2026 Formulary (List of Covered Drugs) — EmblemHealth Uniformed Sanitationmen's Association (US86)
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This document is the EmblemHealth formulary (US86) describing covered prescription drugs, tiers, utilization management (prior authorization, quantity limits, step therapy), and member services for the EmblemHealth Uniformed Sanitationmen's Association plan; it affects plan members, prescribing providers, and pharmacies.
No material clinical or coverage changes in this revision.
Formulary Coverage & Requirements
Formulary coverage and utilization controls
Covered when the formulary entry and any listed utilization controls are met:
See product listing for specific tier assignment.
Examples of QL, SP, and LA are shown in the product listings.
Formulary product listing
Each formulary product is listed with name, strength/form, Drug Tier, and any explicit Requirements/Limits (such as QL, SP, LA). Coverage follows the listed tiering and any Requirements/Limits.
This document section is a product listing; clinical criteria are not provided in these entries.
Not all products shown in this formulary are covered under every EmblemHealth drug benefit. The formulary itself does not guarantee payment — members and providers should confirm coverage, cost-sharing, and any plan-specific rules by consulting the member's Certificate of Coverage or calling the phone number on the member ID card prior to filling.
Within the excerpted sections there are no explicit formulary exclusions listed; entries display drug name, strength, drug tier, and a Requirements/Limits field but do not specify excluded products in these chunks.
Some listed items are noted as OTC in the Requirements/Limits field (for example, nonoxynol‑9 products such as ENCARE, OPTIONS GYNOL II, TODAY SPONGE). Products marked OTC may be available over the counter and their coverage as prescription benefits can differ from other formulary items.
Several products in these sections are annotated as OTC or have blank Requirements/Limits fields; the presence of an OTC designation indicates over‑the‑counter status for those formulations and may affect coverage even though no formal exclusion language is provided in these chunks.
In the provided document segments there are no statements labeling any drug as not medically necessary; the entries are product listings with Drug Tier and Requirements/Limits fields but do not include 'not medically necessary' language in these chunks.
What Providers & Pharmacists Must Do
Obtain prior authorization when PA indicated
Certain drugs require prior authorization (PA) before the plan will pay; if PA is not obtained coverage may be denied.
Follow LA/SP designations (limited access or specialty)
Some products include special requirement codes such as LA (Limited Availability) or SP (Specialty Drugs); these designations indicate additional utilization controls and may require special handling or authorization.
Adhere to stated quantity limits (QL)
Products annotated with explicit QL (Quantity Limit) must be dispensed within the listed limits; dispensing beyond the QL may not be covered.
Obtain PA / route through specialty for SP/LA antineoplastics
Antineoplastic and other specialty agents marked SP or LA are subject to special program handling and likely require prior authorization or specialty pharmacy routing before coverage.
Verify PA when not specified in formulary entry
This segment lists drug tiers and Requirements/Limits fields but does not specify explicit prior authorization rules for every Tier 2 product; verify plan-specific PA requirements when not shown.
Route SP/LA products through special programs
Products marked SP or LA (specialty or limited access) indicate they are managed under special programs or limited distribution and may require additional authorization or specialty pharmacy processing.
PA required for listed LA/SP agents (examples)
Examples of LA/SP agents (e.g., OFEV, ENTYVIO) are designated LA, SP in the formulary and therefore require prior authorization or enrollment in a special program prior to coverage.
- OFEV — Requirements/Limits = LA, SP
- ENTYVIO — Requirements/Limits = LA, SP
Specialty handling required for SP/LA items
Products with Requirements/Limits = SP or LA should be handled via specialty pharmacy or limited-access channels as indicated by the formulary.
Follow PA for DMTs flagged SP/LA
Disease-modifying therapies and other specialty drugs annotated with SP or LA (for example dimethyl fumarate, fingolimod, cladribine, siponimod, diroximel fumarate) are subject to special program controls and prior authorization.
- Tecfidera (dimethyl fumarate) — Requirements/Limits = SP/LA
- Gilenya (fingolimod) — Requirements/Limits = SP/LA
Expect PA for biologic / LA-SP agents
Biologic and specialty medications listed with Requirements/Limits = LA and/or SP (e.g., tocilizumab, apremilast, upadacitinib, tofacitinib) indicate prior authorization or specialty processing is likely required.
