Premera Bluecross Preferred B3 Formulary Coverage

Coverage Criteria and Formulary Overview

Formulary coverage with utilization conditions

Drugs are covered according to plan benefits when included on the formulary; coverage may be subject to the specific utilization management restrictions listed (PA, QL, ST, SP, LA, HCLV).

Formulary coverage with utilization management: Coverage requires the drug to be listed on the member's plan formulary AND any per‑drug Requirements / Limits must be satisfied (e.g., obtain prior authorization (PA) when indicated, comply with quantity limits (QL), complete step therapy (ST) requirements).

Per‑drug specifics and flags appear in the Requirements / Limits column of the formulary entries (see product lines for PA, QL, ST, SP, LA, HCLV).

Tier-based coverage

Coverage and utilization management approach for listed drugs

Tiered coverage: Drugs are assigned to a coverage tier (Tier 1 = Generic, Tier 2 = Preferred Brand, Tier 3 = Non‑Preferred Brand); actual coverage and member cost sharing depend on the member's benefit design and the drug's tier.

Tier assignments are shown on each formulary line.

Utilization management criteria

Utilization management flags applied

Prior Authorization: Products labeled 'PA' on the formulary require prior authorization before coverage will be provided.

Examples of PA‑flagged products appear throughout the list (e.g., DARAPRIM, various oncology and specialty agents).

Quantity Limits: Products labeled 'QL' are subject to a maximum covered quantity over the specified time period (examples shown per drug line).e.g., XIFAXAN QL = 60 per 30 days; STROMECTOL QL = 20 per 30 days

See item‑level 'Requirements / Limits' entries for exact QL values.

Step Therapy: Products labeled 'ST' or 'SP' require step therapy — the member must try and fail specified preferred alternatives or meet step criteria before the requested product is covered.

Step therapy specifics and acceptable prior agents are defined by the plan's step‑therapy program (examples: certain tetracyclines, select CNS agents).

Formulary coverage by product

Products are listed with tier assignment and any requirements/limits; coverage is per formulary/tier with utilization management as noted.

Formulary entries: Each drug line displays: drug name and strength, Tier (1–3), and Requirements / Limits which may include one or more of: PA (prior authorization), ST (step therapy), HCLV (high‑cost/limited‑value), SP (special program/specialty), QL (quantity limit), LA (limited access/site‑of‑care).

No separate clinical eligibility criteria are specified in these line entries; clinical justification is managed via PA/step programs when applicable.

Formulary coverage with administrative requirements

Drugs listed are covered according to assigned tier and subject to any listed requirements/limits.

Drug coverage entries: Coverage for each drug depends on meeting the per‑product Requirements / Limits shown on the formulary (examples: obtain PA when 'PA' is listed; follow ST when 'ST' is listed; observe QL amounts when 'QL' is listed).

Requirements / Limits flags appear inline on each product row and control coverage/claim adjudication.

Formulary listing with per-product requirements

Coverage and utilization controls are indicated inline per medication

Entry pattern: Each medication line specifies: drug name, strengths, Tier (1–3), and one or more 'Requirements / Limits' flags (PA, ST, HCLV, QL, SP, LA). Coverage is provided when the member's benefit includes the tier AND any listed program requirements/limits are met.

Examples in these chunks include specific QL values (e.g., PONVORY QL 30 per 30 days; TECFIDERA 120 mg pack QL 14 per 365 days; VUMERITY QL 120 per 30 days) and PA/SP/LA flags for specialty agents.

Certain elective therapy categories may be excluded depending on the member's specific benefit design. Examples called out in the formulary abbreviations include programs such as breast cancer prevention agents with age-based coverage rules and administrative designations like HCLV (High-Cost Low Value) and LA (Limited Access) that can restrict coverage. Providers and billing staff must check the member's benefit booklet or plan-specific drug list to confirm whether an item is excluded for that plan or subject to limited distribution or specialty pharmacy routing.

The excerpt does not include standalone clinical inclusion or exclusion criteria; instead it furnishes formulary line entries with tier assignments and utilization-management flags. Coverage language in these sections is limited to drug-level entries showing Tier and a Requirements / Limits field (for example, entries noting PA, SP, OCh, LA, or QL). For clinical determination or medical necessity rules, refer to the full policy or the member's benefit documents.

Within the provided chunks there are no explicit statements that certain diagnoses or clinical scenarios are excluded; entries instead list formulary tier placement (1–3) and administrative controls such as PA, SP, OCh, LA, and QL. Operational teams should interpret coverage as contingent on the drug appearing on the member's formulary and meeting any listed program requirements.

