2026 Formulary (XCHG) — Drug List, Tiers, and Utilization Management
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This document is the EmblemHealth formulary listing covered drugs, tiers, and utilization management rules (e.g., prior authorization, step therapy, quantity limits) for members and providers in the plan. It applies to members using the XCHG formulary as of May 1, 2026.
No material clinical or coverage changes in this revision.
Formulary Coverage Criteria
Product-level coverage constraints
Coverage is product-specific and subject to the Requirements/Limits listed for each product.
No indication-specific clinical inclusion/exclusion criteria are provided in this formulary segment.
Formulary controls
Coverage and dispensing controls are indicated on each drug or vaccine line as shown in the Requirements/Limits field.
See individual line items for exact QL numeric values, LD/SP channel requirements, and AC vaccine administrative flags.
Coverage stance
Products listed are subject to the Requirements/Limits specified on each line (examples include PA, LD, QL, SP).
This formulary segment does not provide indication-specific medical necessity rules; those are implemented through the plan's PA or clinical review processes referenced by the flags.
Administrative coverage controls
Coverage and administrative controls are indicated per drug entry using these required flags when present.
Entries in the document are primarily administrative; clinical PA criteria (if required) are managed via the plan's prior authorization process.
Formulary administrative criteria
Coverage and administrative controls for listed outpatient cardiovascular drugs are shown per-line with required flags where applicable.
Clinical indications and diagnosis-level medical necessity criteria are not included in this formulary excerpt; follow the listed administrative flags and the plan's PA process for clinical review.
Formulary coverage conditional on utilization controls
Coverage is conditional on satisfying the utilization controls shown for each product.
Exact clinical PA criteria are managed through the payer's authorization process and are not enumerated in this formulary listing.
Please see the member’s Certificate of Coverage for plan-specific details. Not all drugs in this formulary are paid for by all drug benefit plans; coverage depends on the member’s specific benefits and certificate. Check the member ID card or contact member services for eligibility, coverage, and cost-share questions.
This section does not include explicit exclusion statements. Instead, each line-item shows administrative controls (for example: PA = prior authorization, LD = limited distribution, QL = quantity limit, SP = specialty pharmacy) that must be met for coverage as noted next to the product.
The content here is a formulary list of vaccines and related products showing tier assignments and Requirements/Limits flags (for example, many vaccines are marked AC for administrative coverage). No explicit exclusion statements are provided in these lines.
This formulary segment lists product-level utilization controls (e.g., PA, QL, LD, SP) for each drug line. The document does not present separate clinical exclusion criteria; failure to meet a listed administrative requirement or exceeding a stated QL may result in non‑coverage per plan rules.
The entries in these chunks identify Requirements/Limits such as PA and numeric QL values for listed products but do not designate any items as explicitly "Not Medically Necessary." Coverage determinations therefore follow the administrative flags shown per line item.
No clinical exclusion criteria are specified in this section. Coverage for each listed product is governed by the administrative Requirements/Limits shown (for example, PA, QL, LD, SP), and providers must satisfy those conditions for the plan to consider payment.
This excerpt does not list clinical exclusions. Some formulations do not show Requirements/Limits, which implies standard coverage rules apply; otherwise coverage is conditional on meeting any flags shown (e.g., PA, QL, SP).
There are no explicit exclusion conditions or items labeled 'Not Medically Necessary' in this excerpt. The listing provides formulary attributes (tier and Requirements/Limits) that govern administrative coverage decisions.
This excerpt does not identify any products as 'Not Medically Necessary.' Instead, it includes Requirements/Limits flags (for example, PA and numeric QL values) that determine administrative coverage and may lead to denial if unmet.
No explicit 'Not Medically Necessary' statements are present in these lines. Coverage depends on compliance with the listed administrative controls (e.g., prior authorization or quantity limits) in each product entry.
This section does not include specific 'Not Medically Necessary' determinations. Where Requirements/Limits are present (such as PA, QL, or SP), those administrative conditions control coverage decisions.