- ACTEMRA (tocilizumab iv) — Requirements/Limits = LA, SP
- RINVOQ (upadacitinib) — Requirements/Limits = LA, SP
Confirm coverage when PA not listed
Many formulary entries show Drug Tier and Requirements/Limits fields without explicit PA language; when prior authorization is not listed, confirm coverage by consulting plan resources or the member's Certificate of Coverage.
Treat 'SP' as specialty processing flag
Special processing indicator 'SP' appears adjacent to certain products (for example CIBINQO) and denotes specialty or special processing that may require specialty pharmacy workflows or authorization.
Follow step therapy where indicated
Some drugs are subject to step therapy (ST); the plan may require trying preferred agents first before covering alternatives.
No ST sequence specified in formulary excerpt
No explicit step therapy pathways or required trials are listed in this excerpt; do not assume a specific step sequence from these entries alone.
Verify ST requirements when not listed
This excerpt does not provide step therapy pathways for the listed products; verify any ST requirements via the plan's clinical prior authorization rules before prescribing.
Route SP/LA products through step/authorization workflows
Items marked SP or LA indicate they are subject to plan step/authorization processes and should be routed through the appropriate specialty or authorization channels.
Absence of ST in excerpt — confirm with plan
No step therapy sequences are listed in this excerpt; absence of ST notes does not mean step therapy is not required—confirm with plan authorization rules.
Check plan for explicit step-therapy rules
Step-therapy rules are not explicitly listed for many entries; individual SP/LA or tiering annotations may imply restrictions, but check plan-specific ST policies before treatment.
Follow plan step-edit protocols when applicable
Step therapy is not specified in this segment; follow plan protocols for any step edits that may apply.
Verify ST applicability for each drug
Step therapy requirements are not listed here; verify whether ST applies to the drug prior to prescribing or dispensing.
Consult Certificate of Coverage for plan details
Members should consult their Certificate of Coverage for plan-specific details on coverage, copays, and utilization requirements; the formulary alone does not guarantee payment.
Dispense within listed QL examples
Products annotated with QL must be dispensed within the listed quantity limits (examples include BIKTARVY QL 30 tablets/30 days and tafluprost PF QL 30 containers/30 days).
- BIKTARVY — QL (30 tablets/30 days)
- Tafluprost PF (Zioptan) — QL (30 containers/30 days)
Ensure claim quantities match formulary QLs
When submitting pharmacy claims, follow the product-specific QL shown on the formulary; claims exceeding listed QLs may be restricted or denied.
Include required product details on claims
Specify drug name, strength/form, and quantity on pharmacy claims consistent with the formulary entry and stated QL to avoid claim processing issues.
Observe Tier and Requirements/Limits on claims
Formulary entries include Drug Tier and Requirements/Limits fields; observe these fields when submitting pharmacy claims and when determining coverage pathways.
Document quantity and duration to match QLs/OTC notes
Document prescribed quantity and duration to align with QL or OTC designations where present; failure to do so may lead to denial or noncoverage.
Provide specialty documentation for SP/LA drugs
Many agents list Requirements/Limits = SP or LA (specialty or limited access), implying documentation or prior authorization through specialty pathways may be required.
Confirm coverage for OTC-designated products
OTC designations appear for some prenatal and vitamin products; OTC items may not be covered as prescriptions and should be confirmed against the Certificate of Coverage.
Adhere to ophthalmic/topical QLs on claims
Follow listed quantity limits for ophthalmic and topical products (for example tafluprost PF QL 30 containers/30 days; topical steroids with gram/ml QLs) when dispensing or submitting claims.
- Tafluprost PF (Zioptan) — QL (30 containers/30 days)
- Betamethasone dipropionate oint — QL (200 grams/28 days)
Denial risk: no PA leads to noncoverage
Failure to obtain prior authorization when required may result in the plan not covering the drug.
Denial risk: exceeding QLs
Claims exceeding listed quantity limits (QL) may be restricted or denied; examples include abacavir oral/solution limits and inhaler/blister limits per 30 days.
- Abacavir solution — QL (960 mls/30 days)
- Albuterol — QL (2 inhalers/30 days)
Denial risk: exceeding product-specific QLs
Claims may be denied if dispensing exceeds stated quantity limits such as QL (120 tablets/30 days) for certain products; check the specific QL for each drug.
Denial risk: estradiol QLs may limit coverage
Quantity limits are noted for certain estradiol products (for example Divigel and Climara), and exceeding those QLs may trigger coverage limitations or denial.
