2026 Formulary (List of Covered Drugs)
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This document is EmblemHealth's 2026 formulary listing covered prescription and OTC drugs, formulary rules (e.g., prior authorization, quantity limits, step therapy), and plan contact information; it affects EmblemHealth members and their prescribing providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Flags
General Coverage Conditions
Coverage and utilization management indicators
Providers must follow plan-specific PA/QL/ST rules where indicated next to drug listings.
Formulary coverage with product-specific requirements
Coverage and restrictions for listed drugs are indicated by inline flags
See per-product Requirements/Limits entries for exact flags and quantity thresholds.
Covered with utilization management controls
Coverage and utilization management requirements are indicated per-drug in the Requirements/Limits field; drugs are covered subject to these utilization controls when specified.
Providers must obtain required PA or use specialty pharmacy as specified; follow QL and ST rules per listing.
Formulary coverage contingent on Requirements/Limits
Coverage list entries with requirements/limits
This is a formulary listing; clinical indications and diagnosis codes are not provided here — follow the per-product Requirements/Limits for authorization and quantity thresholds.
Formulary coverage with per-product limits
Coverage and limits for listed psychotropic agents when dispensed within formulary rules
Many entries include QL (quantity limits), PA (prior authorization), ST (step therapy), SP (specialty) or LA/ACA flags — consult the specific line item for exact QL values.
General coverage conditions
Coverage is subject to product-specific requirements noted (PA, QL, LA, SP, ST).
Applied per-product as listed; failure to meet Requirements/Limits may result in denial of coverage at adjudication.
Please consult the member's Certificate of Coverage and benefits summary before assuming coverage. Not all drugs in this formulary are paid for by all drug benefit plans; coverage may vary by plan and by member. The Certificate of Coverage (and the member ID card phone number) identifies plan-specific copays, restrictions and any additional requirements that may apply to a given prescription.
This extract does not contain standalone clinical medical‑necessity decision trees or broad exclusion rules. Instead, coverage conditions are shown at the product level using inline requirement flags such as PA (prior authorization), QL (quantity limit), ST (step therapy), LA (limited access) and SP (specialty). Providers should follow those product-level Requirements/Limits and submit supporting documentation as required when requesting coverage.
Some insulin products in the listing are designated OTC (over‑the‑counter). For example, HUMULIN R and certain NOVOLIN R presentations are marked OTC in the formulary and also list associated quantity limits. OTC designation may alter coverage or member cost‑sharing; verify benefit plan treatment of OTC insulins for each member.
No blanket exclusions are provided in these document segments. Individual formulary line items show coverage status and, where applicable, per‑product limitations (for example, quantity limits, PA, LA, SP). Coverage for each listed product is therefore contingent on meeting any Requirements/Limits shown for that product.
There are no explicit lists of excluded drugs in these excerpts. Drugs that are listed without a Requirements/Limits flag should be treated under the plan's standard coverage rules, while those with flags (e.g., PA/QL/LA/SP) require adherence to the specified administrative controls before the plan will pay.
These chunks do not state specific formulary exclusions. Absence of an exclusion statement here does not imply universal coverage; coverage remains subject to the product‑level Requirements/Limits and the member’s Certificate of Coverage.
No explicit exclusions are listed in this portion of the formulary. Products shown include their Requirements/Limits (for example, INGREZZA lists LA, PA, QL and SP), which govern coverage and any additional administrative steps required.
Within these excerpts there are no statements declaring items as not medically necessary. Drug listings are informational and indicate coverage status and Requirements/Limits; clinical determinations about medical necessity would be reached through the plan’s prior authorization or appeals processes when applicable.
No products are explicitly labeled 'not medically necessary' in the provided segments. Coverage determinations that a therapy is not medically necessary would be made through the plan’s review procedures and are not described in these chunks.
The supplied excerpts do not include any explicit 'not medically necessary' policy language. If a prescriber believes a product is medically necessary despite Requirements/Limits, submit a prior authorization request with clinical justification per the plan’s PA process.