Formulary Listings and Code Tables
| amoxicillin (trihydrate) chew tab 125 mg, 250 mg | Drug Tier = 3 |
| amoxicillin (trihydrate) cap 250 mg, 500 mg | Drug Tier = 1 |
| amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml | Drug Tier = 1 |
| amoxicillin (trihydrate) tab 500 mg, 875 mg | Drug Tier = 1 |
| amoxicillin & k clavulanate for susp various strengths; Augmentin es-600 | Multiple formulations; Drug Tier = 1 (some formulations Tier = 3) |
| penicillin v potassium for soln 125 mg/5ml, 250 mg/5ml; tab 250 mg, 500 mg | Mix of Tier 3 (solution) and Tier 1 (tabs) |
| cefadroxil, cefdinir, cefixime, cefpodoxime, cefprozil, cefuroxime, cephalexin | Various cephalosporins with mixed tiers and requirements |
| azithromycin (susp and tabs), clarithromycin, fidaxomicin (Dificid), erythromycin | Macrolides and related agents with mixed tiers |
| doxycycline, minocycline, omadacycline (NUZYRA - LD), tetracycline | Tetracyclines with some limited distribution |
| delafloxacin (BAXDELA), ciprofloxacin (CIPRO), levofloxacin, moxifloxacin, ofloxacin | Fluoroquinolones with mixed tiers |
| NUZYRA | omadacycline tosylate tab 150 mg — Drug Tier = 3; Requirements/Limits = LD |
| doxycycline hyclate | caps/tabs 20-150 mg — Drug Tier = 1 |
| minocycline hcl | cap 50/75/100 mg — Drug Tier = 1 |
| BAXDELA | delafloxacin meglumine tab 450 mg — Drug Tier = 3 |
| CIPRO | ciprofloxacin for oral susp/tabs — Drug Tier = 3 (susp), 1 (tabs) |
| levofloxacin | oral soln 25 mg/ml; tab 250/500/750 mg — Drug Tier = 1 |
| ARIKAYCE | amikacin sulfate liposome inhal susp 590 mg/8.4ml — Drug Tier = 3; Requirements/Limits = LD, PA, QL (28 vials/28 days), SP |
| TOBI PODHALER | tobramycin inhal cap 28 mg — Drug Tier = 3; Requirements/Limits = LD, SP |
| TOBRAMYCIN (nebulized) | nebulized solution 300 mg/5ml — Drug Tier = 3; Requirements/Limits = SP |
| SIRTURO | bedaquiline fumarate tab 20 mg, 100 mg — Drug Tier = 2; Requirements/Limits = LD, SP |
| CRESEMBA | isavuconazonium sulfate cap 74.5 mg, 186 mg — Drug Tier = 3; Requirements/Limits = PA |
| itraconazole (Sporanox) | cap/solution — Drug Tier = 1; Requirements/Limits = QL (120 capsules/30 days) and PA for solution with QL (1200 mls/30 days) |
| APRETUDE | cabotegravir im extended release susp 600 mg/3ml — Drug Tier = 2; Requirements/Limits = AC, LD, SP |
| BIKTARVY | bictegravir-emtricitabine-tenofovir af tabs — Drug Tier = 2; Requirements/Limits = QL (30 tablets/30 days) |
| EPCLUSA | sofosbuvir-velpatasvir tab/pellet — Drug Tier = 2; Requirements/Limits = PA, QL (28/day), SP |
| HARVONI | ledipasvir-sofosbuvir tab/pellet — Drug Tier = 2; Requirements/Limits = PA, QL (28/28 days), SP |
| MAVYRET | glecaprevir-pibrentasvir tab/pellet — Drug Tier = 2; Requirements/Limits = PA, QL (84/28 days or 140/28 days), SP |
| PAXLOVID | nirmatrelvir + ritonavir pak — Drug Tier = 2; Requirements/Limits = QL (various pack sizes/30 days) |
| SOVALDI / SOFOSBUVIR | sofosbuvir tab/pellet — Drug Tier = 2; Requirements/Limits = PA, QL (28/28 days), SP |
| SUNLENCA | lenacapavir sodium tab therapy pack — Drug Tier = 3; Requirements/Limits = LD, QL (4-5 tablets/365 days), SP |
| VIREAD / tenofovir disoproxil fumarate | tabs 150-300 mg — Drug Tier = 1-2 (varies); Requirements/Limits = QL (30 tablets/30 days) |
| STRIBILD | elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg |
| SUNLENCA | lenacapavir sodium tab/therapy pack 300 mg |
