EmblemHealth 2026 Drug List (Large Group Generic Formulary) — Coverage Criteria
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Governs the covered prescription drugs, tiers, and utilization management (e.g., prior authorization, quantity limits, step therapy) for EmblemHealth large group plans; affects members, prescribing providers, and pharmacies using the plan's drug list.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Controls
General formulary coverage and utilization controls
Coverage with administrative controls
This section lists drugs and their administrative flags; clinical necessity criteria are handled via PA processes referenced by these flags.
Specialty/PAH agent coverage
Covered with prior authorization and quantity limits for specific specialty/PAH agents when PA obtained
LA or SP noted for some products
Standard formulary agents
Formulary-listed common cardiovascular and antihypertensive agents
Some specific formulations (e.g., enalapril oral solution) have PA/QL
General coverage stance
Coverage is product-specific with utilization controls applied where noted
Authorizations required when PA is present.
Formulary coverage with product-specific controls
Coverage and utilization controls as listed per product
Each product line has individualized controls as shown in the formulary entries.
Formulary entries with authorization and quantity rules
Coverage entries for listed drugs (examples):
chunks 164-165
chunk 165
chunk 166
chunk 169
chunks 166-167
chunks 167-168
chunk 171
Formulary coverage and constraints
Covered when listed on formulary with stated tier and requirements/limits
This part enumerates items and their constraints; consult product entries for exact QL/PA/SP requirements.
Please consult the member's Certificate of Coverage for plan-specific benefits and cost-sharing. Not all drugs listed are paid for by all drug benefit plans; listing on the formulary does not guarantee coverage for every plan or member. The Certificate of Coverage and member ID card contact information identify any plan-specific coverage restrictions and how to request further information.
Within the provided formulary excerpt there are no explicit clinical exclusion statements. Entries instead use administrative flags (e.g., PA, QL, SP, LA, ACA) to indicate utilization controls that affect coverage and access rather than categorical clinical exclusions.
Restrictions in this segment are expressed as administrative designations such as PA (prior authorization), QL (quantity limit), LA (limited access), and SP (specialty). The document does not list therapeutic exclusions here; instead, these requirement codes limit coverage or specify dispensing/authorization workflows for particular agents.
Products annotated with ACA (Affordable Care Act) in the formulary—notably contraceptive products and related items—indicate coverage consistent with ACA preventive services requirements rather than exclusion. These ACA-marked contraceptives are therefore represented as mandated coverage under the plan's preventive benefits.
Many formulary entries show blank or no Requirements/Limits fields in this excerpt. A blank Requirements/Limits entry implies standard formulary coverage without a listed prior authorization, quantity limit, specialty routing, or other special administrative constraint in the excerpted segment.
Items designated PA or SP require prior authorization or specialty pharmacy routing before the plan will cover or dispense the product. These designations limit coverage at point of dispensing unless the required authorization or specialty process has been completed.
Within these chunks there are no explicit therapeutic exclusions; the listing is a formulary enumeration. Some items carry administrative designations (e.g., PA, SP) or quantity limits that condition coverage, but no products are expressly listed as excluded in the provided text.
Review of this segment found no statements declaring products Not Medically Necessary. The excerpt is primarily an index/product listing and does not include any explicit "Not Medically Necessary" determinations in the cited text.
