CurrentPremera BluecrossPolicy N/A

Metallic (M4) Formulary Drug List — Premera Blue Cross of Washington

Defines the list of covered generic, brand, and specialty drugs and associated utilization management rules for Premera Blue Cross Metallic (M4) plans in Washington (except certain American Indian/Alaskan Native eligible plans). Applies to prescribers, pharmacies, and plan members for coverage and benefit tiering.

Policy Summary

PayerPremera Bluecross

PolicyMetallic (M4) Formulary Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization where 'PA' is indicated before dispensing for listed drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

WAPlans governed

tiers 1–4Drug tiers represented

PA, QL, ST, ageUtilization restriction types

~20+Drugs with PA in excerpt

quarterlyPT Committee cadence

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General coverage and placement

Covered drugs and placement

Formulary inclusion: A drug is covered when it appears on the formulary drug list for the member's plan and is consistent with the member's coverage contract and benefit tiering.

Drug-specific restrictions (PA, QL, ST, Age limits, LA) may apply as listed.

Preventive medication coverage

ACA preventive and special coverage conditions

ACA preventive coverage: Certain preventive medications are covered in full when USPSTF criteria or ACA preventive designations are met.

Examples: bowel prep (peg 3350-electrolytes) covered for persons 45–75 limited to 2 prescriptions/year; smoking cessation aids covered for persons ≥18 limited to 180 days/year; statins covered for persons 40–75; vaccines and other items designated 'ACA' are covered per ACA provisions.

Formulary coverage actions

Coverage and utilization management actions listed per product include one or more of the following

Formulary display rules: Each product line shows a Drug Tier and any Requirements / Limits flags (examples: PA, LA, QL, Och, ACA). Providers must follow the specific requirement(s) shown for each product when requesting coverage.

If 'PA' is listed the product requires prior authorization; 'QL' indicates a quantity limit; 'LA' indicates limited access; 'Och' indicates oncology program management; 'ACA' indicates ACA preventive designation.

Product-level coverage rules

Coverage stance is product-specific per formulary tier and listed requirements/limits

Formulary coverage indications: Each listed product is assigned a Drug Tier and may have Requirements / Limits. Coverage is determined by the product entry: when 'PA' is present the product requires prior authorization; when 'ACA' is present the product is a preventive/vaccine ACA‑covered item; when 'QL' is present the product is subject to the quantity limit shown; when 'LA' is present the product has limited access; when 'MB' is present the product is billed under the medical benefit.

Use the exact product line entry to determine the applicable coverage rules and any prior authorization or site-of-care requirements.

This formulary applies to Premera Blue Cross Metallic (M4) plans in Washington except for members who are eligible as American Indian/Alaskan Native with zero cost share; coverage for those members is governed by the terms of their member booklet rather than this drug list.

The provided excerpt is a formulary drug listing and does not enumerate specific medically excluded indications. Entries list products and any associated management flags (for example, PA, LA, QL) but do not define clinical exclusions for indications.

This document is a formulary listing that shows drug names, assigned tiers, and any Requirements/Limits; it is not itself a medical‑necessity criteria document. Placement on a tier or presence of flags such as PA, QL, LA, or ST indicate utilization management actions rather than clinical coverage criteria logic.

Within this excerpt there are no explicit clinical exclusion statements. Topical, antiviral, and other line items may show Requirements/Limits values (for example, PA for some topical antifungals or antivirals), but the chart does not list clinical indications that are categorically excluded.

Where a line‑item has no Requirements/Limits noted, the entry is implicitly standard formulary coverage according to the assigned Drug Tier. In other words, absent PA/QL/LA/ST flags the product is treated as standard formulary coverage within its tier.

The extract lists products with drug tier and Requirements/Limits fields but does not include standalone medical necessity or exclusion text. Coverage determinations depend on the product line details (tier and any flags) rather than an explicit medical‑necessity statement in this excerpt.

Several contraceptive products and devices in the list are annotated with Requirements / Limits = ACA, indicating these items are designated under Affordable Care Act preventive/contraceptive coverage provisions (no member cost share where applicable).

In the provided ophthalmic and topical segments there are no explicit exclusion conditions set out; the lines list drugs, tiers, and any Requirements/Limits but do not state excluded uses in this excerpt.

Coverage for a listed product may be denied if applicable utilization management requirements are not met. If a drug's line shows PA, ST, or a QL and those requirements (e.g., obtaining prior authorization, satisfying step therapy, or not exceeding quantity limits) are not satisfied, the claim may be denied.

There are no explicit entries labeled 'Not Medically Necessary' in this excerpt. The formulary instead uses utilization flags and line‑item controls; absence of an explicit NMN statement in these chunks means specific NMN determinations are not presented here.

The excerpt does not contain explicit 'Not Medically Necessary' or similar determinations for the topical and antifungal sections; those items are listed with tiers and occasional Requirements/Limits but no NMN language in this segment.

