Administrative bulletin: 2026-11-003 Pharmacy updates

Date: November 1, 2026

Effective date: January 1, 2027 (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 CHIP Formulary update.
Capital Blue Cross Elite and Exclusive Formulary update.
Capital Blue Cross Value Formulary update.

Professional and facility Providers

Capital Blue Cross Advantage and Value Plus Formulary update

CHIP

EPO

FEP PPO

HMO

Medicare Advantage HMO

POS

PPO

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 and Pharmacy Utilization Management programs.

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

Changes for January 1, 2027, include the following:

Newly marketed drugs – effective immediately.
An expanded list of drugs requiring prior authorization (PA).
Modified and new quantity level limits (QLL) for specific drugs.
Modified and new step therapy (ST) requirements for specific drugs.
Drugs being removed from Formulary.

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 Required; (ST) = Step therapy Required; (QLL) = Quantity Level Limits Apply 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
AQVESME (PA, QLL)	NF	Thalassemia agents
BAXFENDY (PA, QLL)	BNP	Hypertension
BYSANTI (PA, QLL)	NF	Bipolar disorder, acute treatment of Bipolar I schizophrenia, schizophrenia
CARDAMYST (PA)	BNP	Calcium channel blocker
EXDENSUR	NF	Antiasthmatics: Monoclonal antibodies
FOUNDAYO (PA, QLL)	BP	Weight-loss
HEPCLUDEX¹ (PA, QLL)	NF	Hepatitis D
HYRNUO¹ (PA, QLL)	BNP	Non-small cell lung cancer (NSCLC)
ICOTYDE¹ (PA, QLL)	BP	Plaque psoriasis
IDVYNSO (QLL)	BP	HIV-1 infection
KYGEVVI¹	BNP	Neuromuscular movement disorders
LEROCHOL (PA, QLL)	NF	Dyslipidemia, heterozygous familial hypercholesterolemia (HeFH)
LIFYORLI¹ (PA)	BNP	Ovarian cancer
LOARGYS OMLONTI	NF	Arginase-1 deficiency
MYQORZO¹ (PA, QLL)	BNP	Hypertrophic cardiomyopathy
NEREUS (PA, QLL)	NF	Vomiting, motion sickness
OMLONTI (ST, QLL)	NF	Ophthalmic prostaglandins
PIVYA ZYCUBO	NF	Urinary anti-infectives
REDEMPLO¹ (PA, QLL)	BP	Antihyperlipidemic
VOYXACT (PA, QLL)	NF	IgA nephropathy
YUVIWEL EXDENSUR	NF	Achondroplasia
ZYCUBO¹ (QLL)	BP	Rare disorders: Menkes 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 Required; (ST) = Step therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
Prior Authorization (PA) utilization management new additions programs² Effective January 1, 2027
Drug	Indication
ATACAND HCT	Antihypertensive
CUPRIMINE¹	Wilson’s disease, cystinuria
diltiazem hcl cap er 12hr	Calcium channel blocker
EDARBI	Antihypertensive
EDARBYCLOR	Antihypertensive
EXFORGE HCT	Antihypertensive
GLASSIA¹	Alpha1-proteinase inhibitor
MICARDIS HCT	Antihypertensive

¹Indicates specialty medication.

²Impacted members will be notified prior to the change.

³Indicates Limited Distribution.

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

Pharmacy management program update KEY: (PA) = Prior Authorization Required; (ST) = Step Therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
Quantity Level Limit (QLL) Program² Effective January 1, 2027
Drug	Dosage	Quantity limit
almotriptan	6.25 MG TAB	12 tablets / 30 days
BIMZELX¹ (PA, QLL)	320 MG/2 ML	1 syringe / 56 days
DUPIXENT (PA, QLL)	320 MG/2 ML	2 pens / 28 days
eletriptan	20 MG TAB	12 tablets / 30 days
EPIDIOLEX^{1, 3} (PA)	300 MG/2 ML PEN	1000 mLs / 30 days
frovatriptan	2.5 MG TAB	18 tablets / 30 days
RIZAFILM	5 MG FILMS	18 films / 30 days
rizatriptan	5 MG TAB	18 tablets / 30 days
rizatriptan oral disintegrating tab	5 MG TAB	18 tablets / 30 days
sumatriptan nasal spray	5 MG/ACT	12 inhalers / 30 days
sumatriptan succinate	25 MG TAB	18 tablets / 30 days
XARELTO (QLL)	15 MG TAB	42 tablets / 30 days
XARELTO (QLL)	STARTER PACK	51 tablets / 180 days
XIFAXAN (PA, QLL)	200 MG TAB	9 tablets / 90 days
zolmitriptan	2.5 MG TAB	12 tablets / 30 days
zolmitriptan nasal spray	2.5 MG/ACT	12 devices / 30 days
zolmitriptan oral disintegrating tab	2.5 MG TAB	12 tablets / 30 days

¹Indicates specialty medication.

