CurrentPremera BluecrossPolicy N/A

Formulary Drug List (Essentials E1/E4) - Coverage Criteria

This document is Premera Blue Cross's Essentials formulary drug list describing covered generic, brand, and specialty drugs, tier placement, and utilization management requirements that apply to members and providers.

Policy Summary

PayerPremera Bluecross

PolicyFormulary Drug List (Essentials E1/E4) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a product is labeled PA; failure to obtain PA may result in denial of coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4drug tiers described

2Essentials lists referenced

≥1UM restriction types listed

severalentries marked EX

multipleentries with PA/QL/SP/LA flags

Coverage Criteria

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General coverage criteria

Covered when plan coverage and any listed utilization management requirements are met.

Coverage prerequisites: Drug is included on the member's plan drug list AND any applicable plan deductible/coinsurance/out-of-pocket rules have been satisfied

Tier placement affects cost sharing; see member booklet.

Utilization management: If the drug has requirements (PA, QL, Age limit, Step Therapy, SP, EX, LA), those must be satisfied for coverage

Examples: prior authorization obtained; quantity within QL; patient age within age limits; required step therapy agents tried and failed.

Some drugs are excluded from the Essentials formulary and are designated Drug Tier = EX. When a product is marked EX, it is not covered under the formulary and will be the member's responsibility to pay in full unless an exception is approved.

Examples of products marked EX in the listing include DELSTRIGO (Drug Tier = EX) and PIFELTRO (Drug Tier = EX). Entries with Drug Tier = EX indicate those products are excluded from coverage where the EX designation appears.

Multiple specific products are listed with Drug Tier = EX or otherwise shown as excluded. Examples from the formulary include ALINIA oral tablet 500 mg, certain AUGMENTIN XR presentations, and several doxycycline and minocycline extended‑release formulations that are flagged EX in the table.

The formulary also designates some high‑cost oncology and specialty agents as EX on specific lines. Examples shown include products such as AFINITOR DISPERZ, GLEEVEC, and IRESSA, which are marked EX in the Drug Tier field.

Several additional adjunctive and oncology agents are listed with Drug Tier = EX. Representative items include PHYRAGO, certain SANDOSTATIN injection presentations, and products such as SUTENT, TYKERB, VOTRIENT, and XELODA that appear as EX on one or more lines.

The document lists many branded products and kits with Drug Tier = EX (excluded or exception tier). Examples in the anti‑infective and adjunctive sections include branded kits (e.g., MORGIDOX kits), extended‑release tetracycline/minocycline products, and certain specialty oncology agents flagged EX.

Within the anticonvulsant section multiple formulations and starter kits are marked EX. Examples include several LAMICTAL starter kits and line items, as well as other anticonvulsant presentations that carry the EX designation.

Additional neurologic and muscle‑relaxant products are shown as EX in the formulary. Representative excluded items include XENAZINE, ZUNVEYL, and certain formulations of tizanidine and ZANAFLEX that are listed with Drug Tier = EX.

Some central nervous system and psychiatric agents are designated EX. The listing shows examples such as Aplenzin and Caplyta with Drug Tier = EX, indicating exclusion or special non‑formulary status on those lines.

Coding and Pack/Limit Notes

Formulary drug entries (partial)mixed

ANCOBON ORAL CAPSULE 250 MG, 500 MG	Drug Tier = 4
BREXAFEMME ORAL TABLET 150 MG	Drug Tier = 4; Requirements / Limits = PA; QL (24 Tablets per 180 days)
clotrimazole mucous membrane troche 10 mg	Drug Tier = 1
CRESEMBA ORAL CAPSULE 186 MG, 74.5 MG	Drug Tier = 4; Requirements / Limits = PA
DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML	Drug Tier = 4
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml	Drug Tier = 1
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg	Drug Tier = 1
flucytosine oral capsule 250 mg, 500 mg	Drug Tier = 1
griseofulvin microsize oral suspension 125 mg/5 ml	Drug Tier = 1
griseofulvin microsize oral tablet 500 mg	Drug Tier = 1

1–10 of 56

1/6

Formulary entries with explicit pack descriptionsmixed

PAXLOVID ORAL TABLETS, DOSE PACK 150 MG (10)-100 MG (10)	Drug listing with QL (40 Tablets per fill); QL (40 per 90 days)
PAXLOVID ORAL TABLETS, DOSE PACK 150 MG (6)-100 MG (5)	Drug listing with QL (40 per 90 days)

Formulary entries with quantity limitsmixed

RUKOBIA ORAL TABLET EXTENDED RELEASE 600 MG	Requirements: PA; QL (60 Tablets per month)
XOFLUZA ORAL TABLET 40 MG, 80 MG	Requirements: QL (2 Tablets per year)