Formulary Listings and Code Tables

Formulary medications with Prior Authorization (PA)mixed

VIREAD 150 mg tablet	Requirements / Limits = PA
VIREAD 200 mg tablet	Requirements / Limits = PA
VIREAD 300 mg tablet	Requirements / Limits = PA
VIREAD 10 mg/mL oral powder for suspension	Requirements / Limits = PA

Selected drug dosage listings (excerpt)mixed

EMTRIVA ORAL CAPSULE 200 MG	Tier = 3; Requirements / Limits = .
EPCLUSA ORAL TABLET 200-50 MG	Tier = 2; Requirements / Limits = PA; SP; LA
STROMECTOL ORAL TABLET 3 MG	Tier = 3; Requirements / Limits = QL (20 per 30 days)
XIFAXAN ORAL TABLET 200 MG	Tier = 3; Requirements / Limits = PA; QL (60 per 30 days)

Additional dosage listingsmixed

TOBI INHALATION SOLUTION 300 MG/5 ML	Tier = 3; Requirements / Limits = PA; SP; HCLV
TOBI PODHALER 28 MG	Tier = 3; Requirements / Limits = PA; SP; HCLV
ZARONTIN ORAL CAPSULE 250 MG	Tier = 3; Requirements / Limits = PA; QL (180 per 30 days)

Formulary line items (no billing codes) — examplesmixed

DARAPRIM ORAL TABLET 25 MG	Tier = 3; Requirements / Limits = PA; SP
EMVERM ORAL TABLET CHEWABLE 100 MG	Tier = 3; Requirements / Limits = PA
HUMATIN ORAL CAPSULE 250 MG	Tier = 3; Requirements / Limits = PA; SP; LA

Drug listing (no procedure codes present) — examplesmixed

tolmetin oral tablet 600 mg	Tier = 1; Requirements / Limits = .
amoxicillin oral capsule 500 mg	Tier = 1; Requirements / Limits = .
nitrofurantoin oral suspension 50 mg/5 ml	Tier = 3; Requirements / Limits = .

Quantity limit codes and examplesmixed

QL	Quantity limit noted — examples: XIFAXAN QL (60 per 30 days), STROMECTOL QL (20 per 30 days), ZARONTIN QL (180 per 30 days)
QL (per 30 days)	Example usages shown in formulary lines

Formulary medication entries (examples)mixed

EMGALITY SUBCUTANEOUS PEN 120 MG/ML	Tier = 2; Requirements / Limits = PA
ELYXYB ORAL SOLUTION 120 MG/4.8 ML	Tier = 3; Requirements / Limits = PA

Special program / limited access medicationsmixed

EPCLUSA ORAL PELLETS IN PACKET 150-37.5 MG	Requirements / Limits = PA; SP; LA
MAVENCLAD ORAL TABLET 10 MG (various pack sizes)	Requirements / Limits = PA; SP; LA
KESIMPTA SUBCUTANEOUS PEN 20 MG/0.4 ML	Requirements / Limits = PA; SP; LA

Neurology / CNS products — grouped formulary entriesmixed

TECFIDERA ORAL CAPSULE 120 MG	Requirements / Limits = PA; SP; LA; QL (14 per 365 days)
PLEGRIDY SUBCUTANEOUS PEN 125 MCG/0.5 ML	Requirements / Limits = PA; SP; LA
MAYZENT ORAL TABLET 0.25 MG, 1 MG, 2 MG	Requirements / Limits = PA; SP; LA

Cardiovascular products — grouped formulary entriesmixed

BETAPACE AF ORAL TABLET 120 MG	Cardiovascular category — tiering shown in formulary
NORPACE CR ORAL CAPSULE ER 100 MG	Cardiovascular category — requirements/limits per formulary
TIKOSYN ORAL CAPSULE 125 MCG	Requirements / Limits = PA

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

amlodipine oral tablet 5 mg	Tier = 1; Requirements / Limits = .
lisinopril oral tablet 10 mg	Tier = 1; Requirements / Limits = .
losartan oral tablet 50 mg	Tier = 1; Requirements / Limits = .

Quantity limits examples — XIFAXAN and STROMECTOL examples

XIFAXAN exampleQL (60 per 30 days)

STROMECTOL exampleQL (20 per 30 days)

Quantity limits examples — assorted QL examples

Assorted QL examplesZARONTIN QL (180 per 30 days), ZONISADE QL (6 per 30 days)

Quantity limits for select opioids — examples include 60, 90, 120 per 30 days

Select opioid QL examplesmorphine ER QL (60, 90, 120 per 30 days shown for different formulations)

Actions Required by Providers (Authorizations, Documentation, Denials)

Prior Authorization

Prior authorization required

Prior authorization is required for many listed drugs. Providers must submit a prior authorization (PA) request when a drug's "Requirements / Limits" field includes PA — claims may be denied if PA is not obtained.

Submit PA per Premera procedures (see payer website/drugs requiring approval).
PA applies across therapeutic classes (anti-infectives, antivirals, antineoplastics, neurology, cardiovascular, etc.).
Examples: BREXAFEMME, CRESEMBA, NOXAFIL, VIVJOA, EPCLUSA, HARVONI, MAVYRET, SOFOSBUVIR-VELPATASVIR — many require PA; some also require SP/LA/OCh.

Prior Authorization

PA plus specialty/site/other program requirements

Some products require PA plus additional program flags such as Specialty (SP), Limited Access/Distribution (LA), Oncology Chemotherapy (OCh), or Quantity Limits (QL). Providers must follow the combined controls for coverage; obtaining PA alone may be insufficient.

