CurrentPremera BluecrossPolicy N/A

Premera Preferred B3 Drug List — Formulary coverage and utilization management

Lists generic, brand, and specialty drugs covered under Premera Bluecross PPO plans and explains utilization management (PA, ST, QL, SP, LA), tiers, coverage rules, and limits for listed products; applies to providers, pharmacists, and members using Premera prescription benefits.

Policy Summary

PayerPremera Bluecross

PolicyFormulary coverage and utilization management for outpatient drugs (Preferred B3 Drug List)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain required prior authorization, step therapy documentation, or specialty pharmacy enrollment when the drug line indicates PA, ST, SP, LA, or QL.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-tierFormulary tiers

PA/ST/QL/SP/LAUM types described

customer serviceMember help

20+Drugs listed in segment

30–240QL examples noted

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General coverage criteria

Covered when ALL of the following are met

Formulary inclusion: Drug is listed on the Premera drug list (by tier) for the member's plan

See index or category listing in document

Member coverage rules: Coverage is subject to the member's contract terms (deductible, out-of-pocket limits) and to any utilization management restrictions shown in the Requirements/Limits column

Member booklet provides plan-specific financial details

Utilization management compliance: If the drug line indicates PA, ST, QL, SP, or LA, the corresponding requirement must be satisfied for coverage

Details and processes are on the 'Drugs Requiring Approval' webpage

Formulary coverage with utilization management

Drugs listed are on the outpatient formulary with tier assignments; coverage is subject to the listed requirements and limits.

General formulary coverage rules: Coverage for each drug is contingent on meeting all listed conditions: formulary tier, any PA/ST/SP requirements, and applicable quantity limits.

Applies per individual drug entries in the list

Formulary-based coverage management

Coverage is managed per drug with utilization management flags; no clinical AND/OR criteria are provided in this segment.

per-drug coverage flags: Each listed drug line includes a formulary tier and requirement flags (PA, ST, SP, Och, LA, QL) which together determine coverage process.

No patient-level clinical criteria provided in this segment.

Coverage conditional on utilization controls

Coverage is conditional per listed drug when the following utilization controls (as indicated) are satisfied:

utilization controls: Drug is subject to listed controls such as prior authorization (PA), step therapy (ST), site/place limits (SP/LA), and quantity limits (QL) where specified on the drug line.

Apply per-drug requirements listed in the formulary.

Formulary coverage conditional on PA/ST/QL

Coverage is tiered and subject to utilization management; many drugs are covered only with fulfillment of listed requirements

General formulary coverage conditions: Drug coverage depends on tiering and fulfillment of any listed Requirements Limits (PA, ST, QL).

Applies across entries in this document segment

Per-product coverage with utilization controls

Coverage and management stance is product-specific as listed; many agents are covered with utilization controls.

Per-product coverage entries: Each drug entry lists strength, tier, and any Requirements Limits (PA, ST, SP, LA, QL). Coverage decisions follow those entries.

See individual product lines in chunks 216-235 for exact requirements.

Drugs must be listed on the plan’s attached drug list to be considered covered under this document. Coverage for listed products is subject to the formulary tier assignment and any utilization management flags shown on the drug line (for example PA, ST, QL, SP, or LA); when those flags are present the corresponding requirement must be satisfied for coverage. Providers may need to submit supporting clinical information via the plan’s prior authorization process as described on the “Drugs Requiring Approval” webpage.

No explicit blanket exclusion statements are provided in this segment of the formulary; the document presents product line entries with associated requirement flags and quantity limits rather than discrete exclusion language.

This segment does not state any explicit clinical exclusions. Entries list formulary tiers and utilization management indicators for individual products but do not enumerate clinical conditions that are categorically excluded.

No standalone medical necessity criteria or exclusion rules are provided in these chunks; the listing is limited to formulary tier assignments and utilization management flags (for example PA, ST, and numeric QL values) that condition coverage.

