CurrentEmblemHealthPolicy N/A

Formulary drug listing with tiers and requirements/limits (part 2)

A partial (Part 2 of 13) EmblemHealth formulary/drug benefit listing mapping drug products and formulations to tiers and operational controls (PA, QL, LD, SP); covers anti-infectives, vaccines, biologicals, palforzia and numerous antineoplastic agents with product-specific rules.

Policy Summary

PayerEmblemHealth

PolicyFormulary drug listing with tiers and requirements/limits (part 2)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for drugs labeled PA and use designated limited-distribution or specialty channels for LD/SP items as required by the plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes reported for this formulary segment.

100+Drugs listed in this part

manyRequire PA or LD

multipleHave QL specified

numerousVaccines flagged AC

multipleLimited distribution (LD) products

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Coverage Summary & Scope

This file is a segment of a comprehensive EmblemHealth formulary/drug benefit listing. It maps individual drug products and formulations to plan formulary tiers and operational controls (e.g., PA, QL, LD, SP) and is used for coverage determination, pharmacy benefit management, and claims processing.

Scope for this segment: partial formulary / Part 2 of multiple parts covering a portion of the alphabet and product categories (examples shown include anti-infectives, vaccines, biologicals, palforzia, and numerous antineoplastic agents). Coverage stance for this part is mixed — many drugs are listed with varied statuses: covered, subject to PA, QL, LD, SP, or other administrative notes.

Key thresholds and summary

Formulary segment scopeA partial (Part 2 of 13) EmblemHealth formulary segment listing drug products, tiers and operational controls (PA, QL, LD, SP) covering antinfectives, vaccines, biologics, oncology, endocrine, antidiabetics and other classes; dose/formulation-specific rules apply.

Coverage stancemixed — many products are covered with conditions; vaccines flagged AC (ACIP recommended) are covered; numerous drugs require PA/LD/SP or have QL.

Example threshold — OZEMPIC pen limitQL: 1 pen/28 days for some presentations or QL: 3 pens/28 days for other OZEMPIC strengths (PA applies).

Example threshold — Blood glucose test stripsQL: 204 strips/30 days for many brands (e.g., CONTOUR, FREESTYLE, PRECISION).

Example threshold — VIRACEPT (nelfinavir)QL: VIRACEPT 250 mg tab — 270 tablets/30 days; VIRACEPT 625 mg tab — 120 tablets/30 days.

Requirements & Limits (PA / QL / LD / SP / ST)

Requirements/Limits across listed drugs

For each listed product, coverage is subject to the Requirements/Limits noted (examples include: PA = prior authorization, QL = quantity limit, LD = limited distribution, SP = specialty, ST = step therapy).

Product-specific Requirement/Limits examples

GOLYTELY / GAVILYTE-C / PEG-PREP / SUTAB and related bowel preps: GOLYTELY (peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm) Requirements/Limits = AC
Bowel prep examples with none listed: GAVILYTE-C (peg 3350... 240 gm) Requirements/Limits = (none listed)
Cimetidine (ulcer): cimetidine hcl soln 300 mg/5ml Requirements/Limits = PA, QL (1200 mls/30 days)

Provider Actions & Operational Requirements

Prior Authorization

Prior Authorization required for PA-designated drugs

Prior Authorization is required for drugs and specialty agents designated with PA or PA-designated notes in the formulary. This includes specific specialty agents listed on the drug index and any products marked in the formulary with a PA or "Prior Authorization" flag. Providers must obtain approval before dispensing; claims submitted without required authorization may be denied.

Obtain PA before dispensing PA-designated drugs.
PA applies to specialty agents and other products explicitly marked PA in the formulary.
Follow payer PA submission process and include required clinical documentation.

Prior Authorization

Limited Distribution (LD) & Specialty Program (SP) handling

Some drugs in the formulary are limited distribution (LD) or designated as part of the Special Program (SP). LD items may only be available through a manufacturer‑designated distributor or limited pharmacies; SP items require dispensing through an approved Specialty Pharmacy. When a product is marked LD or SP the provider must follow the manufacturer's distribution channel and EmblemHealth's operational requirements.