Across the provided segments there are no explicit 'Not Medically Necessary' labels applied to the listed products. The formulary relies on per‑product Requirements/Limits to control coverage rather than embedding NMN declarations in these excerpts.

This segment does not present items explicitly labeled 'Not Medically Necessary.' Instead, coverage guidance is conveyed via Drug Tier and Requirements/Limits (PA, QL, ACA, LA), and any denial of coverage would be based on failure to meet those requirements.

Coding, Formulary Codes, and Quantity Examples

Drug listing (no procedural codes)mixed

NDC or CPT not listed

No procedure, diagnosis, or billing codes (CPT/HCPCS/ICD-10) are provided in this portion of the document; items are drug names and tiers.

Formulary utilization codes and limitsmixed

QL (60 per 30 days)	Quantity limit example applied to several products (e.g., tenofovir disoproxil fumarate, TIVICAY)
QL (2 per 365 days)	Quantity limit applied to RELENZA DISKHALER (2 per 365 days)
PA	Prior authorization required (flag shown on many products)
LA	Limited access (flag shown on select products)
QL (8 per 30 days)	Quantity limit applied to SELZENTRY ORAL SOLUTION (8 per 30 days)
QL (240 per 30 days)	Quantity limit applied to ALECENSA (240 per 30 days)
QL (20 per 365 days)	Quantity limit applied to fidaxomicin (20 per 365 days)
QL (84 MILLILITERS PER MONTH)	Quantity limit applied to CAYSTON inhalation solution (84 milliliters per month)
QL (60 per 30 days)	Quantity limit applied to several antiviral/antiretroviral formulations (e.g., zidovudine, TIVICAY)
960 MILLILITERS PER MONTH	Limit applied to zidovudine oral syrup (960 milliliters per month)

1–10 of 13

1/2

No procedure/billing codes in this extractmixed

No codes listed

Formulary product list (no procedural/billing codes provided in this segment)mixed

No codes listed

inv-22: Quantity Limits examples — common numeric examples

Common numeric QL examples30 per 30 days; 60 per 30 days; 40 per 90 days; 2 per 365 days; various mL/month limits (e.g., 84 mL/month)

Short-term supply limitsQL 20 per 5 days (ketorolac) and QL 2 per 365 days (RELENZA Diskhaler)

Monthly capsule/tablet capsQL 30 per 30 days (e.g., many antiviral/tablet examples) and QL 60 per 30 days (e.g., some ARV/tablet examples)

inv-23: Examples of quantity limits

Examples with timeframesQL 60 per 30 days; QL 2 per 365 days; QL 84 milliliters per month; QL 20 per 365 days (fidaxomicin)

Yearly limitsQL 40 per 90 days (PAXLOVID example), QL 2 per 365 days (RELENZA)

Milliliter-based QLCAYSTON: 84 milliliters per month

inv-24: Quantity Limits examples (LINZESS, SKYRIZI, ZYMFENTRA, VARUBI, VELSIPITY)

LINZESSQL 30 per 30 days

SKYRIZI (wearable injector / pen)QL 1 per 56 days (wearable injector) or 1 per 84 days for some pen/syringe presentations

ZYMFENTRAQL 2 per 28 days (pen/syringe kit)

VARUBIPA; 2 tablets per fill

VELSIPITYPA; LA; QL 30 per 30 days

inv-25: Quantity limits examples (RINVOQ XR, Simlandi, XELJANZ, estradiol gel)

RINVOQ XR 45 mgPA; LA; QL 112 per 365 days

SIMLANDI (autoinjector 40 mg)PA; LA; QL 4 per 28 days (40 mg autoinjector) and QL 1 per 28 days (80 mg autoinjector)

XELJANZXELJANZ oral tablets QL 60 per 30 days; XELJANZ XR QL 30 per 30 days; oral solution QL 2 per 30 days

estradiol transdermal gel (packet)QL 30 per 30 days

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Other Authorization Triggers

Some covered drugs require prior authorization (PA) or other utilization controls before they will be covered. Prior authorization is required where the drug listing shows PA (examples across the drug list include many specialty, biologic, oncology, MS, immunology, GLP‑1 pens, and certain ophthalmic products). When PA, limited access (LA), oncology (Och), or quantity limits (QL) are shown, providers must obtain authorization or meet the stated limits or coverage may be denied.

