CurrentEmblemHealthPolicy N/A

2026 Formulary (List of Covered Drugs) — EmblemHealth

This document lists covered outpatient prescription drugs, tiers, and utilization management (e.g., prior authorization, quantity limits, step therapy) for EmblemHealth plans and explains how members and providers use the formulary.

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical change

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization (PA) when 'PA' appears in a drug's Requirements/Limits to ensure coverage and avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-04-01formulary effective/update date

877-793-6253member services contact

PA/QL/ST/LD/SPutilization management features

~120drug/product line items

severaldrugs with Prior Authorization (PA)

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Coverage Criteria and Formulary Flags

Coverage conditions per product

Coverage and utilization controls are specified per product line item; products listed include flags that indicate coverage conditions.

Coverage flags: Products are assigned drug tiers and may have one or more requirement flags: QL (quantity limit), PA (prior authorization), LD (limited distribution), SP (specialty), AC (administrative coverage condition). Coverage is contingent on meeting any listed flags.

Listed per product entry

General coverage with administratively-specified restrictions

Covered subject to listed requirements/limits

Formulary coverage conditions: Drugs listed in this segment are covered when the member meets the specific requirements indicated in the 'Requirements/Limits' field (e.g., PA, QL, LD, SP).

Follow PA and QL specifics per drug entry.

Formulary coverage conditions

Coverage and access require meeting the listed administrative programs or limits for each product

General formulary access: Drug is subject to its listed Drug Tier and any listed requirements (PA, LD, QL, SP, ST, AC). Coverage requires submission of PA when 'PA' is listed, dispensing through limited distribution when 'LD' is listed, and adherence to quantity limits when 'QL' is listed.

Applies per product entry as shown.

Formulary coverage flags (informational)

Formulary listing entries: Drugs are listed with Drug Tier and Requirements/Limits (PA, QL, LD, SP, ST, AC); coverage and utilization management follow those flags.

No detailed clinical criteria present in these chunks.

Formulary coverage attributes (excerpt)

Covered when the plan's pharmacy coverage rules for the specific drug are met (examples below reflect attributes from the formulary segment):

Opioid and Controlled Analgesics: Many opioid and opioid-combination products are on the formulary with quantity limits and some require PA (e.g., XTAMPZA ER entries show PA and QL; tramadol entries list QL).see QL entries

Specific clinical criteria for PA not in these chunks

Specialty biologics and targeted therapies: Biologics (adalimumab products, etanercept, abatacept, golimumab) and JAK inhibitors or other targeted agents (upadacitinib, baricitinib, olumiant) are listed as requiring PA, often QL and SP or LD flags. Coverage requires meeting PA and any LD/SP program rules.e.g., QL (2 pens/28 days)

Detailed step or diagnosis-specific criteria not provided here

NSAIDs and non-opioid analgesics:

Coverage for drugs shown in this formulary is plan-specific. Not all drugs in this list are paid for by all drug benefit plans; members and providers must consult the member's Certificate of Coverage for plan-specific payment, benefit limits, and cost-sharing details. The Certificate of Coverage and member portal provide definitive information about whether a listed drug will be paid under a particular plan.

The listed entries do not present explicit clinical exclusions in this segment. Instead, each product line includes administrative requirement flags such as PA (prior authorization), QL (quantity limit), LD (limited distribution), SP (specialty), and AC. Coverage is contingent on meeting any requirements shown for the specific product (for example, VOSEVI is shown with PA, QL (28 tablets/28 days), SP).

This partial extract highlights certain products designated LD and SP (for example, PALFORZIA entries with LD, SP and BEYFORTUS marked AC, SP). No product-specific clinical exclusion statements are provided in these chunks; access and dispensing are governed by the listed distribution and specialty program flags.

The visible entries emphasize administrative controls rather than clinical exclusions. Multiple products include one or more of the following controls: PA, LD, QL, and SP (for example, TEZSPIRE shows LD, PA, QL (1 pen/28 days), SP, and the analgesics section shows aspirin entries with AC). These controls determine coverage workflows and documentation requirements.

In this extract there are no explicit formulary exclusions called out. Product lines primarily list Requirements/Limits such as PA and QL (for example, tramadol entries note QL (240 tablets/30 days)); whether a claim is paid depends on satisfying the listed administrative conditions.

This segment does not include any 'Not Medically Necessary' determinations for the listed items. Instead, many vaccine and biologic entries are shown with an administrative tiering code (e.g., AC) and Requirements/Limits flags that describe coverage handling rather than clinical denial language.

