2026 EmblemHealth Large Group ASO NRA Preferred Formulary (covered drugs list)
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Defines the list of covered outpatient prescription drugs, tiers, and common benefit restrictions (e.g., prior authorization, quantity limits, step therapy, specialty drug handling) for EmblemHealth Large Group ASO NRA Preferred members as of Apr 1, 2026.
No material clinical or coverage changes in this revision.
Coverage and Formulary Scope
General coverage
Covered when listed on the formulary and plan benefit applies.
Some drugs retain additional restrictions (PA, QL, ST, LA, SP) which must be met; absence of PA/QL/ST flags implies standard coverage per benefit
Formulary coverage with PA/QL/SP requirements
Coverage and utilization controls apply per drug as listed below when payer requirements are met.
Provider must comply with specified prior authorization, quantity limits, and specialty pharmacy requirements for listed products
Formulary coverage entries
Drugs listed are subject to formulary tiering and specified utilization controls (QL, ST, PA).
See individual drug lines for exact QL/ST/PA values
Coverage stance for listed drugs
Coverage and dispensing are governed by formulary tier plus any listed Requirement/Limits flags. Drugs with PA/QL/LA/SP require administrative steps.
From the item Requirement/Limits fields
Listing a medicine in this formulary excerpt does not guarantee that the plan will pay for it. The document states that coverage depends on the member’s Certificate of Coverage and that ‘‘Not all drugs in this list are paid for by all drug benefit plans, so coverage is not guaranteed.’’ Providers and members should verify benefit details and any plan-specific requirements before dispensing or filling a prescription.
This extract contains partial formulary listings and does not include explicit exclusions. The entries shown are a subset of the full Prescription Drug List and therefore do not by themselves represent a complete statement of non‑coverage.
The segment is a formulary listing showing drug names, tiers, and utilization controls (for example, Quantity Limits and Step Therapy annotations). No detailed clinical medical‑necessity criteria or explicit exclusions are provided in these chunks; individual drugs are presented with their plan annotations (e.g., QL, ST, PA) which govern coverage conditions.
Within the provided excerpt there are no explicit product‑level exclusions stated. Drug lines include Requirements/Limits flags (such as LA, PA, QL, SP) but do not list products as expressly excluded in these chunks.
This portion of the formulary lists drug tiers and utilization controls but does not set out standalone clinical coverage rules or explicit exclusions. Entries show examples of Requirements/Limits such as PA, QL and LA that must be met for coverage; the extract itself does not provide full clinical criteria for authorization decisions.
No explicit clinical exclusions are stated in the provided extract. The content focuses on the formulary entries (drug name, tier, and any Requirements/Limits) rather than on statements that certain therapies are not medically necessary.
The excerpt does not contain explicit ‘‘not medically necessary’’ determinations. Coverage direction in these chunks is limited to formulary placement and annotations indicating administrative controls (e.g., PA, QL, ST, LA, SP); clinical non‑coverage language is not present here.
The supplied extract does not include explicit statements labeling therapies as medically unnecessary. Instead, it shows drug lines with Requirements/Limits (for example, QL and ST) which prescribe administrative conditions for coverage rather than clinical denial language.
No explicit ‘‘not medically necessary’’ language appears in these sections. The document excerpts presented list quantity limits, prior‑authorization flags, and tier assignments without accompanying statements that a product is not medically necessary.
