CurrentPremera BluecrossPolicy N/A

Preferred (B4) Formulary Drug List — coverage and utilization requirements

Preferred (B4) formulary listing describing covered generic, brand, non-preferred, and specialty drugs, with tiers, utilization management controls (PA, ST, QL), site-of-care restrictions, and limits that apply to members whose benefit includes the Preferred (B4) drug list.

Policy Summary

PayerPremera Bluecross

PolicyPreferred (B4) Formulary Drug List — coverage and utilization requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required documentation when a drug entry lists PA, SP, LA, ST, or QL to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4drug tiers described

~200+distinct drug entries (this fragment)

manyentries with PA/SP/LA/QL

partialdocument fragment

19chunks in extract

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Coverage Criteria & General Conditions

General coverage conditions

Covered when ALL of the following are met:

Formulary coverage prerequisites: Drug must be included on the member's plan drug list (formulary) and coverage is subject to the member's benefit contract and member booklet.

See the Requirements / Limits column for product-specific controls (PA, QL, ST, SP, LA, HCLV, age limits).

Utilization management requirements: When a listed drug has utilization management flags, the corresponding requirement(s) must be satisfied for coverage.

Examples of requirements: Prior Authorization (PA) — obtain payer approval before dispensing; Quantity Limit (QL) — do not exceed the listed quantity per time period; Step Therapy (ST) — trial of specified alternative(s) required before coverage; Specialty Pharmacy (SP) — may require dispensing via specialty channel and generally limited to a one-month supply; Limited Access (LA) — drug may be limited to an in‑network specialty pharmacy; High‑Cost Low Value (HCLV) — drug may be excluded if a lower‑cost therapeutic equivalent exists.

Documentation and prior authorization: Providers must submit required clinical documentation to support prior authorization, step‑therapy exceptions, or requests to exceed quantity limits when those are listed.

Failure to obtain required PA/SP/LA or to meet QL/ST/HCLV rules may result in denial or non‑coverage of the drug.

Drugs designated HCLV (High‑Cost Low Value) may be excluded from coverage under certain member plans when a lower‑cost generic or therapeutic equivalent is available. The formulary notes that HCLV flags indicate the product is not covered under the specific plan if a lower‑cost alternative exists, even when the drug appears on the plan's drug list.

The document portion provided does not define clinical coverage criteria or exclusion logic for individual drugs; instead each formulary line shows administrative requirements and limits (for example: PA, SP, OCh, LA, HCLV, QL). Coverage decisions are governed by those listed Requirements / Limits for each product.

No explicit clinical exclusions are presented in this excerpt. Entries primarily list per‑product administrative controls such as PA, SP, LA, HCLV, ST, and numeric QL values (e.g., QL (1 per 365 days) shown for starter packs).

This excerpt does not contain standalone exclusion statements; instead it records product‑specific requirements and limits (for example: ST; QL (30 per 30 days); HCLV), which the provider must satisfy for coverage per the formulary entry.

No explicit clinical exclusion criteria are included in this portion of the formulary. The entries focus on administrative coverage controls — for example, many multiple sclerosis and specialty agents are listed with PA, SP, LA, and specified QL values that must be met for coverage.

Within this document fragment there are no standalone exclusion rules; the listings show Requirements / Limits such as PA, SP, HCLV, and numeric QL values which govern coverage on a per‑product basis.

Formulary Listings & Coding Notes

Covered NDC / Formulary EntriesNDCCovered

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML	fluconazole oral suspension for reconstitution 40 mg/mL — Tier = 3; Requirements / Limits = HCLV
VFEND ORAL SUSPENSION FOR RECON 200 MG/5 ML (40 MG/ML)	voriconazole oral suspension for reconstitution 200 mg/5 mL (40 mg/mL) — Tier = 3; Requirements / Limits = ST; HCLV

Sample formulary entriesNDC

Sample-1	Example entry 1
Sample-2	Example entry 2
Sample-3	Example entry 3
Sample-4	Example entry 4
Sample-5	Example entry 5

Lipid/Cholesterol agentsNDC

atorvastatin oral tablet	atorvastatin — various strengths; Requirements / Limits = ACA
ezetimibe oral tablet 10 mg	ezetimibe — Requirements / Limits = none listed
CRESTOR ORAL TABLET	rosuvastatin — Requirements / Limits = PA; HCLV

inv-12: Specialty supply limit — generally limited to a month supply on dispense

Specialty supply limitSpecialty Drugs are generally limited to a month supply on dispense.

inv-13: Example quantity limits — EDURANT QL = 30 per 30 days; EDURANT PED QL = 180 per 30 days

Example quantity limitsEDURANT QL = 30 per 30 days; EDURANT PED QL = 180 per 30 days

inv-14: Quantity limit examples — 60 per 30 days; 90 per 30 days; 120 per 30 days