No 'Not Medically Necessary' statements are present in the visible passive immunizing agent and biologics entries. Coverage for products such as BEYFORTUS and PALFORZIA is described via tier and requirement flags (AC, LD, SP) which indicate administrative coverage conditions and distribution controls.

The partial formulary extract does not include product-level 'Not Medically Necessary' language. Entries (for example, SPIRIVA RESPIMAT and TEZSPIRE) show drug tiers and administrative limits — e.g., QL (1 inhaler/30 days) or LD, PA, QL, SP — that govern coverage and dispensing.

This excerpt contains no explicit 'Not Medically Necessary' statements for individual products. Analgesic and biologic listings are presented with tier assignments and requirement flags (for example, aspirin entries with AC, tramadol entries with QL (240 tablets/30 days)) that define administrative coverage conditions rather than clinical exclusion language.

Formulary Drug Listings & Requirement Codes

Prior Authorization, Step Therapy, Documentation & Denial Risk

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Many drugs in this formulary require prior authorization (PA). The plan may deny payment if PA is not obtained before dispensing. Providers should confirm PA requirements before prescribing or filling.

If a drug line shows PA in the Requirements/Limits field, prior authorization is required.
Failure to obtain PA may result in claim denial or member liability.

Prior Authorization

PA Required for Flagged Products

Prior Authorization Required for Flagged Products: Products flagged with PA, LD (limited distribution), SP (specialty), QL (quantity limit), or ST (step therapy) typically require prior authorization and may have distribution or quantity restrictions.

Examples: many oncology, biologic, and specialty products show LD, PA, QL, SP (e.g., TRIKAFTA, KALYDECO, TEZSPIRE).
Limited distribution (LD) items may only be available from select pharmacies and require coordination with the plan.

Specialty and Limited Distribution — Site of Care Notes

Note

Quantity Limits (QL) — Examples and Per-Product Caps

itraconazole cap — QL 120 (example)

Itraconazole (capsules)QL = 120 capsules/30 days for itraconazole 100 mg (Sporanox).

Itraconazole (oral solution)QL = 1200 mls/30 days for itraconazole oral solution 10 mg/ml (Sporanox).

itraconazole oral solution — QL 1200 (example)

Itraconazole oral solutionQL = 1200 mls/30 days specified for itraconazole oral solution 10 mg/ml (Sporanox).

GENVOYA — QL 30

GENVOYAQL = 30 tablets/30 days for GENVOYA (elvitegrav-cobic-emtricitab-tenofov af).

Definitions and Requirement Abbreviations

Definitions and requirement abbreviations

Generic vs BrandGeneric drugs are lower-cost equivalents of brand-name drugs; generic names are shown in lower-case boldface and brands in capital letters.

QL (Quantity Limit)Quantity Limit — maximum quantity allowed per time period as shown (e.g., 30 tablets/30 days).

PA (Prior Authorization)Prior Authorization — medical or administrative approval required before the drug is covered; failure to obtain PA may result in non-coverage.

LD (Limited Distribution)Limited Distribution — product is distributed through restricted channels; dispensing may be limited to certain pharmacies.

SP (Specialty)Specialty — product managed as a specialty drug; may require specialty pharmacy dispensing.

Key definitions (QL, PA, LD, SP, AC)

Step Therapy — Products Marked ST and Related Notes

Topic	Summary
Step therapy (ST)
ST may require trying specified lower‑cost or preferred drugs first before the plan will cover an alternative; members may request an exception to a step requirement.

Topic	Summary
Higher‑tier agents and utilization management
Higher‑tier agents (e.g., Tier 3 oral antimicrobials and other specialty agents) are present and are likely subject to utilization management such as step edits or formulary alternatives; explicit step sequences are not shown in these chunks.

Topic	Summary
Explicit sequences
No explicit step therapy sequences are provided in the extracted segments; product entries instead carry flags such as LD, SP, and PA to indicate program requirements.

Topic	Summary
Limited Distribution (LD) as control
LD (limited distribution) is used for some products and may function as a distribution control that must be satisfied prior to coverage—i.e., product must be obtained through designated channels before benefit applies.

Topic	Summary
ST flag on specialty/oncology drugs
The 'ST' flag is applied to multiple specialty and oncology products in the formulary extract, but specific step requirements or sequences for those agents are not included in these chunks.