Formulary Entries and Code Tables
| amoxicillin (trihydrate) cap 250 mg, 500 mg | amoxicillin capsules 250 mg and 500 mg |
| amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml | amoxicillin oral suspension various strengths |
| amoxicillin (trihydrate) tab 500 mg, 875 mg | amoxicillin tablets 500 mg and 875 mg |
| amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml | amoxicillin-clavulanate oral suspension strengths |
| amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) | amoxicillin-clavulanate suspension 600-42.9 mg/5ml (Augmentin ES-600) |
| amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg | amoxicillin-clavulanate tablets multiple strengths |
| ampicillin cap 500 mg | ampicillin capsules 500 mg |
| dicloxacillin sodium cap 250 mg, 500 mg | dicloxacillin capsules 250 mg and 500 mg |
| amoxicillin (trihydrate) cap 250 mg, 500 mg | amoxicillin (trihydrate) cap 250 mg, 500 mg |
| amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml | amoxicillin (trihydrate) for suspension |
| amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml | amoxicillin-clavulanate suspensions |
| amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) | Augmentin ES-600 suspension |
| amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg | amoxicillin-clavulanate tablets |
| cefadroxil cap 500 mg | cefadroxil 500 mg capsules |
| cephalexin cap 250 mg, 500 mg, 750 mg | cephalexin capsules |
| azithromycin for susp 100 mg/5ml, 200 mg/5ml (Zithromax) | azithromycin suspensions |
| clarithromycin tab er 24hr 500 mg | clarithromycin ER 500 mg |
| doxycycline hyclate cap 50 mg, 100 mg | doxycycline hyclate capsules |
| ACA | Affordable Care Act required coverage/limits flag as listed in Requirements/Limits |
| PA | Prior Authorization required |
| QL | Quantity Limit |
| SP | Specialty pharmacy or specialty handling |
| NDC/HCPCS not provided | Document lists drug names and strengths; no explicit billing codes provided in this section. |
| tolvaptan tab 30 mg | Samsca; QL (30 tablets/365 days) and also listed with QL (60 tablets/365 days) |
| digoxin oral soln 0.05 mg/ml | Digoxin; Drug Tier = 1; Requirements/Limits = PA |
| digoxin tab 62.5 mcg, 125 mcg, 250 mcg | Lanoxin; Drug Tier = 1 |
| nitroglycerin sl tab 0.3/0.4/0.6 mg | Nitrostat |
| ranolazine tab er 500 mg, 1000 mg | Ranexa |
| carvedilol tab 3.125-25 mg | Coreg |
| furosemide tab 20/40/80 mg | Lasix |
| spironolactone tab 25/50/100 mg | Aldactone |
| epinephrine auto-injector 0.15 mg / 0.3 mg | EpiPen-jr / EpiPen (listed under vasopressors) |
| ambrisentan tab 5 mg, 10 mg | Letairis — LA, PA, QL (30 tablets/30 days), SP |
| bosentan tab 62.5 mg, 125 mg | Tracleer — PA, QL (60 tablets/30 days), SP |
| ivabradine tab 5 mg, 7.5 mg | Corlanor — PA, QL (60 tablets/30 days) |
| sildenafil citrate tab 20 mg (Revatio) | PA, QL (90 tablets/30 days), SP |
| tadalafil tab 20 mg (Adcirca) | PA, QL (60 tablets/30 days), SP |
| sacubitril-valsartan tab 24-26 / 49-51 / 97-103 mg | Entresto |
| ezetimibe tab 10 mg | Zetia |
| fenofibrate cap/tab | Tricor / other fenofibrate formulations |
| statins (atorvastatin, simvastatin, rosuvastatin, pravastatin, etc.) | Multiple listed strengths; some entries marked 'ACA' |
| Endometrin | Endometrin — Requirements/Limits = QL (84 suppositories/28 days) |
| terconazole vaginal cream 0.4%, 0.8% | Drug Tier = 1 |
| terconazole vaginal suppos 80 mg | Drug Tier = 1 |
| TODAY SPONGE - nonoxynol-9 vaginal sponge 1000 mg | Drug Tier = 1; Requirements/Limits = ACA |
| VCF VAGINAL CONTRACEPTIVE - nonoxynol-9 foam 12.5% | Drug Tier = 1; Requirements/Limits = ACA |
| VCF VAGINAL CONTRACEPTIVE - nonoxynol-9 film 28% | Drug Tier = 1; Requirements/Limits = ACA |
| VCF VAGINAL CONTRACEPTIVE - nonoxynol-9 gel 4% | Drug Tier = 1; Requirements/Limits = ACA |
| alfuzosin hcl tab er 24hr 10 mg (Uroxatral) | Drug Tier = 1 |
| dutasteride cap 0.5 mg (Avodart) | Drug Tier = 1 |
| finasteride tab 5 mg (Proscar) | Drug Tier = 1 |
| atomoxetine hcl cap 10 mg, 18 mg, 25 mg, 40 mg | Drug Tier = 1; QL (60 capsules/30 days) |
| atomoxetine hcl cap 60 mg, 80 mg, 100 mg | Drug Tier = 1; QL (30 capsules/30 days) |
| caffeine citrate oral soln 60 mg/3ml | Drug Tier = 1 |
| clonidine hcl tab er 12hr 0.1 mg | Drug Tier = 1; QL (120 tablets/30 days) |
| dexmethylphenidate hcl cap er 24 hr (Focalin XR) 5-40 mg | Drug Tier = 1; QL (30 capsules/30 days) |