Quantity limit examplesExamples include 60 per 30 days; 90 per 30 days; 120 per 30 days

inv-15: Example quantity limit — QL (1200 per 30 days)

Example quantity limitQL (1200 per 30 days)

inv-16: Example quantity limits — QL (30 per 30 days); QL (60 per 30 days)

Example quantity limitsQL (30 per 30 days); QL (60 per 30 days)

inv-17: Sodium oxybate/XYREM limits — QL (3 per 30 days)

Sodium oxybate/XYREM limitsQL (3 per 30 days)

inv-18: Quantity Limits examples — Examples include TECFIDERA 120 mg QL 14 per 365 days; TECFIDERA 240 mg QL 60 per 30 days; MAYZENT STARTER QL 7 or 12 per 365 days; VUMERI…

Quantity Limits examplesTECFIDERA 120 mg QL 14 per 365 days; TECFIDERA 240 mg QL 60 per 30 days; MAYZENT STARTER QL 7 or 12 per 365 days; VUMERI examples

Authorization, Documentation, and Step Therapy

Prior Authorization

Prior Authorization Commonly Required

Many medications on the formulary require prior authorization (PA) before they will be covered. Examples include numerous high-cost antiviral, oncology, specialty, and multiple sclerosis agents. When an entry’s Requirements / Limits column lists PA (and/or SP, LA, HCLV, OCh), obtain prior authorization before dispensing — failure to do so may result in non‑coverage or a claim denial.

PA noted alongside many antiviral agents (e.g., EPCLUSA, HARVONI, SOFOSBUVIR-VELPATASVIR, SOVALDI).
Oncology and immunosuppressant products commonly list PA plus SP and site-of-care or limited-access routing.
Multiple sclerosis agents (AUBAGIO, AVONEX, GILENYA, MAVENCLAD, etc.) frequently require PA and specialty pharmacy handling.

Prior Authorization

Quantity Limits May Trigger Prior Authorization

Quantity limits (QL) are shown for specific formulations or dosing schedules (e.g., PAXLOVID QL (40 per 30 days) or (40 per 90 days), EPIDIOLEX QL (400 per 30 days), and many others). If a prescription exceeds the listed quantity limit, prior authorization may be required to approve the excess.

QL entries are per time period (per 30 days, per 365 days, etc.) — confirm the period on the formulary line.
Some QLs appear together with PA (e.g., BRIVIACT, SPRITAM, OJEMDA) — both rules must be satisfied for coverage.

Prior Authorization

Prior Authorization and Specialty/Limited‑Access Requirements

Specialty pharmacy (SP), limited access (LA), high-cost/low-volume (HCLV), and onsite administration (OCh) designations often accompany PA. When SP or LA is indicated, the drug may need to be routed through a designated specialty or limited-access channel; authorization must reflect that routing.

Examples: many hepatitis C agents list PA; SP; LA. Oncology and biologic agents list PA; SP; OCh; LA.
If SP/LA is required, submit requests through the plan’s specialty process — pharmacies may not be able to dispense through retail channels.

Documentation Required

Required Documentation and Supporting Clinical Information

Providers must submit supporting clinical information when drugs are restricted by PA, ST, QL, HCLV, SP, or LA. The formulary line for each product indicates the specific Requirements / Limits; use that as the operational checklist when preparing an authorization request.

Provide diagnosis, prior treatment history (to satisfy step therapy), dosage and expected duration, and justification for any quantity in excess of QL.
For specialty or high-cost agents include site-of-care rationale and any required lab/imaging results if applicable.

Step Therapy

Step Therapy Requirements

Step therapy (ST) applies to many products; items marked ST require that specified alternative therapies be tried and documented before the request for the restricted drug will be approved. Confirm which step(s) are applicable from the formulary entry and document prior trials, dates, and reasons for discontinuation or failure.

Step edits appear across therapeutic classes (e.g., neurology/psychiatry, tetracyclines, select cardiovascular drugs).
When ST is listed, submit documentation showing attempts at required alternatives and clinical rationale for moving to the requested agent.

Denial Risk

Denial Risks and Required Abbreviations

Claims may be denied or delayed if prior authorization, specialty routing, step therapy, or quantity‑limit requirements shown on the formulary are not met. Review the Requirements / Limits column for each product and ensure submissions include all requested information to avoid denial.

Missing PA or SP often triggers a denial or requires retrospective review; excess QL without PA can result in partial or no coverage.
Abbreviations to watch for: PA (prior authorization), SP (specialty pharmacy), LA (limited access), HCLV (high cost/low volume), OCh (office/clinic administration), QL (quantity limit), ST (step therapy).

Step Therapy Instances & Tables

Scope	Policy
Where 'ST' appears in a product's Requirements / Limits
Step therapy applies — the member must try specified alternative agent(s) listed by the plan before coverage will be provided for the requested product.