There are no explicit exclusion lines in this area of the formulary. Some product entries appear without a 'Requirements Limits' annotation — absence of such a flag on the line indicates no utilization control is shown for that formulation in this excerpt, not that the drug is excluded.

The absence of a 'Requirements Limits' entry on a product line does not, by itself, indicate the product is excluded from coverage. Coverage determinations depend on plan terms, tier placement, and any utilization controls specified elsewhere in the formulary.

No explicit exclusion lines are present in this document segment; the content is a product-level formulary listing showing tiers and any applicable utilization management flags rather than listing excluded drugs.

The topical product excerpt provides formulary tiers and utilization flags (for example PA and ST) but does not include explicit clinical coverage criteria or lines declaring specific exclusions.

Coverage for products that fall outside described limits (for example certain Affordable Care Act preventive medications or where age/quantity exceptions may apply) will follow the member’s plan tier and benefit terms; such situations are handled under plan-specific rules rather than by an explicit exclusion in this formulary listing.

This segment does not include any statements explicitly labeling drugs or uses as Not Medically Necessary. The entries focus on administrative utilization controls (PA, ST, QL, SP, LA) tied to individual product lines.

The content emphasizes product-specific administrative and utilization requirements (for example numerous antineoplastic and immunosuppressant agents list PA, ST, SP, LA and QL flags) and does not include statements designating items as medically unnecessary in this excerpt.

No explicit 'not medically necessary' declarations appear in this part of the formulary; instead entries note administrative requirements (PA/ST/QL) that must be met for coverage.

This document segment contains product listings and utilization management flags but does not include explicit statements categorizing items as 'not medically necessary'.

Drug listing and code / quantity annotations

Formulary drug entries (sample)mixed

LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG	Tier = 3; Requirements Limits = PA; SP; LA
LIVTENCITY ORAL TABLET 200 MG	Tier = 3; Requirements Limits = PA; SP
BREXAFEMME ORAL TABLET 150 MG	Requirements Limits = PA; ST; QL (24 per 180 days)
DESCOVY ORAL TABLET 200-25 MG	Requirements Limits = PA; ST; QL (30 per 30 days)
DESCOVY ORAL TABLET 120-15 MG	Requirements Limits = PA; ST
HARVONI ORAL TABLET 90-400 MG	Requirements Limits = PA; ST; SP; LA

Selected listed drugs with requirementsmixed

NURTEC ODT ORAL TABLET, DISINTEGRATING 75 MG	Requirements Limits = PA; ST; QL (8 per 30 days)
REYVOW ORAL TABLET 100 MG, 50 MG	Requirements Limits = PA; ST; QL (8 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR	Requirements Limits = ST; QL (16 per 30 days)

Migraine & cluster headache therapy drugsmixed

AIMOVIG AUTOINJECTOR SUBCUTANEOUS	Requirements Limits = PA; ST
AJOVY AUTOINJECTOR SUBCUTANEOUS	Requirements Limits = PA; ST
EMGALITY SUBCUTANEOUS PEN INJECTOR 120 MGMML	Requirements Limits = PA

Miscellaneous neurological drugsmixed

ADLARITY TRANSDERMAL PATCH WEEKLY 10 MG/24 HOUR	Requirements Limits = PA; ST
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG	Requirements Limits = PA; ST; SP; LA; QL (60 per 30 days)
DAYBUE ORAL SOLUTION 200 MGMML	Requirements Limits = PA; SP

Quantity Limit annotationsmixed

QL (18 per 30 days)	e.g., zolmitriptan example noted in policy
QL (24 per 180 days)	BREXAFEMME example
QL (30 per 30 days)	DESCOVY example
QL (240 per 30 days)	Oncology/specialty examples