Sample Drug/Coding Entries and Quantity Examples
| amoxicillin (trihydrate) chew tab 125 mg, 250 mg | AMOXICILLIN - listed, Drug Tier = 1 |
| amoxicillin (trihydrate) cap 250 mg, 500 mg | amoxicillin caps, Drug Tier = 1 |
| amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml | amoxicillin suspensions, Drug Tier = 1 |
| amoxicillin (trihydrate) tab 500 mg, 875 mg | amoxicillin tablets, Drug Tier = 1 |
| amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml | amoxicillin/clavulanate suspensions, Drug Tier = 1 |
| amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) | amoxicillin/clavulanate susp (ES-600), Drug Tier = 1 |
| amoxicillin & k clavulanate for susp 125-31.25 mg/5ml | AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml, Drug Tier = 1 |
| amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg | amoxicillin/clavulanate extended release, Drug Tier = 1 |
| amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg | amoxicillin/clavulanate tablets, Drug Tier = 1 |
| cefadroxil tab 1 gm | CEFADROXIL - Drug Tier = 1 |
| fidaxomicin tab 200 mg | Dificid — listed with Requirements/Limits |
| demeclocycline hcl tab 150 mg, 300 mg | Demeclocycline — Drug Tier = 1 |
| doxycycline hyclate cap 50 mg, 100 mg; doxycycline hyclate tab 20 mg, 100 mg | Doxycycline formulations — Drug Tier = 1 |
| NUZYRA - omadacycline tosylate tab 150 mg | Omadacycline (Nuzyra), Drug Tier = 1; Requirements/Limits = LA |
| delafloxacin meglumine tab 450 mg | BAXDELA — Drug Tier = 1 |
| ciprofloxacin for oral susp 250 mg/5ml; ciprofloxacin hcl tab 250 mg, 500 mg, 750 mg | CIPRO — various oral forms, Drug Tier = 1 |
| levofloxacin oral soln 25 mg/ml; levofloxacin tab 250 mg, 500 mg, 750 mg | Levofloxacin formulations, Drug Tier = 1 |
| ARIKAYCE - amikacin sulfate liposome inhal susp 590 mg/8.4ml | ARIKAYCE — Requirements/Limits = LA, PA, QL (28 vials/28 days), SP |
| ethambutol hcl tab 100 mg, 400 mg | Ethambutol — Drug Tier = 1 |
| isoniazid syrup 50 mg/5ml; isoniazid tab 100 mg, 300 mg | Isoniazid formulations — Drug Tier = 1 |
| SIRTURO - bedaquiline fumarate tab 20 mg, 100 mg | Bedaquiline (SIRTURO) — Requirements/Limits = LA, SP |
| CRESEMBA - isavuconazonium sulfate cap 74.5 mg, 186 mg | Isavuconazonium (CRESEMBA) — Requirements/Limits = PA |
| itraconazole cap 100 mg; itraconazole oral soln 10 mg/ml | Itraconazole (Sporanox) — Requirements/Limits = QL (120 capsules/30 days) |
| NOXAFIL - posaconazole for delayed release susp packet 300 mg; posaconazole susp 40 mg/ml; posaconazole tab delayed release 100 mg | Posaconazole (NOXAFIL) — Requirements/Limits = PA |
| acyclovir (caps, susp, tabs) | Acyclovir formulations — Drug Tier = 1 |
| APRETUDE - cabotegravir im extended release 600 mg/3ml | APRETUDE — Requirements/Limits = ACA, LA, SP |
| BIKTARVY - bictegravir-emtricitabine-tenofovir af | BIKTARVY — Requirements/Limits = QL (30 tablets/30 days) |
| EPCLUSA - sofosbuvir-velpatasvir pellet pack/tab | EPCLUSA — Requirements/Limits = PA, QL (28 packets/28 days or 28 tablets/28 days), SP |
| HARVONI - ledipasvir-sofosbuvir pellet pack/tab | HARVONI — Requirements/Limits = PA, QL (28 packets/28 days or 28 tablets/28 days), SP |
| MAVYRET - glecaprevir-pibrentasvir tab/pellet pack | MAVYRET — Requirements/Limits = PA, QL (84 tablets/28 days or 140 packets/28 days), SP |
| PEGASYS - peginterferon alfa-2a prefilled syr/ inj | PEGASYS — Requirements/Limits = PA, SP |
| PREVYMIS - letermovir tab/pellet pack | PREVYMIS — Requirements/Limits = QL (200 tablets/365 days or 800 packets/365 days) |
| SUNLENCA - lenacapavir sodium (therapy pack 5 x 300 mg; tab 300 mg) | SUNLENCA — Requirements/Limits = LA, QL (5 tablets/365 days for therapy pack; 4 tablets/365 days for tab), SP |