PA indicated where 'PA' appears next to a product — obtain prior authorization before dispensing.
Many specialty biologics and immunology agents require PA plus LA and often have QL (e.g., ADALIMUMAB products, ACTEMRA, ENBREL, CIMZIA, REPATHA).
Multiple MS agents and other specialty agents require PA/LA/QL (e.g., AVONEX, BETASERON, fingolimod, glatiramer products, ZEPOSIA).
Selected high‑cost hepatitis C and infectious agents require PA/LA (e.g., SOVALDI, VOSEVI) and some anti‑infectives have QL (e.g., fidaxomicin).
Oncology agents frequently carry PA plus oncology program flags (Och) and LA; some also have QL (examples: ALECENSA, MEKINIST, LYNPARZA).
Certain narcotic analgesics require PA and some have QL (examples: morphine preparations, oxycodone products, methadone formulations).
CABLIVI specifically requires PA.
GLP‑1 agents and other injectable pens have PA and per‑period pen limits noted (e.g., MOUNJARO, OZEMPIC, liraglutide pens).
Tolvapatan is listed with PA and a QL (60 units per 30 days).
Ophthalmic products may require PA (e.g., CYSTARAN) — check the product row for PA/QL.
Some agents are flagged PA;LA;MB (medical benefit) or PA;LA;QL — authorization triggers include PA, LA, Och, MB, and QL.
Providers may be required to provide clinical documentation to support medical necessity for PA, evidence of prior therapies for step therapy (ST), and quantity justification when QL applies.
Failure to obtain required PA, to meet step‑therapy (ST), or to remain within QL may result in denial of coverage.

Documentation Required

Documentation and Quantity Limit Expectations

When PA or QL is required, the provider must submit supporting documentation per payer processes. Specialty and biologic drugs commonly require clinical notes, diagnosis, prior treatment history, and quantity justification. Examples in the drug list specify QL amounts (pens, syringes, milliliters, tablets per time period) that must be adhered to.

Quantity limits are explicit where noted (e.g., fidaxomicin = QL 20 per 365 days; liraglutide pens = 2–3 pens per 30 days; OZEMPIC pens = 1 pen per 30 days; tolvaptan = QL 60 per 30 days).
PA documentation expectations include diagnosis, prior therapies, and clinical justification for continued treatment or high quantities.
Specialty product PA often requires submission through specialty pharmacy or medical benefit channels when LA or MB flags are present.

Step Therapy

Step Therapy Requirements

Step therapy (ST) is used for selected drugs — the drug list marks ST where it applies. Providers should review the product row for ST flags and be prepared to document treatment failure or intolerance to the required first‑line agents when requesting an exception.

ST appears for some topical acne agents and certain oral agents (examples: metformin oral solution and selected topical acne products).
If ST is indicated, prior trials of required medications and rationale for switching must be documented to support PA requests or exceptions.

Denial Risk

Denial Risk and Authorization Consequences

Denial risk: coverage may be denied if prior authorization is not obtained, step‑therapy requirements are not met, or quantity limits are exceeded. Providers should confirm PA/QL/ST status on the drug row and follow the payer's authorization process before dispensing.

Denial can occur for missing PA or when QL/ST requirements are unmet.
Check for PA, LA, Och, MB, and QL flags on the product row; these are authorization triggers that must be satisfied. Examples include biologics with PA/LA/QL and specialty injectables with PA/QL limits.

Definitions and Abbreviations

inv-90: Drug tiers and MB definitions

Tier 1Preferred Generic (lowest tier)

Tier 2Preferred Brand

Tier 3Non-preferred generic and brand

Tier 4Specialty drugs (generally biologics) — often require PA/LA/QL

MB (Medical Benefit)Drugs administered in clinic/infusion or via home infusion — billed under medical benefit

inv-91: Restriction abbreviations (AGE, PA, QL, ST, LA)

AGEAge limit — drug coverage limited to specified ages

PAPrior Authorization — approval required before coverage

QLQuantity Limit — limits amount covered per prescription or time frame

STStep Therapy — must try another drug first

LA / LA2Limited Access — restricted distribution or specialty pharmacy requirement

inv-92: PA definition

DefinitionPrior Authorization — you (or your physician) must obtain prior authorization from the plan before the prescription is filled; without approval the drug may not be covered.

Provider actionProviders must submit PA documentation per plan processes when 'PA' is listed on a line item.

Denial riskClaims lacking required PA risk denial or processing as non-covered.

inv-93: QL definition

DefinitionQuantity Limit — maximum quantity covered during the specified time frame (e.g., QL 60 per 30 days).

ExamplesCommon QL formats include per 30 days, per 28 days, per 365 days, or milliliters per month (e.g., 84 mL/month for CAYSTON).

DocumentationRequests exceeding QL may require documentation to support medical necessity.

inv-94: LA definition

DefinitionLimited Access (LA) — additional restriction or limited distribution for the product; may require specialty pharmacy or site-of-care coordination.

ImpactLA entries often accompany PA and can affect where/administered and billing (e.g., MB or infusion center).

ExamplesMany oncology and biologic agents list LA alongside PA (see antineoplastic and immunology sections).

inv-95: PA / QL / LA / ST / ACA abbreviations summary

Summary of abbreviationsPA = Prior Authorization; QL = Quantity Limit; LA = Limited Access (layered/step requirement); ST = Step Therapy; ACA = Affordable Care Act preventive designation (no member cost share for applicable items)

How they appearFlags appear in the 'Requirements / Limits' column on each formulary line item

Action implicationProviders must follow listed flags (obtain PA, adhere to QL, follow ST sequences) to avoid denial

inv-96: QL example (SANTYL)

SANTYL topical ointmentRequirements / Limits = 6 grams per month (QL)

ContextReported as '6 GRAMS PER MONTH' in the formulary Requirements / Limits field

Provider noteDispensing beyond this QL may require documentation to support medical necessity

inv-97: PA indicator (formulary)

Formulary indicatorPA flag is shown in the Requirements / Limits column for many formulary items (e.g., ACTEMRA, ENBREL, ORENCIA) — prior authorization must be obtained before coverage.