| dexmethylphenidate hcl tab (Focalin) 2.5-10 mg | Drug Tier = 1; QL (60 tablets/30 days) |
| dextroamphetamine sulfate (Dexedrine) various formulations | Drug Tier = 1; QL values vary by formulation |
| guanfacine hcl tab er 24hr (Intuniv) 1-4 mg | Drug Tier = 1; QL (30 tablets/30 days) |
| liraglutide (Saxenda) soln pen-inj 18 mg/3ml | Drug Tier = 1*; PA, QL (15 mls/30 days) |
| lisdexamfetamine dimesylate (Vyvanse) caps/chew tabs 10-70 mg | Drug Tier = 1; QL (30 units/30 days) |
| enoxaparin prefilled syringes QL | QL for enoxaparin prefilled syringes (Lovenox) noted as QL (30 syringes/90 days) and enoxaparin vials QL (10 vials/90 days) |
| latanoprost (Xalatan) QL | QL for latanoprost ophthalmic solution (Xalatan) 2.5 mls/30 days |
| erythromycin soln 2% | erythromycin soln 2% |
| fluocinolone acetonide cream 0.01% | fluocinolone acetonide cream 0.01% — QL (120 grams/30 days) |
| fluocinonide cream 0.1% (Vanos) | fluocinonide cream 0.1% (Vanos) — QL (240 grams/28 days) |
| lidocaine patch 5% (Lidoderm) | lidocaine patch 5% — Requirements/Limits = PA, QL (90 patches/30 days) |
| tazarotene cream/gel | tazarotene formulations — some Requirements/Limits = PA |
| lenalidomide caps (Revlimid) | lenalidomide — Requirements/Limits = PA, QL (30 capsules/30 days or 21 capsules/28 days), SP |
| anagrelide hcl cap 0.5 mg | listed as index entry |
| anagrelide hcl cap 1 mg | listed as index entry |
| anastrozole tab 1 mg | listed as index entry |
| apomorphine hcl soln cartridge 30 mg/3ml | listed as index entry |
| aprepitant capsule 80 mg | listed as index entry |
| APRETUDE | listed brand entry |
| azithromycin tab 250 mg | listed as index entry |
| azithromycin tab 500 mg | listed as index entry |
| azithromycin tab 600 mg | listed as index entry |
| buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg | listed formulation and strengths |
| bupropion hcl tab 75 mg | listed |
| bupropion hcl tab 100 mg | listed |
| bupropion hcl tab er 12hr 100 mg | listed |
| bupropion hcl tab er 12hr 150 mg | listed |
| bupropion hcl tab er 24hr 150 mg | listed |
| bupropion hcl tab er 24hr 300 mg | listed |
| butalbital-acetaminophen-caffeine tab 50-325-40 mg | listed |
| buprenorphine hcl sl tab 2 mg, 8 mg (base equiv) | listed |
| buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg, 8-2 mg (base equiv) | listed |
| butalbital-acetaminophen tab 50-325 mg | listed product and strength |
| butalbital-aspirin-caffeine cap 50-325-40 mg | listed product and strength |
| butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg | listed product and strength |
| butorphanol tartrate nasal soln 10 mg/ml | listed product and strength |
| cefadroxil cap 500 mg | listed product and strength |
| cefdinir cap 300 mg | listed product and strength |
| cefixime cap 400 mg | listed product and strength |
| celecoxib cap 50 mg, 100 mg, 200 mg, 400 mg | listed product and strengths |
| cephalexin cap 250 mg, 500 mg, 750 mg | listed product and strengths |
| clindamycin hcl cap 75 mg, 150 mg, 300 mg | listed product and strengths |
| clobetasol propionate cream/foam/gel/oint 0.05% | listed topical formulations and strength |
| cyanocobalamin inj 1000 mcg/ml | listed injectable formulation |
| dexamethasone tab 0.5 mg - 6 mg | oral tablet strengths listed |
| diazepam tab 2 mg, 5 mg, 10 mg | listed product and strengths |
| diclofenac sodium (actinic keratoses) gel 3% | topical product and strength |
| darunavir tab 600 mg, 800 mg | antiretroviral strengths listed |
| efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg | combination antiretroviral |
| enoxaparin sodium inj soln pref syr various strengths | listed LMWH prefilled syringes |
| estradiol td patch and gels various strengths | hormone therapy products listed |
Provider Responsibilities: Authorization, Documentation, and Dispensing
Obtain Prior Authorization for PA‑flagged drugs
Some drugs listed on the formulary require prior authorization (PA). Prescribers must obtain plan approval before dispensing those products or coverage may be denied.
- PA is indicated by the 'PA' flag next to product listings and defined in the abbreviations section.
PA required for select antifungals
Certain antifungal products (for example, posaconazole suspension and voriconazole formulations) are marked PA and require prior authorization before the plan will pay.