| SYMTUZA | darunavir-cobic-emtricitab-tenofov af tab 800-150-200-10 mg |
| TIVICAY | dolutegravir sodium tab 50 mg |
| TRIUMEQ | abacavir-dolutegravir-lamivudine tab 600-50-300 mg |
| VIREAD | tenofovir disoproxil fumarate tab/powder (various strengths) |
| VOSEVI | sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg |
| XOFLUZA | baloxavir marboxil therapy pack |
| YEZTUGO / YEZTUGO (prophylaxis) | lenacapavir sodium subcut/tab (prophylaxis) |
| zidovudine (Retrovir) | zidovudine formulations (cap, syrup, tab) |
| VAXNEUVANCE | pneumococcal 15-valent conjugate vaccine suspension pref syr 0.5 ml |
| VARIVAX | varicella virus vaccine live for injection 1350 pfu/0.5 ml |
| VIVOTIF | typhoid vaccine cap delayed release |
| YF-VAX | yellow fever vaccine for subcutaneous suspension |
| ADACEL | tetanus-diphtheria-acellular pertussis vaccine injection 0.5 ml |
| BOOSTRIX | tetanus-diphtheria-acellular pertussis vaccine pref syringe 0.5 ml |
| BEYFORTUS | nirsevimab-alip IM solution prefilled syringe 50 mg/0.5 ml, 100 mg/ml — Requirements/Limits = AC, SP |
| ENFLONSIA | clesrovimab-cfor IM solution prefilled syringe 105 mg/0.7 ml — Requirements/Limits = AC, SP |
| PALFORZIA | peanut allergen powder-dnfp (multiple level packs listed) — Requirements/Limits = LD, SP |
| abiraterone acetate 250 mg | Zytiga — Requirements/Limits = PA, QL (120 tablets/30 days), SP |
| abiraterone acetate 500 mg | Zytiga — Requirements/Limits = PA, QL (60 tablets/30 days), SP |
| ALECENSA | alectinib HCl cap 150 mg — Requirements/Limits = LD, PA, QL (240 capsules/30 days), SP |
| ALUNBRIG | brigatinib tab (initiation pack and strengths) — Requirements/Limits = LD, PA, QL (varies), SP |
| BOSULIF | bosutinib — Requirements/Limits = LD, PA, QL (various), SP |
| BRUKINSA | zanubrutinib — Requirements/Limits = LD, PA, QL (various), SP |
| CABOMETYX | cabozantinib s-malate — Requirements/Limits = LD, PA, QL (30 tablets/30 days), SP |
| CPLEX_ANTINEOPLASTICS | Multiple antineoplastic agents listed (e.g., palbociclib, imatinib, dasatinib, everolimus, etc.) |
| No codes listed |
| VORANIGO - vorasidenib tab 40 mg | Drug Tier = 2; Requirements/Limits = LD, PA, QL (30 tablets/30 days), SP |
| WELIREG - belzutifan tab 40 mg | Drug Tier = 3; Requirements/Limits = LD, PA, QL (90 tablets/30 days), SP |
| XALKORI - crizotinib cap 200 mg, 250 mg | Drug Tier = 2; Requirements/Limits = LD, PA, QL (120 capsules/30 days), SP |
| XOSPATA - gilteritinib fumarate tablet 40 mg | Drug Tier = 3; Requirements/Limits = LD, PA, QL (90 tablets/30 days), SP |
| XPOVIO - selinexor tab therapy pack | Drug Tier = 3; Requirements/Limits = LD, PA, QL (various), SP |
| XTANDI - enzalutamide | caps/tab 40 mg, 80 mg — Drug Tier = varies; Requirements/Limits = LD, PA, QL (varies) |
| YONSA - abiraterone acetate micronized tab 125 mg | Drug Tier = listed with tier and requirements |
| ZEJULA - niraparib tosylate tab 100/200/300 mg | Drug Tier = listed with requirements and QL |
| ZELBORAF - vemurafenib tab 240 mg | Drug Tier = listed with requirements |
| ZOLINZA - vorinostat cap 100 mg | Drug Tier = listed with requirements |
| TYBLUME | levonorgestrel & ethinyl estradiol chew tab 0.1 mg-20 mcg — Drug Tier = 3 |
| VELIVET | desogestrel-ethinyl estradiol tab (various strengths) — Drug Tier = 3 |
| YAZ | drospirenone-ethinyl estradiol tab 3-0.02 mg — Drug Tier = 3 |
| BAQSIMI ONE PACK | glucagon nasal powder 3 mg/dose — Drug Tier = 2 |
