Prior Authorization Required

Many drugs listed in this formulary require prior authorization (PA) before the plan will pay. Providers must obtain PA where a drug is labeled PA, and should confirm coverage controls (PA, QL, LA, SP, ST, FF, ACA) for each product before prescribing or dispensing. Failure to obtain required authorizations may result in denial of payment.

• Prior Authorization Required Where Labeled: If a product entry includes 'PA' the prescriber must request and receive prior authorization before the plan will pay.
• Prior Authorization Commonly Required: Specialty, oncology, endocrine, biologic, and many GLP-1/GIP agents frequently carry PA requirements and may also have quantity limits (QL), limited access (LA), specialty designation (SP), or step therapy (ST).
• Prior Authorization and Quantity Limits: Many products are subject to QL; requests for quantities above the stated QL will generally require PA with supporting documentation.
• Select GLP-1/GIP and Specialty Agents: Examples include MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY — these agents are labeled with PA and QL and often require documentation of medical necessity.
• Specialty Endocrine Agents: Agents such as GALAFOLD and GENOTROPIN require PA and are often designated SP with QL and LA as noted in product entries.
• PA for Biologics/Specialty: Biologic agents (eg, TYVASO, NUCALA, FASENRA, TEZSPIRE, many anti‑TNFs and anti‑IL agents) commonly require PA and QL and are designated SP/LA.
• PA Required for Listed PA Agents: Any product in the formulary annotated with PA requires prior authorization; check the Requirements/Limits column for specifics (QL, LA, SP, ST, FF).
• PA Required When Indicated: Authorization flags (PA, LA, SP, ST, FF, ACA) in the formulary indicate coverage controls that must be followed to avoid claim denial.
• Prior Authorization and Step Therapy Present: Some drugs require step therapy (ST) — providers may need to document trials of required agents before PA will be approved.
• PA Required for Specified Products: Certain stimulants, wakefulness agents (eg, SUNOSI, WAKIX), specialty/DMT agents (eg, AVONEX, BETASERON, cladribine), and others are labeled PA and require prior authorization.
• PA Required for Listed Specialty Agents: Many specialty immunologic and biologic agents (adalimumab variants, etanercept, abatacept, sarilumab, certolizumab, etc.) are PA and QL labeled — PA must be obtained.
• Prior Authorization Triggers: PA may be triggered by drug type (specialty, biologic, oncology), formulation (oral solution, starter/titration packs), or when requested quantity exceeds QL.

Utilization Management and Denial Risk

Utilization management controls (PA, QL, LA, SP, ST, FF, ACA) are enforced across the formulary and may lead to claim denial if requirements are not met. Providers should review the Requirements/Limits column for each product and submit necessary documentation with PA requests.

• Utilization Management May Trigger Denial: Requests lacking required PA, exceeding QL, or not meeting ST/FF criteria may be denied.
• Coverage Requirement Indicators: The formulary uses flags (PA, QL, LA, SP, ST, FF, ACA) to indicate required actions — treat these as enforceable controls.
• PA/QL/LA/SP Presence Indicates Authorization Needed: When any of these flags appear, submit PA with supporting clinical documentation per product-specific requirements.
• PA/QL and Quantity Limit Risk: Approvals often specify limits (eg, 1 inhaler/30 days, specific pen or syringe counts); exceeding these without authorization risks denial.
• PA/LA Presence May Trigger Denial: Limited access designations (LA) plus PA frequently indicate restricted distribution or specialty channel requirements; verify prior to dispensing.
• Denial Triggers — QL/ST/PA: Quantity Limits, Step Therapy, and Prior Authorization are common denial causes if not satisfied.

Provider Actions: Contact, Claims, and Documentation

Provider actions: contact member services for coverage questions; include complete claim and clinical information when requesting PA; and provide documentation that aligns with the formulary's Requirements/Limits.

• Contact and Coverage Documentation: Call EmblemHealth Member Services at 877-793-6253 (TTY: 711) for coverage questions and to verify PA processes.
• Required Claim Information: When submitting a PA or claim, include product name, strength, dose form, quantity, and intended days' supply so the request can be evaluated against Requirements/Limits.
• Documentation Required When PA/QL/LA/SP Present: Provide clinical notes, prior therapy trials (for ST/FF), lab results, and any specialty documentation requested in product-specific requirements.
• Required Documentation per Formulary Controls: Follow the Requirements/Limits listed for each product (e.g., QL limits, LA distribution channels, SP handling).
• Documentation for PA/SP Items: For biologics and specialty drugs include diagnosis, treatment history, weight/dosing information, and any specialty program enrollment details when applicable.
• Quantity Limits Enforcement and Documentation: If requesting quantities above the stated QL (for example 1 inhaler/30 days or specified pen/syringe limits), submit rationale and supporting clinical evidence.

Step Therapy, Program Restrictions, and Packs

Step therapy (ST) and program/step restrictions (including fail‑first requirements) apply where noted. Some entries use starter/therapy/titration packs that have their own PA/QL/LA rules. If the formulary shows no explicit ST for a product, limited access (LA) or PA may still apply.

• Step Therapy / Fail‑First: When ST is listed, the prescriber must document trials of required agents and reasons for failure before PA will approve the requested product.
• Program/Step Restrictions Noted: Some drugs (eg, APRETUDE, certain LA agents) are flagged with program-level restrictions — follow those program enrollment rules.
• No Explicit Step Therapy in Excerpt: Absence of ST does not eliminate other controls; LA, PA, or QL may still restrict access.
• Step Therapy Present for Some Agents: Examples include ferric citrate (FF and ST) and certain psychiatric agents with ST and QL.
• Step Therapy Requirements When Indicated: Provide documentation of prior drug trials, durations, and outcomes per the ST criteria in Requirements/Limits.
• Step Therapy Indicated for Specific Agents: Several CNS and GI agents list ST and specific titration/therapy packs that require separate handling.
• Step/Titration Packs Noted: Starter and titration packs have dedicated QL and PA rules; submit PA referencing the pack when appropriate.
• Authorization Flags Present: Treat PA, ST, SP, LA, FF annotations as operational requirements — missing authorizations for these flags may lead to denial.