CurrentEmblemHealthPolicy Formulary ID U86M

2026 Formulary (List of Covered Drugs)

A Medicare prescription drug formulary listing covered drugs, tiers, and requirements/limits (prior authorization PA, quantity limits QL, step therapy ST, limited availability LA, special program SP, ACA). Applies to EmblemHealth members as of the formulary update date and provides contact information and instructions for exceptions.

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy Formulary ID U86M

Change TypeAnnual formulary update (no material changes)

Effective DateAug 1, 2025

Next Review Date

Key ActionIf a prescribed drug is not on the formulary, call EmblemHealth member services at 877-793-6253 (TTY 711) to review next steps.

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

15Specialty (SP) products listed

MultipleProducts with QL

SomePA/ST/LA/SP Flags

~300Approx. distinct lines in fragment

vaccinesVaccine entries with ACA

Coverage Summary

Utilization Management & Provider Actions

Prior Authorization / Quantity Limits / Step Therapy / Other Requirements

Covered when plan requirements met:

ALL of the following

Prior Authorization (PA): The plan requires approval before coverage; prescriptions without approval may be denied.
Operational: Prior authorization requests should include clinical rationale, relevant diagnostics, prior medication history when applicable.
Quantity Limits (QL): Coverage may be limited to a specified quantity or dosing interval. Claims exceeding limits may be rejected or require PA.
Examples and numeric limits appear in billing_rule callouts below.
Step Therapy (ST): The plan may require trial of specified preferred agents before non-preferred drugs are covered.

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy Formulary ID U86M

Change TypeAnnual formulary update (no material changes)

Effective DateAug 1, 2025

Next Review Date

Key ActionIf a prescribed drug is not on the formulary, call EmblemHealth member services at 877-793-6253 (TTY 711) to review next steps.

On This Page

Prior Authorization

Prior Authorization requirement

Certain drugs require prior authorization before the plan will cover them. Providers must submit a completed prior authorization request with supporting clinical information. Specialty products and limited-access drugs listed below also require special authorization and coordination with designated distribution channels.

Prior Authorization requirement: PA applies to many listed drugs — verify per-drug notes in the formulary and submit PA with clinical justification.
Special/limited access authorization required for listed drugs: Examples below include limited-availability injectables and specialty agents that require prior authorization and specific distribution.
Specialty Product Distribution/Authorization: Some specialty products require prior authorization and must be dispensed through an approved specialty pharmacy.

Billing Rule

Quantity limits enforcement

Quantity limits are enforced per formulary specifications. Claims exceeding the specified QL will deny at point of sale or require prior authorization for override. Providers should prescribe within the stated limits or document medical necessity.

Example QL — Nitazoxanide: quantity limits apply per dispensing unit (verify NDC-level limit).
Example QL — Pregabalin: limits apply to total daily mg or tablet count per fill.
Example QL — Clobetasol (topical): potency/quantity limits apply (small tube quantities may be allowed; larger quantities limited).
Example QL — FREESTYLE test strips: specific strips-per-month limits are enforced (refer to thresholds).

Step Therapy

Step Therapy enforcement

Step therapy (ST) requires trials of specified lower-cost or clinically preferred agents before the plan will cover alternative agents. Document trials including drug name, dose, dates of therapy, and reason for failure or intolerance to support medical necessity if requesting an exception.

Operational note: Record prior drug trials and responses in the PA request to expedite review.
Specialty/Step Therapy and Prior Authorization indicators: Some drugs carry both ST and PA flags; ensure both criteria are addressed when submitting documentation.

Billing Rule

ACA / OTC / Preventive coverage billing rules

ACA-designated contraceptives and tobacco‑cessation products have special billing rules and may be covered per ACA preventive benefits. Providers should follow formulary tiering and prescribing guidelines when billing.

ACA-designated contraceptives: Covered when billed per ACA preventive coverage rules; follow formulary drug tier and requirements/limits.
Smoking cessation products: OTC nicotine replacement (NICODERM/NICORETTE) and prescription varenicline are subject to ACA/OTC coverage rules — check member benefit for coverage and quantity limits.

