CurrentEmblemHealthPolicy N/A

HMO Preferred Plan Full Rx 2-Tier Formulary (Gold Rx Grandfathered Plan) - 2026 Formulary

This document is the 2026 formulary (list of covered outpatient prescription drugs) for EmblemHealth HMO Preferred Plan Full Rx 2-Tier (Gold Rx Grandfathered) and explains drug coverage, tiers, utilization management, and member resources for plan members and prescribers.

Policy Summary

PayerEmblemHealth

PolicyHMO Preferred Plan Full Rx 2-Tier Formulary (Gold Rx Grandfathered Plan) - coverage criteria / formulary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr. 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization (PA) when a listed drug is marked 'PA' before dispensing to ensure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-04-01formulary effective/updated date

Home deliverymail-order/home delivery option

PA, QL, ST, SP, LAutilization management abbreviations listed

833-269-4653member services phone

multipleantineoplastic & specialty agents

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 & Conditions

General coverage conditions

Covered when ALL of the following are met:

Formulary coverage conditions: Drug must be on the plan formulary and be prescribed consistent with the member's benefit coverage as defined in the Certificate of Coverage.

A medicine listed does not guarantee payment; check member-specific benefits and copays.

Utilization management compliance: All applicable utilization management requirements listed for the product (for example PA, QL, ST, LA, SP) must be satisfied before coverage is approved.

Abbreviations: PA = prior authorization; QL = quantity limit; ST = step therapy; SP = specialty; LA = limited availability.

Coverage conditioned on utilization controls

Covered when ALL of the following administrative requirements are met:

Product on-formulary and tiered: Product is listed on the plan formulary and the claim is submitted under the covered tier shown.

Formulary tiers: Tier 1 = Generic; Tier 2 = Preferred brand.

Prior authorization (PA) when required: If the product line lists PA or the Requirements/Limits column indicates PA, a prior authorization must be obtained and approved before the plan will pay.

Examples of products with PA flags include SKYCLARYS, EVRYSDI, DOPTELET, and many specialty agents; coverage may be denied without PA.

Quantity limits (QL) compliance: Dispensing must not exceed the specified quantity limits (QL) for the listed period; requests exceeding QL require supporting documentation and prior approval.

Examples: EVRYSDI QL 30 tabs/30 days or 240 mL/30 days; ELIQUIS QL values (60–74 per 30 days); many specialty agents have specified QLs.

Specialty and site-of-care requirements (SP/LA): If the product is designated SP (specialty) or LA (limited access), dispense via the specialty channel or required site of care and follow program terms.

Hemophilia and coagulation factor products (e.g., ADVATE, ADYNOVATE, AFSTYLA) and other injectables commonly require SP/LA handling and PA.

This formulary is a plan-specific Prescription Drug List and does not guarantee coverage for every drug shown. Not all drugs in this list are paid for by all drug benefit plans; coverage depends on the member's particular plan, benefit design, and any utilization controls that apply. Members and providers should consult the member’s Certificate of Coverage or the member portal for exact benefit, copay, and coverage details, or call the phone number on the back of the member ID card.

Within the provided segments there are no product-level exclusion statements. The listing enumerates products, tiers, and Requirements/Limits markers (e.g., ACA, OTC) but does not present explicit exclusions in these chunks.

No explicit statements declaring any product or use as "not medically necessary" appear in the cited portions. The document portion supplied lists products, tiers, and utilization controls (PA, QL, LA, SP) but does not include NMN (not medically necessary) determinations in these chunks.