Examples	Notes
Hepatitis C agents (e.g., EPCLUSA, HARVONI) marked PA; SP; LA
These products are routed through specialty pharmacy and prior authorization channels; step or pathway edits may apply as indicated in Requirements / Limits.

Drugs / Classes	Requirement
Tetracycline-class and related agents (examples: DORYX MPC, doxycycline monohydrate, minocycline, NUZYRA, SEYSARA, XIMINO)
Marked 'ST' in Requirements / Limits — step therapy must be satisfied prior to coverage; several entries also include HCLV.

Products	Requirement
Brivaracetam (BRIVIACT) formulations; ELEPSIA XR
ST indicated (brivaracetam entries show ST; QL where listed; ELEPSIA XR listed with ST and QL).

Products	Requirement
Lamotrigine starter/disintegrating kits (LAMICTAL ODT starter packs) and lamotrigine disintegrating tablets
Requirements / Limits = ST (and HCLV for starters); step therapy must be followed before coverage for these starter/disintegrating formulations.

Examples	Requirement
Various products across musculoskeletal and analgesic classes (document examples)
Listed with 'ST' in Requirements / Limits — step therapy applies where indicated (see individual product lines).

Examples	Requirement
COXANTO 300 mg capsule; diclofenac submicronized 35 mg; EC-NAPROSYN delayed-release tablets
Requirements / Limits show 'ST' for these formulations — step therapy must be satisfied prior to coverage.

Selected products	Requirement
BUPROPION ER 450 mg; CLOZARIL; EXXUA; FANAPT; FETZIMA; INVEGA ORAL; LATUDA
Entries list 'ST' in Requirements / Limits for multiple CNS/behavioral health agents — step therapy applies as indicated per product.

Examples	Requirement
Listed antidepressants/antipsychotics and related agents (examples include PAXIL CR, PRISTIQ, QUETIAPINE 150 mg, TRINTELLIX, others)
'ST' designation indicates step therapy requirement must be met before these products are covered.

Cardiovascular examples	Requirement
Agents such as ARBLI, DIOVAN HCT, HYZAAR, BENICAR HCT (and related antihypertensive/antiarrhythmic products) listed in cardiovascular section
Some cardiovascular entries show 'ST' in Requirements / Limits — step therapy applies where indicated for these products.

Examples	Requirement
JAVADIN oral solution; MICARDIS HCT; NORLIQVA (and other listed antihypertensives)
Requirements / Limits include 'ST' for select products — step therapy must be followed prior to coverage as shown per line-item.

Product	Requirement
NIACOR (niacin formulations) listed in formulary
Requirements / Limits = ST — step therapy applies before coverage for the listed NIACOR entry.

Quantity Limits (QL) — Per-product Examples

EDURANT — 30 (quantity limit summary)

EDURANT — summary QL30 per 30 days.

Formulation referencedEDURANT oral tablet 25 mg listed with QL (30 per 30 days).

TierEDURANT is listed at Drug Tier = 2 in the formulary.

EDURANT PED (for suspension) — 180

EDURANT PED (suspension) — QL180 per 30 days.

FormulationEDURANT pediatric oral tablet for suspension 2.5 mg listed with QL (180 per 30 days).

TierPediatric EDURANT listed at Drug Tier = 2 in formulary lines.

EDURANT oral tablet 25 mg — 30

EDURANT 25 mg tablet QL30 per 30 days.

Drug TierEDURANT oral tablet 25 mg listed at Drug Tier = 2.

Reference lineSee formulary entry for EDURANT oral tablet 25 mg with QL (30 per 30 days).

EDURANT pediatric oral tablet for suspension 2.5 mg — 180

EDURANT pediatric suspension 2.5 mg QL180 per 30 days.

RequirementsListed with QL (180 per 30 days) in formulary pediatric entry.

Tier notePediatric EDURANT entry appears under Drug Tier = 2.

PAXLOVID oral tablets, dose pack (150 mg/100 mg variants) — 40

PAXLOVID (150/100 mg dose pack)Quantity limit: 40 (packs) — QL (40 per 90 days) shown for certain variants.

Dose-pack variantsFormulary lists PAXLOVID dose pack variants with QL (40 per 90 days) and QL (40 per 30 days) depending on strength.

Prior auth implicationQuantity limits may trigger PA or coverage checks if exceeded.

PAXLOVID oral tablets, dose pack (300 mg variant) — 40

PAXLOVID (300 mg variant)Quantity limit: 40 (packs) — QL (40 per 30 days) for the 300 mg dose pack.

Formulary noteDifferent dose-pack strengths have QL values that vary by time frame.

Coverage riskExceeding QL may require additional authorization or result in denial.