- Posaconazole susp 40 mg/mL (Noxafil) — Requirements/Limits = PA.
- Voriconazole for suspension and tablet strengths — Requirements/Limits = PA.
PA required for many antineoplastics/specialty oncolytics
Many antineoplastic and specialty oral oncology agents are designated PA (and often QL and SP); prescribers must secure prior authorization for these agents before coverage.
- Examples include abiraterone, dasatinib, erlotinib, everolimus, imatinib and other oncology agents listed with PA, QL, SP.
Obtain PA for selected specialty/limited‑access agents
Drugs marked with Requirements/Limits such as PA, LA, QL, or SP (examples: JYNARQUE/tolvaptan, sapropterin/Kuvan, carglumic acid/Carbaglu, teriparatide) require prior authorization before coverage is allowed.
- JYNARQUE (tolvaptan) — Requirements/Limits = LA, PA, QL, SP.
- Sapropterin (Kuvan) and carglumic acid (Carbaglu) — listed with LA/PA/SP where noted.
Secure PA for select PAH and specialty cardiovascular agents
Several pulmonary hypertension (PAH) agents (ambrisentan, bosentan) and related specialty cardiovascular agents (ivabradine, sildenafil, tadalafil) carry PA and specified quantity limits; prior authorization must be obtained.
- Ambrisentan (Letairis) — Requirements/Limits = LA, PA, QL (30 tablets/30 days), SP.
- Bosentan (Tracleer) — Requirements/Limits = PA, QL (60 tablets/30 days), SP.
- Ivabradine (Corlanor), sildenafil (Revatio), tadalafil (Adcirca) — PA with stated QLs.
PA required for assorted listed drugs (examples)
Many formulary products include Requirements/Limits annotations indicating PA is required for coverage; prescribers must obtain PA for those examples shown in the listing.
- Examples across sections include pirfenidone (Esbriet), famotidine suspensions, glycopyrrolate, and various renal/gastro products listed with PA.
PA required for select topicals (lidocaine, retinoids) and others
Certain topical and other non‑systemic products (e.g., lidocaine topical solutions/ointments/patches and some topical retinoids) are listed with PA and QL; prescribers must obtain authorization when indicated.
- Lidocaine hcl solution 4%/ointment 5%/patch 5% — Requirements/Limits = PA, QL (150 mL / 100 g / 90 patches per 30 days respectively).
- Tazarotene and tretinoin formulations — Requirements/Limits = PA for some formulations.
PA required for weight‑management and controlled products
Weight‑management and certain controlled appetite suppressants (liraglutide/Saxenda, phentermine products, phentermine‑topiramate/Qsymia) are marked PA (and have QL); prescribers must obtain prior authorization.
- Liraglutide (Saxenda) — Requirements/Limits = PA, QL (15 mL/30 days).
- Phentermine and phentermine‑topiramate (Qsymia) — Requirements/Limits = PA and QL as listed.
PA required for select hematologic and specialty agents
Selected listed specialty or hematologic drugs require prior authorization and may be routed via specialty pharmacy; examples include eltrombopag (Promacta), glutamine (Endari), and miglustat (Zavesca).
- Eltrombopag — Requirements/Limits = PA, QL (30 or 60 tablets/30 days depending on strength), SP.
- Endari (glutamine) — Requirements/Limits = PA, SP; Miglustat (Zavesca) — Requirements/Limits = LA, PA, QL (90 capsules/30 days), SP.
PA required for select topical/specialty products (lenalidomide example)
Prescribers must obtain prior authorization for certain topical and specialty oncology products (lenalidomide/Revlimid is listed with PA, QL and SP); coverage requires PA and specialty dispensing compliance.
- Lenalidomide (Revlimid) — Requirements/Limits = PA, QL (30 capsules/30 days or 21 capsules/28 days depending on strength), SP.
Index segment — no PA rules
No prior authorization rules are specified in this index segment.
Index — PA not listed
This index segment does not list prior authorization requirements.
No PA specified in this segment
This segment enumerates drug names and strengths and does not specify prior authorization requirements.
PA not specified in index portion
This portion of the listing does not identify prior authorization requirements; it is a formulary product index.
Follow Step Therapy (ST) requirements where annotated
Some products are subject to step therapy (ST); the plan may require trying specified drugs first before covering alternatives — prescribers should follow ST edits where present.
- ST is defined in the abbreviations and used for agents such as Gralise (once‑daily gabapentin formulations) which are marked ST.