Formulary Listings, Codes & Tiers

Formulary drug listings (partial)mixedCovered

amoxicillin 125 mg chew tab	amoxicillin (trihydrate) chew tab 125 mg
amoxicillin 250 mg chew tab	amoxicillin (trihydrate) chew tab 250 mg
amoxicillin cap 250 mg	amoxicillin (trihydrate) cap 250 mg
amoxicillin cap 500 mg	amoxicillin (trihydrate) cap 500 mg
amoxicillin susp 125 mg/5ml	amoxicillin (trihydrate) for susp 125 mg/5ml
amoxicillin susp 200 mg/5ml	amoxicillin (trihydrate) for susp 200 mg/5ml
amoxicillin susp 250 mg/5ml	amoxicillin (trihydrate) for susp 250 mg/5ml
amoxicillin susp 400 mg/5ml	amoxicillin (trihydrate) for susp 400 mg/5ml
amoxicillin tab 500 mg	amoxicillin (trihydrate) tab 500 mg
amoxicillin tab 875 mg	amoxicillin (trihydrate) tab 875 mg

1–10 of 85

1/9

Quantity Limit Examplesmixed

QL (30 capsules/30 days)	Quantity limit example listed for ENSACOVE 25 mg
QL (60 capsules/30 days)	Quantity limit example listed for ENSACOVE 100 mg
QL (300 mls/30 days)	Quantity limit example listed for VITRAKVI oral solution
QL (420 capsules/30 days)	Quantity limit example listed for KOSELUGO 5 mg
QL (240 capsules/30 days)	Quantity limit example listed for KOSELUGO 7.5 mg

Requirements/Limits codesmixed

PA	Prior Authorization
SP	Specialty
LA	Limited Access / site-of-care designation
ACA	Affordable Care Act related requirement

NDC/CPT/HCPCS not listedmixed

No codes listed

Selected products with utilization controlsmixed

SOHONOS cap 1 mg,1.5 mg,2.5 mg,5 mg,10 mg	palovarotene (SOHONOS) — multiple capsule strengths listed with PA and QL per strength
SKYCLARYS cap 50 mg	omaveloxolone 50 mg — PA, QL (90 capsules/30 days)
FIRDAPSE tab 10 mg	amifampridine phosphate 10 mg — LA, PA, QL (300 tablets/30 days), SP

Anticoagulants with quantity limitsmixed

ELIQUIS tab 2.5 mg, 5 mg; cap sprinkle 0.15 mg	apixaban — QL entries present (e.g., 60 or 74 per 30 days depending on formulation)
PRADAXA cap/pellet 75/110/150 mg; pellet packs 20/30/40/50 mg	dabigatran — QL limits specified
XARELTO tab 2.5 mg, 10 mg, 15 mg, 20 mg; susp 1 mg/ml	rivaroxaban — QL limits specified

Hemophilia factor productsmixedCovered

ADVATE inj 250–4000 unit	antihemophilic factor recombinant (rahf-pfm) — PA, SP
ADYNOVATE inj 250–3000 unit	antihemophilic factor recombinant pegylated — PA, SP
AFSTYLA inj kit 250–3000 unit	antihemophilic factor single chain — PA, SP

Formulary tiers — definitions

Tier 1Generic

Tier 2Preferred brand

ENSACOVE quantity limits

ENSACOVE 25 mgQL: 30 capsules per 30 days

ENSACOVE 100 mgQL: 60 capsules per 30 days

Quantity limit examples — selected oral solutions and suspensions

Prior Authorization, Step Therapy & Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization (PA) is required for many drugs listed in this formulary. PA means the plan requires you or your prescriber to obtain approval before the prescription is filled; without approved PA the plan may deny payment.

PA = Prior Authorization — approval required before filling
Coverage may be denied if PA is not obtained

Prior Authorization

Products Requiring Prior Authorization

Specific products across the formulary are annotated with PA in the Requirements/Limits column. Examples include SOVALDI, VOSEVI, ENSACOVE, VITRAKVI, KOSELUGO, ORIAHNN, and many specialty and hematology agents (ADVATE, ADYNOVATE, AFSTYLA, PROCYSBI, BYLVAY, OMVOH, etc.). When PA is listed for a product, prescribers must request and receive approval before the drug will be covered.