EMTRIVA oral solution 10 mg/mL — 720

EMTRIVA oral solution 10 mg/mLQuantity limit: 720 per 30 days.

Formulary entryEMTRIVA oral solution 10 mg/mL listed with QL (720 per 30 days).

TierEMTRIVA oral solution shown at Drug Tier = 2 in listings.

SUNLENCA oral tablet 300 mg — 2

SUNLENCA oral tablet 300 mgQuantity limit: 2 per 365 days.

Formulary requirementsSUNLENCA tablet listed with PA; SP; QL (2 per 365 days).

TierSUNLENCA listed at Drug Tier = 4.

SUNLENCA subcutaneous solution 309 mg/mL — 6

SUNLENCA subcutaneous solution 309 mg/mLQuantity limit: 6 per 365 days.

RequirementsSUNLENCA subcutaneous solution listed with PA; SP; QL (6 per 365 days).

Tier noteSpecialty handling (PA/SP) applies to injectable formulation.

YEZTUGO oral tablet 300 mg — 4

YEZTUGO oral tablet 300 mgQuantity limit: 4 per 365 days.

Formulary flagsYEZTUGO oral tablet listed with PA; SP; QL (4 per 365 days).

TierYEZTUGO listed at Drug Tier = 4.

YEZTUGO subcutaneous solution 309 mg/mL — 1

YEZTUGO subcutaneous solution 309 mg/mLQuantity limit: 1 per 180 days.

RequirementsYEZTUGO subcutaneous solution listed with PA; SP; QL (1 per 180 days).

Site-of-careInjectable formulation subject to specialty distribution and timeline limits.

XOFLUZA oral tablet — 2

XOFLUZA oral tabletQuantity limit: 2 per 365 days.

Formulary noteXOFLUZA entries show HCLV and QL (2 per 365 days) in listings.

Coverage implicationHCLV designation may affect coverage under specific plans.

CAYSTON inhalation solution 75 mg/mL — 84

CAYSTON inhalation solution 75 mg/mLQuantity limit: 84 per 30 days.

RequirementsCAYSTON listed with PA; SP; LA; QL (84 per 30 days).

TierCAYSTON listed at Drug Tier = 4 for nebulized therapy.

XIFAXAN oral tablet 200 mg and 550 mg — 60

XIFAXAN 200 mg & 550 mgQuantity limit: 60 per 30 days for both 200 mg and 550 mg formulations.

RequirementsXIFAXAN entries list PA and QL (60 per 30 days).

Therapeutic usesUsed for specific infectious indications with PA and QL controls.

Ivermectin / STROMECTOL — 20

Ivermectin / STROMECTOLQuantity limit: 20 per 30 days.

Formulary flagsSome ivermectin strengths also show HCLV; QL (20 per 30 days) is listed for multiple presentations.

TierIvermectin entries appear under Drug Tier = 1-3 depending on formulation.

ALUNBRIG oral tablet (90/180 mg dose pack) — 30

ALUNBRIG dose packQuantity limit: 30 per 30 days for selected 90/180 mg dose pack presentations.

Alternate pack QLSome ALUNBRIG dose pack presentations also list QL (60 per 30 days) for other pack sizes.

RequirementsALUNBRIG entries include PA; SP; OCh and QL controls.

ALECENSA ORAL CAPSULE 150 MG — 240

ALECENSA 150 mgQuantity limit: 240 per 30 days.

RequirementsALECENSA listed with PA; SP; OCh; LA; QL (240 per 30 days).

TierALECENSA is a Tier 4 specialty agent in the formulary.

DANZITEN ORAL TABLET 71 MG, 95 MG — 120

DANZITEN 71 mg, 95 mgQuantity limit: 120 per 30 days.

RequirementsDANZITEN entries include PA; SP; OCh; HCLV; QL (120 per 30 days).

TierListed as Tier 4 specialty medication in the formulary.

LUMAKRAS ORAL TABLET 120 MG — 240

LUMAKRAS 120 mgQuantity limit: 240 per 30 days.

RequirementsListed with PA; SP; OCh; LA; QL (240 per 30 days).

TierLUMAKRAS included as Tier 4 specialty antineoplastic.

ODOMZO — 30

ODOMZOQuantity limit: 30 per 30 days.

RequirementsODOMZO listed with PA; SP; OCh; LA; QL (30 per 30 days).

TierODOMZO is listed as a Tier 4 specialty product.

PIQRAY — (quantity limit not shown in excerpt)

PIQRAY — numeric QL not shownPIQRAY listed with Requirements = PA; SP; OCh; no explicit numeric QL shown in the excerpt.

Formulary flagsPIQRAY entries include specialty and oncology channel controls in the formulary lines.

Coverage actionPA and SP designations apply; consult full formulary details for numeric QL if applicable.

