CurrentEmblemHealthPolicy N/A

2026 Formulary (List of Covered Drugs)

Part 1 of the EmblemHealth 2026 formulary listing covered drugs, tiers, and associated requirements/limits (PA, QL, SP, LA, ACA, FF, ST) for numerous anti-infective therapeutic classes and specific products; includes antibiotics, antifungals, antivirals, antimycobacterial, antiparasitic, and related drug listings through antimalarials. Coverage may vary by specific drug benefit plan.

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionUse the formulary index (starts on page 102) to locate drugs and follow prior authorization, quantity limits, specialty, LA, ACA and step therapy flags as listed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were documented for this formulary part.

manyProducts listed in this part

multipleProducts with PA

multipleProducts with QL

numerousSP/LA-designated

commonOTC/ACA flagged

Coverage Summary

Applicable Codes / Formulary Entries

Drug lists and requirements/limits (by drug/product)mixedCovered

AMOXICILLIN	amoxicillin (trihydrate) chew tab 125 mg, 250 mg; cap 250 mg, 500 mg; susp 125/5ml, 200/5ml, 250/5ml, 400/5ml; tab 500 mg, 875 mg
AMOXICILLIN & K CLAVULANATE	amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml; susp 600-42.9 mg/5ml (Augmentin ES-600); tab ER 12hr 1000-62.5 mg; tab 250-125 mg, 500-125 mg, 875-125 mg
AMPICILLIN	ampicillin cap 500 mg
AUGMENTIN	AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml
DICLOXACILLIN	dicloxacillin sodium cap 250 mg, 500 mg
PENICILLIN V POTASSIUM	penicillin v potassium for soln 125 mg/5ml, 250 mg/5ml; tab 250 mg, 500 mg
CEPHALOSPORINS	class header - cephalosporins
CEFACLOR	cefaclor formulations (oral)
CEFADROXIL	cefadroxil formulations (oral)
CEFDINIR	cefdinir formulations (oral)

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VaccinesmixedCovered

ABRYSVO	ABRYSVO
COMIRNATY 2025-26	COMIRNATY 2025-26
GARDASIL 9	Gardasil 9
SHINGRIX	Shingrix
PNEUMOVAX 23	Pneumovax 23
PREVNAR 20	Prevnar 20
FLUZONE 2025-2026	Fluzone 2025-2026

Antineoplastics and specialty oncologymixedCovered

abiraterone acetate 250 mg	abiraterone acetate 250 mg
abiraterone acetate 500 mg	abiraterone acetate 500 mg
ALECENSA 150 mg cap	Alecensa 150 mg cap
ALUNBRIG	Alunbrig (various strengths)
IBRANCE	Ibrance cap/tab 75/100/125 mg
IMBRUVICA	Imbruvica (various)

PALFORZIA levelsmixedCovered

PALFORZIA INITIAL DOSE ES	PALFORZIA INITIAL DOSE ES
PALFORZIA LEVEL 0	PALFORZIA LEVEL 0
PALFORZIA LEVEL 1	PALFORZIA LEVEL 1
PALFORZIA LEVEL 2	PALFORZIA LEVEL 2
PALFORZIA LEVEL 3	PALFORZIA LEVEL 3
PALFORZIA LEVEL 4	PALFORZIA LEVEL 4
PALFORZIA LEVEL 5	PALFORZIA LEVEL 5
PALFORZIA LEVEL 6	PALFORZIA LEVEL 6
PALFORZIA LEVEL 7	PALFORZIA LEVEL 7
PALFORZIA LEVEL 8	PALFORZIA LEVEL 8

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OTC / ACA listsmixed

ACA	Affordable Care Act OTC coverage annotations
OTC	Over the Counter product listings (multivitamins, common OTC agents)

PA / QL / LA / SP grouped listsmixed

PA	Prior Authorization required — see policy details
QL	Quantity Limit — see policy details
LA	Limited Availability — select retail locations
SP	Specialty drugs — specialty pharmacy requirements

