EmblemHealth 2026 Formulary (CHP) — Prescription Drug Formulary and Utilization Management
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This document is the EmblemHealth 2026 formulary listing covered prescription drugs, tiers, and utilization management indicators (e.g., PA, QL, ST, SP) that govern pharmacy benefits for affected EmblemHealth plan members.
No material clinical or coverage changes in this revision.
Formulary Coverage Criteria
General formulary coverage conditions
Covered when ALL of the following are met
Members should check their Certificate of Coverage for plan-specific benefits; providers must obtain prior authorization when 'PA' is indicated to avoid denial.
Listed product coverage with requirements
Coverage indicated by listing with tier and associated requirement codes
No additional clinical PA criteria are provided in these listing chunks; follow per-product PA/QL/LA/SP rules.
Formulary entries and flags
Formulary coverage with product-specific requirement flags
Providers must follow the indicated management controls (e.g., obtain PA when 'PA' shown; respect numeric QL). Specific clinical authorization criteria are maintained in the payer's PA program documents.
Covered when Tier listed and any PA/QL/LA/SP requirements are met
Coverage and requirements within these chunks are presented as product listings with associated flags; coverage is conditional based on the listed Requirement/Limits fields.
Examples in these chunks include numeric QL values and PA/LA/SP flags; follow the listed per-product limits and authorization processes.
General coverage conditional on utilization management
Covered when product-specific formulary requirements are met
Per-item PA and QL values (e.g., REPATHA QL 6 syringes/28 days; NEXLETOL PA, QL 30 tablets/30 days) must be followed; documentation should be provided with PA requests as required.
Coverage with utilization controls
Coverage and utilization controls are indicated per product; coverage may be conditional on PA, LA, QL, SP, FF, ACA, OTC, or ST flags.
These are illustrative examples from the formulary showing how coverage depends on the listed flags and numeric limits.
Coverage conditioned on formulary controls
Coverage and utilization controls as listed (PA, QL, LA, SP) — coverage is conditional per these controls
Starter/titration packs and specialty distribution requirements are shown on product lines; providers must comply with these controls and submit supporting documentation when required.
This formulary listing does not guarantee coverage for every plan member. Not all drugs in the list are paid for by all drug benefit plans; members and providers must consult the member's Certificate of Coverage or benefit schedule to confirm whether a specific product is covered, applicable copay/coinsurance, and any plan-specific rules. The Certificate of Coverage and member portal at my.emblemhealth.com provide plan-specific coverage details and contact information for benefit questions.
Within the extracted formulary segments there are no standalone exclusion conditions listed. The document presents product lines with requirements/limits flags (e.g., PA, QL, LA, SP) that control coverage and access, but it does not state explicit exclusion rules in these chunks. Providers should assume coverage is conditional on meeting any indicated requirement rather than on an explicit item-level exclusion shown here.
The sections reviewed do not contain clinical exclusion statements. Contraceptive products are frequently identified with an ACA designation and some items show an OTC designation, but the extract does not list clinical exclusions that render a drug non‑covered for medical reasons. Coverage remains subject to the plan's general rules and any product-specific requirement flags.
No explicit exclusion lists are provided in this segment of the formulary. Entries present drug names, tiers, and requirement/limit indicators but do not specify products that are categorically excluded from coverage in the chunks reviewed.
This portion of the formulary shows product listings with associated requirement flags (e.g., PA, QL) but contains no explicit statements excluding particular products from coverage. Any access restrictions shown are implemented via those flags rather than explicit product exclusions in this excerpt.
No explicit exclusion language appears in these chunks. The extract functions as a formulary listing with utilization management indicators rather than a section enumerating excluded products.
This segment does not present any full product exclusion statements. Several over‑the‑counter (OTC) or ACA‑designated items (for example, acetaminophen, aspirin, and nicotine replacement products) are listed as covered with OTC or ACA flags; however, the extract does not identify items that are categorically excluded from coverage.
The reviewed extract does not include language declaring any drug to be not medically necessary. Coverage determinations in these chunks are conveyed through listing status and requirement/limit flags (PA, QL, ST, SP, LA), not through explicit "not medically necessary" statements.
Within these extracted chunks there are no explicit statements that certain therapies are "not medically necessary." Products are presented with formulary tiering and utilization management indicators; absence of an explicit NMN determination means clinical eligibility is controlled by the listed requirement flags and the member's benefit rules.