TYKERB — 180

TYKERBQuantity limit: 180 per 30 days.

RequirementsTYKERB listed with PA; SP; OCh; HCLV; QL (180 per 30 days).

TierTYKERB is a Tier 4 specialty oncology agent.

EPIDIOLEX — 400

EPIDIOLEX oral solutionQuantity limit: 400 per 30 days (mL).

RequirementsEPIDIOLEX listed with PA; SP; LA; QL (400 per 30 days).

TierEPIDIOLEX included as Tier 4 specialty neurology agent.

ELEPSIA XR ORAL TABLET EXTENDED RELEASE — QL (60 per 30 days)

ELEPSIA XR (1,000/1,500 mg)Quantity limit: QL (60 per 30 days).

RequirementsELEPSIA XR entry shows ST; HCLV; QL (60 per 30 days).

Therapeutic classListed among neurologic/anticonvulsant products with QL controls.

EQUETRO ORAL CAPSULE ER — QL (60 per 30 days)

EQUETRO ER (100/200 mg)Quantity limit: QL (60 per 30 days).

RequirementsEQUETRO ER listed with ST; QL (60 per 30 days).

Formulation noteOther EQUETRO strengths may have different QL (e.g., 300 mg = 120 per 30 days).

EQUETRO ORAL CAPSULE ER 300 MG — QL (120 per 30 days)

EQUETRO ER 300 mgQuantity limit: QL (120 per 30 days).

RequirementsEQUETRO ER 300 mg listed with ST; QL (120 per 30 days).

ContextHigher-strength ER formulations have higher QL allowances per 30 days.

LEVETIRACETAM ORAL TABLET ER — QL (60 per 30 days)

LEVETIRACETAM ER 500/750 mgQuantity limit: QL (60 per 30 days).

Formulary noteLevetiracetam ER listed with QL (60 per 30 days) in the anticonvulsant section.

TierListed among neurology agents with QL controls.

OXTELLAR XR 150/300/600 mg — QL (varies)

OXTELLAR XR 150 mgQuantity limit: QL (480 per 30 days).

OXTELLAR XR 300 mgQuantity limit: QL (240 per 30 days).

OXTELLAR XR 600 mgQuantity limit: QL (120 per 30 days).

perampanel oral tablet (various strengths) — QL (30 per 30 days)

Perampanel (various strengths)Quantity limit: QL (30 per 30 days).

RequirementsPerampanel oral tablets listed with PA; QL (30 per 30 days) for tablet strengths.

Formulary classListed under neurology agents with step/authorization controls.

VIMPAT ORAL TABLET 100 MG — QL (120 per 30 days)

VIMPAT 100 mgQuantity limit: QL (120 per 30 days).

VIMPAT 50 mgQuantity limit: QL (240 per 30 days).

RequirementsVIMPAT entries include PA and QL values by strength.

VIMPAT ORAL TABLET 50 MG — QL (240 per 30 days)

VIMPAT 50 mgQuantity limit: QL (240 per 30 days).

Formulary noteHigher QL allowance for lower-strength tablets reflecting dosing patterns.

RequirementsPA and QL specifications apply per product line.

SPRITAM ORAL TABLET FOR SUSPENSION — QL (ranges listed per strength: e.g., 90, 180, 360 per 30 days)

SPRITAM oral suspension tabletsQuantity limits vary by strength: e.g., QL 90, 180, 360 per 30 days depending on strength.

RequirementsSPRITAM entries list PA and strength-specific QL ranges (90–360 per 30 days).

Formulary placementListed under neurology with PA/QL controls for different strengths.

TONMYA sublingual tablet — 60

TONMYA sublingual tabletQuantity limit: 60 per 30 days.

RequirementsTONMYA listed with PA; QL (60 per 30 days) in formulary.

Therapeutic classListed among muscle relaxants/neurology agents with controls.

hydrocodone bitartrate (ER 12hr) — 60

Hydrocodone bitartrate (ER 12 hr)Quantity limit: 60 per 30 days.

RequirementsHydrocodone ER entries include PA and QL (60 per 30 days) for certain extended-release strengths.

Opioid class noteMany opioid ER products show PA and QL controls in the formulary.

morphine oral capsule extended release (examples) — 60

Morphine ER examplesQuantity limit examples: 60 per 30 days (capsules) and 90 per 30 days (pellets) depending on formulation.

RequirementsMorphine ER listings include PA and QL values per formulation/strength.

Formulary noteDifferent morphine presentations have distinct QL controls (60–120 per 30 days).

morphine oral capsule extend.release pellets — 90

Morphine pellets (extended-release)Quantity limit: 90 per 30 days for pellet formulations.

Oxycodone ER rangeOxycodone ER products show QL ranges typically 90–120 per 30 days depending on strength.