Product	Requirement
Selected GLP‑1 receptor agonists and tirzepatide formulations (examples: MOUNJARO, OZEMPIC)
Prior authorization (PA) is required for specified presentations and quantity limits are listed where applicable.

Product	Requirement
KERENDIA (finerenone)
Listed with 'ST' (step therapy) and QL (30 tablets/30 days) per the formulary extract.

Topic	Summary
LD/PA/SP pharmacy channel requirements
Products annotated with LD, PA, and/or SP indicate limited distribution or specialty pharmacy handling and may require dispensing through specific pharmacy channels prior to coverage approval.

Product	Requirement
FOSRENOL (lanthanum carbonate) entries
Formulary entries for FOSRENOL show 'ST' in the Requirements/Limits field indicating a step therapy protocol applies to these products.

Product	Requirement
FETZIMA (levomilnacipran ER)
Marked 'ST' with quantity limit QL (30 capsules/30 days); step therapy required before coverage.

Product	Requirement
Fetzima (levomilnacipran ER)
Formulary shows FETZIMA marked 'ST' (step therapy) and QL (30 capsules/30 days).

Product	Requirement
Fanapt (iloperidone) and Fanapt titration packs
Marked 'ST' in the Requirements/Limits column; titration packs also carry ST and QL entries (example: QL 1 pack/180 days for titration packs).

Product	Requirement
Risperidone ODT (some strengths)
Certain risperidone orally disintegrating tablet strengths are marked 'ST' and have QL values (e.g., QL 60 tablets/30 days).

Product	Requirement
Belsomra (suvorexant) and Dayvigo (lemborexant)
Both agents are listed with QL (30 tablets/30 days) and are annotated 'ST' indicating step therapy applies prior to coverage.

Topic	Summary
Step therapy prior to coverage
The formulary indicates step therapy is required prior to coverage for specified agents (e.g., SAVELLA shows 'ST' and associated QL), meaning trial/failure of preferred alternatives may be required per plan rules.

Product	Requirement
KETOPROFEN ER; MECLOFENAMATE SODIUM (examples)
These NSAID products are noted with 'ST' in the Requirements/Limits field indicating step therapy applies before coverage of these agents.

Formulary Background

This formulary groups drugs by therapeutic class and lists available formulations, drug tiers, and any utilization management indicators used to manage access (examples include PA, QL, LD, SP, and ST). The Requirements/Limits column on each product line signals the administrative conditions that must be met for coverage; failure to obtain required authorizations or to adhere to quantity limits may result in claim denial or noncoverage.

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical change

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization (PA) when 'PA' appears in a drug's Requirements/Limits to ensure coverage and avoid claim denial.

SourceLink

On This Page

Many NSAIDs and non-opioid analgesics are listed with Drug Tier assignments; some have no additional requirements while others have PA and QL. Coverage depends on drug-specific tier and requirements.

No explicit clinical necessity logic present in these chunks

Prior Authorization

PA Required When 'PA' Listed

Prior Authorization When 'PA' Is Listed: When a formulary entry displays 'PA' in Requirements/Limits, providers must submit a prior authorization request with supporting clinical documentation. Check the drug's requirements in the index and the member Certificate of Coverage for plan-specific rules.

Locate drug-level requirements using the formulary index (starts on page 84) and verify member coverage via the Certificate of Coverage or member portal.
If PA is listed with QL or LD, include quantity justification and any specialty-distribution details with the request.

Prior Authorization

PA for Many Specialty Agents

Prior Authorization for Many Specialty Agents: Most specialty, biologic, and high-cost agents require prior authorization and often have additional controls (limited distribution, quantity limits, specialty pharmacy). Expect PA plus QL/LD/SP for agents across oncology, rare disease, immunology, and gene/biologic therapies.

Examples: specialty oncology agents (ALECENSA, BRUKINSA, LENVIMA) and biologics (HUMIRA, ENBREL analogs, ADALIMUMAB biosimilars) are PA + QL + SP.
Specialty drugs may require enrollment with a specialty pharmacy and monitoring documentation.

Prior Authorization

Authorization for Contraceptives & Select Products

Authorization for Contraceptives and Select Products: Some contraceptives and select agents may require authorization or are marked AC (Affordable Care Act) with special coverage treatments. Review the Requirements/Limits field for plan-specific indications.

AC indicates coverage under ACA—verify member eligibility and plan rules.
Contraceptives and certain vaccines may be listed with QL or AC; consult the Certificate of Coverage for cost-sharing details.