No explicit "not medically necessary" rules are contained in this excerpt. The policy fragments show per‑product flags (for example PA and QL) which drive coverage evaluation rather than NMN declarations in these chunks.
This portion of the formulary does not list items as "not medically necessary." Instead, coverage may be conditioned on utilization management controls such as Prior Authorization (PA), Quantity Limits (QL), Limited Access (LA), Specialty Pharmacy (SP), or Step Therapy (ST). Failure to satisfy those controls may result in non‑coverage, but the extract does not state NMN determinations explicitly.
No explicit determinations of "not medically necessary" are indicated in this extract. The document instead flags products with access controls (e.g., PA, QL, LA, SP) and notes that these controls govern coverage decisions for the listed items.
Coding and Code Lists
| amoxicillin (trihydrate) cap 250 mg, 500 mg | amoxicillin (trihydrate) cap 250 mg, 500 mg |
| amoxicillin (trihydrate) tab 500 mg, 875 mg | amoxicillin (trihydrate) tab 500 mg, 875 mg |
| amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg | amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg |
| cefuroxime axetil tab 250 mg, 500 mg | cefuroxime axetil tab 250 mg, 500 mg |
| azithromycin tab 250 mg; 500 mg | azithromycin tab 250 mg (Zithromax z-pak); azithromycin tab 500 mg (Zithromax) |
| clarithromycin tab 250 mg, 500 mg | clarithromycin tab 250 mg, 500 mg |
| fidaxomicin tab 200 mg (Dificid) | fidaxomicin tab 200 mg (Dificid) |
| doxycycline hyclate cap 50 mg, 100 mg | doxycycline hyclate cap 50 mg, 100 mg |
| ciprofloxacin hcl tab 250 mg, 500 mg, 750 mg | ciprofloxacin hcl tab 250 mg (base equiv), 500 mg (base equiv), 750 mg (base equiv) |
| levofloxacin tab 250 mg, 500 mg, 750 mg | levofloxacin tab 250 mg, 500 mg, 750 mg |
| No codes listed |
| ADACEL | tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml |
| BOOSTRIX | tet-diph-acell pertuss ad pref syr 5-2.5-18.5 lf-mcg/0.5ml |
| DAPTACEL | diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml |
| INFANRIX | diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml |
| KINRIX | diph-tetanus-acell pert-polio, ipv vacc susp pref syr 0.5 ml |
| PEDIARIX | diph-tet tox-acell pert-hep b-polio ipv vac susp pref syr |
| PENTACEL | diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp |
| QUADRACEL | diph-tetanus tox ad-acell pert & polio virus, ipv vac inj |
| TENIVAC | tetanus-diphtheria toxoids (td) inj 5-2 lf/0.5ml |
| VAXELIS | diph-tet tox-ac pert ad-polio ipv-hib-hep b rec susp pre syr |
| abiraterone acetate 250 mg | Zytiga |
| abiraterone acetate 500 mg | Zytiga |
| ALECENSA | alectinib hcl cap 150 mg |
| ALUNBRIG | brigatinib (various strengths) |
| AYVAKIT | avapritinib (25-300 mg) |
| BOSULIF | bosutinib (various strengths) |
| BRAFTOVI | encorafenib cap 75 mg |
| BRUKINSA | zanubrutinib (80 mg cap; 160 mg tab) |
| CABOMETYX | cabozantinib s-malate (20/40/60 mg) |
| CAPRELSA | vandetanib tab (100 mg, 300 mg) |
| KOSELUGO - selumetinib sulfate cap 10 mg | Listed with Drug Tier = 1; Requirements/Limits = LA, PA, QL (63 tablets/28 days), SP |
| KOSELUGO - selumetinib sulfate cap 25 mg | Drug Tier = 1; Requirements/Limits = LA, PA, QL (120 capsules/30 days), SP |
| KRAZATI - adagrasib tab 200 mg | Drug Tier = 1; Requirements/Limits = LA, PA, QL (180 tablets/30 days), SP |
| LENVIMA (various daily dose packs) | Multiple therapy pack strengths listed with Drug Tier = 1; Requirements/Limits include LA, PA, QL (various capsules/30 days), SP |
| LUPRON DEPOT (1-,3-,4-,6-month) | Leuprolide acetate injectables listed as Drug Tier = 1; Requirements/Limits = SP |