| FARXIGA | dapagliflozin propanediol tab 5 mg, 10 mg — Drug Tier = 2; Requirements/Limits = QL (30 tablets/30 days) |
| MOUNJARO | tirzepatide soln auto-injector — Drug Tier = 2; Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on strength) |
| OZEMPIC | semaglutide soln pen-inj — Drug Tier = 2; Requirements/Limits = PA, QL (1 pen/28 days or 3 pens/28 days depending on strength) |
| JANUMET / JANUMET XR | sitagliptin-metformin combos — Drug Tier = 2; Requirements/Limits = QL (60 tablets/30 days for JANUMET) |
| TRULICITY | dulaglutide soln auto-injector — Drug Tier = 2; Requirements/Limits = PA, QL (4 pens/28 days) |
| RYBELSUS | semaglutide oral tablets — Drug Tier = 2; Requirements/Limits = PA, QL (30 tablets/180 days or 30/30 depending on strength) |
| No codes listed |
| NEXLETOL - bempedoic acid 180 mg | Requirements/Limits = PA, QL (30 tablets/30 days) |
| NEXLIZET - bempedoic acid-ezetimibe 180-10 mg | Requirements/Limits = PA, QL (30 tablets/30 days) |
| REPATHA - evolocumab 140 mg/mL | Requirements/Limits = QL (6 syringes/28 days) |
| VASCEPA - icosapent ethyl 0.5 g and 1 g | Requirements/Limits = PA, QL (240 capsules/30 days for 0.5 g; 120 capsules/30 days for 1 g) |
| ENTRESTO - sacubitril-valsartan | Requirements/Limits = PA, QL (240 capsules/30 days) for sprinkle; standard tabs listed separately |
| CAMZYOS - mavacamten | Requirements/Limits = LD, PA, QL (30 capsules/30 days), SP |
| TYVASO - treprostinil inhalation solution | Requirements/Limits = LD, PA, QL (7 packages/28 days) |
| UPTRAVI - selexipag | Requirements/Limits = LD, PA, QL (60 tablets/30 days), SP |
| VYNDAMAX - tafamidis 61 mg | Requirements/Limits = PA, QL (30 capsules/30 days), SP |
| WINREVAIR - sotatercept-csrk | Requirements/Limits = LD, PA, QL (1 kit/21 days), SP |
| No codes listed |
| No codes listed |
| No codes listed |
Actions Providers Must Take
Obtain Prior Authorization for Drugs Marked 'PA'
Some listed drugs require prior authorization (PA) before the plan will pay; entries with 'PA' in the Requirements/Limits field indicate this requirement and must have approval obtained prior to dispensing.
Obtain PA and Respect QL/LD/SP Flags
When a product's Requirements/Limits includes PA, QL, LD, or SP, providers must obtain prior authorization where shown, and ensure the dispensed quantity and distribution channel comply with the listed quantity limits (QL) and limited/specialty distribution (LD/SP).
- Adhere to QL numeric limits shown (e.g., tablets/pens per days/period).
- Use designated specialty or limited distribution channels when LD or SP is flagged.
Obtain PA When Indicated for Specific Products
Providers must obtain prior authorization for products listed with 'PA' in the Requirements/Limits field (examples in the formulary include STRIBILD, VOSEVI, and linezolid suspension); do not dispense without the required authorization.
- STRIBILD: Requirements/Limits include PA / QL as noted.
- VOSEVI: Requirements/Limits = PA, QL (28 tablets/28 days).
- Linezolid suspension: listed with Requirements/Limits entries indicating PA where shown.
Secure PA for Specialty and Oncology Agents
Many specialty and oncology agents are flagged with PA (and often LD and SP); providers must secure prior authorization per the Requirements/Limits before the plan will cover these specialty agents.
- Examples include multiple antineoplastics and specialty biologics listed with LD/PA/QL/SP flags.
