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Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the BlueCross BlueShield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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Administrative bulletin: 2026-05-004 Pharmacy updates

Date: May 1, 2026

Effective date: July 1, 2026 (Unless otherwise indicated)

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

Capital Blue Cross Advantage and Value Plus Formulary update.
Capital Blue Cross Elite and Exclusive Formulary update.

Professional and facility Providers

Capital Blue Cross Advantage and Value Plus Formulary update

CHIP

FEP PPO

Medicare Advantage HMO

Traditional and Comprehensive

Medicare Advantage PPO

KEY POINT: The Capital Blue Cross Pharmacy & Therapeutics (P&T) Committee recently reviewed and updated the Commercial Capital Blue Cross Advantage and Value Plus Formularies, as well as the Pharmacy Utilization Management programs.

Please note: The Value Plus Formulary excludes Brand Nonpreferred (BNP).

Changes for July 1, 2026, include the following:

Newly marketed drugs.
An expanded list of drugs requiring prior authorization (PA).
Modified and new quantity level limits (QL) for specific drugs.

A full listing of our Formulary and specifics on our Pharmacy Utilization Management programs are available at CapitalBlueCross.com for Capital Blue Cross and Keystone Health Plan^® Central members.

Capital Blue Cross Formulary update KEY: (PA) = Prior Authorization; (ST) = Step therapy; (QLL) = Quantity Level Limits lowercase bold print = generic; UPPERCASE PRINT = BRAND Formulary Status: Generic Preferred (GP), Generic Non-Preferred (GNP), Brand Preferred (BP), Brand Non-Preferred (BNP), Nonformulary (NF)
Newly marketed drugs effective immediately
Brand name	Tier status	Indication
ANDEMBRY¹ (PA, QLL)	BP	Hereditary angioedema
ANZUPGO (PA, QLL)	BNP	Chronic Hand Eczema (CHE)
BRINSUPRI¹ (PA, QLL)	BNP	Non cystic fibrosis bronchiectasis
DAWNZERA¹ (PA, QLL)	BP	Hereditary angioedema
HERNEXEOS¹ (PA, QLL)	BNP	Anticancer
INLURIYO¹ (PA, QLL)	BNP	Anticancer
JASCAYD¹ (PA, QLL)	BNP	Interstitial Lung Diseases
KOMZIFTI¹ (PA, QLL)	BNP	Acute Myeloid Leukemia (AML)
MODEYSO¹ (PA, QLL)	BNP	Anticancer
REDEMPLO	BP	Antihyperlipidemics
RHAPSIDIO¹ (PA, QLL)	BP	Chronic Spontaneous Urticaria
TRYPTYR (PA, QLL)	BNP	Dry Eye Disease

¹Indicates specialty medication.

Value Plus Formulary excludes Brand Nonpreferred drugs (BNP)

The following medications have either been added to the Prior Authorization (PA) program or updates have been made to the existing Prior Authorization programs.

Pharmacy Management Program update KEY: (PA) = Prior Authorization; (ST) = Step therapy; (QLL) = Quantity Level Limits lowercase bold print = generic; UPPERCASE PRINT = BRAND
Prior Authorization (PA) Utilization Management New Additions Programs² effective July 1, 2026
Drug class/Drug	Purpose/Guidelines
ALKINDI SPRINKLE	Adrenal Insufficiencies
ALLOPURINOL TAB	Gout
ALPHAGAN P	Elevated intraocular pressure (IOP)
AZOPT	Glaucoma
bromfenac sodium ophth soln 0.09% (Base Equiv) (Once-Daily)	Cataracts
carbinoxamine maleate	Allergic Rhinitis
carbinoxamine maleate; CARBZAH	Allergic Rhinitis
CARDIZEM CD	Antihypertension
COMBIGAN	Glaucoma, ocular hypertension
CONDYLOX	Anogenital warts
COREG CR	Mild-to-severe chronic heart failure of ischemic or cardiomyopathic origin
CROTAN; PRURADIK	Scabies
CUPRIMINE	Wilson’s disease
CUVRIOR	Wilson’s disease
furosemide oral soln	Edema
GOCOVRI	Dyskinesia, Parkinson's disease
INDERAL XL; INNOPRAN XL	Hypertension, angina, migraine, hypertrophic subaortic stenosis
JALYN	Symptomatic BPH in men with an enlarged prostate
KEVEYIS	Periodic paralysis
leucovorin calcium tab	Impaired methotrexate elimination
METAXALONE	Skeletal Muscle Relaxant
metaxalone tab 400 mg	Skeletal Muscle Relaxant
MIRAPEX ER	Parkinson’s disease, restless leg syndrome
NORGESIC FORTE; ORPHENGESIC FORTE	Pain Relief
ONGENTYS	Parkinson’s disease
timolol maleate ophth gel forming soln 0.5%	Glaucoma, ocular hypertension
TIMOPTIC OCUDOSE	Elevated intraocular pressure (IOP), glaucoma, ocular hypertension
UCERIS	Ulcerative colitis
ZANAFLEX	Spasticity
zileuton tab er 12hr 600 mg	Prophylaxis, asthma