Drug list (no procedure/diagnosis codes provided in these chunks)NDC|mixed

No codes listed

Drug list (by product name and strength) with associated formulary attributesNDC | mixed

No codes listed

Bowel prep age and frequency — inv-16

Age rangeCovered for persons between 45 and 75 years old

Frequency limitLimited to 2 prescriptions per year

Coverage noteCoverage applies when plan coverage and any listed utilization management requirements are met

Breast cancer prevention age — inv-17

Minimum ageCovered in full for persons 35 years or older

Included agents (examples)tamoxifen, raloxifene, anastrozole, exemestane, Soltamox liquid, letrozole

Coverage conditionCoverage applies when plan coverage and any listed utilization management requirements are met

Fluoride age — inv-18

Covered agesCovered in full for persons 6 months through 16 years

Product categoryFluoride preparations (preventive medication)

Coverage conditionCoverage applies per ACA/preventive medication rules when requirements met

Smoking cessation limit — inv-19

Minimum ageCovered in full for persons 18 years or older

Annual limitLimited to 180 days per year

Example productsNicotine patches and other smoking cessation aids

Statins age — inv-20

Covered age rangeCovered in full for persons 40 through 75 years old

Example agentAtorvastatin (statin class)

Coverage noteCoverage provided when plan coverage and utilization requirements are met

Levetiracetam dispensing limit — inv-21

ProductLevetiracetam (oral tablet/solution)

Quantity limitQL (360 per 30 days)

RequirementsDispensing must adhere to listed QL; PA may apply to some anticonvulsants

Oxcarbazepine XR 150 mg dispensing limit — inv-22

ProductOxcarbazepine XR 150 mg (extended release)

Quantity limitQL (480 per 30 days)

RequirementsListed with PA and QL as applicable; dispensing must not exceed QL

Oxtellar XR 150 mg dispensing limit — inv-23

ProductOxtellar XR 150 mg (extended release)

Quantity limitQL (480 per 30 days)

RequirementsPA and QL apply as listed; dispense within monthly limit

Quantity limits (examples) — inv-24 (summary block)

SourceMultiple specific product QLs listed in formulary quantity limits section; see individual line-items for exact values

ScopeExamples include oncology, anticonvulsant, migraine, cardiovascular, and specialty biologic products

ActionAdhere to each product's listed QL, PA, SP, and LA requirements when dispensing or submitting claims

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many drugs listed in this formulary. Claims for medications marked with PA (and related flags such as SP, LA, ST, QL) may be denied if the required authorization is not obtained before dispensing. Providers should confirm PA requirements before prescribing or submitting a pharmacy claim.

PA-designated drugs across the formulary include but are not limited to select hepatitis antivirals (EPCLUSA, HARVONI, MAVYRET, SOVALDI, SOFOSBUVIR-VELPATASVIR, VOSEVI) which list PA; SP; LA.
Many inhaled and specialty inhalation agents require PA (examples: ARIKAYCE, BETHKIS, CAYSTON, TOBI products) and some inhaled antibiotics have QL and SP/LA designations.
Numerous specialty, high-tier, antineoplastic, MS, and biologic agents require PA; many also carry SP, LA, OCh, and QL constraints (examples: NERLYNX, VENCLEXTA, REVLIMID, PONVORY, COPAXONE, DUPIXENT, REPATHA).
Selected high-tier or specialty CNS/psychiatric agents require PA or ST (examples: LUMRYZ, NUPLAZID, SUNOSI, XYREM, SPRAVATO).
PA is also required for many narcotic analgesics and opioid formulations; absence of PA may result in non-coverage or higher member cost (examples: hydrocodone, morphine, methadone products, HYSINGLA ER).
Step therapy (ST) and limited-access (LA) flags are present for many products; ST requires trying specified alternatives first and LA indicates restricted program access.
Quantity limits (QL) appear on many lines and may interact with PA — requests exceeding QL or lacking PA may be denied (examples: PAXLOVID, BRIVIACT, LUMRYZ, VENCLEXTA, ZEPOSIA, DUPIXENT).
Documentation to support PA/SP/LA requests is required; providers should be prepared to submit clinical information demonstrating medical necessity and prior therapy attempts when applicable.
Excluded or specialty tiers (EX) can result in higher patient cost-sharing or non-coverage; verify tier status when prescribing (several inhaled and specialty agents are EX).
Failure to obtain required PA/SP/ST/QL/LA authorizations will likely trigger claim denials; follow the utilization controls exactly as listed for each product.