| valacyclovir hcl tab 500 mg, 1 gm (Valtrex) | Valacyclovir — Drug Tier = 1 |
| SUNLENCA - lenacapavir sodium tab therapy pack 5 x 300 mg | SUNLENCA therapy pack — Requirements/Limits = LA, QL (5 tablets/365 days), SP |
| SUNLENCA - lenacapavir sodium tab 300 mg | SUNLENCA tab — Requirements/Limits = LA, QL (4 tablets/365 days), SP |
| SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab 800-150-200-10 mg | SYMTUZA — Requirements/Limits = QL (30 tablets/30 days) |
| YEZTUGO - lenacapavir sodium subcutaneous soln 463.5 mg/1.5ml | YEZTUGO — Requirements/Limits = ACA, SP |
| YEZTUGO - lenacapavir sodium tab 300 mg | YEZTUGO tab — Requirements/Limits = ACA, QL (4 tablets/365 days), SP |
| XOFLUZA - baloxavir marboxil tab therapy pack 1 x 40 mg, 1 x 80 mg | XOFLUZA — Requirements/Limits = QL (2 tablets/120 days) |
| linezolid for susp 100 mg/5ml (Zyvox) | Linezolid suspension — Requirements/Limits = PA |
| nitazoxanide tab 500 mg | Nitazoxanide — Requirements/Limits = QL (12 tablets/90 days) |
| No codes listed |
| TIROSINT | levothyroxine sodium cap and solution strengths listed |
| ACTHAR | corticotropin inj gel 80 unit/ml |
| GENOTROPIN | somatropin for subcutaneous inj cartridge |
| GALAFOLD | migalastat hcl cap 123 mg |
| IMCIVREE | setmelanotide acetate subcutaneous soln 10 mg/ml |
| JYNARQUE | tolvaptan tablets (various pack sizes) |
| PALYNZIQ | pegvaliase-pqpz subcutaneous solution |
| STRENSIQ | asfotase alfa subcutaneous inj |
| TYMLOS | abaloparatide subcutaneous solution pen |
| DIGOXIN | digoxin oral solution and tablets |
| No codes listed |
| alosetron hcl tab 0.5 mg / 1 mg | Lotronex — listed |
| AURYXIA - ferric citrate tab 1 gm | AURYXIA — Requirements/Limits = QL (360 tablets/30 days) |
| BYLVAY - odevixibat cap 400 mcg, 1200 mcg | BYLVAY — Requirements/Limits = LA, PA, SP |
| CIMZIA - certolizumab pegol 200 mg/ml | CIMZIA — Requirements/Limits = PA, QL (4 syringes/28 days), SP |
| OMVOH mirikizumab-mrkz | OMVOH — multiple presentations; Requirements/Limits = LA, PA, QL, SP |
| SKYRIZI risankizumab-rzaa | SKYRIZI — Requirements/Limits = PA, QL (1 pen/56 days), SP |
| VOWST fecal microbiota spores, live-brpk caps | VOWST — Requirements/Limits = LA, PA, QL (12 capsules/365 days), SP |
| ZYMFENTRA infliximab-dyyb | ZYMFENTRA — Requirements/Limits = LA, PA, QL (2 pens/28 days), SP |
| Wellbutrin xl 300 mg | bupropion hcl tab er 24hr 300 mg — Requirements/Limits = QL (30 tablets/30 days) |
| bupropion 75 mg | bupropion hcl tab 75 mg — Requirements/Limits = QL (180 tablets/30 days) |
| bupropion 100 mg | bupropion hcl tab 100 mg — Requirements/Limits = QL (120 tablets/30 days) |
| Celexa 10 mg | citalopram hydrobromide tab 10 mg — Requirements/Limits = QL (120 tablets/30 days) |
| ZURZUVAE 20/25 mg | zuranolone cap 20 mg, 25 mg — Requirements/Limits = QL (28 capsules/365 days), SP |
| ZURZUVAE 30 mg | zuranolone cap 30 mg — Requirements/Limits = QL (14 capsules/365 days), SP |
| Hetlioz | tasimelteon capsule 20 mg (Hetlioz) — Requirements/Limits = PA, QL (30 capsules/30 days), SP |
| phenobarbital elixir 20 mg/5ml | phenobarbital elixir — Drug Tier = 1 |
| ramelteon 8 mg | ramelteon tab 8 mg (Rozerem) — Requirements/Limits = QL (30 tablets/30 days) |
| tasimelteon 20 mg | tasimelteon capsule 20 mg (Hetlioz) — Requirements/Limits = PA, QL (30 capsules/30 days), SP |
| Adderall XR | amphetamine-dextroamphetamine cap er 24hr various strengths — Requirements/Limits = QL as listed |
| Nuvigil | armodafinil tab various strengths |
| atomoxetine | atomoxetine hcl caps various strengths — Requirements/Limits = QL as listed |
| SUNOSI | solriamfetol hcl tab 75 mg, 150 mg — Requirements/Limits = PA, QL (30 tablets/30 days) |