Formulary controlsPA, HCLV, and QL designations apply across opioid ER products.

oxycodone ER products — 90-120

Oxycodone ER productsQuantity limits commonly 90–120 per 30 days depending on strength/formulation.

RequirementsOxycodone ER listings include PA; HCLV; QL entries by strength.

Coverage implicationExceeding QL may require PA or be denied per formulary controls.

NUCYNTA ORAL TABLET — 181

NUCYNTA oral tabletQuantity limit: 181 per 30 days.

NUCYNTA ERQuantity limit: 60 per 30 days for ER formulations.

RequirementsNUCYNTA entries show PA; HCLV; QL values in formulary lines.

NUCYNTA ER ORAL TABLET — 60

NUCYNTA ER oral tabletQuantity limit: 60 per 30 days.

Formulary flagsNUCYNTA ER listed with PA; HCLV; QL (60 per 30 days).

Therapeutic classIncluded in opioid ER product listings with utilization controls.

SUBOXONE SUBLINGUAL FILM (selected strengths) — 90

SUBOXONE sublingual film (selected strengths)Quantity limit: 90 per 30 days.

ZUBSOLVQuantity limits vary by strength (e.g., 90 / 30 / 60 / 30) depending on formulation.

RequirementsBuprenorphine products include QL and PA/HCLV flags per strength.

ZUBSOLV SUBLINGUAL TABLET (selected strengths) — 90 / 30 / 60 / 30 (varies by strength)

ZUBSOLV selected strengthsQuantity limits vary by strength: 90 / 30 / 60 / 30 (varies by strength).

Formulary noteDifferent ZUBSOLV strengths have distinct QL entries in the formulary.

Coverage implicationPrescribers should check strength-specific QL when requesting fills.

SPRIX NASAL SPRAY — 5

SPRIX nasal sprayQuantity limit: 5 per 30 days.

RequirementsSPRIX listed with QL (5 per 30 days) in formulary entries.

Formulary classIncluded among analgesic nasal formulations with QL controls.

VYSCOXA ORAL SUSPENSION — 1200

VYSCOXA oral suspensionQuantity limit: 1200 per 30 days.

Formulary flagsVYSCOXA listed with PA; QL (1200 per 30 days).

UnitLarge-volume oral suspensions may have high per-30-day QL values.

BUCAPSOL ORAL CAPSULE 10/15 mg — QL (120 per 30 days)

BUCAPSOL 10/15 mgQuantity limit: QL (120 per 30 days).

BUCAPSOL 7.5 mgQuantity limit: QL (60 per 30 days).

RequirementsBUCAPSOL entries include HCLV and QL values by strength.

BUCAPSOL ORAL CAPSULE 7.5 mg — QL (60 per 30 days)

BUCAPSOL 7.5 mgQuantity limit: QL (60 per 30 days).

Formulary noteLower-strength BUCAPSOL has lower QL allowance than higher strengths.

TierListed in behavioral health/CNS section with HCLV and QL flags.

EXXUA ORAL TABLET EXT REL 24HR — QL (30 per 30 days)

EXXUA ER 24 hrQuantity limit: QL (30 per 30 days).

EXXUA dose packDose pack (32 tabs) QL: 1 per 365 days for the 18.2 mg dose pack.

RequirementsEXXUA entries include ST and QL controls per formulation.

EXXUA ORAL TABLET EXT REL 24HR DOSE PACK 18.2 MG (32 TABS) — QL (1 per 365 days)

EXXUA dose pack (18.2 mg, 32 tabs)Quantity limit: QL (1 per 365 days).

Formulary flagsDose pack listed with ST; QL (1 per 365 days) in the formulary.

Coverage implicationAnnual-limited starter/dose packs require plan-specific authorization.

lisdexamfetamine oral capsule / chewable — QL (30 per 30 days)

Lisdexamfetamine formulationsQuantity limit: QL (30 per 30 days) for oral capsules/chewable forms.

Formulary noteApplies to multiple lisdexamfetamine dosage forms listed in the formulary.

Therapeutic classCNS/stimulant agents commonly constrained to monthly QL (30 per 30 days).

LUMRYZ ORAL EXTEND RELEASE GRANULES — QL (30 per 30 days)

LUMRYZ ER granulesQuantity limit: QL (30 per 30 days).

LUMRYZ starter packQuantity limit: QL (1 per 365 days) for starter pack.

RequirementsLUMRYZ entries include PA; SP; LA; QL per pack/formulation.

LUMRYZ STARTER PACK — QL (1 per 365 days)

LUMRYZ starter packQuantity limit: QL (1 per 365 days).

Formulary flagsStarter pack listed with PA; SP; LA; QL (1 per 365 days).

Coverage noteAnnual starter pack limits require prior authorization per formulary.

On document examples (various) — QL (1200 per 30 days)

On-document example (various)Multiple entries list QL (1200 per 30 days) as an example for select products.

