CurrentPremera BluecrossPolicy N/A

Formulary / Preferred Drug List (PPO C4) — Coverage Criteria

Defines the insurer's formulary drug list (generic, brand, specialty), tier placement, and utilization management restrictions for Premera Blue Cross PPO plans; applies to members and providers using the listed pharmacy benefits.

Policy Summary

PayerPremera Bluecross

PolicyFormulary / Preferred Drug List (PPO C4) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain required prior authorization and submit supporting documentation for drugs flagged PA, SP, LA, or exceeding QL to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Formulary tiers

QuarterlyP&T review

multipleRequirements/limits present

severalTier 4 specialty drugs

800-722-1471Customer service

Coverage Criteria and Formulary Controls

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General coverage conditions

Covered as indicated on the Formulary Drug List when plan benefits allow and any listed requirements/limits are met.

Formulary coverage conditions: Drug is covered if it appears on the member's plan drug list and any required utilization management (age limits, prior authorization, quantity limits, step therapy) conditions are satisfied.

Additional site or specialty fill requirements may apply for LA or SP drugs.

Per-drug coverage flags

Coverage and special requirements are indicated per drug line; drugs flagged with PA/SP/LA/QL have additional authorization or program requirements.

Per-drug coverage flags: If a drug line lists PA, SP, LA, or QL the member/provider must comply with that requirement for coverage.

Document provides per-drug flags but no expanded criteria in these chunks.

Formulary controls for Multiple Sclerosis agents

Coverage of the listed multiple sclerosis agents is subject to the following administrative controls as indicated per product:

Formulary controls: Products require prior authorization (PA) and are managed through specialty pharmacy (SP) and/or limited access (LA) where indicated; quantity limits (QL) apply as listed per product.

Apply per-product as shown in the formulary lines

If a drug listed on the formulary requires prior authorization (PA) and the provider does not obtain the required approval before dispensing, the drug may not be covered. The formulary indicates PA and other utilization controls in the Requirements/Limits column; providers should follow those instructions and submit any requested clinical documentation to avoid claim denial.

Within the provided formulary excerpts there are no standalone exclusion narratives; coverage status and any special handling are indicated directly on each drug line via the Requirements/Limits and Drug Tier fields (for example, items showing PA, SP, LA, or QL).

Certain listed products are annotated with a Drug Tier of EX (for example BELBUCA and several MS CONTIN / opioid-related lines). In this document extract the EX designation is used on product lines in the Requirements/Limits or Drug Tier fields to denote an exception or excluded-tier status for those specific formulations.

The presence of a Drug Tier marked EX in multiple entries suggests special handling or non‑standard coverage (excluded or exception-tier placement). The excerpt itself does not provide the detailed exclusion criteria, but the EX tier consistently flags products for distinct formulary treatment.

Some product lines within these sections show Drug Tier = EX (examples include PAXIL oral suspension and other listed items). Where EX appears for topical or oral products it indicates those items are placed in an exception or excluded tier in the formulary listing.

Entries in the cardiovascular/lipid sections include several items with Drug Tier = EX (e.g., KAPSPARGO, KERENDIA). These EX annotations identify products that are treated separately from standard tiers and may be excluded or otherwise subject to special coverage rules.

Across the formulary pages multiple branded formulations are marked EX (for example ATORVALIQ oral suspension, CADUET, JUXTAPID), indicating an exception/excluded tier designation. The listing uses EX to signal these items are not handled as routine tiered drugs within the excerpt.

Dermatology and topical product lines in this extract include several items with Drug Tier = EX (for example CALCIPOTRIENE TOPICAL FOAM and multiple acne/topical agents). The formulary marks these topical products as EX, which in the context of the listing denotes excluded or exception-tier status.

Within these chunks no explicit statements are made that any listed product is “not medically necessary.” Instead, coverage stance is communicated by the Drug Tier and Requirements/Limits fields; absence of PA, QL, ST, or EX on a line implies routine coverage subject to plan benefits.

The provided excerpts do not contain explicit 'not medically necessary' determinations. Coverage posture in these sections is indicated by tier placement and flags such as PA, SP, LA, QL, or EX rather than by standalone nonmedical necessity language.

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Prior Authorization

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Many drugs listed on the formulary require prior authorization (PA) before they will be covered. This includes individual products flagged with PA, categories of specialty and biologic agents, selected formulations, and numerous high-cost or specialty therapies. Providers should follow the Requirements / Limits shown next to each drug when submitting claims.