| LONSURF - trifluridine-tipiracil (15-6.14 mg, 20-8.19 mg) | Drug Tier = 1; Requirements/Limits = LA, PA, QL (60-80 tablets/28 days), SP |
| LORBRENA - lorlatinib (25 mg, 100 mg) | Drug Tier = 1; Requirements/Limits = LA, PA, QL (30-120 tablets/30 days), SP |
| LYNPARZA - olaparib (100 mg, 150 mg) | Drug Tier = 1; Requirements/Limits = LA, PA, QL (120 tablets/30 days), SP |
| MEKINIST - trametinib (bottle and tablet strengths) | Drug Tier = 1; Requirements/Limits = PA, QL (13 bottles/28 days or tablet QL), SP |
| NINLARO - ixazomib citrate cap (2.3, 3, 4 mg) | Drug Tier = 1; Requirements/Limits = LA, PA, QL (3 capsules/28 days), SP |
| PA | Prior Authorization |
| QL | Quantity Limit |
| LA | Limited Access |
| SP | Specialty Pharmacy |
| FF | Formulary flag (FF) — listing shows FF for one selinexor pack |
| ACA | Affordable Care Act — contraceptive coverage designation |
| OTC | Over-the-counter |
| NP THYROID 90 | thyroid tab 90 mg (1 1/2 grain) |
| RENTHYROID | thyroid tab various strengths (15 mg to 120 mg) |
| SYNTHROID | levothyroxine sodium tab 25 mcg–300 mcg |
| THYQUIDITY | levothyroxine sodium oral solution 100 mcg/5ml |
| TIROSINT | levothyroxine sodium cap various strengths |
| ACTHAR | corticotropin inj gel 80 unit/ml |
| carglumic acid (Carbaglu) | soluble tab 200 mg |
| cinacalcet (Sensipar) | tab 30 mg, 60 mg, 90 mg |
| GALAFOLD | migalastat hcl cap 123 mg |
| GENOTROPIN / OMNITROPE / SKYTROFA | somatropin products (various cartridges and strengths) |
| 140 mg/ml | REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml |
| 140 mg/ml | REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml |
| 180 mg | NEXLETOL - bempedoic acid tab 180 mg |
| 180-10 mg | NEXLIZET - bempedoic acid-ezetimibe tab 180-10 mg |
| 80 mg/10ml | FUROSCIX - furosemide subcutaneous cartridge kit 80 mg/10ml |
| 10 mg/ml | FUROSEMIDE - furosemide oral soln 10 mg/ml |
| N/A | This segment lists NDC-level products and strength forms but does not list CPT/HCPCS/ICD-10 codes. |
| N/A | This excerpt lists drug products and formulary flags; no CPT/HCPCS/ICD-10/NDC codes are provided in these chunks. |
| No codes listed |
| N/A | This part contains drug names, strengths and formulary flags but no CPT/HCPCS/ICD-10/NDC codes in these chunks. |
| No codes listed |
Provider Requirements and Authorization
Prior Authorization and utilization flags
Certain drugs in the formulary are subject to utilization management flags. When a product line lists initials such as PA, QL, ST, SP, LA or FF after the drug name, the provider must follow the associated process (e.g., obtain prior authorization, adhere to quantity limits, enroll in specialty program, or observe site-of-care restrictions) before the plan will pay for the drug.
- PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; SP = Specialty; LA = Limited Availability; FF = Frozen Formulary
Prior authorization required for select specialty antivirals/antifungals
Prior authorization is required for many specialty antivirals and antifungals. Examples in the formulary include CRESEMBA, EPCLUSA, HARVONI, SOFOSBUVIR-containing products, and VOSEVI — each shows PA (and often QL and SP) in the Requirements/Limits field.
- CRESEMBA — Requirements/Limits = PA (chunk 21)
- EPCLUSA / SOFOSBUVIR-containing products — Requirements/Limits = PA, QL, SP (chunks 34, 37)
- HARVONI — Requirements/Limits = PA, QL, SP (chunk 28)
Prior authorization and ACA preventive coverage
Entries marked with ACA (and many vaccines) indicate Affordable Care Act preventive coverage, but where PA is listed next to a medication (e.g., VOSEVI) providers must still obtain prior authorization per the Requirements/Limits shown on the formulary line.