Formulary Listings and Product Codes
| amoxicillin (trihydrate) chew tab 125 mg, 250 mg | Drug and strengths listed with Drug Tier = 3 |
| amoxicillin (trihydrate) cap 250 mg, 500 mg | Drug and strengths listed with Drug Tier = 1 |
| amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml | Drug and strengths listed with Drug Tier = 1 |
| amoxicillin (trihydrate) tab 500 mg, 875 mg | Drug and strengths listed with Drug Tier = 1 |
| amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml | Drug and strengths listed with Drug Tier = 1 |
| amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) | Drug and strengths listed with Drug Tier = 1 |
| amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg | Drug and strengths listed with Drug Tier = 1 |
| amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg | Drug and strengths listed with Drug Tier = 1 |
| AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml | Brand listed with Drug Tier = 3 |
| ampicillin cap 500 mg | Drug and strengths listed with Drug Tier = 1 |
| tazemetostat hbr tab 200 mg | TAZVERIK - tazemetostat hbr tab 200 mg |
| temozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg | temozolomide cap various strengths |
| tepotinib hcl tab 225 mg | TEPMETKO - tepotinib hcl tab 225 mg |
| ivosidenib tab 250 mg | TIBSOVO - ivosidenib tab 250 mg |
| venetoclax tab 10 mg/50 mg/100 mg | VENCLEXTA - venetoclax tablets and starter pack |
| abemaciclib tab 50/100/150/200 mg | VERZENIO - abemaciclib tablet strengths |
| larotrectinib oral soln 20 mg/ml, caps 25 mg/100 mg | VITRAKVI - larotrectinib formulations |
| dexamethasone soln/elixir/conc/tab | DEXAMETHASONE - dexamethasone products listed |
| methylprednisolone tab 2 mg/4 mg/8 mg/16 mg/32 mg | MEDROL / methylprednisolone formulations |
| prednisone oral soln and tabs | PREDNISONE - various formulations |
| testosterone formulations (gels, injections, TD, auto-injector) | Various testosterone products and limits |
| estradiol and conjugated estrogens (multiple forms) | Estrogens listed with QL or tier |
| contraceptives (rings, IUDs, implants, oral) | Multiple contraceptive products with ACA requirement or QL |
| 100 unit/ml | TRESIBA FLEXTOUCH - insulin degludec soln pen-injector strength listed |
| 200 unit/ml | TRESIBA FLEXTOUCH - insulin degludec soln pen-injector strength listed |
| 13 mcg - 200 mcg | TIROSINT levothyroxine sodium capsule strengths listed |
| 13 mcg/ml - 200 mcg/ml | TIROSINT-SOL levothyroxine sodium oral solution concentrations listed |
| 0.4 mg, 0.56 mg, 1.2 mg | VOXZOGO - vosoritide strengths listed |
| 21-14-7 mg/24hr | NICOTINE TRANSDERMAL SYST - nicotine td patch 24 hr kit 21-14-7 mg/24hr |
| 10 mg/ml (0.5 mg/spray) | NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) |
| 125 mcg/0.5ml | PLEGRIDY - peginterferon beta-1a soln auto-injector 125 mcg/0.5ml |
| 220 mg | ARCALYST - rilonacept for inj 220 mg |
| 80 mg/0.8ml | ADALIMUMAB-AATY CD/UC/HS - adalimumab-aaty auto-injector kit 80 mg/0.8ml |
| 40 mg/0.4ml | ADALIMUMAB-AATY 1-PEN KIT - adalimumab-aaty auto-injector kit 40 mg/0.4ml |
| 40 mg/0.4ml | ADALIMUMAB-ADAZ - adalimumab-adaz soln auto-injector 40 mg/0.4ml |
| 25 mg/0.5ml | ENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml |
| 80 mg/0.8ml | HADLIMA - adalimumab-bwwd soln prefilled syringe 40 mg/0.4ml, 40 mg/0.8ml |
Prescriber Requirements, Authorizations, and Denial Risks
Obtain prior authorization when 'PA' is indicated
Some drugs listed on the formulary require prior authorization (PA); the prescriber or patient must obtain PA approval before dispensing to secure coverage.
Submit PA or follow special handling for flagged products
Products annotated with flags such as 'PA', 'ACA', 'LA', or 'SP' require the corresponding authorization, site‑of‑care handling, or specialty pharmacy routing shown on the formulary entry.
- Follow 'ACA' entries for applicable ACA-covered vaccines/therapies.
- Route LA/SP products through the specified site or specialty pharmacy per the formulary.