Observe administrative modifiers (ACA, LA, SP)
Entries include modifiers such as ACA, LA, and SP which denote special coverage categories or site/plan constraints; prescribers should interpret these flags per the abbreviations and plan guidance.
- ACA indicates Affordable Care Act preventive coverage rules; LA indicates limited availability; SP indicates specialty drug handling.
Provide documentation for PA requests (per chunk 36 flags)
Prescribers should provide supporting documentation when prior authorization is requested for products flagged in the formulary (examples flagged in chunk 36).
- Documentation may be requested to support PA decisions for specialty vaccines, biologics, or agents listed with PA/SP.
Step/specialty program applies for some specialty agents
Some specialty agents are subject to step or specialty program requirements; prescribers must follow specialty program enrollment and authorization rules when SP/LA is indicated.
- Examples include octreotide, sapropterin, sodium phenylbutyrate, and tolvaptan variants which are marked SP or LA and require program management.
Submit required documentation with PA/QL requests
Prescriptions for products marked PA or QL require documentation and adherence to the formulary's PA/QL procedures; pharmacies and prescribers must follow the payer's documentation process when submitting requests.
- PA and QL notations (e.g., lidocaine PA/QL, lenalidomide PA/QL/SP) require submission of supporting information as part of the authorization.
No explicit step therapy sequences — follow PA/QL/SP flags
Many entries show PA/QL/SP flags but no explicit step therapy algorithm is provided in these chunks; prescribers should follow PA and QL rules even where ST sequence is not specified.
- PA, QL and SP flags indicate utilization controls even if detailed step sequences are absent.
Index entries — follow PA/QL/SP where noted
This index segment primarily contains tier, QL, PA and SP annotations without explicit step therapy sequences; prescribers must comply with those utilization controls.
Adhere to ST for agents marked ST (e.g., Gralise)
Some products are explicitly marked ST (step therapy), for example Gralise (once‑daily gabapentin formulations); prescribers must meet step requirements before coverage is allowed.
- Gralise formulations — Requirements/Limits include ST and specified QLs.
Provide supporting clinical documentation for specialty PA requests
Prescribers must provide documentation supporting PA when requested for specialty products such as eltrombopag, glutamine (Endari), miglustat (Zavesca), and icatibant (Firazyr).
- Eltrombopag, Endari, Miglustat, Icatibant — listed with PA and SP/LA designations that require supporting clinical documentation.
Step therapy not detailed — follow PA/QL annotations
No explicit step therapy algorithms are listed in these chunks; where ST is absent, follow PA and QL rules indicated for each product.
No step therapy requirements in this index segment
This index portion does not show step therapy requirements; it is a product listing — rely on PA/QL/SP flags for utilization controls.
Follow formulary PA/QL/SP and documentation for index entries (chunk 216)
This provider actions placeholder references items flagged in chunk 216; prescribers should follow PA/QL/SP and documentation instructions found in the formulary when managing these listed products.
Follow PA/QL/SP for entries referenced in chunk 244
This provider actions placeholder references items flagged in chunk 244; ensure PA/QL/SP requirements are met when prescribing the products shown in that index listing.
Comply with PA/QL/SP for indexed products (chunk 263)
This provider actions placeholder references items flagged in chunk 263; for those indexed products, comply with any PA, QL or specialty routing requirements indicated in the formulary.
Check the member's Certificate of Coverage
Members should consult their Certificate of Coverage for plan‑specific benefit details, including whether a listed drug is covered under their particular drug benefit plan.
- Certificate of Coverage will specify coverage and member cost‑sharing; not all drugs in the list are paid for by every plan.
Document QL for select antivirals on PA submissions
Several antiviral oral solutions and suspensions include quantity limits; prescribers must document quantities on PA requests when applicable (examples: abacavir and lamivudine oral solutions QL 960 mL/30 days).
- Abacavir oral solution 20 mg/mL — QL 960 mL/30 days.
- Lamivudine oral solution 10 mg/mL — QL 960 mL/30 days.
Interpret Requirements/Limits flags (ACA, PA, QL, SP)
Interpret 'ACA', 'PA', 'QL', and 'SP' flags per the abbreviations: ACA = ACA preventive coverage, PA = prior authorization required, QL = quantity limit, SP = specialty pharmacy designation.
Provide required documentation for PA/QL requests
Prescribers must follow payer prior authorization and quantity‑limit requirements for drugs marked PA, LA, QL, or SP; submit clinical justification and documentation as requested.
- PA/QL/SP annotations on product lines indicate the need for authorization and supporting documentation.
