET	Combination antihyperglycemic — various biphasic strengths
TRULICITY SUBCUTANEOUS PEN (multiple strengths)	GLP-1 RA injectable presentations
XIGDUO XR ORAL TABLET (various strengths)	SGLT2 + metformin combination

Miscellaneous therapeutics & supportive careNDC

CREON ORAL CAPSULE (many unit sizes)	Pancreatic enzyme replacement — multiple sizes
APREPITANT ORAL CAPSULE (various strengths & dose pack)	Antiemetic — includes dose packs
CLENPIQ ORAL SOLUTION	Bowel prep
CHOLBAM ORAL CAPSULE 250 MG, 50 MG	Bile acid therapy

Quantity Limits & Thresholds

Quantity limits (QL) are enforced per the formulary and specific per-drug QL values are listed in the drug tables. Examples of listed thresholds include QL = 60 per 30 days for many products, QL = 120 per 30 days, QL = 1 per 365 days, and product-specific volumetric limits such as 84 milliliters per month for certain inhalation solutions.

Name	Value
abacavir oral solution 20 mg/ml
60 mL per month
lamivudine oral solution 10 mg/ml
900 mL per month
zidovudine oral syrup 10 mg/ml
960 mL per month
CAYSTON inhalation solution for nebulization 75 mg/ml
84 mL per month
PAXLOVID oral tablets, dose pack
QL (40 per 90 days)
XIFAXAN oral tablet 200 mg, 550 mg
QL (60 per 30 days)
Many ARV tablets (examples: BIKTARVY, TRIUMEQ, tenofovir, emtricitabine)
Common QL: 30 per 30 days (per product listing)
ritonavir oral tablet 100 mg
QL (360 per 30 days)
APREVIT/APREPITANT (examples)
APREPITANT QL: 125/40 mg = 1 per 30 days; 80 mg = 2 per 30 days
APITVIR/APTIVUS
QL (120 per 30 days) for APTIVUS
TIVICAY oral tablet 50 mg
QL (60 per 30 days)
TRIUMEQ oral tablet 600-50-300 mg
QL (30 per 30 days)
APREPITANT (dose pack) and LINZESS
LINZESS QL (30 per 30 days); APREPITANT QLs as above
BUprenorphine-naloxone sublingual film 12-3 mg
QL (60 per 30 days)
buprenorphine-naloxone sublingual film/tablet 2-0.5/4-1/8-2 mg
QL (90 per 30 days)
butorphanol nasal spray
QL (2 per 30 days)
ketorolac oral tablet 10 mg
QL (20 per 5 days)
lisdexamfetamine oral capsule
QL (30 per 30 days)
SUNOSI oral tablet 150 mg
QL (30 per 30 days)
SUNOSI oral tablet 75 mg
QL (60 per 30 days)
AVONEX IM syringe kit 30 mcg/0.5 mL
QL (1 per 30 days)
BETASERON subcutaneous kit 0.3 mg
QL (14 per 30 days)
dimethyl fumarate DR/EC 120 mg (some presentations)
QL (14 per 365 days) for certain packs; DR/EC 240 mg QL (60 per 30 days)
fingolimod oral capsule 0.5 mg
QL (30 per 30 days)
glatiramer products (20 mg, 40 mg)
QL (30 or 12 per 30 days depending on strength)
KESIMPTA subcutaneous pen 20 mg/0.4 mL
QL (1 per 30 days)
PLEGRIDY products
QL (2 per 30 days) or QL (1 per 365 days) for titration packs/starters as listed
REBIF products (various presentations)
QL (12 per 30 days) or QL (4.2 per 30 days) for titration packs
VUMERITY oral capsule (DR/EC) 231 mg
QL (120 per 30 days)
TRULICITY pens per month
4 pens per 30 days (per product listing)
VARUBI oral tablet 90 mg
2 tablets per fill
teriparatide subcutaneous pen injector 20 mcg/dose
QL (1 per 30 days)
dotti transdermal patch semiweekly
QL (8 per 30 days)
estradiol transdermal gel/patch
QL (gel 30 per 30 days; patch semiweekly 8 per 30 days; weekly 4 per 30 days)
OPILL oral tablet 0.075 mg
QL (28 per 28 days)
tiotropium bromide inhalation capsule 18 mcg
QL (30 per 30 days)
wixela inhub inhalation blister 100-50/250-50/500-50 mcg/dose
QL (1 per 30 days)
UMECLIDINIUM-VILANTEROL 62.5-25 MCG/actuation
QL (1 per 30 days)
TYVASO inhalation presentations (DPI/cartridge/solution/refill/starter)
Common QLs: DPI cartridges QL (1 per 30 days) or (1 per 365 days for some); nebulization dosing 2.9 mL per day; refill kit QL (81.2 per 30 days); starter kit QL (1 per 274 days)
zileuton ER 600 mg
ST; QL (120 per 30 days)
AQNEURSA oral granules in packet 1 gram
QL (120 per 30 days)
VELPHORO oral tablet chewable 500 mg
PA required (quantity limit noted elsewhere)

Clinical Evidence & Notes

No formal clinical-trial evidence entries were provided in the brief. High-level program implications: oncology-designated products (Och) listed on the formulary typically require documentation during prior authorization and many are limited access (LA) or require specialty coordination; providers should follow the PA and documentation instructions in the plan's approval process.

FAQs

Q: Will the Formulary Drug List change? A: Yes; it is updated throughout the year. Members taking a drug that will be removed or moved to a higher tier will be notified by letter; upcoming changes are posted on the plan website.

Q: How do I know if my drug has restrictions? A: The Requirements/Limits column beside each drug lists any age limits, PA, QL, ST, LA, MB designations; see the 'Drugs Requiring Approval' page for the prior authorization process.

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