Examples of PA-marked products: SOVALDI, VOSEVI, ENSACOVE, VITRAKVI, KOSELUGO, ORIAHNN
Hemophilia and coagulation factors: ADVATE, ADYNOVATE, AFSTYLA, BENEFIX, ELOCTATE — PA and specialty pharmacy handling noted

Step Therapy Rules & Flags

Coverage label	Summary
ST
Step Therapy (ST) may require trial of specified drugs first before the plan will cover an alternative; failure of the initial preferred agent must be documented to access subsequent therapy.

Coverage label	Summary
Not specified
No explicit step-therapy sequences or required step agents are listed for the products in these sections of the formulary extract.

Coverage label	Summary
Not specified
PALFORZIA entries list multiple level packs and maintenance/titration packets (LA, SP) but do not provide explicit step-therapy failure criteria or step sequences in the listed chunks.

Coverage label	Summary
ST
KERENDIA (finerenone) is annotated with 'ST', indicating step therapy rules apply and that step criteria must be met before coverage.

Coverage label	Summary
Implied ST
High‑cost or specialty cardiovascular agents flagged with LA, PA, QL, or SP imply additional utilization management and may be subject to step edits per the plan's prior authorization process, though explicit step sequences are not listed here.

Coverage label	Summary
Implied ST
Specialty and high‑cost agents that carry 'PA' and 'LA' flags are subject to prior authorization and may include step edits as part of utilization management; providers should follow PA/step processes when indicated.

Coverage label	Summary
ST
Several products are explicitly noted with 'ST' (examples include FETZIMA, FLUOXETINE DR, TRINTELLIX, FANAPT, SECUADO), indicating step therapy requirements apply to those agents.

Coverage label	Summary
ST
Step therapy is required for items marked 'ST' in the listing (for example, some gabapentin formulations and certain hypnotic/antipsychotic entries), and documentation of prior failed trials is expected when required.

Coverage label	Summary
LA / EB
Some agents are flagged LA (limited access) or EB (evidence‑based step edits); these flags indicate referral to the prior authorization process for any applicable step requirements or edits.

Coverage label	Summary
Not specified
No explicit step therapy sequences are specified in these chunks of the formulary; where ST applies it is noted beside the individual product lines rather than via a multi‑step algorithm in the provided excerpt.

Quantity Limits (QL) by Product

Quantity limit — ritonavir (Norvir)

ritonavir tab 100 mg (Norvir)QL: 360 tablets per 30 days

Quantity limit — RUKOBIA

RUKOBIA — fostemsavir 600 mg ERQL: 60 tablets per 30 days

Quantity limit — SELZENTRY oral solution

SELZENTRY — maraviroc oral solution 20 mg/mLQL: 1840 mL per 30 days

Quantity limit — SOVALDI

SOVALDI — sofosbuvir (tabs/packet)

Specialty, Site-of-Care & Dispensing Requirements

Note

Background & Scope

This document is the plan's outpatient drug formulary listing covered medications by name, formulation, and tier, together with any utilization management flags such as PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), SP (Specialty), and LA (Limited Access). It is intended to inform prescribers and members which outpatient prescription drugs are included for the EmblemHealth HMO Preferred Plan Full Rx 2‑Tier benefit and to identify administrative requirements that must be satisfied for coverage. For plan details, cost‑share, and member‑specific rules refer to the Certificate of Coverage or member portal.

Abbreviations & Definitions

Policy Summary

PayerEmblemHealth

PolicyHMO Preferred Plan Full Rx 2-Tier Formulary (Gold Rx Grandfathered Plan) - coverage criteria / formulary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr. 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization (PA) when a listed drug is marked 'PA' before dispensing to ensure coverage.