Combined flagsPA often appears with LA and/or QL for biologics and specialty agents

Provider implicationObtain PA per plan process to avoid claim denial when 'PA' is listed

inv-98: ACA preventive designation

ACA designation'Requirements / Limits = ACA' denotes Affordable Care Act preventive/vaccine coverage (no member cost share where applicable).

ExamplesGARDASIL 9, ADACEL/BOOSTRIX, influenza vaccines in the ACA-designated sections are labeled 'ACA'

ScopeACA flags apply to preventive medications and select contraceptives/devices per formulary listings

inv-99: PA / LA / MB / QL flags summary

Flags summaryPA, LA, MB, QL flags appear on formulary line items: PA = prior authorization required; LA = limited access; MB = medical benefit (administered in clinic/infusion); QL = quantity limit as specified.

Typical combinationsHigh-cost biologics commonly show 'PA; LA; QL' together (examples: ACTEMRA, ORENCIA, RINVOQ XR)

ActionFollow each listed flag to determine provider steps (PA forms, site-of-care coordination, adhere to QL)

inv-100: Drug Tier (label)

Drug Tier label'Drug Tier' column indicates placement: Tier 1–Preferred Generic; Tier 2–Preferred Brand; Tier 3–Non-preferred; Tier 4–Specialty; MB–Medical Benefit.

Billing implicationMB items are billed under medical benefit rather than pharmacy benefit

Tier impactMember cost-sharing and PA requirements depend on tier assignment

inv-101: Requirements / Limits (label explanation)

Requirements / Limits columnDisplays utilization management flags such as PA, LA, QL, ACA — governs prior authorization, limited access, and quantity limits for each drug.

InterpretationIf 'PA' is listed obtain prior authorization; if 'QL' is listed adhere to the numeric/time limit shown; if 'ACA' listed item is ACA-covered where applicable.

DocumentationProviders should submit medical documentation consistent with the flags when requesting PA or exceptions.

inv-102: PA (redundant reference)

PA repeated definitionPrior Authorization — approval required before coverage for certain drugs as indicated in the formulary line item.

Where shownPA is displayed in the Requirements / Limits column next to affected products

EffectClaims submitted without required PA may be denied

inv-103: ACA (redundant reference)

ACA repeated'ACA' indicates Affordable Care Act preventive coverage designation — used for vaccines and many contraceptive products (no member cost share where applicable).

Where usedAppears in Requirements / Limits for vaccines and contraceptives in the formulary listings

Provider noteACA designation affects member cost-sharing, not PA/QL steps unless separately flagged

inv-104: QL (redundant reference)

QL repeatedQuantity Limit — numeric cap over a specified period (e.g., QL 60 per 30 days); appears in Requirements / Limits.

FormatsFormats include per 30 days, per 28 days, per 365 days, or specific mL/month or grams/month (e.g., 6 grams/month for SANTYL).

Provider actionRequests beyond QL may need medical justification/supporting documentation

inv-105: LA (redundant reference)

LA repeatedLimited Access — additional restriction often used with specialty and oncology agents; may require restricted pharmacy or site-of-care coordination.

ExamplesMany MS and oncology agents list LA alongside PA (e.g., ENTYVIO, ACTEMRA, oncology antineoplastics).

Billing impactLA entries can indicate MB billing or infusion-site requirements

inv-106: Requirements / Limits = ACA explanation

ACA as Requirements / Limits'Requirements / Limits = ACA' indicates coverage or limits governed by ACA-mandated contraceptive/preventive coverage provisions as recorded in the formulary.

ExamplesNumerous oral contraceptives, devices, and select vaccines are labeled 'ACA' in the formulary listings.

Member effectACA designation typically means no member cost share when eligibility criteria are met

inv-107: PA (redundant reference)

PA notePrior authorization requires plan approval before the prescription is filled; absence of PA risks denial.

How it's displayedShown in the Requirements / Limits column next to the drug entry

Provider actionSubmit PA per payer process with supporting clinical documentation

inv-108: QL (redundant reference)

QL noteQuantity limits specify the maximum amount covered in the stated time frame (e.g., QL 20 per 365 days for fidaxomicin).

Common unitsCounts per 30/28/365 days, milliliters per month, grams per month, or device counts per period

Provider implicationPharmacy claims exceeding QL may require PA or documentation justification

Step Therapy Rules and Instances

Policy element	Requirement / Note
Step therapy (ST)
Member must try specified first-line medication(s) before coverage of the listed alternative; ST flag indicates prior trial of preferred agent(s) is required (see formulary line-item).