Prior authorization required for PA-marked drugs across therapeutic categories (examples: CRESEMBA, NOXAFIL, TOLSURA, MOTPOLY XR, OXTELLAR XR, OJEMDA, XALKORI).
Prior authorization and program requirements (PA plus specialty pharmacy (SP), limited access (LA), orphan (Och), age or ACA flags) apply to many antineoplastic, immunosuppressant, MS, and other specialty agents (examples: AFINITOR, ALECENSA, AKEEGA, OGSIVEO, ZEPOSIA, LEQEMBI).
Prior authorization and specialty pharmacy requirements apply to multiple products (examples: BEYFORTUS, BETHKIS, TOBI formulations, VOYXACT, ARIXTRA, REPATHA, HEMLIBRA).
Prior authorization required for select products and formulations, including certain suspensions, extended‑release or delayed‑release formulations, inhalation/nebulized products, and injectables (examples: DIFLUCAN suspension, VFEND suspension — ST indicated, TOBI inhalation solution — PA; SP).
Prior authorization required for some formulations of the same active ingredient (examples: extended‑release, sprinkle, suspension, kit or dose‑pack formulations often have PA or QL differences).
Prior authorization required for listed multiple sclerosis agents and many disease‑modifying therapies (examples: AVONEX, TECFIDERA, TECFIDERA dose variations, COPAXONE, BAFIERTAM, VUMERITY).
Prior authorization and specialty requirements may trigger coverage denials if not obtained; PA/SP/LA/Q L and other flags are authorization/restriction indicators that require documentation at time of request.
PA/SP/LA flags imply additional required documentation — providers must submit clinical rationale and supporting documentation when requesting PA for flagged drugs.
Quantity limits (QL) are applied to many agents; documentation may be required to justify quantities above the QL. Examples: QL entries shown for PAXLOVID (40/90 days), MOTPOLY XR, OXTELLAR XR, SPRITAM, many antineoplastic agents, and some MS treatments.
Step therapy (ST) requirements apply to many products; providers must follow the step sequence where indicated (examples: ORAVIG, VFEND, tetracycline‑class agents, AMRIX, many antipsychotics and CNS agents, adapalene topicals).
Special program controls (SP) denote additional programmatic controls or specialty pharmacy handling required for selected biologics and high‑cost drugs.
Follow the listed Requirements / Limits shown next to each formulary entry — failure to meet these requirements may restrict coverage or result in denial.
Documentation for PA/SP products: submit clinical notes, prior therapy history, and any other requested medical records to support the PA request.
Quantity limit documentation: where QL is listed, provide justification for higher quantities or exception requests.
Documentation implied by formulary flags: PA, SP, LA, QL, ST, ACA, Och require satisfying the stated program rules.
Requirements / Limits present on formulary entries must be met before coverage (PA, QL, ST, SP, LA, ACA appear throughout the formulary).
Submit documentation to meet Requirements / Limits via the payer’s PA process; check the ‘Drugs Requiring Approval’ page for instructions and forms.
Step therapy requirements for select agents: some drugs are designated ST and will require trial of preferred agents first (examples across antimicrobial, CNS, and dermatologic classes).
Step/program controls noted: some entries show program controls (LA, Och, ACA) without explicit step sequences — follow operational guidance when requesting PA.
Step therapy not detailed in this segment for every agent — consult program pages or PA criteria for complete step sequences.
Step therapy indications: several psychiatric/neurology agents and others are marked ST (examples: ARIPIPRAZOLE, CAPLYTA, AUVELITY, EXXUA, FANAPT, INVEGA, QUETIAPINE lines).
Step therapy applies to some agents in this list; where ST is present, prior trials are required before non‑preferred agents are approved.
Step therapy (ST) is not shown for all MS agents in this excerpt; many MS agents instead require PA, SP, and LA.
Step therapy present for select products including certain antihypertensives and topical acne agents (examples: Katerzia, SDAMLO lines, adapalene topical products).
Step therapy present for certain acne topicals: adapalene topical cream/gel/solution/swab are marked ST; quantity limits apply for combination topical products.