SourceLink

On This Page

Propranolol oral solution 40 mg/5 mlQL: 2400 mL per 30 days

Propranolol oral solution 20 mg/5 mlQL: 4800 mL per 30 days

Nimodipine oral solution 60 mg/20 mL (3 mg/mL)QL: 2520 mL per 21 days

NYMALIZE nimodipine oral solution 6 mg/mLQL: 1260 mL per 21 days

Enalapril (Epaned) oral solution 1 mg/mLQL: 1200 mL per 30 days

Quantity limit examples — MAVENCLAD, MAYZENT, OTEZLA

MAVENCLAD (cladribine) therapy packsQL: 9–20 tablets per 301 days (therapy-pack specific limits)

MAYZENT 0.25 mgQL: 120 tablets per 30 days

OTEZLA (apremilast)QL: 60 tablets per 30 days

Quantity limit examples — assorted capsule/pen/vial examples

KOSELUGO (selumetinib) 5 mgQL: 420 capsules per 30 days

HUMALOG MIX 50/50 KWIKPENQL: 33 pens per 30 days

HUMALOG MIX 75/25 (vials)QL: 10 vials per 30 days

HUMULIN 70/30QL: 100 mL per 30 days

INSULIN GLARGINE-YFGN (pens)QL: 33 pens per 30 days

Rare/ specialty agents with PA: PROCYSBI, BYLVAY, OMVOH, BYLVAY (pellets)

Prior Authorization

Prior Authorization for Select Specialty / Antineoplastic Drugs

Select specialty and antineoplastic agents often carry multiple requirements (PA plus Limited Availability, Quantity Limits, Specialty designation). Examples include ENSACOVE, VITRAKVI, KOSELUGO, ISTURISA, JYNARQUE, MAVENCLAD, MAYZENT, and many oncology/targeted therapy agents. These may also require specialty pharmacy dispensing and adherence to site-of-care or program-specific processes.

ENSACOVE, VITRAKVI, KOSELUGO — PA, QL, SP listed
MAVENCLAD / cladribine — PA, QL, SP annotations
JYNARQUE, ISTURISA — LA, PA, QL, SP flags

Documentation Required

Authorization Flags and Requirement Indicators

Drugs marked with flags in the Requirements/Limits column (PA, LA, QL, SP, ST, ACA, EB, EG, FF) indicate utilization management requirements. When PA or SP is shown, the prescriber must provide supporting documentation to obtain authorization; claims submitted without meeting these flags may be denied.

Abbreviations: PA = Prior Authorization; QL = Quantity Limit; SP = Specialty; LA = Limited Availability; ST = Step Therapy; ACA/EB/EG/FF describe program exceptions
Claims lacking required PA or exceeding QL may be denied

Documentation Required

Documentation & Quantity Limit Support

Documentation must accompany PA and other requirement flags. Prescribers should submit clinical justification and any requested forms or records showing medical necessity, previous therapies tried (when ST applies), and dosing/quantity support. Quantity limits (QL) shown (for example, QL (30 tablets/30 days)) define normal coverage amounts; requests above QL require supporting rationale.

Provide clinical rationale and prior-treatment history when requesting PA or ST
Include dosing and quantity justification for requests exceeding QL
Specialty products often require SP handling and program-specific documentation

Step Therapy

Step Therapy (ST) — When It Applies

Step therapy (ST) may apply to certain agents and requires trying specified drugs first before covering alternatives. Some entries show ST (e.g., KERENDIA, FETZIMA, FLUOXETINE DR, TRINTELLIX, HORIZANT). The section does not prescribe exhaustive step sequences — follow the plan/PBM step protocol when ST is indicated.

ST flag indicates trial of preferred agent(s) is required before coverage of non-preferred agent
No exhaustive step-by-step sequences included here — refer to plan/PBM for operational step edits
When ST is present, include prior therapy documentation with PA requests

Denial Risk

PA, Site-of-Care & Specialty Pharmacy Requirements

PA, LA, QL, and SP designations are enforced across many specialty, hematology, and biologic products. For coagulation factors and hemophilia therapies, PA and site-of-care documentation may be required; specialty pharmacy dispensing is often indicated. Failure to supply required PA or site-of-care information can result in claim denial.