Program / Flag	Implication in this formulary
Och (oncology program)
Oncology/antineoplastic agents annotated with 'Och' indicate program-level management; these entries commonly require PA and may also have LA or QL — program-level controls apply though explicit step sequences are not detailed in this excerpt.

Product	Formulary flag
Topiramate oral capsule (sprinkle)
ST (step therapy) — product is annotated with ST indicating a step-therapy requirement applies per formulary notes.

Drug / Class	Utilization controls shown
Migraine biologics (e.g., AIMOVIG, AJOVY, EMGALITY) and select migraine agents (NURTEC, UBRELVY)
PA required and QL specified for many products (examples: AIMOVIG PA; QL 1 per 30 days; AJOVY PA; QL 1.5 per 30 days). No explicit multi-step sequences are provided in the cited chunks.

Product group	Utilization controls
Multiple sclerosis and specialty agents (e.g., AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, KESIMPTA)
Many are subject to PA and QL and some to LA (site-of-care/list-assist); the cited chunks do not provide explicit step-therapy sequences.

Product	Formulary flag
Adapalene topical products (e.g., adapalene topical gel 0.3%, adapalene gel with pump)
Marked 'ST' in formulary — step therapy edits apply for these acne topical products; specific step requirements are not listed in the excerpt.

Entries marked	Meaning / action
PA (Prior Authorization)
Indicates prior authorization is required before coverage; providers must obtain PA per plan processes when PA is shown next to the product. Specific PA criteria/forms not included in cited chunks.

Product	Utilization control
SOLIQUA 100/33 subcutaneous insulin pen
Requirements / Limits = PA — product requires prior authorization; no explicit step sequence shown in the cited chunk.

Product	Formulary flag
Metformin oral solution 500 mg/5 ml
Requirements / Limits = ST — product is marked ST indicating step therapy applies (member must try preferred agent(s) first).

Product group	Utilization controls
Specialty/biologic agents (examples in cited chunks: SKYRIZI, ADALIMUMAB variants, OTEZLA, RINVOQ)
Many are annotated with PA and often LA and QL (e.g., SKYRIZI PA; LA; QL 1 per 56 days; ACTEMRA PA; LA; QL 4 per 28 days). These products may also be subject to layered/step requirements though explicit sequences are not provided in the excerpt.

Products	Controls noted
Various biologics and specialty immunology agents (e.g., ACTEMRA, ADALIMUMAB products, RINVOQ, SIMLANDI, SIMPONI)
Require Prior Authorization (PA) and frequently Limited Access (LA) and Quantity Limits (QL); explicit multi-step sequencing is not provided in the cited chunks. Providers must obtain PA and comply with QL/LA where shown.

Flag	Interpretation
LA (Limited Access)
LA indicates layered or site/distribution restrictions often in addition to PA (examples: many biologics and immunology products marked PA; LA; QL). Specific step details for LA are not provided in these chunks.

Segment	Step therapy detail
Selected formulary segments in cited excerpts
No explicit step therapy sequences or multi-step edit details are provided in these chunks; most utilization controls shown are PA, LA, QL, or ACA. Where ST is present it is noted on the line-item but detailed step requirements are not included in the provided excerpts.

Quantity Limits (Per Product Examples)

inv-122: Multiple quantity limit examples summary

Multiple QL examples summaryExamples in the formulary include 30 per 30 days, 60 per 30 days, 18 per 30 days, 1 per 28/30/56/84/365 days, 84 mL per month, 6 grams per month, and device counts (e.g., 2 per 30 days for sensors)

Therapeutic scopeQLs apply across antivirals, injectables, inhalation solutions, topical enzymes, devices, and biologics

Period formatsQLs are expressed per 5/28/30/56/84/90/365 day periods or per month/year depending on product

inv-123: RELENZA DISKHALER inhalation blister with device 5 mg/actuation — QL

RELENZA DISKHALERRequirements / Limits = QL (2 per 365 days)

TierDrug Tier = 3

ImplicationYearly cap of 2 units per 365 days

inv-124: SELZENTRY oral solution 20 mg/mL — QL

SELZENTRY oral solution 20 mg/mLRequirements / Limits = QL (8 per 30 days)

TierDrug Tier = 3

ImplicationMonthly liquid quantity limited to 8 (per 30 days)

inv-125: ALECENSA oral capsule 150 mg — QL 240

ALECENSA oral capsule 150 mgRequirements / Limits = PA; Och; LA; QL (240 per 30 days)

TierDrug Tier = 4 (antineoplastic)

NoteHigh-limit QL for oncology oral agent subject to oncology program and limited access

inv-126: fidaxomicin oral tablet 200 mg — QL 20

fidaxomicin oral tablet 200 mgRequirements / Limits = PA; QL (20 per 365 days)

TierDrug Tier = 3

Period20 tablets per 365 days

inv-127: CAYSTON inhalation solution 75 mg/mL — QL 84

CAYSTON inhalation solution 75 mg/mLRequirements / Limits = PA; 84 MILLILITERS PER MONTH; LA