Product / NDC Groups & Coding

Drugs with Quantity LimitsNDC

BENZNIDAZOLE 12.5/100 mg tab	Benznidazole 12.5 mg per 100 mg tablet
sulfamethoxazole-trimethoprim susp 200-40 mg/ml	Sulfamethoxazole 200 mg - Trimethoprim 40 mg per mL suspension
XIFAXAN 200 mg tab	Rifaximin 200 mg tablet (XIFAXAN)
XIFAXAN 550 mg tab	Rifaximin 550 mg tablet (XIFAXAN)
VEMLIDY 25 mg tab	Tenofovir alafenamide 25 mg tablet (VEMLIDY)
megestrol acetate susp 40 mg/mL	Megestrol acetate oral suspension 40 mg/mL
DEXAMETHASONE soln 0.5 mg/mL	Dexamethasone oral solution 0.5 mg/mL
dexamethasone elixir 0.5 mg/mL	Dexamethasone elixir 0.5 mg/mL
prednisolone sodium phosphate oral soln 15 mg/mL	Prednisolone sodium phosphate oral solution 15 mg/mL
PREDNISONE oral soln 5 mg/mL	Prednisone oral solution 5 mg/mL

Drugs requiring Prior AuthorizationNDC

abiraterone acetate 250 mg tab	Abiraterone acetate 250 mg tablet
abiraterone acetate 500 mg tab	Abiraterone acetate 500 mg tablet
AKEEGA niraparib-abiraterone tabs	Niraparib combined with abiraterone tablets (AKEEGA)
ALECENSA 150 mg cap	Alectinib 150 mg capsule (ALECENSA)
ALUNBRIG various	Brigatinib (ALUNBRIG) various strengths and formulations
BALVERSA erdafitinib 3 mg	Erdafitinib 3 mg tablet (BALVERSA)
BALVERSA erdafitinib 4 mg	Erdafitinib 4 mg tablet (BALVERSA)
BALVERSA erdafitinib 5 mg	Erdafitinib 5 mg tablet (BALVERSA)
LENVIMA packs various mg	Lenvatinib (LENVIMA) pack configurations, various strengths
LUMAKRAS sotorasib various	Sotorasib (LUMAKRAS) various tablet strengths

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1/15

Vaccines (AC = ACIP recommended/covered)NDCCovered

IPOL (IPV)	Inactivated poliovirus vaccine (IPOL)
M-M-R	Measles, Mumps, Rubella vaccine (M-M-R)
PRIORIX	PRIORIX (MMR vaccine)
MENQUADFI	MENQUADFI meningococcal vaccine
MENVEO	MENVEO meningococcal vaccine
PENBRAYA	PENBRAYA (meningococcal product)
TRUMENBA	TRUMENBA meningococcal vaccine
PNEUMOVAX 23	Pneumococcal polysaccharide vaccine (PNEUMOVAX 23)
PREVNAR 20	Pneumococcal 20-valent conjugate vaccine (PREVNAR 20)
VAXNEUVANCE	Pneumococcal conjugate vaccine (VAXNEUVANCE)

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Formulary items with requirements/limitsNDC

VITRAKVI larotrectinib oral soln 20 mg/mL	Larotrectinib oral solution 20 mg/mL (VITRAKVI)
VITRAKVI larotrectinib cap 25 mg	Larotrectinib 25 mg capsule (VITRAKVI)
VITRAKVI larotrectinib cap 100 mg	Larotrectinib 100 mg capsule (VITRAKVI)
LYSODREN mitotane 500 mg tab	Mitotane 500 mg tablet (LYSODREN)
OGSIVEO nirogacestat 50 mg tab	Nirogacestat 50 mg tablet (OGSIVEO)
OGSIVEO nirogacestat 100 mg tab	Nirogacestat 100 mg tablet (OGSIVEO)
OGSIVEO nirogacestat 150 mg tab	Nirogacestat 150 mg tablet (OGSIVEO)
OJEMDA tovorafenib 100 mg tab	Tovorafenib 100 mg tablet (OJEMDA)
OJEMDA tovorafenib oral susp 25 mg/mL	Tovorafenib oral suspension 25 mg/mL (OJEMDA)
ONUREG azacitidine 200 mg tab	Azacitidine 200 mg tablet (ONUREG)

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Quantity Limits & Thresholds (examples)

High‑priority quantity limits & numeric thresholds

Examples & operational notes

Note

Claims that exceed the listed QL (exact numeric threshold shown with each product) may be denied or require prior authorization; see plan PA rules for overrides.

Note

Many products shown with QL are also PA — e.g., abiraterone (PA + QL), VOSEVI (PA + QL), selected oncology agents — prescribers must submit PA before benefit approval.

Note

Items flagged LD and/or SP must be obtained/dispensed via the designated limited distribution or specialty pharmacy channels (examples: LENVIMA packs, LUMAKRAS, IBRANCE, ALECENSA).

Note

Use the exact per‑period thresholds on the formulary when filling claims (examples from list: OZEMPIC pens: 1 pen/28 days or 3 pens/28 days depending on presentation; insulin vials/pens: 100 mls/30 days; TRULICITY pens: 4 pens/28 days or 2 pens/28 days).

Background & Definitions

This document is a portion of the EmblemHealth formulary that lists covered drugs and describes plan-level rules and codes used at claim adjudication. It enumerates drug names, tiers, and specific operational controls.