| WAKIX | pitolisant hcl tab 4.45 mg, 17.8 mg — Requirements/Limits = LA, PA, QL (60 tablets/30 days), SP |
| XYWAV | calcium/mag/potassium/sodium oxybates oral soln 500 mg/ml — Requirements/Limits = LA, PA, QL (540 mls/30 days), SP |
| NDC/HCPCS not listed | No explicit procedure or NDC/HCPCS codes are provided in this section; entries are drug name, strength, tier, and Requirements/Limits. |
Actions, Authorization & Documentation Required
Obtain prior authorization when 'PA' is indicated
Certain drugs listed with the Requirements/Limits flag 'PA' require prior authorization before the plan will pay; if PA is not obtained, the plan may not cover the drug.
- Obtain PA prior to dispensing when the drug line shows 'PA' in Requirements/Limits.
- If PA is not received, coverage may be denied at point of adjudication.
Request PA for listed antifungals and HCV antivirals
Prior authorization is specifically noted for selected antifungals (e.g., CRESEMBA, posaconazole, voriconazole) and many hepatitis C direct-acting antivirals (e.g., EPCLUSA, HARVONI, MAVYRET) — providers must request PA as shown next to those products.
- Follow the Requirements/Limits entry (PA and any accompanying QL or SP) on each antiviral or antifungal line item.
- Example: EPCLUSA is listed with 'PA, QL (28 packets/28 days), SP' and requires PA before coverage.
Follow per-product PA and administrative flags (ACA/LA)
Some products are annotated with PA or other administrative flags (ACA, LA) in the Requirements/Limits column; providers must obtain the specific authorization or satisfy the administrative requirement shown before dispensing.
- If a product shows 'ACA' or 'LA' in addition to PA, follow the administrative/site instructions and obtain required approvals.
- Ensure the PA request references the Requirements/Limits shown on the formulary line item.
Adhere to the requirement type shown for example products (YEZTUGO, SUNLENCA)
Examples in the formulary show specific drugs with PA/ACA/LA and QL flags (for example, YEZTUGO and SUNLENCA) — follow the exact requirement type listed for each product when requesting coverage.
- SUNLENCA entries show 'LA, QL (4–5 tablets/365 days), SP' — obtain PA and comply with QL and site/specialty routing.
- YEZTUGO lines include 'ACA, SP' — follow the listed administrative and specialty requirements.
Submit PA and use specialty pharmacy when 'SP' is indicated
Many specialty and oncology agents are managed through specialty pharmacy and require prior authorization; providers must submit PA requests and ensure specialty routing when 'SP' is indicated.
- Oncology agents frequently list 'LA, PA, QL, SP' — obtain PA and route to specialty pharmacy as required.
- Quantity limits (QL) shown for specialty agents must be respected when completing PA requests.
Obtain PA for listed oncology and specialty oral agents
Numerous specialty oncology and oral targeted agents in the formulary require prior authorization and often include QL and site provisioning (SP/LA); providers must request PA and document adherence to QL and site requirements.
- Examples: LENVIMA therapy packs list 'LA, PA, QL (30–90 capsules/30 days), SP' — obtain PA and follow QL.
- Drugs with LA/PA/SP designations require prior approval before coverage is provided.
Request PA for drugs marked 'PA' in the formulary
Many formulary line-items include PA or other requirement flags; providers must request prior authorization for drugs marked 'PA' before dispensing to obtain coverage.
- Where the Requirements/Limits column includes 'PA' (e.g., XTANDI, ACTHAR), submit a PA request per payer instructions.
- Do not assume coverage without completing the PA process for listed products.