Use-caseHigh QL values applied to large-volume oral suspensions or solutions in the formulary.

Documentation notePrescribers must adhere to listed QL values; exceeding them may require PA.

SUNOSI ORAL TABLET 150 MG — QL (30 per 30 days)

SUNOSI 150 mgQuantity limit: QL (30 per 30 days).

Formulary listingSUNOSI listed with QL (30 per 30 days) in the formulary excerpt.

Therapeutic noteApplies to wakefulness-promoting agent formulations with monthly QL.

XYREM ORAL SOLUTION — QL (3 per 30 days)

XYREM oral solutionQuantity limit: QL (3 per 30 days).

RequirementsXYWAV/XYREM entries list PA; SP; LA; QL (3 per 30 days) for sodium oxybate products.

Coverage implicationRestrictive monthly QL and specialty handling apply to sodium oxybate products.

dimethyl fumarate (Tecfidera) 120 mg/240 mg formulations — multiple QLs

Tecfidera 120 mgQuantity limit: 14 per 365 days for the 120 mg DR/EC formulation.

Tecfidera 240 mgQuantity limit: 60 per 30 days for the 240 mg DR/EC formulation.

Pack variant120 mg (14)-240 mg (46) pack: QL 1 per 365 days for the combined pack.

Mavenclad (tablet packs varying counts) — PA; SP; LA (no numeric QL shown in excerpt)

Mavenclad pack listingsMavenclad (multiple tablet pack sizes) — Requirements: PA; SP; LA (no numeric QL shown in excerpt).

Coverage flagsMavenclad entries include specialty and limited-access designations; numeric QL not provided in excerpt.

ActionRefer to full formulary entry for pack-specific dispensing limits if needed.

MAYZENT starter packs — QL 7 or 12 per 365 days

MAYZENT starter packsQuantity limits: QL 7 per 365 days (1 mg maint starter) and QL 12 per 365 days (2 mg maint starter).

RequirementsMAYZENT starter packs listed with PA; SP; LA in addition to QL limits.

TierMAYZENT designated as Tier 4 specialty therapy in the formulary.

VUMERITY 231 mg — QL 120 per 30 days

VUMERITY 231 mgQuantity limit: QL 120 per 30 days.

RequirementsVUMERITY listed with PA; SP; LA; QL (120 per 30 days).

Therapeutic classListed among multiple sclerosis agents with specialty handling.

PONVORY 20 mg — QL 30 per 30 days

PONVORY 20 mgQuantity limit: QL 30 per 30 days.

RequirementsPONVORY entries include PA; SP; HCLV; LA; QL (30 per 30 days).

TierPONVORY is listed as a Tier 4 specialty MS agent.

INZIRQO oral suspension; HEMICLOR — INZIRQO QL 300 per 30 days; HEMICLOR QL 30 per 30 days

INZIRQO oral suspensionQuantity limit: QL 300 per 30 days.

HEMICLORQuantity limit: QL 30 per 30 days for Hemiclor (12.5 mg tablet).

RequirementsINZIRQO listed with PA; HCLV; QL (300 per 30 days).

HEMICLOR ORAL TABLET 12.5 MG — 30

HEMICLOR 12.5 mgQuantity limit: 30 per 30 days.

RequirementsHemiclor entry lists PA; HCLV; QL (30 per 30 days) in formulary.

Therapeutic classListed under cardiovascular/antiarrhythmic section with utilization controls.

KERENDIA ORAL TABLET 10 MG — 60

KERENDIA 10 mgQuantity limit: 60 per 30 days.

KERENDIA 20/40 mgQuantity limit: 30 per 30 days for 20 mg and 40 mg strengths.

RequirementsKERENDIA entries include PA and QL specifications by strength.

KERENDIA ORAL TABLET 20 MG, 40 MG — 30

KERENDIA 20/40 mgQuantity limit: 30 per 30 days.

Formulary flagsKERENDIA listed with PA; QL (30 per 30 days) for higher strengths.

Therapeutic noteAntihypertensive/renal agents may have strength-specific QL controls.

INZIRQO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML — 300

INZIRQO for reconstitution 10 mg/mLQuantity limit: 300 (per 30 days).

RequirementsINZIRQO entry lists PA; HCLV; QL (300 per 30 days) in the formulary.

Formulary placementListed under cardiovascular/antiarrhythmic agents with utilization controls.

DOPTELET SPRINKLE ORAL CAPSULE, 10 MG — 60

DOPTELET sprinkle 10 mgQuantity limit: 60 per 30 days.

RequirementsDOPTELET SPRINKLE listed with PA; SP; QL (60 per 30 days).