Submit PA and adhere to QL for specialty/oncology drugs
Many antineoplastic and specialty agents are listed with Prior Authorization (PA) and Quantity Limits (QL); providers must submit PA requests and ensure dispensed quantities do not exceed the listed QL.
- Examples include abiraterone (PA, QL) and multiple oncology agents with PA/QL/SP requirements.
- Specialty routing (SP) is commonly required for these agents.
Obtain PA and follow QL/SP/LA for oncology agents
Many oral oncology agents require prior authorization and have specified quantity limits and specialty pharmacy or limited‑access designations; obtain PA and follow QL and SP/LA instructions before dispensing.
- Example: TAZVERIK — Requirements/Limits = LA, PA, QL (240 tablets/30 days), SP.
- Check each oncology line for its exact PA/QL/LA/SP values.
Check for and submit PA when listed on product line
Providers must check the formulary Requirements/Limits field and submit prior authorization when 'PA' appears on the product line; coverage may not be provided without PA.
- Review per‑line Requirements/Limits prior to dispensing.
- Do not assume coverage if PA is listed—obtain approval first.
Submit PA for select antidiabetics/weight agents
Selected GLP‑1/antidiabetic and weight‑management agents (for example, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) are PA‑restricted and subject to QL; submit PA and confirm QL before fill.
- MOUNJARO entries show Requirements/Limits = PA, QL (e.g., 4 pens/180 days or 4 pens/28 days depending on strength).
- OZEMPIC and RYBELSUS list PA and specific QL values.
Obtain PA and use specialty channels for endocrine agents
Many specialty endocrine and high‑cost hormone/growth therapies (e.g., ACTHAR, GENOTROPIN, GALAFOLD) are designated LA/PA/SP and require prior authorization and specialty distribution where shown.
- ACTHAR: Requirements/Limits = LA, PA, SP.
- GENOTROPIN: Requirements/Limits = PA, SP; GALAFOLD: LA, PA, QL, SP.
Obtain PA for specialty/higher‑tier drugs before dispensing
Specialty and higher‑tier drugs in this section commonly require prior authorization and may carry quantity limits or limited‑access designations; obtain PA before dispensing.
- Examples include ADEMPAS (LA, PA, QL) and TYVASO (LA, PA, QL, SP).
- Follow per‑product Requirements/Limits for PA and QL specifics.
Submit PA and use specialty pharmacy for selected biologics
Many biologics and high‑cost oral specialty medications require prior authorization and specialty pharmacy processing; obtain PA and route prescriptions to the designated specialty channel when 'SP' is noted.
- Examples: NUCALA, FASENRA PEN, TEZSPIRE, TRIKAFTA list LA, PA, QL, SP.
- Follow the formulary's SP/LA instructions for distribution and site‑of‑care.
Submit PA for specialty/high‑cost products and follow LA/SP/QL
Many specialty or high‑cost products are annotated with PA and may also have LA, SP, and quantity limits; providers must submit prior authorization and adhere to the listed limits and site‑of‑care rules.
- Examples: GATTEX — Requirements/Limits = LA, PA, SP; VOWST — LA, PA, QL (12 capsules/365 days), SP.
- Confirm PA, QL and any LA/SP routing prior to dispensing.
Obtain PA for listed tasimelteon products
Certain products (for example, tasimelteon presentations) specifically require prior authorization before coverage; obtain PA as indicated on the formulary line.
- Tasimelteon capsule 20 mg: Requirements/Limits = PA, QL (30 capsules/30 days).
- Hetlioz oral suspension: Requirements/Limits = LA, PA, QL, SP.
Submit PA when 'PA' is listed to secure coverage
Providers must submit prior authorization when 'PA' appears on a drug's Requirements/Limits line to obtain coverage for that product.
- Interferon and other immunomodulators (e.g., AVONEX) list PA and QL—submit PA per line item.
- If PA is required and not obtained, coverage may be denied.
