CurrentEmblemHealthPolicy N/A

2026 Formulary (List of Covered Drugs) — Part 2 (drugs, vaccines, biologics; tiers and requirements/limits)

This document lists drugs, vaccines, biologics and associated benefit design attributes (Drug Tier and Requirements/Limits such as PA, QL, ACA, LA, SP, OTC, FF). It is a formulary/drug list excerpt (part of a larger formulary), not standalone prior authorization criteria.

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy N/A

Change TypeFormulary / drug list excerpt

Effective DateApr. 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document indication for products flagged 'PA' and adhere to listed quantity limits (QL) and LA/SP handling to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted for this excerpt (has_material_change=false).

200+Products listed in this excerpt

ManyProducts with QL constraints

MultipleProducts requiring PA

NumerousVaccines designated ACA (preventive)

ManySpecialty (SP) products

Coverage summary — formulary part / benefit design

Drug / vaccine groups and listed requirements

Formulary listing logic & entry-level criteria

Formulary entries include the drug name, available strengths/forms, the formulary tier per product, and any Requirements/Limits (abbreviations explained above). The group below lists the top-level categories and each drug entry as a leaf enumerating per-product tier and Requirements/Limits.

ANY of the following

ANTI-INFECTIVE AGENTS — Drug Tier: . — Requirements/Limits: .

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy N/A

Change TypeFormulary / drug list excerpt

Effective DateApr. 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document indication for products flagged 'PA' and adhere to listed quantity limits (QL) and LA/SP handling to avoid claim denial.

SourceLink

On This Page

PENICILLINS — Drug Tier: . — Requirements/Limits: .

AMOXICILLIN (amoxicillin (trihydrate) chew tab 125 mg, 250 mg) — Drug Tier: 3 — Requirements/Limits: .

AMOXICILLIN (amoxicillin (trihydrate) cap 250 mg, 500 mg) — Drug Tier: 1 — Requirements/Limits: .

AMOXICILLIN (amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml) — Drug Tier: 1 — Requirements/Limits: .

AMOXICILLIN (amoxicillin (trihydrate) tab 500 mg, 875 mg) — Drug Tier: 1 — Requirements/Limits: .

AMOXICILLIN & K CLAVULANATE (for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml) — Drug Tier: 1 — Requirements/Limits: .

AMOXICILLIN & K CLAVULANATE (for susp 600-42.9 mg/5ml (Augmentin es-600)) — Drug Tier: 1 — Requirements/Limits: .

AMOXICILLIN & K CLAVULANATE (tab ER 12hr 1000-62.5 mg) — Drug Tier: 1 — Requirements/Limits: .

AMOXICILLIN & K CLAVULANATE (tab 250-125 mg, 500-125 mg, 875-125 mg) — Drug Tier: 1 — Requirements/Limits: .

AMPICILLIN (cap 500 mg) — Drug Tier: 1 — Requirements/Limits: .

AUGMENTIN (amoxicillin & k clavulanate for susp 125-31.25 mg/5ml) — Drug Tier: 3 — Requirements/Limits: .

DICLOXACILLIN SODIUM (cap 250 mg, 500 mg) — Drug Tier: 1 — Requirements/Limits: .

PENICILLIN V POTASSIUM (for soln 125 mg/5ml, 250 mg/5ml) — Drug Tier: 3 — Requirements/Limits: .

PENICILLIN V POTASSIUM (tab 250 mg, 500 mg) — Drug Tier: 1 — Requirements/Limits: .

CEPHALOSPORINS — Drug Tier: . — Requirements/Limits: .

CEFACLOR (cap 250 mg, 500 mg) — Drug Tier: 3 — Requirements/Limits: .

CEFADROXIL (tab 1 gm) — Drug Tier: 3 — Requirements/Limits: .

cefadroxil (cap 500 mg) — Drug Tier: 1 — Requirements/Limits: .

cefadroxil (for susp 250 mg/5ml, 500 mg/5ml) — Drug Tier: 1 — Requirements/Limits: .

cefdinir (cap 300 mg) — Drug Tier: 1 — Requirements/Limits: .

cefdinir (for susp 125 mg/5ml, 250 mg/5ml) — Drug Tier: 1 — Requirements/Limits: .

cefixime (cap 400 mg) — Drug Tier: 1 — Requirements/Limits: .

cefixime (for susp 100 mg/5ml, 200 mg/5ml) — Drug Tier: 1 — Requirements/Limits: .

CEFPODOXIME PROXETIL (for susp 50 mg/5ml, 100 mg/5ml) — Drug Tier: 3 — Requirements/Limits: .

CEFPODOXIME PROXETIL (tab 100 mg, 200 mg) — Drug Tier: 1 — Requirements/Limits: .

cefprozil (for susp 125 mg/5ml, 250 mg/5ml) — Drug Tier: 1 — Requirements/Limits: .

cefprozil (tab 250 mg, 500 mg) — Drug Tier: 1 — Requirements/Limits: .

cefuroxime axetil (tab 250 mg, 500 mg) — Drug Tier: 1 — Requirements/Limits: .

cephalexin (cap 250 mg, 500 mg, 750 mg) — Drug Tier: 1 — Requirements/Limits: .

cephalexin (for susp 125 mg/5ml, 250 mg/5ml) — Drug Tier: 1 — Requirements/Limits: .

MACROLIDES — Drug Tier: . — Requirements/Limits: .

azithromycin (for susp 100 mg/5ml, 200 mg/5ml (Zithromax)) — Drug Tier: 1 — Requirements/Limits: .

azithromycin (tab 250 mg (Zithromax z-pak)) — Drug Tier: 1 — Requirements/Limits: .

azithromycin (tab 500 mg (Zithromax)) — Drug Tier: 1 — Requirements/Limits: .

azithromycin (tab 600 mg) — Drug Tier: 1 — Requirements/Limits: .

CLARITHROMYCIN (for susp 125 mg/5ml, 250 mg/5ml) — Drug Tier: 3 — Requirements/Limits: .

CLARITHROMYCIN (tab ER 24hr 500 mg) — Drug Tier: 1 — Requirements/Limits: .

CLARITHROMYCIN (tab 250 mg, 500 mg) — Drug Tier: 1 — Requirements/Limits: .

DIFICID (fidaxomicin for susp 40 mg/ml) — Drug Tier: 2 — Requirements/Limits: .

E.E. — (entry appears in source; Drug Tier/Requirements/Limits not specified).

OpenPayer

2026 Formulary (List of Covered Drugs) — Part 2 (drugs, vaccines, biologics; tiers and requirements/limits)

Coverage summary — formulary part / benefit design

Drug / vaccine groups and listed requirements

Formulary listing logic & entry-level criteria

Quantity limits and numeric thresholds

What providers must do (PA, documentation, billing rules)

Fee-schedule mappings and product-to-line annotations