²Impacted members will be notified prior to the change.

The following medications have been added to the Quantity Level Limits (QL) program.

Pharmacy Management Program update KEY: (PA) = Prior Authorization; (ST) = Step therapy; (QLL) = Quantity Level Limits lowercase bold print = generic; UPPERCASE PRINT = BRAND
Quantity Level Limits (QLL) Program² Effective July 1, 2026
Drug^*	Dosage	Quantity limits
abacavir sulfate tab 300 mg (Base Equiv)	300 MG	60 TABS/30 DAYS
APTIVUS	250 MG	120 CAPS/30 DAYS
atazanavir sulfate cap 150 mg (Base Equiv)	150 MG	30 CAPS/30 DAYS
BIKTARVY	30‑120‑15 MG, 50‑200‑25 MG	30 TABS/30 DAYS
CIMDUO	300‑300 MG	30 TABS/30 DAYS
COMBIVIR	150‑300 MG	60 TABS/30 DAYS
COMPLERA	200‑25‑300 MG	30 TABS/30 DAYS
DELSTRIGO	100‑300‑300 MG	30 TABS/30 DAYS
DESCOVY	120‑15 MG, 200‑25 MG	30 TABS/30 DAYS
DOVATO	50‑300 MG	30 TABS/30 DAYS
EDURANT	25 MG	30 TABS/30 DAYS
EDURANT PED	2.5 MG	180 TABS/30 DAYS
efavirenz	50 MG	90 CAPS/30 DAYS
efavirenz	200 MG	60 CAPS/30 DAYS
efavirenz/lamivudine/teno; symfi lo	400‑300‑300 MG	30 TABS/30 DAYS
efavirenz‑emtricitabine‑tenofovir df tab 600‑200‑300 mg	600‑200‑300 MG	30 TABS/30 DAYS
EMTRIVA	10 MG/ML	680 MLS/28 DAYS
EMTRIVA	200 MG	30 CAPS/30 DAYS
EPIVIR	10 MG/ML; 300 MG/30ML	960 MLS/30 DAYS
	300 MG	30 TABS/30 DAYS
	150 MG	60 TABS/30 DAYS
EPZICOM	600‑300 MG	30 TABS/30 DAYS
EVOTAZ	300‑150 MG	30 TABS/30 DAYS
FUROSEMIDE ORAL SOLN	10 MG/ML	1800 ML/30 DAYS
FUZEON	90 MG	60 VIALS/30 DAYS
GENVOYA	150‑150‑200‑10 MG	30 TABS/30 DAYS
INTELENCE	25 MG	120 TABS/30 DAYS
	200 MG	60 TABS/30 DAYS
	100 MG	60 TABS/30 DAYS
ISENTRESS	25 MG	180 TABS/30 DAYS
	100 MG	180 TABS/30 DAYS
	400 MG	60 TABS/30 DAYS
	100 MG	60 TABS/30 DAYS
ISENTRESS HD	600 MG	60 TABS/30 DAYS
JULUCA	50‑25 MG	30 TABS/30 DAYS
KALETRA	400‑100 MG/5ML	480 MLS/30 DAYS
KALETRA	200‑50 MG	120 TABS/30 DAYS
KALETRA	100‑25 MG	180 TABS/30 DAYS
leucovorin calcium tab	25 MG, 15 MG	30 TABS/30 DAYS
	10 MG	60 TABS/30 DAYS
	5 MG	120 TABS/30 DAYS
LEXIVA	700 MG	120 TABS/30 DAYS
LEXIVA	50 MG/ML	1800 MLS/30 DAYS
