Formulary drug list (Preferred B3) — anti-infectives and other categories (partial)
A portion of Premera Bluecross Preferred (B3) formulary drug list describing covered generic, brand, and specialty drugs, tier assignments (Generic=1, Brand=2, Non-Preferred Brand=3) and utilization management restrictions (PA, QL, ST, SP, LA, HCLV, ACA).
No material clinical or coverage changes reported in this brief.
Coverage Summary
General formulary coverage rules and restrictions
General formulary coverage rules and restrictions. Covered drugs are listed on the Preferred (B3) formulary with tier assignment and any Requirements / Limits noted in the adjacent column. Coverage is subject to the member's benefit plan and to the following plan-level rules and utilization management (UM) flags:
ALL of the following
- Drugs are assigned to one of three tiers: Tier 1 (Generic), Tier 2 (Preferred Brand), Tier 3 (Non-Preferred Brand).
- Coverage for a drug is determined by the member's specific benefit plan; the formulary indicates inclusion but final coverage depends on the contract and member booklet.
- Prior Authorization (PA): Certain drugs require prior approval before coverage. Without PA, the drug may not be covered.
Provider must submit clinical documentation supporting medical necessity when PA is required.
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