- VOSEVI — Requirements/Limits = PA, QL, SP (chunk 37)
- Multiple vaccine/passive immunizing agent entries are marked ACA (chunks 56)
Prior authorization and limits
Many products are listed with PA and may also include quantity limits (QL), limited access (LA), or specialty (SP) designations; providers must obtain PA and respect QL/LA/SP constraints as indicated on each line.
- abiraterone examples show PA and QL (chunk 60)
- Itraconazole oral solution shows PA and QL (chunk 22)
Prior authorization required when PA listed
When a formulary entry shows 'PA' in the Requirements/Limits field, the provider must obtain prior authorization before the plan will cover the drug. Many specialty and oncology agents on the list include PA, QL, and SP flags.
- KOSELUGO, KRAZATI, LENVIMA entries include PA and QL (chunk 72)
- ROMVIMZA, ROZLYTREK examples list PA, QL, SP (chunk 83)
- XTANDI, ZEJULA entries show PA and QL (chunk 91)
Prior authorization and limit flags
Formulary entries often combine PA with limit flags (QL, SP, LA); providers must follow the specified authorization and quantity rules for those products to avoid claim denials.
- Selinexor (XPOVIO) therapy packs list FF, PA, QL and SP (chunk 90)
- REPATHA and other biologics list explicit QL alongside PA/SP (chunk 162)
PA required for selected GLP-1 / incretin agents
Prior authorization is required for many GLP‑1 and incretin agents as indicated by 'PA' in their entries. Examples include MOUNJARO, OZEMPIC, RYBELSUS and TRULICITY where PA and QL are shown.
- MOUNJARO — Requirements/Limits = PA, QL (chunk 111)
- OZEMPIC — Requirements/Limits = PA, QL (chunk 111)
- TRULICITY and RYBELSUS are shown with PA/QL in adjacent sections (chunks 111,115)
Prior authorization and specialty program required
Many specialty endocrine/metabolic and high‑cost agents require both prior authorization and enrollment in a specialty program (SP) or specialty distribution channel before coverage will be approved.
- ACTHAR and other endocrine agents list LA, PA, SP (chunk 128)
- GALAFOLD, IMCIVREE show LA, PA, QL and SP (chunk 130)
PA required for listed PA or LA/SP products
Prior authorization is required for products explicitly marked 'PA' and for many products with LA or SP flags; providers must obtain PA when 'PA' appears in the Requirements/Limits field (examples include FUROSCIX, NEXLETOL/NEXLIZET, VASCEPA).
- FUROSCIX — LA, PA, QL (8 kits/180 days) (chunk 157)
- NEXLETOL / NEXLIZET — PA, QL (30 tablets/30 days) (chunk 162)
- VASCEPA — PA, QL (chunk 163)
Prior authorization required where PA listed
Many formulary lines simply indicate 'PA' next to the product name; the provider is responsible for obtaining prior authorization for any drug that shows 'PA' before coverage will be provided.
- NEXLETOL/NEXLIZET examples show PA required (chunk 162)
Examples: biologic PA and QL
Some biologic and specialty injectables list specific quantity limits in addition to PA (for example, REPATHA shows QL = 6 syringes/28 days); providers must request authorization consistent with those QL values.
- REPATHA prefilled syringe — QL 6 syringes/28 days (chunk 167)
- REPATHA SURECLICK — QL 6 pens/28 days (chunk 167)
Prior authorization required for multiple specialty agents
Prior authorization is required for numerous specialty immunologic and respiratory biologics and injectables; the formulary lists NUCALA, TEZSPIRE, XOLAIR, ALYFTREK and others with LA/PA/QL/SP flags — obtain PA and follow site‑of‑care and QL rules.
- NUCALA — LA, PA, QL (3 pens/28 days), SP (chunk 180)
- XOLAIR — LA, PA, SP (chunk 183)
- ALYFTREK — LA, PA, QL (chunk 183)
- CIMZIA, ENTYVIO PEN examples appear with PA, QL, SP (chunk 199)
Prior authorization requirement
Many specialty or higher‑cost products (e.g., CIMZIA, ENTYVIO PEN, GATTEX, SKYRIZI, TREMFYA, ZYMFENTRA) require prior authorization and may also include QL, LA, SP or ST restrictions; providers must secure PA and comply with those limits.