Documentation Required

Actionable contacts & documentation

For drugs not listed or for help with prior authorization, coverage exceptions, distribution logistics, or documentation requirements, contact Member Services. Have the member ID, prescriber information, and clinical documentation ready to expedite assistance.

Contact for drugs not listed: Call 877-793-6253 (TTY 711) for assistance with non‑formulary requests, PA status, or distribution questions.
Next steps: Submit PA with clinical rationale; document prior drug trials, quantities dispensed, and site-of-care requirements when applicable.

Formulary Drug Groups & Flags

Formulary drug list (by therapeutic class and individual product)mixedCovered

AMOXICILLIN	amoxicillin (trihydrate) chew tab 125 mg, 250 mg; cap 250 mg; 500 mg; tab 500 mg; 875 mg; susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
AMOXICILLIN&KCLAVULANATE	amoxicillin & k clavulanate susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml; tab 250-125 mg; 500-125 mg; 875-125 mg; ER 12hr 1000-62.5 mg
AMPICILLIN	ampicillin cap 500 mg; ampicillin sodium for IV soln 1 gm, 2 gm, 10 gm
AMPICILLIN-SULBACTAM	ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm, 3 (2-1) gm; IV soln 15 (10-5) gm (bulk)
DICLOXACILLIN	dicloxacillin sodium cap 250 mg; 500 mg
NAFCILLIN	nafcillin sodium for inj 1 gm, 2 gm; in dextrose inj 2 gm/100 ml
OXACILLIN	oxacillin sodium for inj 1 gm, 2 gm; in dextrose inj 2 gm/50 ml; IV soln 10 gm (base equivalent)
PENICILLIN G SODIUM	penicillin g sodium for inj 5,000,000 unit; other parenteral strengths
PENICILLIN V POTASSIUM	penicillin v potassium for soln 125 mg/5 ml, 250 mg/5 ml; tabs 250 mg, 500 mg
PIPERACILLIN-TAZOBACTAM	piperacillin-tazobactam for inj 3.375 gm (3-0.375 gm); 2.25 gm (2-0.25 gm) — Limited Availability (LA)

1–10 of 36

1/4

Drugs with Quantity Limits (examples extracted)mixed

sulfamethoxazole-trimethoprim susp	sulfamethoxazole-trimethoprim susp 200-40 mg/5 ml
sulfamethoxazole-trimethoprim tab	sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim); 800-160 mg (Bactrim DS)
nitrofurantoin macrocrystalline cap	nitrofurantoin macrocrystalline cap 25 mg; 50 mg; 100 mg (Macrodantin) — QL examples
nitrofurantoin monohydrate macrocrystalline cap	nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)
sulfamethoxazole-trimethoprim susp 200-40	sulfamethoxazole-trimethoprim susp 200-40 mg/5 ml

Drugs with Special Flags (ACA, LA, SP, ACA examples)mixed

piperacillin-tazobactam inj 3.375 gm	piperacillin-tazobactam inj 3.375 gm — LA (Limited Availability)
piperacillin-tazobactam inj 2.25 gm	piperacillin-tazobactam inj 2.25 gm — LA
Products designated Over-the-Counter (OTC) or ACA	Vaccines and certain preventive agents may be ACA preventive coverage — see vaccine group

Products designated Specialty (SP)mixedCovered

APRETUDE	APRETUDE (long-acting cabotegravir) — specialty product
BEYFORTUS	BEYFORTUS nirsevimab-alip prefilled syringe 50 mg/0.5 ml, 100 mg/ml — passive immunizing agent; specialty distribution
BIOLOGICALS	Biological specialty agents (see immunologics, oncology biologics)

Medical devices and durable medical equipment (DME) - distribution eligibility (DE)mixed

nebulizers and inhalation solutions	tobramycin nebu soln (TOBI) and other inhaled products — pharmacy or specialized DME distribution per plan
insulin delivery devices	AUTOPEN, CEQUR SIMPLICITY and other injection devices — DME/retail channel depending on plan

OpenPayer

2026 Formulary (List of Covered Drugs)

Coverage Summary

Utilization Management & Provider Actions

Formulary Drug Groups & Flags

Quantity Limits (QL) & Thresholds

Specialty Products & Distribution Eligibility

Revision History