Documentation Required

Authorization & Restriction Flags — Action Required

Authorization requirements, step therapy (ST), restricted programs (SP), limited access (LA), quantity limits (QL), and other flags are indicated on each product line. Providers should review the product-specific Requirements / Limits column and follow the listed process to avoid delays or denials.

Verify PA, SP, LA, ST, QL indicators on the formulary product line before prescribing.
Step therapy (ST) means alternate agents must be tried first per the formulary (examples: EPIVIR, ARTHROTEC, CARDIZEM, ZOLOFT, REMERON).
Quantity limits (QL) specify permitted amounts per fill or period (examples: PAXLOVID QL limits; BRIVIACT QL; ZEPOSIA QL; DUPIXENT QL).
Special program (SP) and limited access (LA) products often require additional administrative steps or dispensing through specialty channels (examples: hepatitis antivirals, certain biologics).

Documentation Required

Documentation and Submission Requirements

When a drug requires PA, SP, LA, ST, or has QL constraints, providers must submit supporting documentation demonstrating medical necessity, previous therapies tried (if ST applies), and any clinical criteria required by the plan. Keep supporting records available in case of audit or appeal.

Documentation may include: diagnosis, prior treatment history, clinical rationale for the requested drug, lab results, and treatment dates.
For specialty programs (SP/LA) include prescriber specialty, dispensing pharmacy information, and any required enrollment forms.
Requests exceeding QL should include justification for additional quantity and duration.
Failure to provide required documentation may result in denial or delayed coverage.

Billing Rule

Utilization Controls — Where They Apply

Utilization controls (PA, SP, ST, LA, QL) are common across many therapeutic categories in this formulary — antineoplastics, immunosuppressants, MS agents, specialty biologics, inhaled antibiotics, anticonvulsants, narcotic analgesics, and select hepatitis antivirals. Confirm controls at the product level to prevent non-coverage.

Antineoplastic & immunosuppressant drugs frequently require PA and may have QL, SP, OCh, LA flags.
Selected inhaled/specialty antibiotics (ARIKAYCE, CAYSTON, TOBI, BETHKIS) are PA and may be in EX tier or have QL.
Many anticonvulsants list PA and QL requirements (examples: BRIVIACT, VIMPAT, XCOPRI, ZONISADE).
Numerous narcotic analgesics and opioid products require PA (examples: hydrocodone combinations, morphine, methadone, HYSINGLA ER).

Step Therapy

Step Therapy & Limited-Access Indicators

Step therapy and limited-access indicators are applied to many products. When ST is listed, the plan requires trial and failure of specified alternatives before covering the requested medication. Limited-access (LA) and special program (SP) drugs may require enrollment or restricted dispensing.

Examples of ST: EPIVIR formulations, ARTHROTEC products, CARDIZEM products, REMERON, ZOLOFT, and various ACE inhibitor combinations (VASERETIC, VASOTEC, ZESTORETIC).
Examples of LA/SP: Hepatitis antivirals (EPCLUSA, HARVONI, MAVYRET, SOVALDI), specialty biologics and MS agents (many list SP; LA).
If ST or LA applies, include documentation of trials of required agents or enrollment confirmation with PA submission.

Step Therapy Tables

Requirement	Notes / Examples
Step therapy (ST)
Some drugs require step therapy — the member must try specified alternative drugs first and demonstrate failure or intolerance before the requested drug is covered (see drug-specific listing).

Product	Requirement
EPIVIR Oral Solution 10 mg/mL
Requirements / Limits = ST (step therapy)

Product group / example	Requirement / routing
Antineoplastic & immunosuppressant oral agents (e.g., many entries in Adjunctive Agents and oncology sections)
Requirements / Limits frequently include PA (Prior Authorization) and SP (Specialty) and may include OCh or LA for channel/site routing

When ST appears	Action
Any product line that lists 'ST' or references step edits in Requirements / Limits
Follow plan-specific step edits: member must try required alternative(s) first and documentation of failure/intolerance must be provided per PA/process requirements

Designation	Implication
SP (Specialty)
Indicates specialty designation which may require dispensing via specialty pharmacy and specialty routing for fulfillment

Designation	Potential program impact
SP or LA flags on product lines
May indicate supplemental programs, limited-access distribution, or additional step/limited-access rules; providers must follow listed program requirements

Product	Requirement
ARTHROTEC 50 / ARTHROTEC 75 oral tablets
Requirements / Limits = ST (step therapy) as listed on product lines

Examples	Requirement
ANAPROX DS, EC-NAPROSYN (examples of non-narcotic analgesics)
Some formulations are marked 'ST' indicating step therapy may be required prior to coverage