NEVIRAPINE	50 MG/5ML	1200 MLS/30 DAYS
nevirapine	100 MG	90 TABS/30 DAYS
nevirapine tab 200 mg	200 MG	60 TABS/30 DAYS
NEVIRAPINE Tab ER 24HR 400 MG	400 MG	30 TABS/30 DAYS
NORVIR	100 MG	360 TABS/30 DAYS
NORVIR	100 MG	360 PACKTS/30 DAYS
ODEFSEY	200‑25‑25 MG	30 TABS/30 DAYS
PIFELTRO	100 MG	30 TABS/30 DAYS
PREZCOBIX	675‑150 MG, 800‑150 MG	30 TABS/30 DAYS
PREZISTA	800 MG	30 TABS/30 DAYS
	75 MG	300 TABS/30 DAYS
	150 MG	180 TABS/30 DAYS
	600 MG	60 TABS/30 DAYS
	100 MG/ML	400 MLS/30 DAYS
RETROVIR	50 MG/5ML	1920 MLS/30 DAYS
RETROVIR	100 MG	180 CAPS/30 DAYS
REYATAZ	50 MG	240 PACKTS/30 DAYS
	300 MG	30 CAPS/30 DAYS
	200 MG	60 CAPS/30 DAYS
RUKOBIA	600 MG	60 TABS/30 DAYS
SELZENTRY	300 MG	120 TABS/30 DAYS
	25 MG	240 TABS/30 DAYS
	75 MG, 150 MG	60 TABS/30 DAYS
	20 MG/ML	1840 MLS/30 DAYS
STRIBILD	150‑150‑200‑300 MG	30 TABS/30 DAYS
SUNLENCA	300 MG	4 TABS/30 DAYS
SUNLENCA; YEZTUGO	300 MG	4 TABS/30 DAYS
SUSTIVA	600 MG	30 TABS/30 DAYS
SYMFI	600‑300‑300 MG	30 TABS/30 DAYS
SYMTUZA	800‑150‑200‑10 MG	30 TABS/30 DAYS
TIVICAY	25 MG, 50 MG	60 TABS/30 DAYS
TIVICAY	10 MG	240 TABS/30 DAYS
TIVICAY PD	5 MG	360 TABS/30 DAYS
TRIUMEQ	600‑50‑300 MG	30 TABS/30 DAYS
TRIUMEQ PD	60‑5‑30 MG	180 TABS/30 DAYS
TRIZIVIR	300‑150‑300 MG	60 TABS/30 DAYS
TRUVADA	200‑300 MG, 167‑250 MG, 133‑200 MG, 100‑150 MG	30 TABS/30 DAYS
TYBOST	150 MG	30 TABS/30 DAYS
VIRACEPT	625 MG	120 TABS/30 DAYS
VIRACEPT	250 MG	270 TABS/30 DAYS
VIREAD	300 MG, 250 MG, 200 MG, 150 MG	30 TABS/30 DAYS
VIREAD	40 MG/GM	240 GRAMS/30 DAYS
ZIAGEN	20 MG/ML	960 MLS/30 DAYS
ZIDOVUDINE Tab 300 MG	300 MG	60 TABS/30 DAYS

¹Indicates specialty medication.

²Impacted members will be notified prior to the change.

Capital Blue Cross Elite and Exclusive Formulary update

CHIP

FEP PPO

Medicare Advantage HMO

Traditional and Comprehensive

Medicare Advantage PPO

KEY POINT: The Capital Blue Cross Pharmacy & Therapeutics (P&T) Committee recently reviewed and updated the Commercial Capital Blue Cross Elite and Exclusive Formularies, as well as the Pharmacy Utilization Management programs.