Document PA and QL for enalapril oral solution (Epaned)
Enalapril maleate oral solution (Epaned) is designated PA with a quantity limit of 1200 mL per 30 days; prescribers must document PA and QL adherence when requesting coverage.
- Enalapril oral solution 1 mg/mL (Epaned) — Requirements/Limits = PA, QL (1200 mL/30 days).
Document suspensions/packets on PA requests
Some oral suspensions and packet formulations (e.g., famotidine suspension, esomeprazole packets) have PA and/or QL; include supporting prescription and diagnosis documentation when submitting PA.
- Esomeprazole delayed‑release suspension packets — QL (60 packets/30 days).
- Famotidine suspension 40 mg/5 mL — Requirements/Limits = PA, QL (2400 mL/30 days).
Obtain PA and follow specialty dispensing rules for PA/QL/SP products
Products marked PA or PA, QL, SP require the prescriber or pharmacy to obtain prior authorization and to follow specialty dispensing rules where SP is indicated.
- Tasimelteon (Hetlioz) — Requirements/Limits = PA, QL (30 capsules/30 days), SP.
- Liraglutide (Saxenda) — Requirements/Limits = PA, QL (15 mL/30 days).
Route SP‑designated drugs through specialty pharmacy
Products designated SP should be dispensed via specialty pharmacy channels as indicated by the formulary; prescribers and pharmacies must route fills accordingly.
- Examples include Tecfidera, Copaxone, Gilenya and other SP‑flagged agents.
Be prepared to submit clinical documentation with PA
When prior authorization is requested, prescribers must be prepared to provide clinical supporting documentation as requested by the payer for products marked PA.
- Supporting clinical information may be required for approval of specialty or PA‑flagged agents (e.g., eltrombopag, Endari, miglustat, icatibant).
Document quantity limits when submitting PA/QL requests
PA and QL annotations require documentation per formulary policy; prescribers should include quantity justification when requesting coverage for QL‑limited products.
- Quantity limits (e.g., lidocaine solution 150 mL/30 days, lidocaine patch 90 patches/30 days) must be documented to support dispenses.
Index segment — see product listings for authorization rules
This index segment provides names and page references only and does not include authorization requirements; consult the product listing pages for PA/QL/SP flags.
Follow PA/QL/SP and documentation for entries in chunk 216
This provider actions placeholder references items flagged in chunk 216—follow the formulary's PA/QL/SP and documentation guidance for those listed products.
Comply with PA/QL/SP for entries in chunk 234
This provider actions placeholder references items flagged in chunk 234—ensure PA/QL/SP requirements are met and documentation submitted as required by the payer for those products.
Follow PA/QL/SP for products indexed in chunk 258
This provider actions placeholder references items flagged in chunk 258—prescribers and pharmacies must follow PA, QL and specialty routing rules for those indexed products.
Denial risk if PA not obtained
Failure to obtain required prior authorization (PA) may result in the plan not covering the drug; prescribers should obtain PA prior to dispensing PA‑flagged products.
- If approval is not obtained, the plan may deny coverage at point of service.
Denial risk for antifungals without PA
If a product flagged PA is dispensed without prior authorization (for example posaconazole or voriconazole), the claim may be denied; obtain PA to avoid non‑coverage.
PA risk for oncology/specialty agents
Coverage for listed PA items (notably antineoplastics and specialty oncology agents) is subject to prior authorization; failure to secure PA can result in coverage denial or limits.
Denial risk when PA/LA/QL/SP criteria not met
Products with Requirements/Limits (PA, LA, QL, SP) such as JYNARQUE, Kuvan, Carbaglu and teriparatide will require approval processes and may be denied if criteria or documentation are not met.
PA/QL enforcement may trigger denial
PA and quantity‑limit enforcement applies to selected agents (e.g., ambrisentan, bosentan, ivabradine, sildenafil/tadalafil for PAH); claims may be denied if PA is missing or QL exceeded.
- Ivabradine (Corlanor) — PA, QL (60 tablets/30 days); sildenafil (Revatio) and tadalafil (Adcirca) — PA with stated QLs.
Ivabradine (Corlanor) — PA and QL denial risk
Requests for ivabradine (Corlanor) are subject to prior authorization and a quantity limit (60 tablets/30 days); failure to obtain PA or exceeding QL may result in denial.
- Ivabradine (Corlanor) — Requirements/Limits = PA, QL (60 tablets/30 days).
PA/QL/SP denial risk for respiratory agents
Certain inhaled and specialty respiratory agents (e.g., Symbicort, Advair Diskus, pirfenidone/Esbriet) list prior authorization, quantity limits and specialty designation; claims may be denied if PA/QL/SP criteria are not met.