²Impacted members will be notified prior to the change.

³Indicates Limited Distribution.

The following medications have been added to the Step Therapy (ST) program.

Pharmacy management program update
Step Therapy (ST) utilization management changes or updates² Effective January 1, 2027
Drug	Indication
ONGLYZA (QLL)	Antidiabetic
saxagliptin-metformin	Antidiabetic

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)
Removed from Formulary ² Effective January 1, 2027
Brand name	Tier status	Indication	Alternative
amlodipine-valsartan-hctz	GNP	Antihypertensive	olmesartan-amlodipine hctz tab
ANUSOL-HC 25MG	BNP	Anorectal Agents	hydrocortisone sup
JANUMET ³ (ST, QLL)	BP	Antidiabetic	sitagliptin/metformin
JANUMET XR ⁴ (ST, QLL)	BP	Antidiabetic	sitagliptin/metformin
JANUVIA ⁴ (ST, QLL)	BP	Antidiabetic	sitagliptin
NEULASTA ¹ (PA)	BP	Hematopoietic Agents	FULPHILA, UDENYCA
OPSUMIT ¹ (PA, QLL)	BNP	Cardiovascular Agents	ADEMPAS, UPTRAVI, TYVASO
PRALUENT (PA, QLL)	BNP	Antihyperlipidemics	REPATHA
PREMARIN	BNP	Vaginal Products	estradiol tablet/patch,
TAZVERIK ^{1, 5}	BP	Oncology	rituximab
VENTOLIN HFA (QLL)	BP	Antiasthmatic and Bronchodilator Agents	albuterol sulfate inhaler
VUITY (QLL)	BNP	Ophthalmic Agents	None
XELJANZ ¹ (PA, QLL)	BP	Anti-inflammatory	tofacitinib
XELJANZ XR ¹ (PA, QLL)	BP	Anti-inflammatory	tofacitinib
XEPI	BNP	Dermatological	mupirocin

¹Indicates specialty medication.

²Impacted members will be notified prior to the change.

³Indicates Limited Distribution.

⁴This change is effective October 1, 2026. Existing users will have a PA to grandfather them until 10/1.

⁵Discontinued drug

Capital Blue Cross CHIP Formulary update

CHIP

EPO

FEP PPO

HMO

Medicare Advantage HMO

POS

PPO

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 CHIP Formulary and Pharmacy Utilization Management programs.

Changes for January 1, 2027, include the following:

An expanded list of drugs requiring prior authorization (PA).
Modified and new quantity level limits (QLL) for specific drugs.
Modified and new step therapy (ST) requirements for specific drugs.
Drugs being removed from formulary.

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.

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 Required; (ST) = Step therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
Prior Authorization (PA) Utilization management new additions programs² Effective January 1, 2027
Drug class/Drug	Purpose/Guidelines
ALKINDI SPRINKLE ¹	Adrenocortical Insufficiency
allopurinol tab	Gout
ALPHAGAN P	Glaucoma, Ocular Hypertension
ATACAND HCT	Hypertension
AZOPT	Glaucoma, Ocular Hypertension
bromfenac sodium ophth soln 0.09% (Base Equiv) (Once-Daily)	Eye Disease
carbinoxamine maleate	Antihistamine
CARBZAH	Antihistamine
CARDIZEM CD	Hypertension
COMBIGAN	Glaucoma, Ocular Hypertension
CONDYLOX	Human Papillomavirus (HPV)
COREG CR	Hypertension
CROTAN	Antiparasitic
CUPRIMINE	Genitourinary System Disease, Wilson’s disease
CUVRIOR ¹	Wilson’s disease,
diltiazem hcl cap er 12hr	Hypertension
EDARBI	Hypertension
EDARBYCLOR	Hypertension
EXFORGE HCT	Hypertension
furosemide oral soln (PA, QLL)	Edema, Hypertension
GLASSIA	Lung Disease
GOCOVRI	Parkinson’s Disease
INDERAL XL	Hypertension
INNOPRAN XL	Hypertension
JALYN	Benign Prostatic Hyperplasia (BPH)
KEVEYIS	Nervous System Diseases
leucovorin calcium tab (PA, QLL)	Methotrexate Toxicity, Megaloblastic Anemia, Cerebral Folate Deficiency (CFD)
METAXALONE	Musculoskeletal System and Connective Tissue Diseases
metaxalone tab 400 mg	Musculoskeletal System and Connective Tissue Diseases
MICARDIS HCT	Hypertension
MIRAPEX ER	Parkinson’s Disease
NORGESIC FORTE	Pain Relief
ONGENTYS	Parkinson’s Disease
ORPHENGESIC FORTE	Pain Relief
PRURADIK	Scabies
timolol maleate ophth gel forming soln 0.5%	Glaucoma, Ocular Hypertension
TIMOPTIC OCUDOSE	Glaucoma, Ocular Hypertension
UCERIS	Ulcerative Colitis (UC)
ZANAFLEX	Spasticity
zileuton tab er 12hr 600 mg	Antiasthmatic