Obtain PA for GLP‑1/GIP–GLP‑1 and similar agents
Certain GLP‑1/GIP–GLP‑1 agents and other specialty metabolic products (e.g., MOUNJARO, OZEMPIC, TRULICITY) are listed with PA and QL requirements; obtain PA and document compliance with QL values when submitting claims.
- MOUNJARO entries show 'PA, QL (4 pens/180 days or 4 pens/28 days depending on strength)' — include this information in the PA request.
- OZEMPIC and TRULICITY are listed with 'PA, QL' — secure PA prior to dispensing.
Submit PA for specified agents listed with 'PA'
Drugs flagged with 'PA' in the Requirements/Limits column (examples include ACTHAR, carglumic acid, GENOTROPIN) require prior authorization; providers must submit PA requests for these specific agents.
- Refer to the formulary line item for each product and submit PA when 'PA' is shown.
- Include any product-specific details from the Requirements/Limits field in the authorization request.
Obtain PA for the listed selected products
Multiple products (e.g., nimodipine oral solutions, DIURIL suspension, FUROSCIX, NEXLETOL/NEXLIZET, REPATHA, VASCEPA, ENTRESTO, CAMZYOS) are shown with 'PA' in Requirements/Limits — providers must obtain PA for these items as listed.
- Check the formulary line item for each product's Requirements/Limits and submit PA where indicated.
- Include quantity justification when QL is present (e.g., REPATHA QL values) in the PA documentation.
PA required for drugs noted 'PA' (including VASCEPA and biologics)
Numerous drugs are designated 'PA' in the Requirements/Limits column (examples include VASCEPA, ADEMPAS and many biologics); providers must request prior authorization per the formulary entry before the plan will cover the drug.
- When a formulary entry shows 'PA' (with or without QL, LA, SP), submit the payer's prior authorization request before dispensing.
- For biologics noted with PA and SP, ensure PA documentation includes specialty routing information.
Obtain PA and comply with LA/QL/SP for specialty/high‑cost drugs
Many specialty or high‑cost medications are listed with PA and may also show LA, QL and SP designations; obtain prior authorization and comply with any limited access or specialty requirements shown to secure coverage.
- Check for accompanying QL, LA or SP flags and include relevant site-of-care or specialty pharmacy details in the PA submission.
- Failure to include site or specialty information when required may delay or prevent coverage.
Request PA and follow listed limits/route per product
The formulary indicates PA and/or limits (QL, LA, SP, ST) for numerous drugs; providers must submit prior authorization requests and adhere to specified limits and routing per the Requirements/Limits field.
- Submit PA where 'PA' is listed and ensure quantities requested do not exceed QL values.
- If 'SP' or 'LA' is present, route dispensing to the specialty pharmacy or designated site of care.
Obtain PA and follow QL/SP for tasimelteon (Hetlioz)
Tasimelteon (Hetlioz) is listed with 'PA, QL (30 capsules/30 days), SP' — providers must obtain prior authorization and follow the specialty pharmacy and quantity limit noted on the formulary line.
- Include the QL (30 capsules/30 days) in the PA request for tasimelteon.
- Ensure specialty pharmacy routing is used when arranging dispensing.
Follow QL and specialty routing for zuranolone (ZURZUVAE)
Zuranolone (ZURZUVAE) entries include QL values and specialty designation (e.g., QL 28 capsules/365 days; QL 14 capsules/365 days) — providers must observe those limits and any specialty routing when seeking coverage.
- Do not exceed the listed QL per 365‑day period when requesting fills.
- If SP is indicated, coordinate dispensing via specialty pharmacy as required.
Request PA for all drugs listed with 'PA'
Many products across the formulary are indicated as requiring prior authorization; providers must request PA for any drug with 'PA' shown in the Requirements/Limits column before dispensing to avoid non‑coverage.
- Review the Requirements/Limits field for each line item and submit PA when 'PA' is present.
- Include product‑specific QL, LA, SP or ST details in the authorization request where shown.
Submit PA for listed biologic and specialty agents
Multiple listed products (including many biologic and specialty agents) require prior authorization as indicated in the Requirements/Limits field; providers must submit PA requests and follow specialty routing where 'SP' is shown.
- Examples include biologics with 'PA' and QL (e.g., adalimumab products showing PA, QL (2 pens/28 days), SP).
- Ensure PA requests contain documentation to satisfy medical necessity and any site/specialty requirements.
Comply with step therapy requirements when 'ST' is shown
Step therapy (ST) applies where the formulary marks a drug with 'ST'; providers must follow plan step edits (try required preferred drugs first) or request an exception.