- CIMZIA — PA, QL (4 syringes/28 days) (chunk 199)
- ENTYVIO PEN — LA, PA, QL (2 pens/28 days) (chunk 199)
- GATTEX — LA, PA, SP (chunk 200)
- SKYRIZI — PA, QL (1 pen/56 days) (chunk 203)
Prior authorization required for specified products
Certain specified products are designated PA on the formulary (e.g., tasimelteon / Hetlioz capsules and oral suspension); providers must obtain prior authorization for these formulations when shown as PA.
- Tasimelteon (Hetlioz) capsule and suspension — Requirements/Limits = PA, QL (30 capsules/30 days) (chunk 232)
Prior authorization required for specific listed drugs
Several listed drugs (including SUNOSI, AUSTEDO/AUSTEDO XR and many MS disease‑modifying therapies) show 'PA' in their Requirements/Limits; obtain PA before dispensing to ensure coverage.
- SUNOSI — PA, QL (30 tablets/30 days) (chunk 238)
- AUSTEDO / AUSTEDO XR — PA, QL, SP (chunks 238–239)
- MS agents (e.g., KESIMPTA) — PA, QL, SP (chunk 244)
Prior authorization required for specified agents
Many specialty agents and certain opioid/controlled products are listed with 'PA' and QL requirements (examples include BELBUCA, fentanyl patches, hydromorphone ER); providers must obtain PA and adhere to QL for these agents to avoid noncoverage.
- BELBUCA and buprenorphine products — PA/QL noted (chunk 254)
- Fentanyl transdermal patches — PA, QL (15 patches/30 days) (chunk 255)
- Hydrocodone ER and morphine ER entries show PA, QL (chunks 255, 258–261)
- Multiple biologics (adalimumab variants, ENBREL) require PA, QL, SP (chunks 262–265)
Step Therapy overview
Step therapy (ST) is used for some products and requires trial of specified preferred drugs before the plan will cover alternatives; providers can request exceptions per plan process.
- ST = Step Therapy as defined in the formulary abbreviations (chunk 8)
- Examples of products flagged ST appear elsewhere in the listing (multiple chunks)
Step therapy not present in this segment
This extract does not include explicit step‑failure sequences or detailed step therapy protocols for particular drugs; where 'ST' appears it indicates a step requirement but the specific sequence is not listed in this segment.
- No explicit step therapy sequences are provided in these chunks (chunk 37)
PALFORZIA level packaging
PALFORZIA is listed in multiple level packs (initial, titration, maintenance) with LA and SP flags; providers should follow the product-level pack designations and any PA/LA/SP rules when initiating and continuing therapy.
- PALFORZIA levels (Initial, Level 0–11, Titration, Maintenance) all list LA and SP (chunks 56–57)
Step therapy flags
Some products in the formulary are flagged with ST (step therapy); for example KERENDIA is shown with an 'ST' indicator — providers should verify step requirements before submitting PA requests.
- KERENDIA is flagged ST in the endocrine/metabolic listing (chunk 130)
Utilization Management Indicators
The formulary uses requirement flags (PA, QL, ST, SP) after drug names to indicate utilization management. Providers must check the Requirements/Limits shown on each drug line and follow the indicated processes prior to dispensing.
- Flags appear after drug names to indicate PA, QL, ST, SP, LA, FF (chunks 6, 8)
Prior authorization/documentation requirement
When a drug entry includes 'PA' or 'SP', providers must submit the plan‑required prior authorization request and any supporting clinical documentation per EmblemHealth procedures to secure coverage.
- Example: itraconazole oral solution requires PA and QL (chunk 22)
Documentation for PA
Quantity limits (QL) shown for many agents define the maximum covered dispensing (e.g., tablets/30 days, mL/30 days). Providers and pharmacies must adhere to QL and include appropriate documentation when requesting quantities above the listed limit.
- Examples: GALAFOLD QL 14 capsules/28 days; ITRACONAZOLE QL 120 capsules/30 days (chunks 130, 22)
Prior Authorization required when PA listed
Products listed with PA and/or QL require review and prescriber documentation supporting the clinical indication and dosing schedule; include such documentation with PA requests to facilitate approval.
- abiraterone entries show PA and QL (chunk 60)
PA/LA/SP/QL requirements present
When PA or QL is listed for a product, the provider must submit prior authorization documentation or adhere to the stated quantity limits as specified on the formulary line to avoid claim denial.