¹Indicates specialty medication.

²Impacted members will be notified prior to the change.

The following medications have been added to the Quantity Level Limit (QLL) program.

Pharmacy Management Program update KEY: (PA) = Prior Authorization Required; (ST) = Step therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
Quantity Level Limit (QLL) Program² Effective January 1, 2027
Drug	Dosage	Quantity limit
abacavir sulfate (Base Equiv)	300 MG	60 tablets / 30 days
ADDERALL	30 MG	60 tablets / 30 days
	7.5 MG, 20 MG	90 tablets / 30 days
	12.5 MG, 15 MG	120 tablets / 30 days
	5 MG, 10 MG	180 tablets / 30 days
ADDERALL XR	25 MG, 30 MG	30 capsules / 30 days
ADDERALL XR	5 MG, 10 MG, 15 MG, 20 MG	60 capsules / 30 days
ADZENYS XR-ODT	9.4 MG, 12.5 MG, 15.7 MG, 18.8 MG	30 tablets / 30 days
ADZENYS XR-ODT	3.1 MG. 6.3 MG	60 tablets / 30 days
almotriptan (ST, QLL)	6.25 mg	12 tablets / 30 days
APTENSIO XR	10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG	30 capsules / 30 days
APTIVUS	250 MG	120 capsules / 30 days
ARYNTA	10 MG/ML	240 mLs / 30 days
atazanavir sulfate (Base Equiv)	150 MG	30 capsules / 30 days
AURYXIA	210 MG tab	360 tablets / 30 days
AZSTARYS	26.1-5.2 MG, 39.2-7.8 MG, 52.3-10.4 MG	30 capsules / 30 days
BIKTARVY	30-120-15 MG, 50-200-25 MG	30 tablets / 30 days
BIMZELX (PA, QLL)	320 MG/2ML	1 pen / 56 days
BIMZELX (PA, QLL)	320 MG/2ML	1 syringe / 56 days
CIMDUO	300-300 MG	30 tablets / 30 days
clonidine HCl ER 12HR	0.1 MG	120 tablets / 30 days
COMBIVIR	150-300 MG	60 tablets / 30 days
COMPLERA	200-25-300 MG	30 tablets / 30 days
CONCERTA	54 MG	30 tablets / 30 days
CONCERTA	18 MG, 27 MG, 36 MG	60 tablets / 30 days
COTEMPLA XR-ODT	8.6 MG	30 tablets / 30 days
COTEMPLA XR-ODT	17.3 MG, 25.9 MG	60 tablets / 30 days
DAYTRANA	10MG/9HR, 15MG/9HR, 20MG/9HR, 30MG/9HR	30 patches / 30 days
DELSTRIGO	100-300-300 MG	30 tablets / 30 days
DESCOVY	120-15 MG, 200-25 MG	30 tablets / 30 days
desoxyn	5 MG	150 tablets / 30 days
DEXEDRINE	10 MG, 15 MG	120 capsules / 30 days
dextroamphetamine sulfate	10 MG	180 tablets / 30 days
	2.5 MG, 7.5 MG, 15 MG, 20 MG	90 tablets / 30 days
	30 MG	60 tablets / 30 days
	5 MG	360 tablets / 30 days
dextroamphetamine sulfate ER 24HR	5 MG	90 capsules / 30 days
dextroamphetamine sulfate Oral Solution	5 MG/5ML	1800 mLs / 30 days
DOVATO	50-300 MG	30 tablets / 30 days
DUPIXENT (PA, QLL)	300 MG/2ML Pen	2 pens / 28 days
DYANAVEL XR	2.5 MG/ML	240 mLs / 30 days
DYANAVEL XR	5 MG, 10 MG, 15 MG, 20 MG	30 tablets / 30 days
EDURANT	25 MG	30 tablets / 30 days
EDURANT PED	2.5 MG	180 tablets / 30 days
efavirenz	50 MG	90 capsules / 30 days
efavirenz	200 MG	60 capsules / 30 days
EFAVIRENZ/LAMIVUDINE/ TENOFOVIR	400-300-300 MG	30 tablets / 30 days
efavirenz-emtricitabine-tenofovir DF Tab 600-200-300 MG	600-200-300 MG	30 tablets / 30 days