Prior Authorization

PA for Select GLP‑1 / Tirzepatide Agents

PA for Select GLP‑1/Tirzepatide Agents: Several GLP‑1 receptor agonists and tirzepatide (weight‑loss or diabetes agents) are subject to PA and quantity limits. Provide indication and prior treatment history when requesting authorization.

Examples: MOUNJARO (tirzepatide), OZEMPIC (semaglutide), TRULICITY (dulaglutide) show PA and QL requirements.
Include diagnosis (diabetes vs weight management) and prior therapy/failure documentation if applicable.

Prior Authorization

PA and Distribution Requirements

Prior Authorization and Distribution Requirements: Many products carry combined requirements: PA plus limited distribution (LD), specialty pharmacy (SP), and quantity limits (QL). Coordination with the designated distributor or specialty pharmacy is required for coverage and dispensing.

When LD is indicated, prescriptions may need to be filled at specific pharmacies—verify arrangements before prescribing.
PA requests should note required distribution channel (LD/SP) and the intended pharmacy.

Prior Authorization

PA for Specialty / High‑Tier Products

PA Requirement for Specialty / High‑Tier Products: High‑tier and specialty items (e.g., TEZSPIRE, XOLAIR, TRIKAFTA, KALYDECO, ORKAMBI) commonly require PA and may have QL and LD designations. Ensure prior approval and supply logistics are in place to avoid treatment delays.

Examples from the formulary: TEZSPIRE (LD, PA, QL, SP), KALYDECO (LD, PA, QL, SP), TRIKAFTA (LD, PA, QL, SP).
Document clinical necessity and any prior therapies when submitting PA.

Prior Authorization

PA Required for Select Agents

Prior Authorization Required for Select Agents: Individual formulary lines indicate PA and other controls—review each drug's Requirements/Limits entry before prescribing.

Example: tasimelteon 20 mg is listed with PA and QL.
Many antiviral and specialty antiviral agents list PA and QL (e.g., HARVONI, MAVYRET).

Prior Authorization

PA Required for Many Entries

PA Required for Many Entries: Numerous biologic and high‑cost agents across therapeutic classes are flagged for PA (and often QL/SP). Confirm authorization rules at the drug level.

Biosimilars and biologics (adalimumab products, HUMIRA, ENBREL-type entries) show PA + QL + SP.
Where QL is present, supply/quantity justification must be provided with PA.

Denial Risk

PA Denial Triggers

Prior Authorization Denial Triggers: PA requests can be denied if required documentation is missing, criteria are not met, step‑therapy requirements are unmet, or quantity/distribution limits are exceeded. Denials may result in non‑coverage and member financial liability.

Common denial reasons: absence of PA, failure to document prior therapy or clinical rationale, exceeding QL, or not using required LD/SP channels.
Providers and members may request an exception or appeals per plan procedures.

Prior Authorization

Authorization & Distribution Restrictions

Authorization & Distribution Restrictions: Claims for items flagged with PA, LD, or SP may be denied without required approvals or when filled outside authorized channels. Follow plan-specified specialty pharmacy and limited distribution instructions.

If a drug is LD/SP, confirm the appropriate dispensing pharmacy prior to submission.
Ensure PA approval explicitly covers the dispensing site and quantity authorized.

Prior Authorization

Prior Authorization Indicated

Prior Authorization Indicated: Where the formulary indicates 'PA' (or combined flags like LD, QL, SP), submit a prior authorization request with clinical documentation and specify intended supply arrangements.

Many oncology therapy packs and specialty injectables list PA and QL — include regimen and dosing schedule in the request.
Check the Certificate of Coverage and member portal for plan-specific submission contacts.

Note

How to Find Drug‑Level Requirements

How to Find Drug‑Level Requirements: Use the formulary index (page 84) to locate drugs and review the Requirements/Limits field in each line. For plan-specific coverage, consult the member's Certificate of Coverage or the member portal (my.emblemhealth.com).

Index shows brand/generic formatting and directs you to each drug entry.
Certificate of Coverage contains final coverage, cost‑share, and exception/appeal processes.

Documentation Required

Documentation for QL / LD / SP Drugs

Documentation for QL/LD/SP Drugs: When QL, LD, or SP flags appear, providers must document quantity rationale, frequency, and any specialty distribution arrangements. Submission must include clinical indication and prior treatment history where relevant.