PA required for drugs annotated 'PA' (submit supporting docs)
Products annotated with 'PA' in the Requirements/Limits column (for example PLEGRIDY, REBIF and sodium oxybate) require prior authorization; submit supporting documentation with the PA request.
- PLEGRIDY entries show LA, PA, QL and SP designations.
- REBIF lines list PA and QL (e.g., 12 syringes/28 days); sodium oxybate lists LA, PA, QL.
Missing PA can result in non‑coverage
If you fail to obtain a required prior authorization, the plan may not cover the drug; obtain PA before dispensing to reduce the risk of non‑payment.
Flags imply authorization/site/specialty requirements
Formulary flags (PA, ACA, LA, SP, QL) imply administrative requirements—missing these approvals or failing to follow the flag instructions may trigger coverage denials.
Check PA, QL, LA, SP controls per drug
Requests may be subject to prior authorization, quantity limits, site‑of‑care review, and specialty pharmacy designation depending on the drug; check each entry and follow the listed controls.
Denial risk if PA/QL/SP/LA requirements unmet
Claims may be denied if required prior authorization is not obtained, quantity limits are exceeded, or specialty pharmacy/site‑of‑care requirements are not met; ensure PA, QL and SP/LA routing are satisfied.
Denial risk for missing PA/LA/SP or exceeding QL
Claims lacking required prior authorization, missing site‑of‑care approval for LA products, not routed through specialty pharmacy when SP is indicated, or exceeding QL may be denied.
PA or QL absence/exceedance may trigger denial
Drugs with PA or QL noted on the formulary may require PA approval or be subject to quantity limits; failure to obtain PA or dispensing beyond the QL can result in claim denial.
Denial risk when PA/ST/SP/QL conditions unmet
If PA, step therapy (ST), specialty pharmacy (SP), or quantity limits (QL) conditions listed for a drug are not met, the request or claim may be denied.
Obtain PA and meet limits to avoid denials
Requests for drugs listed with Requirements/Limits = PA, LA, QL, or SP may be denied if those conditions are not met; obtain PA, respect QL, and follow LA/SP instructions where present.
Obtain PA and follow SP/LA for specialty respiratory biologics
Specialty respiratory biologics (for example FASENRA, NUCALA, TEZSPIRE) list LA/PA/QL/SP—obtain required authorizations and route via specialty pharmacy as indicated to ensure coverage.
- FASENRA PEN: LA, PA, QL (1 pen/28 days), SP
- NUCALA: LA, PA, QL (1–3 pens/syringes/28 days), SP
Obtain PA and meet LA/QL/SP for CF modulators
CF modulators and related specialty agents (e.g., TRIKAFTA, ALYFTREK, KALYDECO) list LA, PA, QL and SP; absence of authorization, exceeding QL, or incorrect routing risks denial.
Denial risk when PA/LA/QL/SP criteria are not met
Coverage may be denied if required prior authorization, site‑of‑care review, specialty designation, or quantity‑limit conditions listed on product lines are not met; follow listed requirements exactly.
Adhere to QL and ST to avoid denials
If quantity limits or step therapy requirements are present for a product, failure to meet those limits or follow ST sequencing can result in denial or reduced coverage.
- Examples with ST/QL: FETZIMA (QL 30 capsules/30 days, ST), FLUOXETINE DR (QL 4 capsules/28 days, ST).
PA required for tasimelteon products
Prior authorization is required for the listed tasimelteon presentations (capsule and oral suspension); lack of PA may result in denial.
Submit PA for PA‑flagged items (e.g., Saxenda)
Providers must obtain prior authorization for products annotated with 'PA' (examples include liraglutide (Saxenda) and other PA‑flagged items); failure to obtain PA may limit or deny coverage.
Claims may be denied when QL is exceeded
Claims exceeding specified Quantity Limits (QL) (for example QL 30 capsules/30 days or QL 60 tablets/30 days) may be denied unless prior authorization or exception is obtained.
- Verify the per‑product QL (days and unit) before dispensing to avoid claim denial.