EMTRIVA	10 MG/ML	680 mLs / 28 days
EMTRIVA	200 MG	30 capsules / 30 days
EPIDIOLEX (PA, QLL)	100 MG/ML	1000 mLs / 30 days
EPIVIR	10 MG/ML; 300 MG/30ML	960 mLs / 30 days
	300 MG	30 tablets / 30 days
	150 MG	60 tablets / 30 days
EPZICOM	600-300 MG	30 tablets / 30 days
EVEKEO	5 MG, 10 MG	180 tablets / 30 days
EVOTAZ	300-150 MG	30 tablets / 30 days
FOCALIN	10 MG	60 tablets / 30 days
	5 MG	120 tablets / 30 days
	2.5 MG	240 tablets / 30 days
FOCALIN XR	25 MG, 30 MG, 35 MG, 40 MG	30 capsules / 30 days
FOCALIN XR	5 MG, 10 MG, 15 MG, 20 MG	60 capsules / 30 days
FROVA (ST, QLL)	2.5 mg tablet (base equivalent)	18 tablets / 30 days
furosemide (PA, QLL)	10 MG/ML	1800 mLs / 30 days
FUZEON	90 MG	60 vials / 30 days
GENVOYA	150-150-200-10 MG	30 tablets / 30 days
IMITREX (ST, QLL)	25 mg tablet	18 tablets / 30 days
INTELENCE	25 MG	120 tablets / 30 days
INTELENCE	100 MG, 200 MG	60 tablets / 30 days
INTUNIV	2 MG	90 tablets / 30 days
	3 MG	60 tablets / 30 days
	1 MG, 4 MG	30 tablets / 30 days
ISENTRESS	400 MG	60 tablets / 30 days
	100 MG	60 packets / 30 days
	25 MG, 100 MG	180 tablets / 30 days
ISENTRESS HD	600 MG	60 tablets / 30 days
JORNAY PM	20 MG, 40 MG, 60 MG, 80 MG, 100 MG	30 capsules / 30 days
JULUCA	50-25 MG	30 tablets /30 days
KALETRA	400-100 MG/5ML	480 mLs / 30 days
KALETRA	200-50 MG	120 tablets / 30 days
KALETRA	100-25 MG	180 tablets / 30 days
leucovorin calcium (PA, QLL)	15 MG, 25 MG	30 tablets / 30 days
	10 MG	60 tablets / 30 days
	5 MG	120 tablets / 30 days
LEXIVA	700 MG	120 tablets / 30 days
METADATE CD	40 MG, 50 MG, 60 MG	30 capsules / 30 days
METADATE CD	10 MG, 20 MG, 30 MG	60 capsules / 30 days
METHYLIN	5 MG/5ML	450 mLs / 30 days
METHYLIN	10 MG/5ML	900 mLs / 30 days
methylphenidate hcl ER 24HR (LA)	60 MG	30 capsules / 30 days
methylphenidate hcl Chew	2.5 MG, 5 MG, 10 MG	180 tablets / 30 days
methylphenidate hcl er	10 MG, 20 MG	90 tablets / 30 days
methylphenidate hcl	27 MG, 36 MG	60 tablets / 30 days
methylphenidate hcl	18 MG, 27 MG, 45 MG, 54 MG, 63 MG	30 tablets / 30 days
MYDAYIS	12.5 MG, 25 MG, 37.5 MG, 50 MG	30 capsules / 30 days
NEVIRAPINE	50 MG/5ML	1200 mLs / 30 days
nevirapine	200 MG	60 tablets / 30 days
nevirapine ER 24HR	400 MG	30 tablets / 30 days
NORVIR	100 MG	360 tablets / 30 days
NORVIR	100 MG	360 packets / 30 days
ODEFSEY	200-25-25 MG	30 tablets / 30 days
ONYDA XR	0.1 MG/ML	120 mLs / 30 days
oxycodone acetaminophen	10-300 MG/5ML	75 mLs / 30 days
oxycodone acetaminophen	10-300 MG/5ML	45 mLs / 30 days
PIFELTRO	100 MG	30 tablets / 30 days
PREZCOBIX	675-150 MG, 800-150 MG	30 tablets / 30 days
PREZISTA	800 MG	30 tablets / 30 days
	75 MG	300 tablets / 30 days
	150 MG	180 tablets / 30 days
	600 MG	60 tablets / 30 days
	100 MG/ML	400 mLs / 30 days
