Pharmacy Management

Access forms and resources online so you can get the information you need.


The drug formulary is a list of drugs that are included in most BCBSNE prescription drug plans. Coverage of these drugs is subject to the member's prescription benefit plan design. Download each prescription drug list (PDL) below:

You can also search the prescription drug lists on  MyPrime.com

Drugs Administered in an Outpatient Setting

In addition, certain prescription drugs and covered services administered in an outpatient setting are only available under a BCBSNE prescription drug plan.

To verify benefits, please call Customer Services at 800-635-0579.

Benefits for certain prescription drugs and covered services administered in an outpatient setting are available only under your prescription drug plan. These benefits are not available under your medical plan. Examples of an outpatient setting include a home health care agency, physician’s office, outpatient hospital or other outpatient facility.

Benefits for the following drugs are only available if the drugs are purchased through an in-network pharmacy

Abrilada 
Actimmune 
Adalimumab-Aacf 
Adalimumab-Aaty 
Adalimumab-Adbm 
Adalimumab-Fkjp 
Adalimumab-Ryvk 
Advate Rahf-Pfm 
Adynovate 
Adzynma 
Afinitor 
Afstyla 
Aldurazyme 
Alkeran 
Alphanate 
Alphanine Sd 
Alprolix 
Altuviio 
Amevive
Antihemophilic Factor Human Method M Monoclonal Purified 
Arcalyst 
Autoplex T  
Avonex 
Benefix 
Berinert 
Betaseron 
Cablivi 
Ceredase 
Cerezyme 
Cesamet 
Cinryze 
Copaxone 
Crysvita 
Cyltezo 
Cytoxan 
Dostinex 
Elaprase 
Elelyso 
Eloctate 
Emend 
Enbrel 
Evomela 
Extavia 
Fabrazyme

Factor Ix+Complex 
Feiba Vh Aicc 
Firazyr 
Forteo  
Furoscix 
Fuzeon 
Genotropin 
Glatiramer Acetate 
G-Lumizyme 
Haegarda 
Helixate Fx 
Hemady
Hemofil M 
Hercessi 
Hulio 
Humate-P 
Humatrope 
Humira 
Hyate 
Hycamtin 
Icatibant 
Idacio 
Idelvion 
Ilaris 
Ilumya 
Increlex 
Intron A 
Intron A Multidose Pen 
Iressa 
Jesduvroq 
Jivi 
Kalbitor 
Kanuma 
Koate-Dvi 
Kogenate Fs 
Konyne-80 
Kovaltry 
Lumizyme 
Makena 
Monoclate-P 
Mononine 
Myozyme 
Naglazyme 
Nexviazyme 
Norditropin 
Novoeight 

Novoseven 
Novoseven Rt 
Nutropin/Nutropin Aq  
Octreotide 
Oforta 
Omnitrope 
Pegasys 
Peg-Intron 
Plegridy 
Profilnine Sd 
Proplex T 
Pulmozyme 
Pyzchiva 
Rebif 
Rebinyn 
Recombinate 
Rixubis  
Ruconest 
Saizen 
Sandostatin 
Selarsdi 
Serostim 
Sevenfact 
Simlandi 
Supprelin La 
Takhzyro 
Temodar 
Tobi 
Tyvaso 
Ustekinumab-Ttwe  
Vepesid 
Vimizim 
Vonvendi 
Vowst 
Vpriv 
Wilate 
Xeloda 
Xenpozyme 
Xyntha 
Yuflyma 
Zorbtive 
Zortress 

 
Note: This list is subject to change without notice. Inclusion on this list does not guarantee coverage. If you have any questions about this list or about your prescription drug benefits, please call our Member Services department at the number on the back of your member ID card. Product names are the property of their respective owners. Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross Blue Shield Association. 

Important: Formularies may be updated at any time without notice. Please be aware that including a medication on a formulary does not ensure coverage.

Oral Oncology Medications

Oral oncology medications obtained through an in-network specialty pharmacy may be covered at no cost to the member.

Orally Administered Cancer Medications
Abiraterone Gilotrif Nubeqa Toremifene
Afinitor Gleevec Odomzo Torpenz
Afinitor disperz Hycamtin Ogsiveo Tretinoin
Akeega Ibrance Ojemda Truqap
Alecensa Iclusig Ojjaara Truseltiq
Alunbrig Idhifa Orgovyx Turalio
Augtyro Imatinib Orserdu Tykerb
Ayvakit Imbruvica Pazopanib Vanflyta
Balversa Inlyta Piqray Venclexta
Bexarotene Inrebic Pomalyst Verzenio
Bosulif Iressa Revlimid Vitrakvi
Braftovi Itovebi Revuforj Vizimpro
Brukinsa Iwilfin Rezlidhia Vonjo
Cabometyx Jakafi Rozlytrek Voranigo
Calquence Jaypirca Rydapt Votrient
Capecitabine Kisqali Sorafenib Welireg
Caprelsa Krazati Sprycel Xalkori
Cometriq Lapatinib Stivarga Xeloda
Copiktra Lazcluze Sunitinib Xospata
Cotellic Lenalidomide Sutent Xpovio
Danziten Lenvima Tabloid Xtandi
Dasatinib Lonsurf Tafinlar Yonsa
Daurismo Lorbrena Tagrisso Zejula
Erivedge Lumakras Talzenna Zelboraf
Erleada Lysodren Tarceva Zolinza
Erlotinib Lytgobi Targretin Zydelig
Everolimus Matulane Tasigna Zykadia
Exkivity Mekinist Tazverik Zytiga
Fareston Mektovi Temozolomide  
Fotivda Nerlynx Tepmetko  
Fruzaqla Nexavar Thalomid  
Gefitinib Ninlaro Tibsovo  
Formulary Review Requests (Non-Medicare Only)

Physicians and other health care professionals may ask for a product to be added to the formulary. Please provide clinical studies, safety data, unique qualities, etc. to support your recommendation. Also, please let us know if the formulary review was requested by a pharmaceutical representative. Send your request to:

Blue Cross and Blue Shield of Nebraska
Attn: Pharmacy Director
1919 Aksarben Drive
P.O. Box 3248
Omaha, NE 68180-0001
Formulary Exception Review Requests (Qualified Health Plans Only)

Physicians and other health care professionals may ask for coverage of an Essential Health Benefit medication not covered on the formulary. Not all medications are covered based on coverage guidelines provided in regulation and member contracts.
Download the Formulary Exception Form (Qualified Health Plans Only)

Formulary Exception Review Requests (PDL 20 and 30)

Physicians and other health care professionals may ask for coverage of a medication not covered on the formulary.
Download the Formulary Exception Form (PDL 20 and 30 Only)

Pharmacy Preauthorization

Please refer to the  Drugs Requiring Preauthorization list for our standard list of medications requiring preauthorization.  Additional medications may require preauthorization per individual contract. You may also refer to our  Outpatient Drug Exclusions List for members. If you are unable to submit a pharmacy preauthorization online through NaviNet, you can print the form. See all pharmacy preauthorizations forms.

Submit a Pharmacy Pre-Authorization Online »

Please use the appropriate ICD-10 codes.

Amazon Pharmacy Home Delivery is our exclusive home-delivery pharmacy. 

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