Examples: PA requests for LD/SP products should include dosing schedule, anticipated duration, and reason LD/SP is clinically appropriate.
If QL is expressed as tablets/30 days or syringes/28 days, requests must justify need beyond the stated limit.

Documentation Required

PA & Quantity‑Limit Documentation

PA and QL Documentation: For drugs with PA plus QL, include clinical notes that support the requested quantity (dose and days supply), prior therapy attempts or contraindications, and monitoring plans.

Examples: testosterone products and certain antidiabetics list PA + QL — include labs, diagnosis, and prior treatments.
For oncology/specialty agents list planned cycles, total supply needed, and supportive care requirements.

Documentation Required

Quantity Limit Documentation

Quantity Limit Documentation: Quantity limits (QL) are expressed per time period (e.g., 30 tablets/30 days). When requesting override or exception, provide objective clinical justification, duration of need, and prior treatment history.

Examples: FARXIGA QL 30 tablets/30 days; JANUMET-like products QL examples appear in antidiabetics.
For chronic therapies, indicate maintenance dose and monitoring to support higher quantities.

Documentation Required

Example Documentation Expectations

Example Documentation Expectations: Some entries show typical documentation needs—e.g., testosterone products require PA plus QL, with supporting labs and diagnosis; specialty oncology agents require regimen details and distribution plan.

Testosterone: include baseline labs, diagnosis, and previous treatment trials.
Oncology agents: include diagnosis, line of therapy, stage, and planned cycles.

Documentation Required

Documentation Expectations (General)

Documentation Expectations (General): Across PA/LD/QL/SP flags, submit complete clinical rationale, previous therapy history, and specify dispensing channel. Missing or incomplete documentation increases denial risk and processing delays.

Include contact information for the dispensing pharmacy when LD/SP applies.
Attach relevant labs, imaging, or specialist notes that support medical necessity.

Documentation Required

Required Documentation Examples

Required Documentation Examples: The formulary lists drugs with typical required documentation—e.g., NEXLETOL/NEXLIZET require PA and QL; many specialty drugs require LD/SP arrangements and evidence of prior authorization.

NEXLETOL/NEXLIZET: PA and QL (30 tablets/30 days) — include indication and prior therapy.
Biologics (adalimumab variants): PA plus QL (syringes/pens per 28 days) and SP — include diagnosis and prior DMARD history.

Documentation Required

Required Submission Items

Required Submission Items: When submitting PA for LD/PA/QL/SP drugs, include prescriber details, diagnosis code, clinical rationale, prior therapies/trials, requested quantity/days supply, and preferred dispensing pharmacy.

For specialty injectables, include weight-based dosing if applicable and administration schedule.
If step therapy (ST) applies, document trials of required first‑line agents or provide justification for exception.

Documentation Required

Required Documentation for PA / LD / SP

Required Documentation for PA/LD/SP: Prescribers must supply prior authorization forms and any supporting documentation requested by the plan for drugs marked PA, LD, or SP. Items filled outside required channels or without approved PA may be denied.

Confirm PA approval covers the quantity, duration, and dispensing site.
For LD items, attach evidence the chosen pharmacy participates in the limited distribution program.

Documentation Required

Documentation Expectations (Specialty)

Documentation Expectations (General) — Specialty Emphasis: High‑cost biologics and specialty agents require comprehensive submission packets: diagnosis, prior treatment history, monitoring plan, dosing schedule, and confirmation of specialty pharmacy enrollment when required.

Examples: OMVOH, SKYTROFA, and other specialty biologics show LD/PA/QL/SP — include specialty pharmacy details.
Incomplete specialty documentation commonly causes denials or delays.

Step Therapy

Step Therapy / Step Edits

Step Therapy / Step Edits: Step therapy (ST) applies to select formulary entries. When ST is present, the plan may require trials of preferred or lower‑cost agents before authorizing higher‑tier drugs. Providers can request exceptions with clinical justification.

Examples of ST: FOSRENOL and select analgesics/neurologic agents list ST.
If ST applies, document prior trial(s) and reasons for failure or intolerance when requesting exception.

Billing Rule

Limited Distribution & Controls

Limited Distribution and Controls: LD indicates limited distribution channels—these products often require coordination with specific specialty pharmacies and may have PA/QL requirements. Plan prior approval must reflect LD constraints.

When LD is listed, verify the authorized dispenser and include that pharmacy in the PA request.
LD items commonly overlap with SP and PA flags; plan approval often requires adherence to the designated supply pathway.