QELBREE	150 MG	60 capsules / 30 days
	100 MG	30 capsules / 30 days
	200 MG	90 capsules / 30 days
QUILLICHEW ER	30 MG	60 tablets / 30 days
QUILLICHEW ER	20 MG, 40 MG	30 tablets / 30 days
QUILLIVANT XR	25 MG/5 ML	360 mLs / 30 days
RELEXXII	45 MG, 54 MG, 63 MG, 72 MG	30 tablets / 30 days
RELEXXII	18 MG, 27 MG, 36 MG	60 tablets / 30 days
RELPAX (ST, QLL)	20 mg	12 tablets / 30 days
RETROVIR	50 MG/5ML	1920 mLs / 30 days
RETROVIR	100 MG	180 capsules / 30 days
REYATAZ	50 MG	240 packets / 30 days
	300 MG	30 capsules / 30 days
	200 MG	60 capsules / 30 days
RITALIN	20 MG	90 tablets / 30 days
	10 MG	180 tablets / 30 days
	5 MG	360 tablets / 30 days
RITALIN LA	20 MG	90 capsules / 30 days
	30 MG	60 capsules / 30 days
	10 MG, 40 MG	30 capsules / 30 days
RIZAFILM (ST, QLL)	5 mg	18 films / 30 days
rizatriptan oral disintegrating tab (ST, QLL)	5 mg (base eq)	18 tablets / 30 days
rizatriptan (ST, QLL)	5 mg (base equivalent)	18 tablets / 30 days
RUKOBIA	600 MG	60 tablets / 30 days
SELZENTRY	300 MG	120 tablets / 30 days
	20 MG/ML	1840 mLs / 30 days
	150 MG	60 tablets / 30 days
STRATTERA	18 MG, 25 MG	120 capsules / 30 days
	60 MG, 80 MG, 100 MG	30 capsules / 30 days
	10 MG, 40 MG	60 capsules / 30 days
STRIBILD	150-150-200-300 MG	30 tablets / 30 days
sumatriptan nasal spray (ST, QLL)	5 mg/act nasal spray	12 inhalers / 30 days
SUNLENCA	300 MG	5 tablets / 365 days
SUNLENCA	300 MG	4 tablets / 365 days
SUSTIVA	600 MG	30 tablets / 30 days
SYMFI	600-300-300 MG	30 tablets / 30 days
SYMTUZA	800-150-200-10 MG	30 tablets / 30 days
TIVICAY	50 MG	60 tablets / 30 days
TIVICAY PD	5 MG	360 tablets / 30 days
TRAMADOL HCL	5 MG/ML	400 mLs / 30 days
TRAMADOL HCL	5 MG/ML	240 mLs / 30 days
TRIUMEQ	600-50-300 MG	30 tablets / 30 days
TRIUMEQ PD	60-5-30 MG	180 tablets / 30 days
TRUVADA	100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG	30 tablets / 30 days
TYBOST	150 MG	30 tablets / 30 days
VIRACEPT	625 MG	120 tablets / 30 days
VIRACEPT	250 MG	270 tablets / 30 days
VIREAD	150 MG, 200 MG, 250 MG, 300 MG	30 tablets / 30 days
VIREAD	40 MG/GM	240 mLs / 30 days
VYVANSE	10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG,	30 capsules / 30 days
VYVANSE	10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG	30 tablets / 30 days
XARELTO	Tab 15 MG	42 tablets / 30 days
XARELTO starter pack	Starter Therapy Pack 15 MG & 20 MG	51 tablets / 30 days
XELSTRYM	4.5 MG/9HR, 9 MG/9HR, 13.5 MG/9HR, 18 MG/9HR	30 patches / 30 days
XIFAXAN (PA, QLL)	200 MG Tab	9 tablets / 90 days
ZIAGEN	20 MG/ML	960 mLs / 30 days
ZIDOVUDINE	300 MG	60 tablets / 30 days
zolmitriptan nasal spray (ST, QLL)	2.5 mg/act nasal spray	12 inhalers / 30 days
zolmitriptan oral disintegrating tab (ST, QLL)	2.5 mg tablet	12 tablets / 30 days
zolmitriptan (ST, QLL)	2.5 mg tablet	12 tablets / 30 days