- If the Requirements/Limits column includes 'ST' for a product, ensure the member has completed required prior steps or submit a step‑therapy exception request.
- Examples: agents annotated with 'ST' (e.g., FOSRENOL, VELPHORO, SAVELLA) are subject to step therapy where indicated.
Follow utilization management and site/administrative flags (SP/LA/ACA)
Some products include 'SP' and 'LA' or 'ACA' flags that imply utilization management or site/administrative rules; when these flags appear, providers must follow plan‑specific step, site or administrative processes before dispensing.
- 'SP' typically indicates specialty pharmacy routing — arrange specialty dispensing when shown.
- 'LA' or 'ACA' flags may require site‑of‑care approval or administrative coverage steps prior to approval.
Check Requirements/Limits flags on each formulary line
The formulary places initials after drug names (PA, QL, ST, LA, SP) to indicate required actions — providers must consult the Requirements/Limits field on each line and follow the plan's instructions when prescribing or submitting claims.
- Confirm whether PA, QL, ST, LA or SP applies from the line item before submitting a claim.
- Use the Requirements/Limits details to populate PA requests and support documentation.
Document compliance with Requirements/Limits on claims
Pharmacy claims should document compliance with the Requirements/Limits field (for example, QL values and PA where indicated) to support coverage — include quantity justification and PA documentation where required.
- When a QL is present, include quantity justification in the claim or PA submission.
- Attach prior authorization approval codes or supporting medical documentation to the claim when 'PA' is required.
Follow PA and QL processes to avoid denials
Prescribers and pharmacies must follow the plan's PA and QL processes where indicated; failure to obtain required PA or to adhere to QL may result in denial of coverage at claim adjudication.
- Submit PA requests per payer procedures and ensure requested quantities do not exceed QL.
- If authorization is not obtained or QL exceeded, the claim may be denied.
Ensure claims reference exact quantity limits and PA
Pharmacy claims must meet specified Requirements/Limits (e.g., PA and QL such as 60 tablets/30 days for enzalutamide or 30 tablets/30 days for niraparib) — providers should ensure claims and PA submissions reference the exact QL values.
- Include the formulary QL value in the PA or claim to avoid dose/quantity denials.
- Examples: XTANDI = QL (60 tablets/30 days); ZEJULA = QL (30 tablets/30 days).
Risk of denial if PA not obtained
Failure to obtain required prior authorization may result in the plan not covering the drug; providers should request PA in advance and submit supporting documentation to mitigate denial risk.
- Obtain PA prior to dispensing when 'PA' is indicated; if not obtained, coverage may be denied.
- Providers may request exceptions per plan processes, but coverage is not guaranteed without PA.
Heed PA/LA/SP/ACA flags as triggers for administrative controls
Drugs flagged with 'PA', 'LA', 'SP' or 'ACA' indicate administrative controls that may trigger prior authorization or special handling; providers must follow those controls to obtain coverage.
- When these flags appear in Requirements/Limits, include evidence of meeting those controls in the authorization submission.
- Specialty or limited‑access products often require additional documentation or site approvals.
Denial risk when exceeding QL or missing required authorizations
Requests that exceed listed quantity limits (QL) or lack required PA/LA/SP authorizations may be denied or subjected to additional review at adjudication.
- If a request exceeds the QL shown on the formulary line, obtain PA or provide justification to avoid denial.
- Ensure site‑of‑care approvals are in place for LA/FF/ SP‑designated products.
Coordinate specialty pharmacy routing and PA when 'SP' is listed
If specialty pharmacy (SP) requirements are present for a drug, providers must arrange dispensing through the specialty channel and obtain any required PA; failure to do so may limit or deny coverage.
- Coordinate with the plan's specialty pharmacy when 'SP' is indicated on the drug line.
- Include specialty routing information and PA documentation with the claim.
Obtain PA and adhere to QL to prevent claim denial
Claims for drugs listed with 'PA' or that exceed specified QL values may be denied if authorization is not obtained; providers should secure PA and respect QL to prevent claim denials.
- For drugs with PA and QL, include PA approval and ensure dispensed quantities align with QL before submitting the claim.
- Examples: sodium oxybate (Xyrem) shows 'LA, PA, QL (540 mls/30 days), SP' — obtain PA and follow QL.