Step Therapy Indicators and Affected Agents

Drug / Product	Requirement(s)
ORAVIG muco-adhesive buccal tablet 50 mg
VFEND oral suspension for reconstitution 200 mg/5 mL (40 mg/mL)
AMRIX oral capsule, extended release 24hr 15 mg, 30 mg
INVEGA oral tablet extended release 24hr (3 mg, 6 mg, 9 mg)
QUETIAPINE (150 mg line) / SEROQUEL oral tablet and XR
Various listed products where Requirements / Limits = ST (step therapy) as shown in product lines

Drug / Product	Requirement(s)
MAVYRET oral pellets / tablets (glecaprevir-pibrentasvir)
EPCLUSA oral pellets / tablet (sofosbuvir-velpatasvir)
HARVONI oral pellets / tablet (ledipasvir-sofosbuvir)
OJD/OGSIVEO / OJEMDA antineoplastic agents
Selected antifungals (NOXAFIL oral suspension) — high-cost anti-infective examples

Drug / Product	Requirement(s)
AVIDOXY (various formulations)
DORYX MPC oral tablet, delayed release 60 mg
DORYX oral tablet, delayed release (200 mg, 80 mg)
DOXYCYCLINE HYCLATE delayed release (DR/EC) 80 mg
ORACEA oral capsule (biphasic 40 mg)
SEYSARA oral tablet (60 mg, 100 mg, 150 mg)

Drug / Product	Requirement(s) / Note
Octreotide acetate injection (various strengths)
OGSIVEO oral tablet 100 mg, 150 mg
OJEMDA oral formulations
MAVYRET (PA; SP; LA) — limited access / specialty controls

Drug / Product	Requirement(s)
AMRIX oral capsule, extended release 24hr 15 mg, 30 mg
Cyclobenzaprine ER and Norgesic (muscle relaxant class lines) — some entries marked ST

Drug / Product	Requirement(s) / QL
Bayer low dose aspirin oral tablet, delayed release (81 mg)
BAYER chewable aspirin oral tablet 81 mg (Drug Tier = EX) — ACA noted on some aspirin entries
Selected opioid-related products with QL examples (buprenorphine-naloxone films QL 60/90 per 30 days as shown) — QL noted in nearby lines

Drug / Product	Requirement(s)
Aripiprazole (ABILIFY) oral tablet — Requirements / Limits = ST
AUVELITY oral tablet IR and ER (45-105 mg) — Requirements / Limits = ST
CAPLYTA oral capsule (10.5 mg, 21 mg, 42 mg) — Requirements / Limits = ST

Drug / Product	Requirement(s)
EXXUA oral tablet dose pack (dose pack lines) — Requirements / Limits = ST
FANAPT oral tablet and titration packs — Requirements / Limits = ST
INVEGA oral tablet extended release and injectable lines — some oral tablet lines Requirements / Limits = ST

Drug / Product	Requirement(s)
QUETIAPINE oral tablet (150 mg line) and SEROQUEL (tablet and XR) — Requirements / Limits = ST
RISPERDAL oral solution and RISPERDAL CONSTA injectable lines — oral solution Requirements / Limits = ST
SAPHRIS sublingual tablet — Requirements / Limits = ST

Drug / Product	Requirement(s)
Katerzia oral suspension 1 mg/mL — Requirements / Limits include ST on select entries
Micardis HCT (combination) / related antihypertensive lines — some formulations show ST; QL examples present nearby
SDAMLO and select cardiovascular combinations — some entries include ST

Annotation	Interpretation
SP annotation on product lines (e.g., FRAGMIN, HEMLIBRA, REPATHA entries)
Indicates specialty program / specialty pharmacy designation; may imply step therapy prerequisites or specialty handling prior to coverage

Drug / Product	Requirement(s)
Adapalene topical cream 0.1%; gel 0.3%; solution 0.1%; swab 0.1%
Adapalene-benzoyl peroxide topical gel with pump (0.1-2.5%, 0.3-2.5%) — Requirements / Limits = QL (45 per 30 days)
ADAPALENE TOPICAL LOTION 0.1% (Drug Tier = EX) — no ST on EX lotion line as printed

OpenPayer

Formulary / Preferred Drug List (PPO C4) — Coverage Criteria

Coverage Criteria and Formulary Controls

Sample Drug Entries, Requirement Codes, and Quantity Examples

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Key Abbreviations and Formulary Terms

Step Therapy Indicators and Affected Agents

Quantity Limits by Product (Selected Examples)

Specialty Pharmacy, Infusion, and Administration Requirements

Formulary Background and Scope