Step Therapy

Step Therapy Flags Present

Step Therapy Flags Present: Several products show ST in the Requirements/Limits field — these require documentation of trial/failure of step agents or an exception justification.

Examples: KERENDIA shows ST; select psychiatric and analgesic agents also show ST.
Provide dates, agents tried, duration, and reason for discontinuation when submitting PA under ST.

Step Therapy

Step Therapy Flag

Step Therapy Flag (Example): Kerendia (finerenone) is listed with a step therapy flag — prescribers should document required prior trials or provide rationale for an exception.

KERENDIA — Requirements/Limits = QL (30 tablets/30 days), ST.

Step Therapy

Step Therapy Presence

Step Therapy Presence: Many drugs annotated LD/PA/SP may also have step requirements — verify each drug line for ST and supply required supporting documentation.

Examples across therapeutic areas show combined ST with QL and PA.
Failure to meet ST conditions can be a basis for denial.

Step Therapy

Step Therapy Present for Select Drugs

Step Therapy Present for Select Drugs: The formulary indicates ST for several specific drugs (examples include Fetzima, Savella, certain antipsychotics and analgesics). Document prior preferred-agent trials or exception rationale.

Examples: FETZIMA, SAVELLA, RISPERIDONE ODT show ST in Requirements/Limits.
Include dates and outcomes of prior therapy trials when submitting an exception request.

Step Therapy

Step Therapy Requirements (Examples)

Step Therapy Requirements (Examples): Where ST is shown, coverage may require documented failure/intolerance of preferred alternatives before authorizing non‑preferred agents.

FOSRENOL entries show ST and QL; SAVELLA lists ST and QL requirements.
Provide clinical notes supporting why first‑line agents are contraindicated or ineffective.

Step Therapy

Step Therapy Applies to Some NSAIDs

Step Therapy Applies to Some NSAIDs: A small subset of NSAIDs (e.g., KETOPROFEN ER, MECLOFENAMATE) are marked ST; check requirements and document prior therapy trials when applicable.

KETOPROFEN ER — Requirements/Limits = ST.
MECLOFENAMATE SODIUM — Requirements/Limits = ST.

ISENTRESS (various strengths/forms) — QL 60-180

ISENTRESS chew/tab/packQL = 60-180 (e.g., QL (180 tablets/30 days) for chewable forms; QL (60 tablets/30 days) for 400 mg tablets; QL (60 packets/30 days) for packet).

PAXLOVID (various pack sizes) — QL 11-30

PAXLOVID (nirmatrelvir + ritonavir pack)QL = 30 tablets/30 days listed for PAXLOVID; some pack representations show QL ranges (11-30) depending on pack size.

SUNLENCA - lenacapavir — QL 4-5 or 4 depending on pack

SUNLENCA — lenacapavir therapy packsQL = 4–5 tablets/365 days depending on therapy pack (SUNLENCA therapy pack 4 x 300 mg or 5 x 300 mg).

multiple (examples provided) — assorted QL examples (30/60/4/28/240/360 etc.)

Assorted common QLsExamples across the formulary include QL values such as 30, 60, 4 (annual packs), 28, 240, 360, reflecting tablets/capsules/grams/mLs per period.

Therapy-pack capsMany therapy-pack presentations list specific pack-based QLs (e.g., 28 packets/28 days, 56 packets/28 days).

High-volume solution limitsSeveral oral solutions/suspensions have large-volume QLs (e.g., 900 mls, 540 mls, 1200 mls) for 30-day supplies.

abiraterone acetate 250 mg — QL 120

abiraterone acetate 250 mgQL = 120 tablets/30 days for abiraterone acetate (Zytiga).

BRAFTOVI (encorafenib) 75 mg — QL 180

BRAFTOVI (encorafenib) 75 mgQL = 180 capsules/30 days for encorafenib 75 mg.

IMBRUVICA oral suspension — QL 216

IMBRUVICA oral suspensionQL = 216 mls/30 days for ibrutinib oral suspension presentations.

IMBRUVICA 70 mg/mlQL = 216 mls/30 days specified for ibrutinib oral suspension 70 mg/ml.

IMBRUVICA 70 mg/ml — QL 216 mls

IMBRUVICA 70 mg/ml (oral suspension)QL = 216 mls/30 days for the 70 mg/ml oral suspension formulation.