²Impacted members will be notified prior to the change.

The following medications have been added to the Step Therapy (ST) program.

Pharmacy Management Program update KEY: (PA) = Prior Authorization Required; (ST) = Step therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
Step Therapy (ST) Utilization management changes or updates² Effective January 1, 2027
Drug class/Drug	Indication
AURYXIA (ST, QLL)	Phosphate Binders
FOSRENOL (ST, QLL)	Phosphate Binders
ONGLYZA (ST, QLL)	Antidiabetic
RENAGEL (ST, QLL)	Phosphate Binders
RENVELA (ST, QLL)	Phosphate Binders
saxagliptin-metformin (ST, QLL)	Antidiabetic
sevelamer hcl (ST, QLL)	Phosphate Binders
VELPHORO (ST, QLL)	Phosphate Binders

²Impacted members will be notified prior to the change.

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)
Removed from Formulary² Effective January 1, 2027
Brand name	Indication	Alternative
JANUMET ⁴ (ST, QLL)	Antidiabetic	sitagliptin
JANUVIA ⁴ (ST, QLL)	Antidiabetic	sitagliptin/metformin

²Impacted members will be notified prior to the change.

⁴This change is effective October 1, 2026. Existing users will have a PA to grandfather them until 10/1.

Capital Blue Cross Elite and Exclusive Formulary update

CHIP

EPO

FEP PPO

HMO

Medicare Advantage HMO

POS

PPO

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 and Pharmacy Utilization Management programs.

Changes for January 1, 2027, 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.
Modified and new step therapy (ST) requirements for specific drugs.
Drugs being removed from formulary.

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.

The following medications have been added to the Step Therapy (ST) program.

Pharmacy Management Program update KEY: (PA) = Prior Authorization Required; (ST) = Step Therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
Step Therapy (ST) Utilization management changes or updates² Effective January 1, 2027
Drug	Indication
ONGLYZA (ST, QLL)	Antidiabetic
saxagliptin-metformin (ST, QLL)	Antidiabetic

²Impacted members will be notified prior to the change.

Capital Blue Cross Formulary update KEY: (PA) = Prior Authorization; (ST) = Step therapy; (QLL) = Quantity Level Limits lowercase bold print = generic; UPPERCASE PRINT = BRAND
Removed from Formulary² Effective January 1, 2027
Drug	Indication	Alternative
JANUMET (ST, QLL)	Antidiabetic	sitagliptin
JANUVIA (ST, QLL)	Antidiabetic	sitagliptin/metformin
NEFFY NASAL SPRAY	Allergic reactions	epinephrine auto injector

Capital Blue Cross Value Formulary update

CHIP

EPO

FEP PPO

HMO

Medicare Advantage HMO

POS

PPO

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 Value Formulary and Pharmacy Utilization Management programs.

Changes for January 1, 2027, include the following:

Modified and new quantity level limits (QLL) for specific drugs.
Modified and new step therapy (ST) requirements for specific drugs.
Drugs being removed from formulary.

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.

The following medications have been added to the Quantity Level Limit (QLL) program.

Pharmacy Management Program update KEY: (PA) = Prior Authorization Required; (ST) = Step Therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
Quantity Level Limit (QLL) Program² Effective January 1, 2027
Drug	Dosage	Quality limit
almotriptan (ST, QLL)	6.25 mg	12 tablets / 30 days
eletriptan	20 mg tablet (base equivalent)	12.00 tablets / 30 days
frovatriptan (ST, QLL)	2.5 mg tablet (base equivalent)	18.00 tablets / 30 days
rizatriptan	5 mg (base equivalent)	18 tablets / 30 days
rizatriptan oral disintegrating tab (ST, QLL)	5 mg (base eq)	18 tablets / 30 days
sumatriptan	5 mg/act nasal spray	12.00 inhalers / 30 days
sumatriptan succinate (ST, QLL)	25 mg tablet	18.00 tablets / 30 days
zolmitriptan	2.5 mg tablet	12.00 tablets / 30 days

²Impacted members will be notified prior to the change.