- Divigel — QL (30 packets/30 days or 37.5 grams/30 days)
- Climara — QL (4 patches/28 days)
Denial risk: unspecified triggers require verification
Some formulary entries list Drug Tier and 'Requirements/Limits =' placeholders without explicit denial triggers; absence of explicit denial language does not guarantee coverage—verify with the plan.
Quantity Limits & Example Codes
Selected Quantity Limits (Examples by Product)
Specialty Distribution & Infusion Requirements
Route antineoplastics to infusion center or specialty pharmacy
Some antineoplastic and specialty agents flagged SP/LA likely require specialty pharmacy distribution or administration in an infusion/site program rather than standard retail dispensing.
Infusion center routing for LA/SP IV biologics
IV biologics and infusion products listed with SP or LA designations are managed in the infusion/site program and should be routed accordingly.
Use specialty pharmacy for SP/LA medications
Agents marked SP or LA are likely to require specialty pharmacy handling or limited-access distribution channels; coordinate with specialty pharmacies for authorization and dispensing.
Formulary Terms & Abbreviations
Step Therapy — Presence and Notes
| Product / Example | Designation | Implication for Step Therapy / Access |
|---|---|---|
| TOBI PODHALER (tobramycin inhal cap 28 mg) | LA, SP | LA/SP flags indicate limited access or specialty program placement; access controlled per plan rather than explicit step edits in the listing |
| Deflazacort (Emflaza) formulations | LA, SP | LA/SP designation implies special access handling; follow plan-specific authorization or specialty processes instead of a stated step sequence |
| RINVOQ (upadacitinib) and oral solution | LA, SP | LA/SP indicates specialty or limited access — may require prior authorization or specialty routing; no explicit step therapy sequence provided |
| Step Sequence Name | Description / Drugs Included | Presence in Document |
|---|---|---|
| N/A — no step sequences provided | No explicit step therapy pathways or required trials are listed in the provided excerpt | No |
| Product / Class | LA or SP Flag | Plan Action (authorization / routing) |
|---|---|---|
| Bosentan (Tracleer) | SP | Marked SP — specialty program placement; follow plan prior authorization and specialty pharmacy processes |
| NUPLAZID (pimavanserin) | LA, SP | Designated LA/SP — limited access and specialty handling; plan-specified prior authorization/specialty workflows apply |
| OTEZLA (apremilast) | SP | SP indicates specialty processing; follow plan authorization requirements and specialty dispensing routes |
| Tier / Product group | Quantity Limits (example) | Step Therapy Sequence Present? |
|---|---|---|
| Respiratory inhalers (PULMICORT FLEXHALER, QVAR, TRELEGY) | Examples: PULMICORT 90 mcg = QL 1 inhaler/30 days; PULMICORT 180 mcg = QL 2 inhalers/30 days; TRELEGY = QL 1 inhaler/30 days | No — only tiers and QLs provided; no step therapy steps listed |
| Blister-pack inhalers (SEREVENT DISKUS) | QL 60 blisters/30 days | No |
| Designation | Meaning in Document | Example Entries |
|---|---|---|
| SP (Special Program / Specialty) | Indicates specialty program handling or special processing; may require specialty pharmacy or prior authorization | Examples: TOBI nebulized solutions = SP; BOSENTAN = SP |
| LA (Limited Access) | Indicates limited access — product access restricted and likely requires additional authorization or routing | Examples: TOBI PODHALER = LA, SP; NUPLAZID = LA, SP; RINVOQ = LA, SP |
| Therapeutic Area / Example Drugs | SP/LA Notation | Potential Effect (step edits / additional controls) |
|---|---|---|
| Immunomodulators / JAK inhibitors (apremilast, upadacitinib, tofacitinib) | OTEZLA = SP; RINVOQ = LA, SP; XELJANZ = SP | SP/LA designations indicate specialty processing and likely prior authorization or routing; may be subject to plan step edits though no sequences are listed in excerpt |
| Corticosteroids / Selected specialty agents (deflazacort) | LA, SP | LA/SP flags denote limited access or specialty program placement — follow plan authorization workflows |
Policy Context & Scope
This document is the EmblemHealth drug formulary listing covered medications by name, strength/form, assigned Drug Tier, and any stated Requirements/Limits (examples include QL, SP, LA, or OTC). The listing identifies drugs subject to utilization controls (e.g., quantity limits or specialty/limited‑access designations) and serves as reference for prescribing, dispensing, and benefit determination.
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