Drug list (no procedure/diagnosis codes in this segment)mixed

HARVONI ORAL TABLET 45-200 MG, 90-400 MG	Requirements Limits = PA; ST; SP; LA
EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG	Requirements Limits = PA; SP; LA
LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG	Requirements Limits = PA; SP; LA
LIVTENCITY ORAL TABLET 200 MG	Requirements Limits = PA; SP

What providers must do (authorizations, documentation, denials)

Prior Authorization

Prior Authorization and Documentation Requirements

Prior authorization (PA) is required for many drugs listed in this formulary. When a drug’s Requirements/Limits column includes “PA” the prescriber (or their delegated representative) must request and obtain prior authorization from Premera before the prescription is dispensed or coverage may be denied. PA is commonly applied to high-cost, specialty, oncology, oral antineoplastic, and selected immunosuppressive agents as well as certain migraine medications and other selected products.

Obtain PA before dispensing when the Requirements/Limits column includes “PA”.
Many oncology and immunosuppressant oral agents are designated PA; examples include abiraterone, alectinib (ALECENSA), alunbrig, everolimus, imatinib (GLEEVEC), osimertinib (TAGRISSO) and numerous others listed under Antineoplastic & Immunosuppressant Drugs.
Some migraine agents and triptans have quantity limits or PA requirements; examples include REYVOW (PA; ST; QL 8/30 days), RELPAX (QL 18/30 days), rizatriptan and zolmitriptan (QL 18/30 days).
Quantity limits (QL) shown (e.g., “QL (60 per 30 days)”, “QL (240 per 30 days)”) must be observed; requests exceeding QL may be denied without supporting documentation or PA.
Step therapy (ST) applies where indicated. When a drug’s Requirements/Limits includes “ST” prescribers must document trials and failures of required preferred agents per the payer’s step protocol before coverage is approved.
Special programs and limited-access flags (SP, LA, Och, ACA PV) may require enrollment in a specialty pharmacy, medical benefit billing, or other program prior to approval.
Supporting documentation is required for PA/ST/SP/QL requests. Provide clinical rationale, prior treatment history, dosing, and any specialty program enrollment information when submitting an authorization request.
Failure to obtain PA, to follow ST, to enroll in required specialty programs, or to adhere to QL may result in denial or non-coverage of the drug.
High-risk denial triggers: missing PA; unmet ST requirements; exceeding QL; lacking SP/LA enrollment; or failing to supply required supporting documentation.
When PA/ST/QL/SP/LA flags are present, include documentation clearly addressing those flags in the initial authorization request to avoid delays or denials.
Some formulary line items explicitly combine PA and ST (e.g., many antineoplastic, specialty, and topical agents). Prescribers must satisfy both PA and ST where both flags appear.
UM noncompliance (not following utilization management requirements listed in the formulary) is grounds for claim denial; verify the Requirements/Limits column for each product before prescribing or dispensing.
If a medication is marked “PA” or “PA; ST; SP” the prescriber should use Premera’s PA submission channels (electronic portal or fax) and follow posted documentation checklists available on the payer website (Drugs Requiring Approval page).
When quantity limits are listed (for example: QL 120 per 30 days, QL 1 per 30 days, QL 60 per 30 days), indicate the member’s required dosing schedule and rationale for quantities exceeding the listed QL in the authorization request.

Key terms and abbreviations

PA definition — Prior Authorization required before coverage

Prior Authorization (PA)Authorization required before a prescription will be covered; without prior approval the drug may not be covered.

QL definition — Quantity Limit explained (and related terms)

Quantity Limit (QL)A limit on the amount of drug covered per prescription or within a specified time frame (commonly expressed per 30 days).

Step Therapy (ST)Requirement to try preferred or specified alternative therapies first before covering the requested drug.

Specialty Pharmacy (SP)Drugs that require dispensing via a specialty channel and often limited to a month supply; may need enhanced clinical support.

Limited Access (LA)Drugs limited to in‑network specialty pharmacy or restricted distribution due to handling or FDA distribution requirements.