Additional notable products (selected)mixedCovered

CAYSTON	Cayston (aztreonam inhalation)
linezolid suspension	linezolid for suspension
nitazoxanide 500 mg tab	nitazoxanide 500 mg tablet
BAQSIMI ONE PACK	BAQSIMI glucagon nasal powder 3 mg/dose
GVOKE HYPOPEN	Gvoke autoinjector and kit formulations

Contraceptives and reproductive healthmixedCovered

levonorgestrel & ethinyl estradiol 0.1-20	levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
levonorgestrel tab 1.5 mg	levonorgestrel tab 1.5 mg (emergency)
LILETTA	Liletta IUD levonorgestrel 20.1 mcg/day (52 mg)
MIRENA	Mirena IUD levonorgestrel 20 mcg/day (52 mg)
NEXPLANON	Nexplanon etonogestrel implant 68 mg
NUVARING	NuvaRing vaginal ring
PARAGARD	Paragard copper IUD

Diabetes and glucagon productsmixedCovered

BAQSIMI TWO PACK	BAQSIMI two-pack
GLUCAGON EMERGENCY KIT	glucagon for injection 1 mg
GVOKE KIT	Gvoke rescue kit and PFS
MOUNJARO	Mounjaro (tirzepatide) multi-strength pens
OZEMPIC	Ozempic (semaglutide) pens
RYBELSUS	Rybelsus (semaglutide) oral

Insulins and devicesmixedCovered

Rapid-Acting Insulins	FIASP, Humalog, Lyumjev, Novolog and related
Basal Insulins	insulin glargine, degludec, insulin glargine-yfgn, Semglee, Toujeo, Tresiba
Insulin pens and needles	pen needles and delivery devices

Policy Summary

PayerEmblemHealth

Policy2026 Formulary (List of Covered Drugs)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionUse the formulary index (starts on page 102) to locate drugs and follow prior authorization, quantity limits, specialty, LA, ACA and step therapy flags as listed.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria (Interpretation)

Coverage entries and associated requirements

Covered when ANY of the following apply. The 'ANY' branch preserves examples and class-level notes. Requirement flags used in this section: PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; LA = Limited Availability; FF = Frozen Formulary; OT C = Over the Counter; SP = Specialty. Definitions: PA = plan requires approval before fill; QL = plan limits amount covered; ST = plan requires trying specified drugs first; LA = product may only be available at select pharmacies; FF = product affected by frozen formulary mandate; OTC = non-prescription; SP = specialty handling required.

ANY of the following

Drug is listed on the formulary with no associated utilization management flags (no PA/QL/ST/LA/FF/SP)
Drug is listed with one or more requirement flags: PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), LA (Limited Availability), FF (Frozen Formulary), SP (Specialty). See definitions mapping above.
Class-level notes or examples: contraceptives, insulin products, and endocrine agents may have class-specific coverage observations (e.g., interchangeability rules, preferred agents, or distribution channel restrictions).

Coverage / Requirements per listed drug

Coverage and any requirements for listed drugs or product groups. Use the ANY operator to indicate that coverage applies when any of the specified product-level conditions are met.

ANY of the following

Contraceptives
- Formulary includes oral, transdermal, implantable, and IUD contraceptives; specific products may be subject to PA or LA depending on brand, formulation, or availability.
- Generic oral contraceptives are preferred when available; brand products may require PA or be placed on a higher tier.
Insulins
- Short-, rapid-, intermediate-, and long-acting insulin products are listed on the formulary; certain newer or concentrated formulations may require PA or be designated SP.

OpenPayer

2026 Formulary (List of Covered Drugs)

Coverage Summary

Applicable Codes / Formulary Entries

Coverage Criteria (Interpretation)

Provider Actions (PA, QL, SP, Documentation)

Quantity Limits & Thresholds

Revision History