Formulary (drug list)

Formulary updates

Formulary requirements/ 
Guide to prescription drug benefits

Here you’ll find lists of drugs that have special requirements before they are covered by your plan, and an overview of how to use your prescription drug benefits.

If you’re uncertain which formulary applies to you, please check your plan documents, or call the Member Services number on the back of your ID card.

Providers can complete a Prescription Prior Auth through Cover My Meds.

Members please call the number on the back of your ID card to request a copy of a pharmacy clinical policy.

If your provider would like to discuss a pharmacy denial with a physician reviewer, they may call our clinical review department toll free at 866.230.7269.

Clinical pharmacy policies - Prior authorization

Clinical pharmacy policies - Quantity limits

Clinical pharmacy policies - Step therapy

PPACA preventive services

Some preventive medications may be covered at no cost to you when filled at a participating pharmacy with a valid prescription.

ACA Copay Waiver

Capital Blue Cross offers a standard cost-share waiver policy that is applied across all Affordable Care Act categories.

ACA copay waiver form

QHDHP drugs

(This option is available to large groups of 100+ employees and is standard for all groups of less than 100 employees.)

Check you Certificate of Coverage to see if this option applies to your QHDHP. If so, some medications will have the deductible waived, and you will be charged only a copay

Due to a drug list update the following drugs are being removed from the QHDHP List effective January 1, 2024. This list of removed drugs is inclusive of all of the QHDHP collaterals and is subject to change. 2024 QHDHP drug removal list.

Value-Based Design drug list

The prescription drug Value-Based Benefits program is designed to increase adherence to medications used to treat angina/arrhythmia, asthma, diabetes, diabetic supplies, high blood pressure/other cardiovascular conditions, and high cholesterol, which are available to you at a reduced cost. When taken regularly and as prescribed, medications to treat these conditions can increase your likelihood for healthier outcomes.

Limited distribution specialty drugs

This drug list includes drugs on our Commercial formulary. Limited distribution (LD) meaning there is a restriction on which pharmacies can dispense them. This limits where the member may obtain the prescription. Members may be required to use another pharmacy for limited distribution prescription drugs.

Additional offerings

The Enhanced zero dollar drug list includes drugs on our Value Formulary offered at no cost share. This list is not a complete list and does not contain any prior authorization, step therapy or quantity level limit requirements. The Enhanced Zero Dollar Drug List is only applicable to Individual Accounts (non-QHDHP).

The Maintenance Drug List includes drugs that are commonly used to treat conditions that are considered chronic or long-term such as high cholesterol, high blood pressure, asthma, diabetes, or heart disease.

The oral chemotherapy medication list includes drugs on our Commercial formulary.

Refer to the Value, Value Plus, Elite or Exclusive formularies for the medications included with those plans.