CurrentEmblemHealthPolicy N/A
2026 Formulary (List of Covered Drugs)
Part 1 of the EmblemHealth 2026 formulary listing covered drugs, tiers, and associated requirements/limits (PA, QL, SP, LA, ACA, FF, ST) for numerous anti-infective therapeutic classes and specific products; includes antibiotics, antifungals, antivirals, antimycobacterial, antiparasitic, and related drug listings through antimalarials. Coverage may vary by specific drug benefit plan.
Policy Summary
PayerEmblemHealth
Policy2026 Formulary (List of Covered Drugs)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateMar 1, 2026
Next Review DateN/A
Key ActionUse the formulary index (starts on page 102) to locate drugs and follow prior authorization, quantity limits, specialty, LA, ACA and step therapy flags as listed.
POLICY UPDATE CHANGES
No material clinical or coverage changes were documented for this formulary part.
manyProducts listed in this part
multipleProducts with PA
multipleProducts with QL
numerousSP/LA-designated
commonOTC/ACA flagged
Coverage Summary
Applicable Codes / Formulary Entries
Drug lists and requirements/limits (by drug/product)mixedCovered
| AMOXICILLIN | amoxicillin (trihydrate) chew tab 125 mg, 250 mg; cap 250 mg, 500 mg; susp 125/5ml, 200/5ml, 250/5ml, 400/5ml; tab 500 mg, 875 mg |
| AMOXICILLIN & K CLAVULANATE | amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml; susp 600-42.9 mg/5ml (Augmentin ES-600); tab ER 12hr 1000-62.5 mg; tab 250-125 mg, 500-125 mg, 875-125 mg |
| AMPICILLIN | ampicillin cap 500 mg |
| AUGMENTIN | AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml |
| DICLOXACILLIN | dicloxacillin sodium cap 250 mg, 500 mg |
| PENICILLIN V POTASSIUM | penicillin v potassium for soln 125 mg/5ml, 250 mg/5ml; tab 250 mg, 500 mg |
| CEPHALOSPORINS | class header - cephalosporins |
| CEFACLOR | cefaclor formulations (oral) |
| CEFADROXIL | cefadroxil formulations (oral) |
| CEFDINIR | cefdinir formulations (oral) |
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1/13
VaccinesmixedCovered
| ABRYSVO | ABRYSVO |
| COMIRNATY 2025-26 | COMIRNATY 2025-26 |
| GARDASIL 9 | Gardasil 9 |
| SHINGRIX | Shingrix |
| PNEUMOVAX 23 | Pneumovax 23 |
| PREVNAR 20 | Prevnar 20 |
| FLUZONE 2025-2026 | Fluzone 2025-2026 |
Antineoplastics and specialty oncologymixedCovered
| abiraterone acetate 250 mg | abiraterone acetate 250 mg |
| abiraterone acetate 500 mg | abiraterone acetate 500 mg |
| ALECENSA 150 mg cap | Alecensa 150 mg cap |
| ALUNBRIG | Alunbrig (various strengths) |
| IBRANCE | Ibrance cap/tab 75/100/125 mg |
| IMBRUVICA | Imbruvica (various) |
PALFORZIA levelsmixedCovered
| PALFORZIA INITIAL DOSE ES | PALFORZIA INITIAL DOSE ES |
| PALFORZIA LEVEL 0 | PALFORZIA LEVEL 0 |
| PALFORZIA LEVEL 1 | PALFORZIA LEVEL 1 |
| PALFORZIA LEVEL 2 | PALFORZIA LEVEL 2 |
| PALFORZIA LEVEL 3 | PALFORZIA LEVEL 3 |
| PALFORZIA LEVEL 4 | PALFORZIA LEVEL 4 |
| PALFORZIA LEVEL 5 | PALFORZIA LEVEL 5 |
| PALFORZIA LEVEL 6 | PALFORZIA LEVEL 6 |
| PALFORZIA LEVEL 7 | PALFORZIA LEVEL 7 |
| PALFORZIA LEVEL 8 | PALFORZIA LEVEL 8 |
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OTC / ACA listsmixed
| ACA | Affordable Care Act OTC coverage annotations |
| OTC | Over the Counter product listings (multivitamins, common OTC agents) |
PA / QL / LA / SP grouped listsmixed
| PA | Prior Authorization required — see policy details |
| QL | Quantity Limit — see policy details |
| LA | Limited Availability — select retail locations |
| SP | Specialty drugs — specialty pharmacy requirements |
Additional notable products (selected)mixedCovered
| CAYSTON | Cayston (aztreonam inhalation) |
| linezolid suspension | linezolid for suspension |
| nitazoxanide 500 mg tab | nitazoxanide 500 mg tablet |
| BAQSIMI ONE PACK | BAQSIMI glucagon nasal powder 3 mg/dose |
| GVOKE HYPOPEN | Gvoke autoinjector and kit formulations |
Contraceptives and reproductive healthmixedCovered
| levonorgestrel & ethinyl estradiol 0.1-20 | levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg |
| levonorgestrel tab 1.5 mg | levonorgestrel tab 1.5 mg (emergency) |
| LILETTA | Liletta IUD levonorgestrel 20.1 mcg/day (52 mg) |
| MIRENA | Mirena IUD levonorgestrel 20 mcg/day (52 mg) |
| NEXPLANON | Nexplanon etonogestrel implant 68 mg |
| NUVARING | NuvaRing vaginal ring |
| PARAGARD | Paragard copper IUD |
Diabetes and glucagon productsmixedCovered
| BAQSIMI TWO PACK | BAQSIMI two-pack |
| GLUCAGON EMERGENCY KIT | glucagon for injection 1 mg |
| GVOKE KIT | Gvoke rescue kit and PFS |
| MOUNJARO | Mounjaro (tirzepatide) multi-strength pens |
| OZEMPIC | Ozempic (semaglutide) pens |
| RYBELSUS | Rybelsus (semaglutide) oral |
Insulins and devicesmixedCovered
| Rapid-Acting Insulins | FIASP, Humalog, Lyumjev, Novolog and related |
| Basal Insulins | insulin glargine, degludec, insulin glargine-yfgn, Semglee, Toujeo, Tresiba |
| Insulin pens and needles | pen needles and delivery devices |
Policy Summary
PayerEmblemHealth
Policy2026 Formulary (List of Covered Drugs)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateMar 1, 2026
Next Review DateN/A
Key ActionUse the formulary index (starts on page 102) to locate drugs and follow prior authorization, quantity limits, specialty, LA, ACA and step therapy flags as listed.
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