It maps products to tiers and to administrative controls (e.g., PA = prior authorization; QL = quantity limits; LD = limited distribution; SP = specialty pharmacy), and is intended for use by prescribers, PBMs, pharmacy operations, and claims processors when determining coverage and benefit adjudication.

Definitions in this segment: PA = Prior Authorization (plan requires approval before fill); QL = Quantity Limit (maximum quantity covered in specified days-supply); LD = Limited Distribution (product distributed via restricted channels).

Also defined: SP = Specialty Pharmacy (specialty dispensing/handling); ST = Step Therapy (prior required trials before coverage); AC = ACIP-recommended/advance coverage or administrative coverage designator (often used for vaccines/contraceptives).

Clinical Evidence & Notes

This segment contains formulary operational controls and product-level coverage rules (PA, QL, LD, SP, ST, AC). There are no clinical trial summaries or structured clinical evidence cards included in this fragment; the content is focused on mapping products to tiers and operational requirements rather than clinical trial metrics.

Revision History

Policy Summary

PayerEmblemHealth

PolicyFormulary drug listing with tiers and requirements/limits (part 2)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for drugs labeled PA and use designated limited-distribution or specialty channels for LD/SP items as required by the plan.

SourceLink

On This Page

Proton pump inhibitors (examples): dexlansoprazole 30 mg Requirements/Limits = QL (60 capsules/30 days); dexlansoprazole 60 mg Requirements/Limits = QL (30 capsules/30 days); esomeprazole magnesium susp packet Requirements/Limits = QL (60 packets/30 days)

H2 blocker suspension: famotidine for susp 40 mg/ml Requirements/Limits = QL (2400 mls/30 days), PA

Glycopyrrolate (Cuvposa): glycopyrrolate oral soln 1 mg/ml (Cuvposa) Requirements/Limits = PA, QL (1350 mls/30 days)

Lansoprazole / Omeprazole / Pantoprazole / Rabeprazole QL examples: lansoprazole cap dr 15 mg Requirements/Limits = QL (60 capsules/30 days); omeprazole cap dr 10/20/40 mg Requirements/Limits = QL (60 capsules/30 days); pantoprazole 20/40 mg Requirements/Limits = QL (60 tablets/30 days); rabeprazole 20 mg Requirements/Limits = QL (60 tablets/30 days)

Pancreatic enzyme products and sucrase: CREON pancrelipase Requirements/Limits = (none listed); SUCRAID sacrosidase soln Requirements/Limits = LD, PA, QL (300 mls/30 days), SP

Enteral / GI specialty agents (examples): AURYXIA ferric citrate Requirements/Limits = QL (1080 tablets/365 days), ST; BYLVAY odevixibat Requirements/Limits = LD, PA, SP; GATTEX teduglutide Requirements/Limits = LD, PA, SP

Infusions / biologics (examples): CIMZIA certolizumab Requirements/Limits = QL (2 kits/28 days), SP, PA; ENTYVIO PEN vedolizumab Requirements/Limits = LD, PA, QL (2 pens/28 days), SP

Selected CNS / other examples: ELMIRON pentosan Requirements/Limits = PA, QL (90 capsules/30 days); FILSPARI sparsentan Requirements/Limits = LD, PA, QL (30 tablets/30 days), SP

Oncology / specialty examples with explicit QL/PA/LD/SP flags: (Many oncology agents listed in this segment show LD, PA, QL, SP flags; see entries such as ALECENSA, AKEEGA, LENVIMA, LUMAKRAS, IBRANCE, etc. for product-level Requirements/Limits.)

Drug-specific Requirements/Limits

Each listed drug includes zero or more requirement/limit qualifiers (PA = prior authorization, QL = quantity limit, LD = limited distribution, SP = specialty, etc.).