- MOUNJARO and OZEMPIC entries list PA and QL with specified pen/tablet QLs (chunk 111)
Failure to meet listed requirements may trigger denial
If required prior authorization is not obtained or quantity limits/site restrictions (LA/SP) are not met, the plan may deny coverage or the claim at the point of adjudication.
- Not obtaining required PA may result in noncoverage (chunk 6)
- Drugs marked PA/LA/SP/QL may trigger denial if requirements aren’t met (chunk 19)
Prior authorization indicated
Entries marked 'PA' (for example, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) indicate prior authorization is required; failure to obtain PA may cause denial of coverage.
- MOUNJARO, OZEMPIC examples show PA and QL on their form lines (chunk 111)
OTC-designated products
Some insulin products are marked 'OTC' in the listing (e.g., certain Humulin/Novolin formulations); OTC designation can affect coverage pathways — verify member benefit details before dispensing.
- OTC designation appears for some insulin-related entries (chunk 115–116)
Quantity limits and PA may trigger denial
Requests that exceed the listed quantity limits or that do not include required prior authorization are at risk for denial; providers should confirm QL values and include supporting rationale when requesting larger quantities.
- Examples: tablet QL 210 tablets/30 days for some oral agents (chunk 144)
- FUROSCIX QL 8 kits/180 days (chunk 157)
PA/QL/LA/SP trigger utilization management
Products listed with PA, QL, LA or SP flags are subject to utilization management — providers must obtain required authorizations, comply with quantity limits, and route dispensing through specialty pharmacy when indicated.
- NEXLETOL/NEXLIZET require PA and QL (chunk 162)
- CIMZIA and ENTYVIO PEN list PA, QL, SP (chunk 199)
- NUCALA lists LA, PA, QL, SP (chunk 180)
Step Therapy Indicators and Starter Packs
| Step therapy overview | Notes / examples |
|---|---|
| Step therapy (ST) may require trying specified preferred drugs first before coverage of alternatives | |
| Exceptions may be requested; see PA/appeals processes |
| Agent class / examples | Formulary controls noted |
|---|---|
| HCV agents (e.g., HARVONI, SOVALDI, SOFOSBUVIR/VELPATASVIR) and HIV regimens (e.g., GENVOYA, STRIBILD, ISENTRESS) | |
| Many are listed with PA and QL and some with SP/LA; specific entries show PA, QL (e.g., HARVONI PA, QL 28 packets/28 days; VOSEVI PA, QL 28 tablets/28 days) |
| Explicit step sequences present? | Source note |
|---|---|
| No — this extract does not list explicit multi-step failure sequences | |
| Formulary shows flags (PA, QL, SP, LA, ST) but not the step-by-step prior-failure criteria in these chunks |
| Product | Packaging / implication |
|---|---|
| PALFORZIA | |
| Multiple level/pack configurations listed (initial, titration, maintenance) implying staged dosing program; Requirements/Limits = LA, SP |
| Agent / pack format | Formulary note |
|---|---|
| selinexor (XPOVIO) therapy packs (80 mg; 20 mg packs) | |
| Therapy pack formats and QL shown (e.g., 4 tablets/28 days; 24 tablets/28 days; 32 tablets/28 days) — no explicit step-failure sequencing provided |
| Agent group / examples | Formulary controls |
|---|---|
| Selected GLP-1 / GLP/GIP agents (examples: MOUNJARO, OZEMPIC, TRULICITY) | |
| These are marked PA and have QL values (e.g., MOUNJARO PA, QL 4 pens/28 or 180 days; OZEMPIC PA, QL 1–3 pens/28 days) — step therapy specifics not detailed here |
| Product | ST flag noted |
|---|---|
| KERENDIA (finerenone) | |
| Flagged with 'ST' in the listing indicating potential step therapy requirement |
| Presence of step sequences | Formulary context |
|---|---|
| No explicit step therapy steps listed in these chunks | |
| Entries predominantly show utilization flags (PA, QL, LA, SP) rather than detailed step criteria |
| Agents with access controls | Comment |
|---|---|
| Multiple agents listed with PA, QL, LA that may function as access controls | |
| The document does not provide explicit step sequences — these controls may act as alternative utilization management mechanisms |
| Product | ST indicator / notes |
|---|---|
| ferric citrate (Auryxia) 1 gm | |
| Requirements/Limits include ST (step therapy), FF, and QL (360 tablets/30 days) |
| Statement | Examples / implication |
|---|---|
| Some products are designated 'ST' (step therapy) | |