ST definition — Step Therapy explained (and SP/LA notes)

ST (Step Therapy)Before coverage is provided for a drug marked ST, the member must have a documented trial and failure or intolerance of specified preferred agents.

SP (Specialty Pharmacy)Indicates the drug must be dispensed through the designated specialty pharmacy channel and may require enrollment/documentation.

LA (Limited Access)Indicates distribution or administration restrictions (site or limited channel) requiring use of an in‑network specialty pharmacy or specific setting.

PA / QL / SP definitions — alternate excerpts

PA — definition (alternate)Approval required before coverage; listed on drug line as 'PA' — failure to obtain may result in non‑coverage.

QL — definition (alternate)Numeric or supply limit specified per time period (examples shown as 'per 30 days' or per 180 days).

SP — definition (alternate)Specialty drugs typically require enhanced clinical support and are often limited to a 1‑month supply when dispensed via specialty pharmacy.

QL definition (example SOFDRA) — QL 1 per 30 days

QL 1 per 30 days (topical example)SOFDRA topical gel and SOFDRA with pump: QL 1 per 30 days (topical presentations).

QL small-count examplesSome starter/titration kits and topical dose packs are limited to 1 unit per 30 days or 1 per 365 days for starter kits.

PA/ST triggersDrugs annotated with PA or ST require documented authorization or step‑therapy history before coverage is approved.

Step therapy requirements and enforcement

Requirement	Explanation
Attempt required prior agent(s) before coverage	Step therapy requires that specified alternative (preferred) drugs be tried first; coverage for the listed drug is provided only if prior agent(s) fail or are not tolerated.

Requirement	Where shown
ST required	Drugs annotated with 'ST' in the Requirements/Limits column require step therapy before the requested product will be covered.

Requirement	Action required
Meet ST requirements	When the ST flag is present on a drug line, the member must have documented trial and failure (or intolerance) of the required prior therapy per plan step therapy rules before coverage is approved.

Observation	Note
Multiple agents include 'ST'	Many listed products are annotated with 'ST' indicating step therapy applies; specific preferred agents and exact sequencing are shown on the full drug line or must be obtained from the complete policy/list.

Requirement	Documentation expected
Document prior trial(s)/failure(s)	Providers must document prior trials and failures (or contraindications/intolerance) of preferred therapies when ST is present to support authorization of the requested drug.

Requirement	Indicator
ST required where 'ST' listed	If 'ST' appears next to a drug entry in Requirements/Limits, step therapy is a requirement prior to coverage of that product.

Requirement	Effect on coverage
Follow ST for 'ST' annotated products	Products annotated with 'ST' must follow the plan's step therapy edits (trial and failure/intolerance of preferred alternatives) before the requested agent will be approved.

Requirement	Coverage condition
ST must be satisfied	Step therapy requirements (ST flag) must be satisfied before coverage is granted for ST-flagged products; failure to meet ST may result in denial.

Requirement	Scope
ST required when Requirements Limits include ST	Any product with Requirements Limits that list 'ST' requires step therapy — examples and multiple occurrences are present throughout the formulary listing.

Requirement	Implication
ST must be satisfied (flag present)	When a drug line shows the ST flag, members must have met the step therapy conditions before the drug will be covered; noncompliance with ST may trigger denial.

Requirement	Typical product examples
ST applies where 'Requirements Limits = ST'	Step therapy applies for products where the Requirements Limits field equals 'ST' — this is shown for multiple branded combination products and common classes (e.g., ARBs/ACE combinations) in the formulary.

Requirement	Provider action
Trial of preferred alternatives required	Providers must document that the member tried preferred formulary alternatives and either failed to respond or was intolerant before the listed agent will be covered under step therapy rules.

Requirement	Timing
ST required prior to coverage for products marked ST	For products marked with 'ST', the step therapy trial must be completed and documented prior to authorization of the requested drug; these entries appear throughout the formulary listing.