Hemophilia/coagulation therapies: ADVATE, ADYNOVATE, BENEFIX, ELOCTATE, BERINERT — PA and SP noted
Site-of-care and specialty pharmacy documentation may be required for infusion/IV and high-cost agents
Follow plan processes for PA submission to avoid denial

QL: 28 tablets or 28 packets per 28 days; PA required as indicated

Quantity limit — STRIBILD

STRIBILDQL: 30 tablets per 30 days

Quantity limit — SUNLENCA / YEZTUGO

SUNLENCA / YEZTUGO lenacapavir oralQL: 4 tablets per 365 days or 5 tablets per 365 days depending on pack; LA/SP indicated

Quantity limit — TIVICAY

TIVICAY 50 mgQL: 60 tablets per 30 days

Quantity limit — TRIUMEQ

TRIUMEQQL: 30 tablets per 30 days

Quantity limit — VOSEVI

VOSEVIQL: 28 tablets per 28 days; PA indicated

Quantity limit — XOFLUZA

XOFLUZA — baloxavirQL: 2 tablets per 120 days

Quantity limits — ENSACOVE (ensartinib)

ENSACOVE — ensartinib 25 mgQL: 30 capsules per 30 days

ENSACOVE — ensartinib 100 mgQL: 60 capsules per 30 days

Quantity limits — KOSELUGO (selumetinib)

KOSELUGO — selumetinib 5 mgQL: 420 capsules per 30 days

KOSELUGO — selumetinib 7.5 mgQL: 240 capsules per 30 days

Quantity limit — VITRAKVI oral solution

VITRAKVI — larotrectinib oral solutionQL: 300 mL per 30 days

Quantity limit — HUMALOG MIX 50/50 KWIKPEN

HUMALOG MIX 50/50 KWIKPENQL: 33 pens per 30 days

Quantity limit — HUMALOG MIX 75/25 (vials)

HUMALOG MIX 75/25 (vials)QL: 10 vials per 30 days

Quantity limit — HUMULIN 70/30

HUMULIN 70/30QL: 100 mL per 30 days

Quantity limit — INSULIN GLARGINE‑YFGN (pens)

INSULIN GLARGINE‑YFGN (pens)QL: 33 pens per 30 days

Quantity limit — TRESIBA (vials)

TRESIBA (vials)QL: 10 vials per 30 days

Quantity limit — IMCIVREE

IMCIVREE — setmelanotide acetateQL: 10 vials per 30 days; LA/PA/SP indicated

Quantity limits — ISTURISA (osilodrostat)

ISTURISA 1 mgQL: 240 tablets per 30 days

ISTURISA 5 mgQL: 300 tablets per 30 days

Quantity limits — JYNARQUE

JYNARQUE — therapy packQL: 56 tablets per 28 days (therapy pack); LA/PA/SP indicated

JYNARQUE 15 mgQL: 60 tablets per 30 days

Quantity limit — GALAFOLD

GALAFOLDQL: 14 capsules per 28 days

Quantity limit — propranolol 40 mg/5 mL solution

propranolol oral solution 40 mg/5 mLQL: 2400 mL per 30 days

Quantity limit — propranolol 20 mg/5 mL solution

propranolol oral solution 20 mg/5 mLQL: 4800 mL per 30 days

Quantity limits — nimodipine formulations

nimodipine oral solution 60 mg/20 mL (3 mg/mL)QL: 2520 mL per 21 days

NYMALIZE nimodipine oral solution 6 mg/mLQL: 1260 mL per 21 days

Quantity limit — enalapril (Epaned) solution

enalapril maleate oral solution 1 mg/mL (Epaned)QL: 1200 mL per 30 days

Quantity limits — DIURIL / FUROSCIX / furosemide solution

DIURIL — chlorothiazide suspension 250 mg/5 mLQL: 1200 mL per 30 days

FUROSCIX — furosemide subcutaneous cartridge kit 80 mg/10 mLQL: 8 kits per 180 days