JAYPIRCA 50 mg — QL 30 tablets

JAYPIRCA (pirtobrutinib) 50 mgQL = 30 tablets/30 days for JAYPIRCA 50 mg tablets.

VENCLEXTA 100 mg — QL 180 tablets; STARTING PACK — 1 pack

VENCLEXTA 100 mgQL = 180 tablets/30 days for venetoclax 100 mg tablets.

VENCLEXTA starting/starter packQL = 1 starter pack/180 days for the venetoclax therapy starter pack (10, 50, 100 mg).

VENCLEXTA STARTING PACK — 1 pack

VENCLEXTA STARTING PACKQL = 1 pack/180 days for the venetoclax therapy starter pack (10, 50, 100 mg).

VENCLEXTA STARTING PACK details — starter pack strengths listed as QL 1 pack

VENCLEXTA starter pack strengthsStarter pack includes 10 mg, 50 mg, and 100 mg tablets packaged as 1 pack; QL shown as 1 pack/180 days.

VERZENIO — QL 60 tablets

VERZENIO (abemaciclib)QL = 60 tablets/30 days for VERZENIO abemaciclib formulations.

XALKORI — QL 120 capsules

XALKORI (crizotinib)QL = 120 capsules/30 days for XALKORI crizotinib capsules (200 mg, 250 mg).

testosterone cypionate im inj 100 mg/ml — QL 1 vial

Testosterone cypionate 100 mg/ml (IM)QL = 1 vial/28 days for testosterone cypionate IM injection 100 mg/ml (PA also indicated).

FARXIGA — QL 30

FARXIGA (dapagliflozin)QL = 30 tablets/30 days for FARXIGA formulations.

GLYXAMBI — QL 30

GLYXAMBI (empagliflozin-linagliptin)QL = 30 tablets/30 days for GLYXAMBI.

MOUNJARO — QL 4 pens (some presentations)

MOUNJARO (tirzepatide) - some presentationsQL = 4 pens (often shown as QL (4 pens/180 days) or 4 pens/28 days depending on presentation).

OZEMPIC — QL 1-3 pens

OZEMPIC (semaglutide)QL = 1–3 pens (examples: QL (1 pen/28 days) or QL (3 pens/28 days) depending on strength/presentation).

TRULICITY — QL 2-4 pens

TRULICITY (dulaglutide)QL = 2–4 pens/28 days for TRULICITY depending on strength.

RYBELSUS — QL 30 tablets

RYBELSUS (oral semaglutide)QL = 30 tablets (commonly QL (30 tablets/30 days) for RYBELSUS).

Various specialty agents — assorted vial/pen/capsule QL examples

Various specialty vials/pens/capsulesExamples include QL (10 vials/30 days), QL (30 vials/30 days), QL (1 injection device/28 days), QL (2 pens/28 days), QL (60 capsules/30 days).

teriparatide (Forteo) / YORVIPATH — 1 pen/28 days; 2 pens/28 days examples

teriparatide (Forteo) / YORVIPATHQL = 1 pen/28 days (Forteo) or QL = 2 pens/28 days (YORVIPATH) depending on product presentation.

NEXLETOL / NEXLIZET — QL 30

NEXLETOL / NEXLIZETQL = 30 tablets/30 days for NEXLETOL and NEXLIZET.

REPATHA — QL 6

REPATHA (evolocumab)QL = 6 syringes/pens per 28 days (QL (6) as listed for REPATHA).

VASCEPA — QL 240 (0.5 g) / 120 (1 g)

VASCEPA 0.5 gQL = 240 capsules/30 days for VASCEPA 0.5 g.

VASCEPA 1 gQL = 120 capsules/30 days for VASCEPA 1 g.

ADEMPAS and CAMZYOS — QL 90 / 30

ADEMPAS (riociguat)QL = 90 tablets/30 days for ADEMPAS.

CAMZYOS (mavacamten)QL = 30 capsules/30 days for CAMZYOS.

TYVASO — QL 7

TYVASO (treprostinil inhalation)QL = 7 packages/28 days for TYVASO inhalation solution.

VERQUVO / NUCALA — QL 30 / 3

VERQUVO (vericiguat)QL = 30 tablets/30 days for VERQUVO.

NUCALA (pen 100 mg/ml)QL = 3 pens/28 days for NUCALA pen presentations.

SPIRIVA / TRELEGY — inhaler/blister QLs

SPIRIVA RESPIMATQL = 1 inhaler/30 days for SPIRIVA RESPIMAT.

