CurrentPremera BluecrossPolicy N/A

Formulary Drug List (Open A1 / Preferred A2)

Provides the list of generic, brand, and specialty drugs covered under Premera Bluecross plans with associated drug tiers and utilization management restrictions (PA, QL, ST, age limits, specialty pharmacy, high-cost low-value, limited access).

Policy Summary

PayerPremera Bluecross

PolicyFormulary Drug List (Open A1 / Preferred A2)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization via the plan's Drugs Requiring Approval process for drugs listed with 'PA' before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

200+Drugs listed in this part

ManyRequire Prior Authorization (PA)

MultipleHave Quantity Limits (QL)

SeveralSpecialty (SP) / Limited Access (LA)

MultipleACA preventive coverage flags

Coverage Summary & Scope

General Coverage Principles

General Coverage Principles — coverage is available when ALL of the following plan- and utilization-management criteria are met:

ALL of the following

Member has an active benefit under a Premera Bluecross medical plan and the drug is included on the formulary attached to that member's plan (A1 for HSA/HDHP; A2 for PPO).
Coverage is subject to the terms, limits, and exclusions of the member's specific benefit contract (member booklet).
Any utilization management restrictions that apply to the drug (see Utilization Management Restriction Definitions and Flags) are satisfied prior to coverage.
Examples: prior authorization approved, step therapy completed, quantity limit not exceeded, age within specified range.

Policy Summary

PayerPremera Bluecross

PolicyFormulary Drug List (Open A1 / Preferred A2)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization via the plan's Drugs Requiring Approval process for drugs listed with 'PA' before dispensing.

SourceLink

On This Page

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Utilization Management Definitions & Flags

Utilization Management Restriction Definitions

Definitions for utilization management restrictions and common requirement/limit abbreviations used in the formulary.

PA = Prior Authorization. You (or your physician) are required to get prior authorization from us before coverage; without approval the drug may not be covered.
Used when prior clinical review is required.
QL = Quantity Limit. We limit the amount of this drug that is covered per prescription, or within a specific time frame.
Often expressed as X per Y days.
ST = Step Therapy. Prior trial of specified alternative drug(s) is required before this drug will be covered.
Document trials and reasons for failure or intolerance.
NP = Not Covered / Non-Preferred. Drug is not covered under the plan or is considered non-preferred requiring alternative coverage route.
May require exception or medical necessity review.
HCLV = High-Cost, Low-Value. Drug not covered when a lower cost generic or therapeutic equivalent is available.
May apply even if drug appears on formulary.
LA = Limited Access. Drug is restricted to distribution via specialty or network pharmacies (e.g., REMS, handling or coordination needs).
May require specialty pharmacy fill.
ACA = Affordable Care Act Preventive Medication. Covered in full when applicable USPSTF criteria/age requirements are met.
Examples: certain statins, smoking cessation, select cancer prevention agents.
SP = Specialty Pharmacy. Drug is routed through specialty pharmacy channel; usually limited to 1-month supply and enhanced patient support is provided.
May carry separate dispensing rules or prior authorization.
OCh = Oral Chemotherapy. Indicates oral chemotherapy agents that may be covered under medical benefit per plan terms.
Check member booklet for coverage under medical vs pharmacy benefit.
OPT = Optional Benefits. Coverage varies by plan for indications such as ED, fertility, or weight management; refer to specific benefit plan.

Requirement / Limit abbreviationsmixed

PA	Prior Authorization
QL	Quantity Limit
ST	Step Therapy
NP	Not Covered / Non-Preferred
HCLV	High-Cost Low-Value
LA	Limited Access (specialty distribution)
ACA	Affordable Care Act preventive medication
SP	Specialty Pharmacy
OCh	Oral Chemotherapy
OPT	Optional Benefits

OpenPayer

Formulary Drug List (Open A1 / Preferred A2)

Coverage Summary & Scope

Utilization Management Definitions & Flags

Utilization Controls Applied to Formulary Drugs

Formulary Product Listings & Code Groups (excerpt)