Changes for July 1, 2026, include the following:

Newly marketed drugs.
An expanded list of drugs requiring prior authorization (PA).
Modified and new quantity level limits (QLL) for specific drugs.

A full listing of our Formulary and specifics on our Pharmacy Utilization Management programs are available at CapitalBlueCross.com for Capital Blue Cross and Keystone Health Plan^® Central members.

Capital Blue Cross Formulary update KEY: (PA) = Prior Authorization; (ST) = Step therapy; (QLL) = Quantity Level Limits lowercase bold print = generic; UPPERCASE PRINT = BRAND Formulary Status: Generic Preferred (GP), Generic Non-Preferred (GNP), Brand Preferred (BP), Brand Non-Preferred (BNP), Nonformulary (NF)
Newly marketed drugs effective immediately
Brand name	Tier status	Indication
ANDEMBRY¹ (PA, QLL)	BP	Hereditary angioedema
ANZUPGO (PA, QLL)	BNP	Chronic Hand Eczema (CHE)
BRINSUPRI¹ (PA, QLL)	BNP	Non cystic fibrosis bronchiectasis
DAWNZERA¹ (PA, QLL)	BP	Hereditary angioedema
HERNEXEOS¹ (PA, QLL)	BNP	Anticancer
INLURIYO¹ (PA, QLL)	BNP	Anticancer
JASCAYD¹ (PA, QLL)	BNP	Interstitial Lung Diseases
KOMZIFTI¹ (PA, QLL)	BNP	Acute Myeloid Leukemia (AML)
MODEYSO¹ (PA, QLL)	BNP	Anticancer
REDEMPLO	BP	Antihyperlipidemics
RHAPSIDIO¹ (PA, QLL)	BP	Chronis Spontaneous Urticaria
SEPHIENCE¹ (PA)	BNP	Phenylketonuria
TRYPTYR (PA, QLL)	BNP	Dry Eye Disease

¹Indicates specialty medication.

²Impacted members will be notified prior to the change.

¹Indicates specialty medication.

²Indicates Limited Distribution.

The following medications have either been added to the Prior Authorization (PA) program or updates have been made to existing Prior Authorization programs.

Pharmacy Management Program update KEY: (PA) = Prior Authorization; (ST) = Step therapy; (QLL) = Quantity Level Limits lowercase bold print = generic; UPPERCASE PRINT = BRAND
Prior Authorization (PA) Utilization Management New Additions Programs² effective July 1, 2026
Drug class/Drug	Purpose/Guidelines
ALKINDI SPRINKLE	Adrenal Insufficiency
allopurinol tab	Gout
ALPHAGAN P	Elevated intraocular pressure (IOP)
AZOPT	Glaucoma
bromfenac sodium ophth soln 0.09% (Base Equiv) (Once-Daily)	Cataracts
carbinoxamine maleate	Allergic Rhinitis
carbinoxamine maleate; CARBZAH	Allergic Rhinitis
CARDIZEM CD	Antihypertension
COMBIGAN	Glaucoma, ocular hypertension
CONDYLOX	Anogenital warts
COREG CR	Mild-to-severe chronic heart failure of ischemic or cardiomyopathic origin
CROTAN; PRURADIK	Scabies
CUPRIMINE	Wilson’s disease
CUVRIOR	Wilson’s disease
furosemide oral soln	Edema
GOCOVRI	Dyskinesia, Parkinson's disease
INDERAL XL; INNOPRAN XL	Hypertension, angina, migraine, hypertrophic subaortic stenosis
JALYN	Symptomatic BPH in men with an enlarged prostate
KEVEYIS	Periodic paralysis
leucovorin calcium tab	Impaired methotrexate elimination
METAXALONE	Skeletal muscle relaxant
metaxalone tab 400 mg	Skeletal muscle relaxant
MIRAPEX ER	Parkinson’s disease, restless leg syndrome
NORGESIC FORTE; ORPHENGESIC FORTE	Pain Relief
ONGENTYS	Parkinson’s disease
timolol maleate ophth gel forming soln 0.5%	Glaucoma, ocular hypertension
TIMOPTIC OCUDOSE	Elevated intraocular pressure (IOP), Glaucoma, ocular hypertension
UCERIS	Ulcerative colitis
ZANAFLEX	Spasticity
zileuton tab er 12hr 600 mg	Prophylaxis, asthma

²Impacted members will be notified prior to the change

¹Indicates specialty medication.