- Follow specialty program/site-of-care requirements for SP-designated drugs.
PA Required — Observe LD and QL Conditions
Prior authorization is required for many listed specialty and branded agents; some entries also specify loading dose (LD) or quantity limits (QL) that must be met — obtain PA and document LD/QL compliance before dispensing.
- Confirm and document any LD (loading dose) requirements prior to initial dispensing.
- Ensure requested quantity does not exceed stated QL (e.g., pack or per‑period limits).
Obtain PA When 'PA' Is Shown
If 'PA' appears in a product's Requirements/Limits field, providers must obtain prior authorization before the plan will cover the medication; PA is commonly required for higher‑tier and specialty drugs.
PA Required for GLP‑1 and Related Agents
Certain GLP‑1 and related agents (e.g., MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) and other specialty products are listed with PA; providers must submit prior authorization requests for these products as indicated.
- MOUNJARO: Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on strength).
- OZEMPIC: Requirements/Limits = PA, QL (1 pen/28 days).
- TRULICITY: Requirements/Limits = PA, QL (4 pens/28 days).
PA Required for LD/PA‑Flagged Products
Products marked 'PA' or 'LD, PA' (for example, ACTHAR, GENOTROPIN, CRENESSITY) require prior authorization; providers must follow the plan's PA process for these limited‑distribution or specialty items.
- ACTHAR: Requirements/Limits = LD, PA, SP.
- GENOTROPIN: Requirements/Limits = PA, SP.
- CRENESSITY: Requirements/Limits include PA and QL as specified.
PA Required for Selected Formulations (e.g., Liquid/Specialty)
Certain liquid formulations and specialty products explicitly list 'PA' (examples include propranolol oral solutions, nimodipine oral solutions, and specialty lipid or cardiac agents); obtain prior authorization and document the request.
- Propranolol oral solutions: Requirements/Limits = PA, QL (2400 mls/30 days and 4800 mls/30 days).
- NEXLETOL/NEXLIZET and VASCEPA: Requirements/Limits = PA and QL as noted.
PA Required for Many Formulary Agents
Numerous products across the formulary require prior authorization (PA) as indicated next to each drug; providers must use the plan's PA process before submitting claims for these drugs.
Obtain PA for Listed Products in This Segment
Prior authorization is required for products listed with PA in the Requirements/Limits field (examples in this segment include SYMPROIC, TREMFYA, TRULANCE, VOWST, ZYMFENTRA); obtain PA before dispensing.
- TREMFYA: Requirements/Limits = PA, QL (1 syringe/28 days), SP.
- VOWST: Requirements/Limits = LD, PA, QL (12 capsules/365 days), SP.
PA Required for Specialty/Restricted Drugs
Specialty or restricted drugs annotated with PA, LD, or SP (for example SUNOSI, WAKIX, AUSTEDO, AVONEX, BETASERON) require prior authorization; providers must secure PA and follow any limited distribution instructions before claim submission.
- SUNOSI: Requirements/Limits = PA, QL (30 tablets/30 days).
- WAKIX: Requirements/Limits = LD, PA, QL (60 tablets/30 days).
PA Required for Specialty/Branded Agents
Many specialty and branded agents in the formulary require prior authorization as indicated in the Requirements/Limits column; obtain PA and confirm any additional handling (LD/SP) before dispensing.
PA Required for Numerous Formulary Drugs
Many formulary drugs (notably specialty biologics, ER opioids, targeted therapies, and migraine/preventive agents) are flagged with PA; providers must obtain prior authorization for these products as listed.
Follow Step Therapy (ST) Before Coverage
Step therapy (ST) requires trying specified first‑line drugs before other agents will be covered; members or providers may request an exception if the preferred agent is not appropriate.
- If a drug is marked 'ST' in Requirements/Limits, ensure any required prior trial(s) of first‑line agents are documented or request an exception.
No Detailed Step Sequences Provided Here
No explicit step‑therapy sequences are provided in this formulary excerpt; where 'ST' is not specified, the document does not list step‑by‑step required trials.
Follow Specialty Program (SP) Requirements
Some products include 'SP' (special program) indicators that denote specialty program or site‑specific management; follow the payer's specialty program requirements where SP is flagged.