- Advair Diskus — QL noted; Symbicort — QL (1 inhaler/30 days); Pirfenidone (Esbriet) — PA, QL, SP.
PA required for listed specific products — denial risk
This portion lists products with PA annotations; prescribers must obtain prior authorization for the specific products shown to avoid denial.
- Tasimelteon (Hetlioz) and Liraglutide (Saxenda) are examples of PA‑required products in these chunks.
PA triggers for weight‑management/controlled agents — denial risk
Prior authorization is required for several weight‑management and controlled products (liraglutide/Saxenda, phentermine, Qsymia); dispensing without PA may result in denial.
- Saxenda (liraglutide) — PA and QL; Phentermine and Qsymia — PA and QL requirements are noted.
Denial risk for quantity‑limit exceedance
Claims that exceed stated quantity limits (e.g., stimulants, opioids, migraine triptans) may be denied without an override or PA; prescribers should adhere to QL values or request authorization.
- Concerta — QL 30 or 60 tablets/30 days depending on formulation; oxycodone solutions and other opioid formulations have high‑volume QLs and require compliance.
Eltrombopag — PA/QL/SP denial risk
Coverage for eltrombopag (Promacta) requires prior authorization and is subject to quantity limits and specialty pharmacy routing; absence of PA may lead to denial.
- Eltrombopag — Requirements/Limits = PA, QL (30 or 60 tablets/30 days depending on strength), SP.
LA and PA products — additional denial risk if not authorized
Limited access (LA) and PA‑flagged products (e.g., icatibant, miglustat) have additional authorization steps; failure to meet those steps may result in denial.
- Icatibant (Firazyr) — Requirements/Limits = LA, PA, QL (6 syringes/30 days), SP.
- Miglustat (Zavesca) — Requirements/Limits = LA, PA, QL (90 capsules/30 days), SP.
Lidocaine topical products — PA/QL denial risk
Requests for lidocaine topical products (solution, ointment, patch) are subject to prior authorization and quantity limits; lack of PA or QL documentation could trigger denial at point of sale.
- Lidocaine solution 4% — PA, QL 150 mL/30 days; Lidocaine oint 5% — PA, QL 100 g/30 days; Lidocaine patch 5% (Lidoderm) — PA, QL 90 patches/30 days.
Topical retinoids — PA required, denial risk
Some topical retinoids (tazarotene, tretinoin) are noted as requiring prior authorization; claims submitted without PA may be denied.
- Tazarotene cream/gel and tretinoin cream/gel formulations are listed with PA for certain strengths and forms.
Lenalidomide — PA/QL/SP required; denial risk if not met
Lenalidomide (Revlimid) entries indicate prior authorization, quantity limits and specialty pharmacy designation; prescribers must obtain PA and comply with specialty distribution to ensure coverage.
- Lenalidomide caps (various strengths) — Requirements/Limits = PA, QL (30 capsules/30 days or 21 capsules/28 days depending on strength), SP.
No provider actions in this segment
No provider actions are stated in this index listing segment.
No explicit provider triggers in this index area
No explicit authorization or denial criteria are present in these chunks; this area functions as an index and product listing.
No provider actions specified in this chunk
No explicit triggers for prior authorization or denial are present in this chunk of the document.
No provider actions in this listing chunk
No provider actions are stated in this chunk; review product listings for PA/QL/SP flags.
Quantity Limits (QL) — Examples and Values
Specialty Pharmacy and Dispensing Requirements
Dispense SP‑designated products via specialty pharmacy
Some products are labeled SP indicating specialty pharmacy distribution is required; prescribers must route prescriptions to the specialty channel as designated.
- SP designation appears on multiple specialty, high‑cost or specialty‑handled agents and often accompanies PA/QL flags.
Specialty pharmacy routing required for SP products
Products marked SP should be dispensed via specialty pharmacy channels per the formulary; prescribers and pharmacies must follow the specialty routing instructions.
- Examples: tasimelteon (Hetlioz), liraglutide (Saxenda), lenalidomide and other SP‑flagged agents.