TierDOPTELET included as Tier 4 specialty agent in formulary.

eltrombopag olamine formulations — 30-60 depending on strength

Eltrombopag olamine formulationsQuantity limits: 30–60 per 30 days depending on strength (e.g., 30 per 30 days for some powder/tablet forms; 60 per 30 days for others).

RequirementsEltrombopag listings include PA; SP; QL by formulation and strength.

Therapeutic classHematology agents with strength-specific QL controls.

DOPTELET SPRINKLE ORAL CAPSULE 10 MG — 60

DOPTELET sprinkle 10 mg (repeat)Quantity limit: 60 per 30 days.

Formulary flagsPA; SP; QL (60 per 30 days) present for the sprinkle formulation.

Coverage noteSpecialty handling and quantity controls apply for DOPTELET.

icosapent ethyl oral capsule — 120

Icosapent ethyl oral capsuleQuantity limit: 120 per 30 days.

RequirementsIcosapent ethyl entries list PA; QL (120 per 30 days) in formulary.

Therapeutic classLipid/cholesterol lowering agent with monthly QL.

QFITLIA PEN / QFITLIA SOLUTION — 1

QFITLIA pen/solutionQuantity limit: 1 (per 30 days).

Formulary noteQFITLIA entries list QL (1) indicating single-unit dispensing per period.

Coverage actionSpecialty or limited-access handling may apply for single-unit high-cost products.

Specialty Pharmacy, Infusion Centers & Limited Access

Billing Rule

Route SP/LA products to in‑network specialty pharmacy or vendor

Certain products require PA and specialty designation (PA; SP; LA) and may be limited to in-network specialty pharmacy dispensing or limited distribution vendors; providers must route orders accordingly.

Examples: HEMLIBRA Requirements = PA; SP; LA; many high-cost injectables require SP or LA routing.

Billing Rule

Use specialty pharmacy for SP‑designated high‑cost antivirals

Several high-cost antivirals and other specialty drugs are marked SP; when SP is indicated the medication is generally limited to specialty pharmacy dispensing and requires the specialty workflow.

Examples: EPCLUSA, HARVONI list PA; SP; LA — use specialty pharmacy for dispensing per the entry.

Note

Comply with OCh/LA/HCLV site‑of‑care restrictions

Some products are limited to the oncology channel (OCh), have limited distribution (LA), or are handled through high-cost/limited‑vendor processes (HCLV); providers must comply with these site-of-care designations when arranging therapy.

Examples: many antineoplastic agents list PA; SP; OCh; LA — verify administration setting and vendor routing before requesting coverage.

Note

Coordinate with specialty pharmacy or limited‑access vendor when SP/LA apply

Products with SP or LA designations require adherence to additional site or limited-access rules (e.g., PA; SP; LA) as specified in the formulary entry; providers should coordinate with the in‑network specialty pharmacy or vendor.

Example: LUMRYZ and other specialty products show PA; SP; LA; QL — coordinate specialty pharmacy dispensing and provide required documentation.

Billing Rule

Follow specialty distribution and PA for injectable/subcutaneous specialty agents

Many injectable and specialty agents list SP and may require limited access or specialty distribution; providers must follow the specialty distribution instructions and obtain PA as required.

Examples: VYVGART HYTRULO, ZILBRYSQ — Requirements / Limits = PA; SP; LA.

Note

Confirm site‑of‑care and limited‑access rules for SP/LA products

Products listed with SP or LA require adherence to additional site or limited‑access rules (PA; SP; LA); confirm dispensing vendor and site-of-care before ordering.

Example: HETLIOZ entries show PA; SP; LA and may have QL — ensure correct specialty pathway is used.

Billing Rule

Adhere to SP/LA processes for affected agents

Specialty (SP) and limited‑access (LA) designations are applied to multiple agents and may affect coverage setting and vendor selection; providers must follow the plan's specialty processes.

When SP/LA appears for a product, obtain PA and coordinate dispensing via the in‑network specialty pharmacy or limited‑access vendor.

Note

Verify specialty routing for injectables and specialty agents

Specialty designation (SP) for injectables and specialty agents may affect administration and coverage setting; providers must confirm the required specialty routing and obtain PA when indicated.

Examples: CABLIVI, DOPTELET, HEMLIBRA — Requirements / Limits include PA; SP; LA; coordinate with specialty pharmacy and vendor.

Formulary Background & Governance

The formulary groups drugs by condition and tier (generic, preferred brand, non‑preferred brand, specialty). An independent Pharmacy & Therapeutics Committee evaluates and selects drugs based on safety, effectiveness, and cost and reviews the formulary at least quarterly.

Key Abbreviations & Definitions

Policy Summary

PayerPremera Bluecross

PolicyPreferred (B4) Formulary Drug List — coverage and utilization requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required documentation when a drug entry lists PA, SP, LA, ST, or QL to avoid coverage denial.

SourceLink

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