- BEYFORTUS, ENFLONSIA, PALFORZIA levels are shown with AC/LD/SP or LD/SP flags indicating specialty program handling.
Follow 'AC' Access Criteria for Contraceptives and Similar Items
Contraceptives and select drug groups may show 'AC' or other access flags indicating plan-specific access criteria; providers should follow payer access/coverage pathways when AC appears.
- Examples include ANNOVERA and other contraceptive listings with Requirements/Limits = AC.
Adhere to Step Therapy Flags ('ST') Where Shown
Some products are explicitly marked 'ST' (step therapy) in the Requirements/Limits field (examples include KERENDIA and others); providers must document required prior therapies or obtain an exception.
- KERENDIA: listed with 'ST' indicating step therapy may be required prior to coverage.
Document Prior Trials for 'ST'‑Flagged Agents
Some agents are subject to step therapy as noted by 'ST' in Requirements/Limits (examples in the formulary include VELPHORO, FETZIMA, FLUOXETINE DR, TRINTELLIX); ensure prior‑trial requirements are met before coverage.
- VELPHORO: Requirements/Limits include ST.
- FETZIMA and TRINTELLIX: Requirements/Limits include QL and ST where specified.
Comply with Step Edits for ST‑Flagged Drugs
Step edits apply to several products marked 'ST' (examples include FANAPT packs, SECUADO patch, DAYVIGO, BELSOMRA); follow the step therapy requirements noted for each product listing.
Check Step Therapy for Select Agents (NSAIDs/Analgesics)
Select agents (e.g., certain NSAIDs/analgesics and others) include 'ST' flags indicating step therapy applies; verify required prior therapies before prescribing higher‑tier alternatives.
- Ketoprofen ER and meclofenamate sodium are examples of agents noted with 'ST'.
Contact Member Services for Coverage Questions
For coverage or questions about drugs not listed or to resolve PA/QL/LD/SP requirements, providers or members may contact EmblemHealth Member Services at 877-793-6253 (TTY 711).
Observe Quantity Limits (QL) When Submitting Claims
Quantity limits (QL) shown next to many products indicate the maximum covered amount per time period; when submitting claims or PA requests, ensure the requested quantity and days supply comply with the listed QL.
- Examples: FARXIGA QL 30 tablets/30 days; OZEMPIC QL 1 pen/28 days; REPATHA QL 6 syringes/28 days.
Document Dispensing Channel for LD/QL Items
Medications marked with 'LD' (limited distribution) or 'LD, PA' may require documentation of the dispensing channel or enrollment in a specialty pharmacy program; providers must document where and how the product will be obtained.
- Document specialty pharmacy enrollment or designated dispensing site when LD/SP is indicated.
Include Clinical Documentation with PA Requests
Providers must submit documentation supporting prior authorization requests and must demonstrate dosing consistent with listed quantity limits and any loading dose (LD) specifications when applicable.
- Include diagnosis, clinical rationale, requested quantity, and days supply when submitting PA requests.
- Provide evidence of prior therapy where step therapy (ST) is required or an exception rationale if applicable.
Provide Medical Necessity Documentation for PA/QL/LD/SP
Prescribers must supply documentation of medical necessity and any required supporting information when a product is marked 'PA', 'QL', 'LD', or 'SP' to satisfy the plan's utilization management requirements.
- Use product‑specific prior authorization forms when available and include indication, prior treatments, and dosing schedule.
Attach Supporting Documentation for PA/QL Requests
When a product is flagged 'PA', 'QL', or 'LD', prescribers must provide documentation supporting the prior authorization and the requested quantity/days supply; lack of such documentation may lead to denial.
- For products like NEXLETOL/NEXLIZET/VASCEPA, include diagnosis and requested quantity consistent with QL.
Adhere to Administrative Controls to Avoid Denials
Use the formulary flags (PA, LD, SP, ST, QL) shown for each product as administrative controls; failure to meet these controls (e.g., missing PA, not using specialty channel, or exceeding QL) may result in claim denial.
- Verify PA approval and specialty pharmacy dispensing before submitting claims for SP/LD products.
- Confirm requested quantity is within the listed QL to avoid denial.