TierDrug Tier = 4

MeasureQuantity limit expressed in milliliters per month

inv-128: TENOFOVVIR DISOPROXIL FUMARATE 300 mg — QL 30

TENOFOVIR DISOPROXIL FUMARATE 300 mgRequirements / Limits = QL (30 per 30 days)

TierDrug Tier = 1

ImplicationMonthly tablet limit of 30

inv-129: JAKAFI oral tablet — QL 60

JAKAFI oral tabletRequirements / Limits = PA; Och; LA; QL (60 per 30 days)

TierDrug Tier = 4

Monthly cap60 tablets per 30 days

inv-130: KOMZIFTI oral capsule — QL 90

KOMZIFTI oral capsuleRequirements / Limits = PA; Och; QL (90 per 30 days)

TierDrug Tier = 4

Monthly cap90 capsules per 30 days

inv-131: LYNPARZA oral tablet — QL 120

LYNPARZA oral tabletRequirements / Limits = PA; Och; LA; QL (120 per 30 days)

TierDrug Tier = 4

Monthly cap120 tablets per 30 days

inv-132: REVUFORJ oral tablet — up to 240/160/110 depending on strength

REVUFORJ oral tablet (various strengths)Requirements / Limits = PA; Och; QL (up to 240/160/110 per 30 days depending on strength)

TierDrug Tier = 4

Strength-dependentQL varies by strength (examples provided in formulary)

inv-133: EPIDIOLEX oral solution — QL 400

EPIDIOLEX oral solutionRequirements / Limits = QL (400 per 30 days)

TierDrug Tier = (listed in section) — high-cost specialty formulation

Monthly cap400 mL (or units as listed) per 30 days

inv-134: Migraine and triptan class examples (AIMOVIG, AJOVY, EMGALITY, NURTEC, UBRELVY) — varied QL

Migraine / Triptan class examplesAIMOVIG QL 1 per 30 days; AJOVY QL 1.5 per 30 days; EMGALITY QL 1 per 30 days (or 3 per 30 days for 300 mg syringes); NURTEC QL 8 per 30 days; UBRELVY QL 10 per 30 days; triptans often QL 18 per 30 days

PA presenceMany migraine biologics require PA in addition to QL

VariationQL varies by product presentation (pens, syringes, tablets)

inv-135: Examples including memantine and extended-release opioids — varied QL

Varied QL examples (memantine, ER opioids)memantine QL 30 per 30 days; morphine ER QL 120 per 30 days; oxycodone ER QL 90 or 120 per 30 days; dalfampridine QL 60 per 30 days

ImplicationER opioid and neurologic agents have higher monthly caps with PA flags for some formulations

Provider noteMonitor QL when prescribing extended‑release opioids to avoid exceedance

inv-136: ketorolac oral tablet — QL 20 per 5 days

ketorolac oral tabletRequirements / Limits = QL (20 per 5 days)

Use-caseShort-duration analgesic limit (per 5 days)

Provider actionAdhere to 5-day supply limit to remain within formulary QL

inv-137: AVONEX intramuscular syringe kit — QL 1 per 30 days

AVONEX intramuscular syringe kitRequirements / Limits = PA; LA; QL (1 per 30 days)

TierDrug Tier = 4

Monthly cap1 kit per 30 days

inv-138: BETASERON subcutaneous kit — QL 14 per 30 days

BETASERON subcutaneous kitRequirements / Limits = PA; LA; QL (14 per 30 days)

TierDrug Tier = 4

Monthly cap14 kits per 30 days

inv-139: dimethyl fumarate DR/EC — multiple QL depending on pack/strength

dimethyl fumarate (DR/EC)Requirements / Limits = PA; QL (14 per 365 days) or PA; LA; QL (1 per 365 days) or PA; QL (60 per 30 days) depending on pack/strength

Variation by packMultiple QL entries reflect pack/strength differences

Provider implicationCheck exact SKU/strength to determine applicable QL

inv-140: glatiramer 20 mg/ml — QL 30 per 30 days

glatiramer 20 mg/mL syringeRequirements / Limits = PA; LA; QL (30 per 30 days)

glatiramer 40 mg/mL syringeRequirements / Limits = PA; LA; QL (12 per 30 days)

Provider noteMS agents commonly carry PA/LA/QL requirements

inv-141: glatiramer 40 mg/ml — QL 12 per 30 days

glatiramer 40 mg/mL syringeRequirements / Limits = PA; LA; QL (12 per 30 days)

TierDrug Tier = 3

Monthly cap12 syringes per 30 days

inv-142: KESIMPTA subcutaneous pen — QL 1 per 30 days

KESIMPTA subcutaneous penRequirements / Limits = PA; LA; QL (1 per 30 days)

TierDrug Tier = 4

Monthly cap1 pen per 30 days

inv-143: teriflunomide tablets — QL 30 per 30 days

teriflunomide tablets (7 mg, 14 mg)Requirements / Limits = PA; LA; QL (30 per 30 days)