Requirement	Applies to
ST required for listed products flagged ST	Multiple topical and dermatologic products (and other listed agents) flagged 'ST' require completion of step therapy before coverage as indicated on their drug lines.

Quantity limits (QL) by product examples

Examples: zolmitriptan; BREXAFEMME; DESCOVY — sample per-period QL values

Zolmitriptan exampleWe will cover 18 per 30-day supply of zolmitriptan oral tablets (example in coverage restrictions).

BREXAFEMMERequirements Limits = PA; ST; QL (24 per 180 days).

DESCOVYDESCOVY oral tablet 200-25 mg: Requirements Limits = PA; ST; QL (30 per 30 days).

KITABIS PAK inhalation solution — QL 20

KITABIS PAKRequirements Limits = QL (20 per 30 days); PA; ST; SP indicated on drug line.

SIVEXTRO oral tablet 200 mg — QL 6

SIVEXTRO 200 mgRequirements Limits = QL (6 per 30 days)

XIFAXAN oral tablet — QL 60

XIFAXAN 200/550 mgRequirements Limits = PA; ST; QL (60 per 30 days)

ALECENSA oral capsule 150 mg — QL 240

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

capecitabine 500 mg tablet — QL 84 per 30 days

Capecitabine 500 mgRequirements Limits = SP; Och; LA; QL (84 per 30 days)

everolimus 1 mg tablet — QL 300

Everolimus 1 mg (immunosuppressive)Requirements Limits = PA (immunosuppressive formulations noted) — QL 300 per 30 days shown in brief list.

lorbrena 25 mg tablet — QL 120

Lorbrena 25 mgRequirements Limits = PA; SP; Och; LA; QL (120 per 30 days)

ONUREG examples — QL 21 and 14

ONUREG 200 mgRequirements Limits = PA; ST; SP; Och; LA; QL (21 per 30 days)

ONUREG 300 mgRequirements Limits = PA; ST; SP; Och; LA; QL (14 per 30 days)

Per-product QL examples — assorted oncology & neurologic entries

PEMAZYREQL 28 per 30 days

PIQRAYQL 30 per 30 days

QINLOCKQL 90 per 30 days

REVLIMIDQL 30 per 30 days

TABLOIDQL 210 per 30 days

VONJOQL 120 per 30 days

EPIDIOLEXQL 400 per 30 days

KEPPRA (various strengths)QL examples: 9; 90; 360; 180; 120 per 30 days by strength

Selected antiepileptic QL examples

EPIDIOLEXQL 400 per 30 days

FINTEPLA oral solutionQL 210 per 30 days

VIMPAT 50 mgQL 240 per 30 days

TROKENDI XR examplesQL examples: 120; 60; 480; 240 per 30 days

LAMICTAL & KEPPRA examples — multiple QLs

LAMICTAL ODT/tabletQL examples include 225; 113; 900; 450 per 30 days (by formulation/kit)

LAMICTAL XRQL examples include 225; 90; 75; 300 per 30 days depending on strength

KEPPRA solutionQL 9 per 30 days (oral solution entry)

Opioid and related QL examples

Hydrocodone ERQL 60 per 30 days

Morphine ERQL 120 per 30 days

OxyContin / oxycodoneQL 90–120 per 30 days

Buprenorphine‑naloxone films/tabletsQL 60–90 per 30 days depending on strength

Topical small‑count QL examples

ZORYVE topical foam 0.3%QL 1 per 30 days

SOFDRA topical gel (with pump)QL 1 per 30 days

OpenPayer

Premera Preferred B3 Drug List — Formulary coverage and utilization management

Coverage criteria and formulary management

Drug listing and code / quantity annotations

What providers must do (authorizations, documentation, denials)

Key terms and abbreviations

Requirements before initiating therapy

Step therapy requirements and enforcement

Quantity limits (QL) by product examples

Specialty dispensing, infusion, and limited access considerations

Policy governance and formulary maintenance