Formulary / Preferred (B3) Drug List (Partial)
Part 1 of a multi-page formulary drug list from Premera Bluecross describing covered drugs, tiers (Generic 1, Brand 2, Non-Preferred Brand 3), and utilization management requirements (age limits, prior authorization, quantity limits, step therapy, specialty pharmacy, ACA preventive drugs, HCLV, LA, SP). This part contains policy instructions, coverage abbreviations, special requirements and a large set of anti-infective drug entries with tiers and requirements/limits.
No material changes — formulary updated; no material clinical/coverage changes flagged.
Coverage Summary & Formulary Scope
Coverage/Utilization Management Restrictions Definitions
Coverage / Utilization Management Restrictions Definitions and related special requirements. Use the Requirements / Limits column in the drug chart to identify which of these apply to a specific drug.
ALL of the following
- PA — Prior Authorization: You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug.
- QL — Quantity Limit: We limit the amount of this drug that is covered per prescription or within a specific time frame.
- ST — Step Therapy: Before we provide coverage for this drug you must first try another drug to treat your medical condition. This drug may only be covered if the other drug does not work for you.
- AGE — Age Limit: We limit the use of a drug to certain ages. The prescription is covered if the member's age is within the specified age range.
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