TierDrug Tier = 4

Monthly cap30 tablets per 30 days

inv-144: VUMERITY oral capsule — QL 120 per 30 days

VUMERITY oral capsule 231 mgRequirements / Limits = PA; LA; QL (120 per 30 days)

TierDrug Tier = 4

Monthly cap120 capsules per 30 days

inv-145: eltrombopag — QL varies by strength

eltrombopagRequirements / Limits = PA; QL (30 or 60 per 30 days depending on strength)

FormulationsPowder/tablet strengths determine 30 vs 60 per 30 days limits

Provider noteVerify strength to determine applicable QL

inv-146: rivaroxaban 2.5 mg — QL 60 per 30 days

rivaroxaban 2.5 mgRequirements / Limits = QL (60 per 30 days)

TierDrug Tier = 1

Monthly cap60 tablets per 30 days

inv-147: icosapent ethyl — QL 120 per 30 days

icosapent ethylRequirements / Limits = QL (120 per 30 days)

TierDrug Tier = 1

Monthly cap120 capsules per 30 days

inv-148: SKYRIZI / STEQEYMA / TALTZ / TREMFYA / YESINTEK — various QL

SKYRIZI / STEQEYMA / TALTZ / TREMFYA / YESINTEKVarious QL specified (examples: 1 per 84 days, 1 per 28 days, 1 per 56 days, 6 per 365 days) depending on product and presentation

Common patternPA and often LA accompany QL for these biologics

Provider actionCheck specific SKU to confirm exact QL period and quantity

inv-149: adapalene-benzoyl peroxide topical gel pump — QL 45 per 30 days

adapalene-benzoyl peroxide gel (pump)Requirements / Limits = QL (45 per 30 days)

TierDrug Tier = 1

Monthly cap45 pumps per 30 days

inv-150: SANTYL topical ointment — QL 6

SANTYL topical ointment 250 unit/gramRequirements / Limits = 6 grams per month

TierDrug Tier = 3

MeasureQuantity expressed in grams per month

inv-151: FORZINITY subcutaneous solution — QL 1

FORZINITY subcutaneous solution 80 mg/mLRequirements / Limits = PA; QL (1 per 30 days)

TierDrug Tier = 4

Monthly cap1 unit per 30 days

inv-152: JOENJA oral tablet 70 mg — QL 60

JOENJA oral tablet 70 mgRequirements / Limits = PA; QL (60 per 30 days)

TierDrug Tier = 4

Monthly cap60 tablets per 30 days

inv-153: PYRUKYND oral tablet — QL 60

PYRUKYND oral tabletRequirements / Limits = PA; QL (60 per 30 days)

TierDrug Tier = 4

Monthly cap60 tablets per 30 days

inv-154: trientine oral capsule 250 mg — QL 240

trientine oral capsule 250 mgRequirements / Limits = PA; QL (240 per 30 days)

TierDrug Tier = 3

Monthly cap240 capsules per 30 days

inv-155: DEXCOM G7 sensor device — QL 2 per 30 days

DEXCOM G7 sensor deviceRequirements / Limits = QL (2 per 30 days)

TierDrug Tier = 3 (device)

Monthly cap2 sensors per 30 days

inv-156: calcitonin nasal spray — QL 1 per 30 days

calcitonin (salmon) nasal sprayRequirements / Limits = PA; QL (1 per 30 days)

TierDrug Tier = 3

Monthly cap1 unit per 30 days

inv-157: MYALEPT and tolvaptan — QL examples

MYALEPTRequirements / Limits = PA; LA; 27 units per month

tolvaptanRequirements / Limits = PA; LA; QL (60 per 30 days)

Provider implicationBoth products require PA and have specified monthly/unit limits

inv-158: testosterone gel (metered-dose and packet) — QL examples

testosterone gel (metered-dose 50 mg/5 g)Requirements / Limits = 60 units per fill

testosterone gel (packet)Requirements / Limits = 30 packets per fill

Alternate packSome packet presentations listed with QL 30 or 60 per 30 days depending on strength/formulation

inv-161: tolvaptan oral tablet — QL 60 per 30 days

tolvaptan oral tabletRequirements / Limits = PA; LA; QL (60 per 30 days)

TierDrug Tier = 4

Monthly cap60 tablets per 30 days

inv-162: Injectable pens and GLP-1 pen limits

liraglutide penRequirements / Limits = PA; 2-3 pens per 30 days (product dependent)

MOUNJARO / TRULICITY / OZEMPIC pensRequirements / Limits = PA; 1-4 pens per 30 days (product dependent)

RYBELSUSRequirements / Limits = PA; QL (30 per 30 days)

inv-163: MOUNJARO / TRULICITY / OZEMPIC pens — QL ranges

MOUNJARO / OZEMPIC / TRULICITY pensRequirements / Limits = PA with pen-per-30-days limits (examples: 1–4 pens per 30 days for some products)