The following medications have been added to the Step Therapy (ST) program.

Pharmacy Management Program update
Step Therapy² Effective January 1, 2027
Drug	Indication
ONGLYZA (QLL)	Antidiabetic
saxagliptin-metformin (QLL)	Antidiabetic

²Impacted members will be notified prior to the change.

The following medications have changed tier.

Pharmacy Management Program update KEY: (PA) = Prior Authorization Required; (ST) = Step Therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND
IBRANCE ^{1, 3} (PA, QLL)	Anticancer	BNP

Pharmacy Management Program update

KEY: (PA) = Prior Authorization Required; (ST) = Step Therapy Required; (QLL) = Quantity Level Limits Apply lowercase bold print = generic; UPPERCASE PRINT = BRAND

Tier change² Effective January 1, 2027

Drug

Indication

New tier

IBRANCE ^{1, 3} (PA, QLL)

Anticancer

BNP

¹Indicates specialty medication.

²Impacted members will be notified prior to the change.

³Indicates Limited Distribution.

The following medications have changed tier.

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)
Removed from Formulary² Effective January 1, 2027
Drug	Tier status	Indication	Alternative
JANUMET XR ⁴ (ST, QLL)	BP	Antidiabetic	sitagliptin/metformin
JANUVIA ⁴ (ST, QLL)	BP	Antidiabetic	sitagliptin

²Impacted members will be notified prior to the change.

³Indicates Limited Distribution.

⁴This change is effective October 1, 2026. Existing users will have a PA to grandfather them until 10/1.

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Breadcrumb DnD

Web Content Viewer - Fixed Context

Administrative bulletin: 2026-11-003 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 January 1, 2027

Pharmacy management program update

Quantity Level Limit (QLL) Program2 Effective January 1, 2027

Pharmacy management program update

Step Therapy (ST) utilization management changes or updates2 Effective January 1, 2027

Capital Blue Cross Formulary update

Removed from Formulary 2 Effective January 1, 2027

Capital Blue Cross CHIP Formulary update

Pharmacy Management Program update

Prior Authorization (PA) Utilization management new additions programs2 Effective January 1, 2027

Pharmacy Management Program update

Quantity Level Limit (QLL) Program2 Effective January 1, 2027

Pharmacy Management Program update

Step Therapy (ST) Utilization management changes or updates2 Effective January 1, 2027

Capital Blue Cross Formulary update

Removed from Formulary2 Effective January 1, 2027

Capital Blue Cross Elite and Exclusive Formulary update

Pharmacy Management Program update

Step Therapy (ST) Utilization management changes or updates2 Effective January 1, 2027

Capital Blue Cross Formulary update

Removed from Formulary2 Effective January 1, 2027

Capital Blue Cross Value Formulary update

Pharmacy Management Program update

Quantity Level Limit (QLL) Program2 Effective January 1, 2027

Pharmacy Management Program update

Step Therapy2 Effective January 1, 2027

Pharmacy Management Program update

Tier change2 Effective January 1, 2027

Capital Blue Cross Formulary update

Removed from Formulary2 Effective January 1, 2027

Prior Authorization (PA) utilization management new additions programs² Effective January 1, 2027

Quantity Level Limit (QLL) Program² Effective January 1, 2027

Step Therapy (ST) utilization management changes or updates² Effective January 1, 2027

Removed from Formulary ² Effective January 1, 2027

Prior Authorization (PA) Utilization management new additions programs² Effective January 1, 2027

Quantity Level Limit (QLL) Program² Effective January 1, 2027

Step Therapy (ST) Utilization management changes or updates² Effective January 1, 2027

Removed from Formulary² Effective January 1, 2027

Step Therapy (ST) Utilization management changes or updates² Effective January 1, 2027

Removed from Formulary² Effective January 1, 2027

Quantity Level Limit (QLL) Program² Effective January 1, 2027

Step Therapy² Effective January 1, 2027

Tier change² Effective January 1, 2027

Removed from Formulary² Effective January 1, 2027