²Indicates Limited Distribution.

The following medications have been added to the Quantity Level Limits (QL) program.

Pharmacy Management Program update KEY: (PA) = Prior Authorization; (ST) = Step therapy; (QLL) = Quantity Level Limits lowercase bold print = generic; UPPERCASE PRINT = BRAND
Quantity Level Limits (QLL) Program² Effective July 1, 2026 (unless otherwise noted below)
Drug class/Drug	Dosage	Quantity limits (per 30 days or as specified)
abacavir sulfate tab 300 mg (base equiv)	300 MG	60 TABS/30 DAYS
APTIVUS	250 MG	120 CAPS/30 DAYS
atazanavir sulfate cap 150 mg (Base Equiv)	150 MG	30 CAPS/30 DAYS
BIKTARVY	30‑120‑15 MG, 50‑200‑25 MG	30 TABS/30 DAYS
CIMDUO	300‑300 MG	30 TABS/30 DAYS
COMBIVIR	150‑300 MG	60 TABS/30 DAYS
COMPLERA	200‑25‑300 MG	30 TABS/30 DAYS
DELSTRIGO	100‑300‑300 MG	30 TABS/30 DAYS
DESCOVY	120‑15 MG, 200‑25 MG	30 TABS/30 DAYS
DOVATO	50‑300 MG	30 TABS/30 DAYS
EDURANT	25 MG	30 TABS/30 DAYS
EDURANT PED	2.5 MG	180 TABS/30 DAYS
efavirenz	50 MG	90 CAPS/30 DAYS
efavirenz	200 MG	60 CAPS/30 DAYS
efavirenz/lamivudine/teno; symfi lo	400‑300‑300 MG	30 TABS/30 DAYS
efavirenz‑emtricitabine‑tenofovir df tab 600‑200‑300 mg	600‑200‑300 MG	30 TABS/30 DAYS
EMTRIVA	10 MG/ML	680 MLS/28 DAYS
EMTRIVA	200 MG	30 CAPS/30 DAYS
EPIVIR	10 MG/ML; 300 MG/30ML	960 MLS/30 DAYS
	300 MG	30 TABS/30 DAYS
	150 MG	60 TABS/30 DAYS
EPZICOM	600‑300 MG	30 TABS/30 DAYS
EVOTAZ	300‑150 MG	30 TABS/30 DAYS
FUROSEMIDE ORAL SOLN	10 MG/ML	1800 MLS/30 DAYS
FUZEON	90 MG	60 VIALS/30 DAYS
GENVOYA	150‑150‑200‑10 MG	30 TABS/30 DAYS
INTELENCE	25 MG	120 TABS/30 DAYS
	200 MG	60 TABS/30 DAYS
	100 MG	60 TABS/30 DAYS
ISENTRESS	25 MG	180 TABS/30 DAYS
	100 MG	180 TABS/30 DAYS
	400 MG	60 TABS/30 DAYS
	100 MG	60 TABS/30 DAYS
ISENTRESS HD	600 MG	60 TABS/30 DAYS
JULUCA	50‑25 MG	30 TABS/30 DAYS
KALETRA	400‑100 MG/5ML	480 MLS/30 DAYS
	200‑50 MG	120 TABS/30 DAYS
	100‑25 MG	180 TABS/30 DAYS
leucovorin calcium tab	25 MG, 15 MG	30 TABS/30 DAYS
	10 MG	60 TABS/30 DAYS
	5 MG	120 TABS/30 DAYS
LEXIVA	700 MG	120 TABS/30 DAYS
LEXIVA	50 MG/ML	1800 MLS/30 DAYS
NEVIRAPINE	50 MG/5ML	1200 MLS/30 DAYS
nevirapine	100 MG	90 TABS/30 DAYS
nevirapine tab 200 mg	200 MG	60 TABS/30 DAYS
NEVIRAPINE Tab ER 24HR 400 MG	400 MG	30 TABS/30 DAYS
NORVIR	100 MG	360 TABS/30 DAYS
NORVIR	100 MG	360 PACKTS/30 DAYS
ODEFSEY	200‑25‑25 MG	30 TABS/30 DAYS
PIFELTRO	100 MG	30 TABS/30 DAYS
PREZCOBIX	675‑150 MG, 800‑150 MG	30 TABS/30 DAYS
PREZISTA	800 MG	30 TABS/30 DAYS
	75 MG	300 TABS/30 DAYS
	150 MG	180 TABS/30 DAYS
	600 MG	60 TABS/30 DAYS
	100 MG/ML	400 MLS/30 DAYS
RETROVIR	50 MG/5ML	1920 MLS/30 DAYS
RETROVIR	100 MG	180 CAPS/30 DAYS
REYATAZ	50 MG	240 PACKTS/30 DAYS
	300 MG	30 CAPS/30 DAYS
	200 MG	60 CAPS/30 DAYS
RUKOBIA	600 MG	60 TABS/30 DAYS
SELZENTRY	300 MG	120 TABS/30 DAYS
	25 MG	240 TABS/30 DAYS
	75 MG, 150 MG	60 TABS/30 DAYS
	20 MG/ML	1840 MLS/30 DAYS
STRIBILD	150‑150‑200‑300 MG	30 TABS/30 DAYS
SUNLENCA	300 MG	4 TABS/30 DAYS
SUNLENCA; YEZTUGO	300 MG	4 TABS/30 DAYS
SUSTIVA	600 MG	30 TABS/30 DAYS
SYMFI	600-300-300 MG	30 TABS/30 DAYS
SYMTUZA	800-150-200-10 MG	30 TABS/30 DAYS
TIVICAY	25 MG, 50 MG	60 TABS/30 DAYS
TIVICAY	10 MG	240 TABS/30 DAYS
TIVICAY PD	5 MG	360 TABS/30 DAYS
TRIUMEQ	600-50-300 MG	30 TABS/30 DAYS
TRIUMEQ PD	60-5-30 MG	180 TABS/30 DAYS
TRIZIVIR	300-150-300 MG	60 TABS/30 DAYS
TRUVADA	200-300 MG, 167-250 MG, 133-200 MG, 100-150 MG	30 TABS/30 DAYS
TYBOST	150 MG	30 TABS/30 DAYS
VIRACEPT	625 MG	120 TABS/30 DAYS
VIRACEPT	250 MG	270 TABS/30 DAYS
VIREAD	300 MG, 250 MG, 200 MG, 150 MG	30 TABS/30 DAYS
VIREAD	40 MG/GM	240 GRAMS/30 DAYS
ZIAGEN	20 MG/ML	960 MLS/30 DAYS
ZIDOVUDINE Tab 300 MG	300 MG	60 TABS/30 DAYS