Listed drug entries

Mycophenolate / Neoral / Tacrolimus examples: mycophenolate mofetil cap 250 mg (Cellcept) Requirements/Limits: .; MYHIBBIN mycophenolate mofetil oral susp 200 mg/ml Drug Tier = 2 Requirements/Limits: .; NEORAL cyclosporine modified cap 25 mg; 100 mg Requirements/Limits: .; PROGRAF tacrolimus cap 0.5 mg; 1 mg; 5 mg Requirements/Limits: .
Lenalidomide / Revlimid examples: REVLIMID lenalidomide caps 2.5 mg Requirements/Limits = LD, PA, QL (30 capsules/30 days), SP; REVLIMID lenalidomide cap 5 mg, 10 mg Requirements/Limits = LD, PA, QL (30 capsules/30 days), SP; other REVLIMID presentations with QL (21 capsules/28 days)
Thalidomide examples: THALOMID thalidomide cap 50 mg Requirements/Limits = LD, PA, QL (90 capsules/30 days), SP; THALOMID thalidomide cap 100 mg Requirements/Limits = LD, PA, QL (120 tablets/30 days), SP
Imatinib / other antineoplastics: imatinib mesylate tab 100 mg Requirements/Limits = PA, QL (90 tablets/30 days), SP; imatinib mesylate tab 400 mg Requirements/Limits = PA, QL (60 tablets/30 days), SP; many antineoplastic agents carry LD/PA/QL/SP flags
Ibrutinib examples: IMBRUVICA ibrutinib oral susp 70 mg/ml Requirements/Limits = QL (216 mls/30 days), SP, PA; IMBRUVICA caps and other strengths show LD, PA, QL, SP as listed
Palforzia levels / biologic allergen examples: PALFORZIA various levels: initial dose: Requirements/Limits = SP; many PALFORZIA LEVEL entries marked LD and/or SP depending on level
Selected oncology QL thresholds: Examples: IBRANCE palbociclib QL (21 capsules/28 days); LUMAKRAS QL (240 or 120 or 90 tablets/30 days per strength); LORBRENA QL (120 or 30 tablets/30 days); many product lines provide per-strength QL values

LD items: procure only through manufacturer‑specified distributor; check formulary notes for distributor details.
SP items: must be dispensed via the plan's approved Specialty Pharmacy network unless an exception is authorized.
When LD/SP restricts source, claims from non‑authorized pharmacies may be denied or returned.
For LD items that also require PA, include documentation showing enrollment/authorization with the LD distributor.

Documentation Required

Advance contraceptive products and Vaccine AC designation

Certain products are designated Advance Contraceptive (AC) or Vaccine AC. These designations affect dispensing/site‑of‑care rules and may have zero cost‑sharing when used per preventive guidelines. Providers should follow the AC designation for coverage and billing.

Vaccines marked AC: follow vaccine AC billing and reporting guidance; may be covered under preventive benefits.
Advance contraceptive (AC) products: follow formulary designation for coverage and member cost‑share.
Check formulary index mapping for which products carry AC or Vaccine AC labels.

Billing Rule

Quantity limits enforced at claim adjudication and dispensing

Quantity limits (QL) noted in the formulary are enforceable at both claim adjudication and at dispensing. Providers and pharmacies must follow the QL values; exceeding dispensing limits without prior approval can result in claim denial or pharmacy reimbursement adjustments.

QLs are enforced during claim adjudication — do not expect overrides without a PA or exception.
Pharmacies must not dispense quantities exceeding the formulary QL unless an approved PA or documented exception exists.
Examples: per‑day, per‑fill, and per‑30/90‑day limits listed in formulary must be observed.
Requests exceeding QL require submission of a PA with clinical rationale.

Step Therapy

Step therapy (ST) applies where noted

Step therapy (ST) requirements apply to select products as noted in the formulary (ST/Step Therapy or SP/ST designations). When step therapy applies, members are expected to try and fail required first‑line agents before higher‑tier or specialty agents are approved. Providers should follow the step algorithm or obtain a PA documenting why the step is not appropriate.

Follow step therapy sequence in formulary before prescribing later‑line agents (examples include KERENDIA, AURYXIA where step rules are used).
If an exception is clinically indicated, submit a PA with documentation explaining contraindication, intolerance, or prior failure.
Claims for drugs subject to ST submitted without required trial/PA may be denied.

Documentation Required

Specialty Pharmacy (SP) dispensing requirement

Specialty Pharmacy dispensing requirements: products flagged SP or requiring specialty handling must be dispensed by an authorized Specialty Pharmacy. Pharmacies and providers must ensure the dispensing pharmacy is in the plan's specialty network and that any required enrollment, monitoring, or REMS steps are completed prior to fill.

Dispense SP products only through plan‑approved Specialty Pharmacies unless an exception is granted.
Ensure necessary monitoring and REMS documentation is included with the claim when applicable.
Failure to use the required Specialty Pharmacy may result in claim denial or claim reprocessing.

Note

1) Verify QL numeric limit on the formulary line for the exact NDC/presentation; 2) Check PA/LD/SP flags and follow specialty or manufacturer channels; 3) Deny or route to PA if requested quantity exceeds the stated QL window; 4) For vaccines marked AC follow vaccine billing/documentation guidance.

Note

If claim.quantity > formulary.QL.quantity AND no active PA override → deny. (Use the exact QL value from the formulary entry, e.g., VIRACEPT 250 mg QL = 270 tablets/30 days).

Note

QLs are specified with the numerator and days‑supply window (e.g., '/30 days' or '/28 days' or '/365 days'); apply the same interval when enforcing limits for that product.