Quantity Limit Examples by Product
Specialty, Infusion, and Dispensing Channels
Abbreviations and Formulary Flags
Step Therapy Indicators and Affected Products
| Policy point | Details / examples |
|---|---|
| Step therapy (ST) requirement | |
| Step Therapy (ST) may require trying specified preferred drugs first; exceptions can be requested. (See formulary abbreviations and step therapy description). |
| Policy point | Details / examples |
|---|---|
| Administrative / specialty flags on HIV and specialty agents | |
| Certain specialty HIV agents and other specialty products are flagged with administrative/limited-access indicators (LA, ACA) and specialty designation (SP) — e.g., SUNLENCA listings with LA, QL and SP; PALFORZIA entries with LA, SP. |
| Policy point | Details / examples |
|---|---|
| Prior authorization and specialty pharmacy handling | |
| Many specialty and oncology agents require prior authorization (PA) and are managed through specialty pharmacy (SP); examples include oncology biologics and other specialty products listed with PA and SP flags. |
| Policy point | Details / examples |
|---|---|
| Complete required prior steps per plan | |
| Presence of LA/FF flags suggests additional step or formulary restrictions; providers should complete any required prior steps per the plan before coverage. (Examples: leucovorin with FF/PA/QL; various therapy packs showing LA/PA/QL). |
| Policy point | Details / examples |
|---|---|
| Contraceptives and specialty agents with administrative flags | |
| Some contraceptives and specialty agents are flagged with ACA or LA (administrative coverage annotations) or PA, which may imply administrative or step-related requirements; specific step sequences are not provided in this extract (examples: many contraceptives listed with ACA; IUDs KYLEENA noted ACA, LA). |
| Policy point | Details / examples |
|---|---|
| PA required for GLP‑1 / related agents | |
| Prior authorization (PA) is required before coverage for several GLP‑1 and related agents — e.g., MOUNJARO and OZEMPIC are listed with PA and quantity limits. |
| Policy point | Details / examples |
|---|---|
| Agents designated 'ST' / step therapy noted in Requirements/Limits | |
| Some drugs are designated 'ST' or have step therapy indicated in Requirements/Limits; follow the plan's step therapy rules where ST appears (examples: FANAPT entries show ST; other lines list ST alongside QL). |
| Policy point | Details / examples |
|---|---|
| No explicit step-therapy steps listed in extract | |
| The document does not provide step-by-step ST sequences in this extract; some agents are marked ACA indicating administrative coverage controls rather than explicit step edits. Providers should refer to plan systems for specific step requirements. |
| Policy point | Details / examples |
|---|---|
| No explicit ST sequences provided | |
| No explicit step-therapy sequences are provided in these chunks; the listings show PA/QL/LA/SP designations but not the detailed step order. |
| Policy point | Details / examples |
|---|---|
| ST applies where 'ST' appears in Requirements/Limits | |
| Step therapy applies to drugs with 'ST' in the Requirements/Limits field — examples in the formulary include FOSRENOL / VELPHORO entries and other listed agents with ST. |
| Policy point | Details / examples |
|---|---|
| Products annotated 'ST' alongside QL entries | |
| Several listed products include 'ST' indicating they are subject to step therapy — examples include titration packs and formulations (e.g., FETZIMA/FANAPT titration packs referenced with QL and ST in the listings). |
| Policy point | Details / examples |
|---|---|
| SAVELLA marked ST | |
| SAVELLA (milnacipran) is specifically listed with ST (and QL), indicating step therapy applies to this product. |
| Policy point | Details / examples |
|---|---|
| Selected medications noted as subject to step therapy | |
| Multiple medications are noted as subject to step therapy where 'ST' appears in Requirements/Limits (examples include FANAPT titration packs and SAVELLA). Providers should follow the plan's ST requirements for these agents. |
Formulary Background and Scope
This formulary includes both brand‑name and generic medications and notes that pharmacists will generally dispense generic equivalents when available. The document describes utilization management tools used by the plan — principally PA (prior authorization), QL (quantity limits) and ST (step therapy) — and indicates that many specialty drugs require specialty pharmacy handling (SP) or have limited access/site‑of‑care designations (LA). Home delivery is available and may be an option for ongoing chronic therapy.
Policy Dates & Revision Notes
Formulary updated and effective on April 1, 2026.
Policy last reviewed on April 1, 2026.
Next scheduled review date set for April 1, 2026.
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