Examples: EPCLUSA, HARVONI, MAVYRET, SOFOSBUVIR-VELPATASVIR = PA; SP; LA.

Step Therapy Policies and Affected Products

Coverage requirement	Notes / examples
Step therapy (ST)
When a product's Requirements / Limits column lists 'ST', step therapy is required before coverage of the listed agent. Examples in the formulary include cyclobenzaprine extended‑release and other agents marked 'ST' (muscle relaxants, certain NSAID formulations, some CNS agents). Providers must document prior trial/failure or contraindication to preferred agents per the plan's step‑therapy rules.

Coverage requirement

Notes / examples

Step therapy (ST)

When a product's Requirements / Limits column lists 'ST', step therapy is required before coverage of the listed agent. Examples in the formulary include cyclobenzaprine extended‑release and other agents marked 'ST' (muscle relaxants, certain NSAID formulations, some CNS agents). Providers must document prior trial/failure or contraindication to preferred agents per the plan's step‑therapy rules.

Coverage requirement	Notes / examples
SP (step program / specialty) designation
Products flagged 'SP' in the Requirements / Limits column are subject to step edits (step‑therapy program). Examples shown include EPCLUSA, HARVONI, MAVYRET, SOFOSBUVIR‑VELPATASVIR, SOVALDI and other antiviral agents; specifics of required prior steps are not provided in this excerpt and must be confirmed in the full step‑therapy policy.

Coverage requirement	Notes / examples
Step therapy applies to tetracycline-class products
Multiple tetracycline formulations are labeled 'ST' in the Requirements / Limits column (examples include DORYX MPC, doxycycline DR/EC 80 mg, minocycline ER), indicating step therapy must be met before coverage of these agents.

Coverage requirement	Notes / examples
ST required for certain muscle relaxants and ER formulations
Some muscle relaxants and extended‑release formulations are marked 'ST' (step therapy) — e.g., AMRIX (cyclobenzaprine formulations) and certain cyclobenzaprine ER entries show 'ST' as a requirement in the formulary list.

Documentation required	Notes
Documentation of prior therapy or rationale for exceptions
Providers must supply clinical information demonstrating prior trial and failure, intolerance, or contraindication to preferred agents when step therapy (ST) is indicated. The formulary notes that drugs subject to restrictions generally require additional information to obtain coverage (e.g., examples described in 'Are there any restrictions on my coverage?').

Coverage requirement	Notes / examples
ST applies where indicated on line items
The formulary indicates 'ST' on multiple line items across therapeutic areas (examples include selected CNS/neurology and cardiovascular formulations); when 'ST' appears on a product line, step therapy must be satisfied before coverage is approved.

Coverage requirement	Notes / examples
ST required for higher‑tier/branded combination products where indicated
Many higher‑tier or branded combination cardiovascular and antihypertensive agents list 'ST' in Requirements / Limits (for example EXFORGE, EXFORGE HCT, CARDIZEM products, LOTENSIN HCT and others). These products require compliance with step‑therapy programs prior to coverage as indicated per their formulary lines.

Quantity Limits (QL) by Product — Examples

zolmitriptan example — 18 per 30 days

Zolmitriptan (example)Quantity limit example: 18 per 30 days

ContextQuantity limits are listed in the Requirements / Limits column and limit amounts covered per timeframe

EDURANT PED oral tablet for suspension example — 180 per 30 days

EDURANT PED (oral tablet for suspension)QL = 180 per 30 days

EDURANT (regular tablet)EDURANT oral tablet 25 mg listed with QL = 30 per 30 days on formulary lines (see EDURANT entries)

PAXLOVID quantity limit example — 40

Specialty, Infusion, and Limited-Access Site Requirements

Billing Rule

Use in‑network specialty pharmacy when required

For certain specialty or limited distribution drugs the formulary requires dispensing through an in‑network specialty pharmacy or has specialty site‑of‑care routing; fill these via the designated specialty pharmacy channel or follow site‑of‑care instructions indicated.

Example: many products labeled 'SP' or 'LA' must be filled at an in‑network specialty pharmacy.

Documentation Required

Follow LA/OCh site‑of‑care instructions

Some products include LA or OCh flags indicating site‑of‑care or limited access requirements (e.g., certain inhaled/infused agents); check the product line for LA/OCh and arrange administration at the specified setting (infusion center, office, or home) as required.

Abbreviations and Requirement Flags

Formulary Scope and Notes

This formulary organizes medications by therapeutic category and assigns each product a coverage Tier (1–3) reflecting Generic, Preferred Brand, or Non‑Preferred Brand placement; actual member cost-share and coverage depend on the member's benefit design. The list shows per‑product utilization controls in the Requirements / Limits column — common program flags include PA (prior authorization), QL (quantity limits), ST/SP (step therapy/step program), SP (specialty pharmacy), LA (limited access), and HCLV (high-cost/low-value). The Pharmacy & Therapeutics committee reviews placement periodically, and specialty or limited-distribution drugs may be required to be filled through an in‑network specialty pharmacy or specific site of care as noted.

OpenPayer

Formulary (Preferred B3) Drug List — Coverage Criteria