Quantity Limits and Examples
Dispensing Channel and Site-of-Care Notes
Biosimilars and Related Notes
Abbreviations and Definitions
Step Therapy Rules and Notes
| Step therapy summary | Supporting detail / guidance |
|---|---|
| Step therapy (ST) may require trial of specified first-line drugs before coverage of an alternative agent. | |
| Per formulary definition: members may be required to try certain drugs first; exceptions can be requested and the member/ provider may discuss alternatives. |
| Step therapy summary | Supporting detail / guidance |
|---|---|
| No explicit step-therapy sequences are provided in this excerpt. | |
| Product lines in this segment list Requirements/Limits entries (PA, QL, LD, SP) but do not define step sequences for specific agents. |
| Step therapy summary | Supporting detail / guidance |
|---|---|
| No explicit step therapy sequences are listed in these chunks; explicit step controls are not present here. | |
| Listings show utilization flags (e.g., PA, QL, LD, SP) and QL values for products but do not provide ordered step requirements. |
| Step-related flag | Implication for coverage / distribution |
|---|---|
| LD (Limited Distribution) | |
| Indicates limited distribution channel; product may be required to be dispensed via designated specialty pharmacy or restricted channel. (Examples: PALFORZIA, SUNLENCA list LD and SP). |
| Loading dose (LD) notes | Implication / coverage note |
|---|---|
| Some medications indicate LD (loading dose) prior to regular fills. | |
| Formulary entries show LD for select products (e.g., SUNLENCA therapy packs; metoprolol entries include LD/PA/QL flags), but explicit multi-step sequences are not provided in this excerpt. |
| Prior authorization (PA) presence | Examples / affected agents |
|---|---|
| PA required prior to coverage for specified agents. | |
| Several GLP‑1 and related products are listed with PA (examples in this segment include MOUNJARO, OZEMPIC, TRULICITY showing PA and QL). |
| ST flag present | Example |
|---|---|
| 'ST' annotation indicates step therapy may be required before coverage. | |
| KERENDIA is listed with 'ST' in the Requirements/Limits — indicating step therapy requirements apply per product listing. |
| SP / ST flags | Implication |
|---|---|
| Products annotated with SP or ST may have step or specialty program requirements prior to coverage. | |
| Examples: PALFORZIA and SUNLENCA include LD and SP; other entries show ST alongside QL (see various product lines). |
| High-cost/specialty flags | Coverage implication |
|---|---|
| Several specialty and high‑cost agents are flagged LD, PA, or SP suggesting step, limited distribution, or additional administrative processes before coverage. | |
| Formulary examples include oncology and specialty agents with LD/PA/SP and explicit QLs (e.g., LONSURF, LORBRENA, ALUNBRIG, ALYFTREK, and many others require LD/PA/QL/SP). |
| Products with 'ST' notes | Examples from formulary |
|---|---|
| Certain products require step therapy prior to coverage as indicated by 'ST' in Requirements/Limits. | |
| Examples from the listing: VELPHORO includes 'ST'; FETZIMA, FLUOXETINE DR, TRINTELLIX, and other listed agents show 'ST' alongside QL in their Requirements/Limits entries. |
| ST annotation meaning | Formulary statement / examples |
|---|---|
| Entries annotated 'ST' indicate step therapy is required before coverage of the listed product. | |
| Multiple psychotropic, GI and other products are marked ST in the formulary (e.g., FANAPT titration packs, BELSOMRA, DAYVIGO, and others have ST flags noted). |
| LD and PA combined | Implication |
|---|---|
| Some agents list LD and PA together, implying limited distribution and prior authorization are required before coverage. | |
| Examples include LUMRYZ and MAYZENT starter/maintenance packs where LD and PA (and QL) are shown for coverage control; explicit step sequences are not provided in the excerpt. |
| ST noted for select NSAIDs/analgesics | Examples |
|---|---|
| ST indicated for some NSAID/analgesic products, requiring prior trial of preferred agents. | |
| Formulary examples: KETOPROFEN ER and MECLOFENAMATE SODIUM are listed with 'ST' in their Requirements/Limits entries. |
Policy Background
The formulary is an administrative listing of covered drugs with per-line utilization controls rather than clinical exclusion rules. Providers should follow the Requirements/Limits shown (for example, obtain PA when indicated or adhere to the stated QL) to support coverage.
Policy Revision History
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.