²Impacted members will be notified prior to the change.

¹Indicates specialty medication.

²Indicates Limited Distribution.

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Administrative bulletin: 2026-05-004 Pharmacy updates

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Professional and facility Providers

Capital Blue Cross Advantage and Value Plus Formulary update

Capital Blue Cross Formulary update

Newly marketed drugs effective immediately

Pharmacy Management Program update

Prior Authorization (PA) Utilization Management New Additions Programs2 effective July 1, 2026

Pharmacy Management Program update

Quantity Level Limits (QLL) Program2 Effective July 1, 2026

Capital Blue Cross Elite and Exclusive Formulary update

Capital Blue Cross Formulary update

Newly marketed drugs effective immediately

Pharmacy Management Program update

Prior Authorization (PA) Utilization Management New Additions Programs2 effective July 1, 2026

Pharmacy Management Program update

Quantity Level Limits (QLL) Program2 Effective July 1, 2026 (unless otherwise noted below)

Prior Authorization (PA) Utilization Management New Additions Programs² effective July 1, 2026

Quantity Level Limits (QLL) Program² Effective July 1, 2026

Prior Authorization (PA) Utilization Management New Additions Programs² effective July 1, 2026

Quantity Level Limits (QLL) Program² Effective July 1, 2026 (unless otherwise noted below)