Step Therapy and Related Flags
| Product | Flags / Notes |
|---|---|
| APRETUDE - cabotegravir IM extended‑release suspension 600 mg/3 mL | ACA, LA, SP — indicated in formulary Requirements/Limits (special access and specialty distribution) |
| Atazanavir sulfate capsules (150–300 mg) | QL indicated (30–60 capsules/30 days) and PA noted for select strengths |
| DESCOVY — emtricitabine/TAF 200/25 mg | ACA; QL 30 tablets/30 days; PA indicated in listing |
| Lenacapavir (YEZTUGO) — tablet 300 mg / subcutaneous formulation | ACA; QL (4 tablets/365 days for oral); SP designation for specialty handling |
| Vancomycin HCl (Vancocin/Firvanq) — oral capsules and solution | Listed with Drug Tier = 1; no explicit PA/QL in cited chunks |
| Product / Class | Specialty Routing Implication |
|---|---|
| Octreotide acetate injection (various strengths) | Requirements/Limits = SP — routed via specialty pharmacy per formulary notes |
| Sapropterin (Kuvan) — powder/ tablets | Requirements/Limits = LA, PA, SP — limited access and specialty distribution implied |
| Enoxaparin (Lovenox) — prefilled syringes/vials | Requirements/Limits = PA, SP noted in anticoagulant listings; specialty/managed distribution may apply |
| Lenacapavir (YEZTUGO) / other antiretrovirals | ACA/ SP flags present for some ARV products — specialty routing and QL apply |
| Agent | Step / Specialty Notes |
|---|---|
| Tolvaptan (JYNARQUE / Samsca) | Listed with QL (30 or 60 tablets/365 days for Samsca; JYNARQUE pack QL noted); SP/LA flags for certain packs — subject to specialty program requirements |
| Sapropterin (Kuvan) | Requirements/Limits = LA, PA, SP — specialty and prior authorization controls apply |
| Sodium phenylbutyrate (Buphenyl) | Requirements/Limits = PA, SP — high‑cost endocrine/metabolic agent with specialty handling |
| Octreotide injection | Requirements/Limits = SP — specialty agent subject to specialty program routing |
| Product / Example | LA / PA / SP Notes |
|---|---|
| Sapropterin (Kuvan) — powder and tablet forms | Requirements/Limits = LA, PA, SP — limited access with prior authorization and specialty distribution noted |
| Teriparatide (Forteo) — pen‑injector 560 mcg/2.24 mL | Requirements/Limits = PA; QL 1 pen/28 days; SP designation for specialty handling |
| Miglustat (Zavesca) — 100 mg capsules | Requirements/Limits = LA, PA, QL (90 capsules/30 days), SP — limited access plus PA and specialty routing |
| Lenalidomide (Revlimid) — capsules (2.5–25 mg) | Requirements/Limits = PA, QL (30 capsules/30 days or 21 capsules/28 days depending on strength), SP — prior authorization and specialty distribution required |
| Product | Authorization / Quantity Limit |
|---|---|
| Liraglutide (Saxenda) — solution pen‑injector 18 mg/3 mL | Requirements/Limits = PA; QL 15 mL/30 days; no explicit step sequence shown in cited chunks |
| Phentermine / Phentermine‑topiramate (Qsymia) | Requirements/Limits = PA; QL 30 capsules/30 days — listed as PA‑required weight‑management agents |
| Tasimelteon (Hetlioz) 20 mg | Requirements/Limits = PA, QL (30 capsules/30 days), SP noted for specialty dispensing where applicable |
| Product | Step Therapy Indicator |
|---|---|
| Gralise (gabapentin once‑daily) — tablets 300–900 mg | Requirements/Limits = QL (30–90 tablets/30 days depending on strength) and ST — step therapy required prior to coverage |
| Situation | Implication |
|---|---|
| Products flagged LA or SP (limited access / specialty) | May require stepwise authorization processes, prior authorization, and specialty pharmacy routing per formulary notes |
| High‑cost endocrine/metabolic agents (e.g., sapropterin, sodium phenylbutyrate) | Marked LA/PA/SP — subject to additional authorization steps and specialty management |
| Antineoplastic and hematologic specialty agents (e.g., lenalidomide, eltrombopag) | PA, QL, SP commonly applied; specialty distribution and PA are prerequisites for coverage |
| Product | Specialty / Prior Authorization Status |
|---|---|
| Lenalidomide (Revlimid) — capsules 2.5, 5, 10, 15, 20, 25 mg | Requirements/Limits = PA; QL (30 capsules/30 days or 21 capsules/28 days depending on strength); SP — specialty distribution and prior authorization required |
Definitions and Acronyms
Background
Background: This document is an excerpt of the EmblemHealth large-group formulary listing brand and generic drugs covered under the plan. Entries show assigned Drug Tier and, where applicable, utilization controls such as PA, QL, SP, LA, or ACA that govern access and dispensing for listed products.
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