Provider actionPA required and pen limits vary by product — check specific SKU

Denial riskClaims exceeding pen QL or without PA may be denied

inv-164: CIMZIA — QL 1 per 28 days

CIMZIARequirements / Limits = PA; LA; QL (1 per 28 days)

TierDrug Tier = 4

Monthly cap1 kit per 28 days

inv-165: ENTYVIO pen — QL 2 per 28 days

ENTYVIO pen 108 mg/0.68 mLRequirements / Limits = PA; LA; QL (2 per 28 days)

TierDrug Tier = 4

Biologic cap2 pens per 28 days

inv-166: RYBELSUS — QL 30 per 30 days

RYBELSUS oral tabletRequirements / Limits = PA; QL (30 per 30 days)

TierDrug Tier = 2

Monthly cap30 tablets per 30 days

inv-167: granisetron tablet — QL 6

granisetron HCl 1 mg tabletRequirements / Limits = QL (6 per 30 days)

TierDrug Tier = 3

Monthly cap6 tablets per 30 days

inv-168: LINZESS — QL 30

LINZESS oral capsuleRequirements / Limits = PA; QL (30 per 30 days)

TierDrug Tier = 2

Monthly cap30 capsules per 30 days

inv-169: SKYRIZI wearable injector — QL 1

SKYRIZI wearable injectorRequirements / Limits = PA; LA; QL (1 per 56 days for wearable injector) and some presentations QL 1 per 84 days

TierDrug Tier = 4

Dose intervalInjectable biologic with extended dosing interval reflected in QL

inv-170: ZYMFENTRA pen/syringe kit — QL 2

ZYMFENTRA pen/syringe kitRequirements / Limits = PA; QL (2 per 28 days)

TierDrug Tier = 4

Pack limit2 kits per 28 days

inv-171: VELSIPITY — QL 30

VELSIPITY oral tablet 2 mgRequirements / Limits = PA; LA; QL (30 per 30 days)

TierDrug Tier = 4

Monthly cap30 tablets per 30 days

inv-172: VARUBI — QL 2

VARUBI oral tablet 90 mgRequirements / Limits = PA; 2 tablets per fill

TierDrug Tier = 3

Per-fill cap2 tablets per fill

inv-173: various biologics — QL examples

Biologics examples (typical QL patterns)Examples shown: 4 per 28 days; 8 per 28 days; 1 per 28 days; 1 per 365 days; 30 per 30 days; 112 per 365 days depending on product

Common flagsPA and LA commonly accompany QL for high-cost biologics (e.g., ACTEMRA, ENBREL, ORENCIA, ADALIMUMAB variants)

Provider actionVerify exact SKU and QL period for each biologic to determine allowable dispensing

inv-174: teriparatide pen — QL 1 per 30 days

teriparatide subcutaneous pen injectorRequirements / Limits = PA; LA; QL (1 per 30 days)

TierDrug Tier = 4

Monthly cap1 pen per 30 days

inv-175: ORENCIA — QL 4 per 28 days

ORENCIA (various presentations)Requirements / Limits = PA; LA; QL (4 per 28 days)

TierDrug Tier = 4

Period4 units per 28 days depending on presentation

inv-176: RINVOQ XR 45 mg — QL 112

RINVOQ XR 45 mgRequirements / Limits = PA; LA; QL (112 per 365 days)

TierDrug Tier = 4

Yearly cap112 tablets per 365 days

inv-177: SIMLANDI — QL examples

SIMLANDI autoinjector 40 mgRequirements / Limits = PA; LA; QL (4 per 28 days)

SIMLANDI autoinjector 80 mgRequirements / Limits = PA; LA; QL (1 per 28 days)

SIMLANDI syringes (20/40 mg)Requirements / Limits = PA; LA; QL (2 or 4 per 28 days depending on syringe strength)

inv-181: SIMPONI — QL 1

SIMPONI pen/syringeRequirements / Limits = PA; LA; QL (1 per 28 days)

TierDrug Tier = 4

Monthly cap1 pen or syringe per 28 days

inv-182: XELJANZ products — QL examples

XELJANZ oral solutionRequirements / Limits = PA; LA; QL (2 per 30 days)

XELJANZ tabletsRequirements / Limits = PA; LA; QL (60 per 30 days)

XELJANZ XRRequirements / Limits = PA; LA; QL (30 per 30 days)

inv-185: YUFLYMA products — varied QL

YUFLYMA productsRequirements / Limits = PA; QL varies by SKU (examples: 1 per 365 days, 1 per 28 days, 4 per 28 days)

TierDrug Tier = 4

SKU-dependentCheck specific presentation to determine QL and period

OpenPayer

Metallic (M4) Formulary Drug List — Premera Blue Cross of Washington

Coverage Criteria and Formulary Scope

Coding, Formulary Codes, and Quantity Examples

Provider Actions, Prior Authorization, and Documentation

Policy Background and Governance

Definitions and Abbreviations

Step Therapy Rules and Instances

Quantity Limits (Per Product Examples)

Site-of-Care and Benefit Type (Medical vs Pharmacy)