FUROSEMIDE — furosemide oral solution 10 mg/mLQL: 1800 mL per 30 days

Quantity limits — NEXLETOL / NEXLIZET

NEXLETOL — bempedoic acid 180 mgQL: 30 tablets per 30 days

NEXLIZET — bempedoic acid‑ezetimibe 180–10 mgQL: 30 tablets per 30 days

Quantity limits — JUXTAPID (inventory note)

JUXTAPID — lomitapide mesylate capsRequirements/Limits: LA, SP noted; QL present but numeric summary not provided in this segment

Quantity limit — ATTRUBY

ATTRUBY — acoramidis HCl tab packQL: 112 tablets per 28 days

Quantity limit — ADEMPAS

ADEMPAS — riociguatQL: 90 tablets per 30 days

Quantity limits — bosentan (suspension and tablets)

bosentan (oral suspension)QL: 120 tablets per 30 days (suspension)

bosentan (tabs)QL: 60 tablets per 30 days

Quantity limit — CAMZYOS

CAMZYOS — mavacamtenQL: 30 capsules per 30 days

Quantity limit — CORLANOR oral solution

CORLANOR — ivabradine oral solutionQL: 600 mL per 30 days

Quantity limit — ENTRESTO sprinkle caps

ENTRESTO — sacubitril‑valsartan sprinkle capsQL: 240 capsules per 30 days

Quantity limit — ADEMPAS (alternate chunk)

ADEMPAS (riociguat)QL: 90 tablets per 30 days

Quantity limit — CAMZYOS (alternate chunk)

CAMZYOS (mavacamten)QL: 30 capsules per 30 days

Quantity limit — sildenafil suspension

sildenafil citrate for suspension 10 mg/mLQL: 2 bottles per 30 days

Quantity limit — TYVASO DPI cartridges

TYVASO DPI Maintenance Kit — cartridgesQL: 112 cartridges per 28 days (example pack)

Quantity limit — UPTRAVI

UPTRAVI (selexipag)QL: 60 tablets per 30 days

Quantity limit — OFEV

OFEV (nintedanib)QL: 60 capsules per 30 days

Quantity limit — TRIKAFTA (packets)

TRIKAFTA granules/packetsQL: 56 packets per 28 days

Quantity limit — OFEV (alternate)

OFEV packets/capsulesQL: 60 per 30 days

Quantity limit — TRIKAFTA (granules)

TRIKAFTA granulesQL: 56 per 28 days

Quantity limit — LIVDELZI

LIVDELZI — seladelparQL: 30 tablets per 30 days

Quantity limit — OMVOH

OMVOH — mirikizumab prefilled syringeQL: 1 syringe per 28 days

Quantity limit — FERRIC CITRATE (AURYXIA)

FERRIC CITRATE (AURYXIA)QL: 360 tablets per 30 days

Quantity limit — Wellbutrin XL

bupropion HCl ER 300 mg (Wellbutrin XL)QL: 30 tablets per 30 days

Quantity limit — FETZIMA

FETZIMA cap ERQL: 30 capsules per 30 days

Quantity limit — REXULTI

REXULTI (brexpiprazole)QL: 30 tablets per 30 days

Quantity limit — risperidone oral solution

risperidone oral solutionQL: 480 mL per 30 days

Quantity limit — VRAYLAR

VRAYLAR (cariprazine)QL: 30 capsules per 30 days

Quantity limit — risperidone solution 1 mg/mL

risperidone solution 1 mg/mLQL: 480 mL per 30 days

Quantity limit — risperidone tablets

risperidone tablets (various strengths)QL: 60 tablets per 30 days

Quantity limit — VRAYLAR (duplicate chunk)