TRELEGY ELLIPTAQL = 60 blisters/30 days for TRELEGY ELLIPTA (100-62.5-25 mcg/act).

TRIKAFTA — QL 56 packets

TRIKAFTA (packets)QL = 56 packets/28 days for TRIKAFTA packet presentations.

KALYDECO — QL 60 tablets

KALYDECO (ivacaftor)QL = 60 tablets/30 days for KALYDECO formulations.

LIVDELZI / OMVOH / sevelamer — assorted QLs

LIVDELZI (seladelpar)QL = 30 tablets/30 days for LIVDELZI.

OMVOH (mirikizumab)QL = 1–2 pens or syringes/28 days depending on presentation for OMVOH.

sevelamer carbonate packet 0.8 gmQL = 510 packets/30 days for sevelamer carbonate 0.8 gm packets.

TREMFYA INDUCTION PACK FO — QL 3 kits

TREMFYA induction packQL = 3 kits/180 days for TREMFYA induction pack presentations.

FILSPARI / FETZIMA — QL 30 tablets/capsules

FILSPARI (sparsentan)QL = 30 tablets/30 days for FILSPARI formulations.

FETZIMA (levomilnacipran)QL = 30 capsules/30 days for FETZIMA ER.

escitalopram / zuranolone — solution and capsule QLs

Escitalopram solutions & tabletsExamples: escitalopram solution 5 mg/5 ml QL = 600 mls/30 days; escitalopram 5 mg tab QL = 120 tablets/30 days; 10 mg QL = 60 tablets/30 days; 20 mg QL = 30 tablets/30 days.

zuranolone capsulesExamples: zuranolone 20/25 mg QL = 28 capsules/365 days; zuranolone 30 mg QL = 14 capsules/365 days.

Rexulti / Versacloz / tasimelteon — assorted examples

Rexulti (brexpiprazole)QL = 30 tablets/30 days for Rexulti tablets.

Versacloz suspensionQL = 540 mls/30 days for Versacloz (clozapine) suspension.

tasimelteon (Hetlioz)QL = 30 capsules/30 days for tasimelteon 20 mg.

methylphenidate / sodium oxybate / other solution QLs

methylphenidate solutions and tabletsExamples: methylphenidate HCl solution 10 mg/5 ml QL = 900 mls/30 days; other methylphenidate formulations have QLs of 60–900 tablets/mLs per 30 days depending on form.

sodium oxybate oral solution — QL 540 mls

sodium oxybate oral solutionQL = 540 mls/30 days for sodium oxybate formulations (Xyrem/XYWAV/LUMRYZ).

cladribine therapy pack — various QL entries (e.g., 8 tablets/301 days; 20 tablets/301 days)

cladribine therapy packsQL = various pack-based limits (examples include 8 tablets/301 days and 20 tablets/301 days for cladribine therapy packs).

butalbital-acetaminophen / BELBUCA — QL examples

butalbital-acetaminophenQL = 180 tablets/30 days for butalbital-containing products (e.g., butalbital-acetaminophen).

BELBUCA buprenorphine buccal filmQL = 60 films/30 days and PA required for BELBUCA.

adalimumab products — assorted QL examples (2 pens/28 days etc.)

adalimumab products (biosimilars and originator)Requirement: PA and QL = 2 pens/28 days (or QL as noted per kit) for many adalimumab presentations; SP indicated.

OLIMPIANT/OLUMIANT/RINVOQ — LD, PA, QL examples

OLIMPIANT/OLUMIANT/RINVOQ (JAK inhibitors)Example: Some strengths/formulations listed with LD, PA and QL = 30 tablets/30 days; other formulations show the specific LD/PA/QL as listed.

QL — Quantity Limit definitionQuantity Limit: the maximum quantity allowed per specified time period (examples in this formulary include tablets, capsules, mLs, pens, inhalers).

PA — Prior Authorization definitionPrior Authorization: payer approval required before coverage; drugs labeled 'PA' need prescriber or member to obtain authorization.

LD — Limited Distribution definitionLimited Distribution: drug is available only through designated distributors or channels; often combined with PA and SP.

SP — Specialty definitionSpecialty: denotes specialty pharmacy management; many SP drugs also require PA and have QL or LD flags.

AC — Administrative coverage flagAC: administrative/coverage condition flag used for certain vaccines and other items (may affect coverage or cost-sharing).