Product examples	Requirements
Caplyta (lumateperone) — CAPLYTA oral capsule
Requirements / Limits = ST (step therapy) as listed; other CNS agents such as Desvenlafaxine ER, Fanapt, Fetzima are similarly marked ST in the formulary

Products	Requirement
LYBALVI; PAXIL CR; REMERON
Listed with Requirements / Limits = ST (step therapy) in formulary entries

Products	Requirement
ZOLOFT oral tablets and ZYPREXA oral tablets
Requirements / Limits = ST (step therapy) indicated for these products in the listing

Products / examples	Designations / notes
ORNITRAM (titration kits) and UPTRAVI oral tablets
Requirements / Limits include PA; SP; LA indicating specialty program management and limited-access routing; step/program controls apply as listed

Examples	Requirement
VASERETIC, VASOTEC, ZESTORETIC, CADUET (oral ACE/combination products)
Requirements / Limits = ST noted for several of these oral agents/combinations in the formulary

Product	Requirement
ranolazine oral tablet extended release (Ranexa) 500 mg, 1000 mg
Requirements / Limits = ST (step therapy) listed for ranolazine extended release

Quantity Limits (Selected Products)

BREXAFEMME ORAL TABLET 150 MG — inv-122

ProductBREXAFEMME ORAL TABLET 150 MG

Quantity limit24 Tablets per 180 days

RequirementListed with PA; dispense per 180‑day QL

EDURANT ORAL TABLET 25 MG — inv-123

ProductEDURANT ORAL TABLET 25 MG

Quantity limit30 (per 30 days)

TierDrug Tier = 2

EDURANT PED ORAL TABLET FOR SUSPENSION 2.5 MG — inv-124

ProductEDURANT PED ORAL TABLET FOR SUSPENSION 2.5 MG

Quantity limit180 (per 30 days)

TierDrug Tier = 2

PAXLOVID — inv-125

ProductPAXLOVID (oral tablets, dose pack)

Quantity limits40 Tablets per fill; 40 per 90 days

TierDrug Tier = 2

RUKOBIA — inv-126

ProductRUKOBIA ORAL TABLET EXTENDED RELEASE 600 MG

Quantity limit60 Tablets per month

RequirementsPA; QL

XOFLUZA — inv-127

ProductXOFLUZA ORAL TABLET 40 MG, 80 MG

Quantity limit2 Tablets per year

TierDrug Tier = 4

SUNLENCA ORAL TABLET — inv-128

ProductSUNLENCA ORAL TABLET 300 MG

Quantity limit2 Packs per year

RequirementsPA; QL; SP

CAYSTON INHALATION SOLUTION — inv-129

ProductCAYSTON INHALATION SOLUTION for nebulization 75 mg/mL

Quantity limit84 Milliliters per month

RequirementsPA; QL; SP; LA

XIFAXAN ORAL TABLET 200 MG, 550 MG — inv-130

ProductXIFAXAN ORAL TABLET 200 MG, 550 MG

Quantity limit60 Tablets per month

RequirementsPA; QL

STROMECTOL ORAL TABLET 3 MG — inv-131

ProductSTROMECTOL ORAL TABLET 3 MG

Quantity limit20 Tablets per month

RequirementsQL

AROMASIN and similar entries — inv-132

ProductAROMASIN (exemestane) and similar entries

Quantity limit30 (per 30 days)

RequirementsPA; QL; OCh as listed

ENSACOVE — inv-133

ProductENSACOVE ORAL CAPSULE

Quantity limit60 (per 30 days)

RequirementsPA; SP; OCh; QL noted

LUMAKRAS — inv-134

ProductLUMAKRAS ORAL TABLET

Quantity limit240 (per month) for specific strength

RequirementsPA; QL (varies by strength); SP; OCh; LA

NEMLUVIO SUBCUTANEOUS PEN — inv-135

ProductNEMLUVIO SUBCUTANEOUS PEN

Quantity limit2 Pens (per month)

RequirementsPA; QL; SP; LA

NERLYNX ORAL TABLET — inv-136

ProductNERLYNX ORAL TABLET

Quantity limit180 Tablets (per month)

RequirementsPA; QL; SP; OCh; LA

OpenPayer

Formulary Drug List (Essentials E1/E4) - Coverage Criteria

Coverage Criteria

Coding and Pack/Limit Notes

Provider Actions and Authorization Requirements

Step Therapy Tables

Quantity Limits (Selected Products)

Site of Care / Specialty Pharmacy Requirements

Definitions and Abbreviations

Background