VRAYLAR (cariprazine)QL: 30 capsules per 30 days

Quantity limit — eszopiclone 1 mg

eszopiclone 1 mgQL: 90 tablets per 30 days

Quantity limit — orlistat 120 mg

orlistat 120 mgQL: 90 capsules per 30 days

Quantity limit — MAVENCLAD therapy packs

cladribine (MAVENCLAD) therapy packsQL: various therapy‑pack quantities (8–20 tablets) over 301 days; PA and SP indicated

Quantity limit — MAVENCLAD (examples)

MAVENCLAD therapy packs (examples)QL: 9–20 tablets per 301 days

Quantity limit — MAYZENT

MAYZENT 0.25 mgQL: 120 tablets per 30 days

Quantity limit — VUMERITY

VUMERITYQL: 120 capsules per 30 days

Quantity limit — BELBUCA

BELBUCAQL: 60 films per 30 days

Quantity limit — OTEZLA

OTEZLA (apremilast)QL: 60 tablets per 30 days; PA indicated

Quantity limit — RINVOQ

RINVOQ (15/30 mg)QL: 30 tablets per 30 days; LA/PA/SP indicated

Quantity limit — NURTEC

NURTECQL: 16 tablets per 30 days

Quantity limits — SOHONOS (examples)

SOHONOS (palovarotene)QL: varies by strength (examples: 112 caps/28 days for 1 & 1.5 mg; 140 caps/28 days for 2.5 mg; 84 caps/28 days for 5 mg; 56 caps/28 days for 10 mg)

Quantity limit — SKYCLARYS

SKYCLARYS (omaveloxolone) 50 mgQL: 90 capsules per 30 days

Quantity limit — FIRDAPSE

FIRDAPSE (amifampridine) 10 mgQL: 300 tablets per 30 days

Quantity limits — Anticoagulants (examples)

ELIQUIS / PRADAXA / XARELTO (anticoagulants)Multiple QLs specified — examples include ELIQUIS: 60–74 per 30 days; PRADAXA pellet packs: 60 or 120 packets per 30 days; XARELTO suspension: 620 mL per 30 days; tablets: 30–60 per 30 days

Quantity limits — Hemophilia factor products (note)

ADVATE / ADYNOVATE / AFSTYLAPA required; QL not explicitly summarized in these chunks

Quantity limits — PRADAXA pellet packs

PRADAXA pellet pack (20/150 mg)QL: 60 packets per 30 days

PRADAXA pellet pack (30/40/50/110 mg)QL: 120 packets per 30 days

Quantity limits — XARELTO (suspension and tabs)

rivaroxaban suspension (Xarelto) 1 mg/mLQL: 620 mL per 30 days

rivaroxaban tab 2.5 mgQL: 60 tablets per 30 days

Quantity limit — XARELTO starter pack

XARELTO starter pack (15 & 20 mg)QL: 51 tablets

Quantity limit — EMPAVELI

EMPAVELI (pegcetacoplan) 1080 mg/20 mLQL: 8 vials per 28 days

Quantity limit — HYMPAVZI

HYMPAVZI (marstacimab) 150 mg/mL pensQL: 4 pens per 28 days

Quantity limit — RUCONEST

RUCONEST 2100 unitQL: 8 vials per 30 days

Quantity limit — ORLADEYO

ORLADEYO (berotralstat) 110/150 mgQL: 30 capsules per 30 days

Quantity limit — PYRUKYND

PYRUKYND (mitapivat) 5/20/50 mgQL: 56 tablets per 28 days

Quantity limit — PYRUKYND taper pack

PYRUKYND TAPER PACKQL: 14 tablets (taper pack) per 365 days

Quantity limit — LATANOPROST (ophth)

LATANOPROST (Xalatan) ophthalmic solutionQL: 2.5 mL per 30 days

Quantity limits — select ophthalmic solutions

LUMIGAN (bimatoprost) ophthalmic solution / RHOPRESSA/ROCKLATAN/VYZULTAQL: 2.5 mL per 30 days