| Listings (e.g., FOSRENOL shows ST; other entries note ST in Requirements/Limits) indicate these products will require trial/failure of alternatives per the payer's step program before approval |
| Examples of products with ST or titration packs | Formulary listing notes |
|---|---|
| Fetzima (levomilnacipran) — includes ST and titration pack entries | |
| Fanapt (iloperidone) titration packs, Trintellix and other antidepressants/hypnotics listed with ST or starter/titration pack QL values — Requirements/Limits include QL and ST where shown |
| Starter / titration kits noted | Examples |
|---|---|
| Starter/titration packs and starter kits are listed for multiple agents | |
| Examples include MAVENCLAD, MAYZENT, ZEPOSIA starter kits and other therapy packs (e.g., ZEPOSIA starter kit QL and PA shown) — these imply required induction/titration regimens prior to full dispensing |
| Class / examples | Step therapy flag |
|---|---|
| Certain NSAIDs / analgesics (examples: KETOPROFEN ER, MECLOFENAMATE SODIUM) | |
| Designated 'ST' in Requirements/Limits indicating step therapy applies before preferred alternatives are covered |
Quantity Limits by Product
Specialty, Limited Access, and Site-of-Care Flags
specialty pharmacy
Drugs designated 'SP' require specialty pharmacy distribution; providers should ensure prescriptions for SP‑flagged biologics and complex therapies are routed to the specialty pharmacy and that PA documentation is submitted.
- KESIMPTA, KESIMPTA QL/PA listed (chunk 244)
- Multiple adalimumab biosimilars and reference products list PA, QL, SP (chunks 262–263)
specialty
Several agents are flagged 'SP' indicating specialty pharmacy dispensing is required or preferred; prescribers must coordinate specialty distribution and any required PA with the specialty pharmacy.
- VOSEVI shows SP in its Requirements/Limits (chunk 37)
- Formulary notes many products with SP designation (chunk 245)
infusion center
Many specialty agents are marked 'LA' (limited access) for site‑of‑care restrictions such as infusion center or limited dispensing sites; providers must follow LA instructions and obtain any required PA for administration at approved sites.
- LA flags appear on oncology and specialty injectables (chunks 246, 247)
- Entries marked LA indicate site‑of‑care or limited availability constraints (chunk 253)
specialty
SP designation indicates specialty pharmacy handling and may be paired with LA (limited access); providers must comply with specialty distribution routes and any PA or QL rules associated with SP products.
- Specialty (SP) designation appears alongside PA/QL/LA for many biologics and high‑cost agents (chunks 247, 252, 255)
infusion center | office | specialty pharmacy
Many specialty injectables and high‑cost agents are designated SP and/or LA, implying they must be dispensed through specialty pharmacy channels or administered at limited sites; verify site‑of‑care requirements and obtain PA as needed.
- Examples: SKYTROFA, IMCIVREE, GATTEX list LA/PA/SP (chunks 137, 130, 200)
infusion center
Specialty products flagged 'SP' or 'LA' often require specialty pharmacy distribution or limited‑site administration; providers should coordinate with the payer and specialty pharmacy to meet authorization and dispensing requirements.
- ADEMPAS, ambrisentan, JUXTAPID shown with LA/PA/SP (chunk 162)
- Many agents designated SP require specialty distribution (chunks 251–252)
Abbreviations and Definitions
Background and Scope
Background: This formulary lists covered anti-infective agents, vaccines, specialty agents and many other drug classes with available strengths and formulations, and it indicates formulary tier placement and utilization management flags (such as PA, QL, ST, SP, LA, and formulary flags). The listing is intended to guide prescribing and dispensing by showing which products are covered and what management controls may apply.
Biosimilar Listings
adalimumab (HUMIRA)
Multiple entries for adalimumab reference products and biosimilars are listed with PA, QL (commonly 2 pens/syringes per 28 days or 1 kit/180 days) and SP designation; prescribers must obtain PA and comply with QL and specialty pharmacy routing for these biologics.
- ADALIMUMAB biosimilars show PA, QL, SP across kit and pen/syringe presentations (chunks 262–265, 270)
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