PA is required when listed in Requirements/Limits
Drugs listed with 'PA' in the Requirements/Limits field require prior authorization before coverage; check each drug line and submit PA when shown to obtain payment.
Submit PA and required documentation for PA/LA/QL/SP items
When a drug entry includes PA, LA, QL, or SP, the provider must submit the applicable prior authorization and supporting documentation and adhere to quantity or site restrictions as specified.
- For LA/SP products, route prescriptions through the designated specialty pharmacy or site-of-care program.
- Provide medical necessity and prior‑treatment documentation for ST/PA reviews.
Follow step therapy: document prior trials when 'ST' is indicated
Step therapy (ST) is applied to selected products; providers must document prior trials of required agents per the formulary's ST annotation before coverage will be authorized for the next therapy.
- Examples with ST: FETZIMA, FETZIMA titration pack, FLUOXETINE DR, FANAPT titration packs, RISPERIDONE ODT (some strengths).
- Document prior agent use and treatment failure as part of the PA/ST submission when requested.
Confirm PA/LA/SP even when ST not specified
Some products are labeled with LA and SP but do not show explicit step‑therapy sequences in this extract; still confirm PA/LA/SP requirements and supply routing before dispensing.
Route LA/SP products through specialty channels and confirm PA
For products with LA and SP designations (for example certain dosing packs), ensure prescriptions are routed to the specialty channel and obtain any required site‑of‑care approvals per the formulary.
- Palforzia packs show LA and SP—route per payer instructions.
- If ST is not listed, still verify PA/LA/SP requirements before dispensing.
Adhere to ST and site restrictions where noted (e.g., KERENDIA)
Some agents are marked with ST or site restrictions (e.g., KERENDIA) — follow the ST/site designation and document required prior therapy or site‑of‑care details when requesting authorization.
Check tier/QL for inhaled products; implied step edits may apply
Tiering and quantity limits for inhaled combination products may imply preferred alternatives and step edits; check QL and tier before dispensing and follow any implied step edits in the benefit system.
- BREO ELLIPTA and TRELEGY entries include QL values—verify prior authorization or step requirements if applicable.
Follow ST sequences and include prior‑therapy documentation
When step therapy is listed for a product (for example AUVELITY, FETZIMA titration, FLUOXETINE DR), follow the ST requirements and include documentation of prior therapy and clinical rationale with the authorization request.
ST applies to selected CNS/psychiatric products—document prior trials
Step therapy applies to selected psychiatric and CNS drugs (e.g., FETZIMA, FLUOXETINE DR, FANAPT titration packs, RISPERIDONE ODT strengths); providers must follow ST and document prior trials when requesting coverage.
Follow ST for gabapentin formulations and HORIZANT
Gabapentin formulations and HORIZANT are labeled 'ST' in the formulary; obtain any required prior trials documentation and follow the ST requirement before coverage.
Route SP‑designated drugs through the specialty pharmacy
Some specialty products carry 'SP' indicating they must be dispensed via a designated specialty pharmacy; route prescriptions accordingly and enroll the member in specialty programs if required.
- Examples: many adalimumab biosimilars and interferon products list SP—use the specialty pharmacy channel.
Interpret and act on formulary annotations (PA/QL/ST/LA/SP)
Formulary entries include abbreviations (PA, QL, ST, LA, SP); providers must interpret these flags and take the administrative actions shown (e.g., submit PA, respect QL, route to SP) when submitting claims or prescriptions.
Submit required documentation for flagged products
When a product line includes PA, QL, ACA, LA, or SP flags, the provider must submit the appropriate authorization request and adhere to quantity and site/program requirements indicated on the formulary line.
- Include supporting clinical documentation and prior‑therapy history where ST is indicated.
Follow per‑line Requirements/Limits when submitting claims/PA
Drug entries list specific Requirements/Limits such as PA, QL, LA and SP; providers must follow those instructions when submitting claims or prior authorization requests.
Step Therapy and Initial Treatment Rules
Step therapy (initial therapy) rules
Step therapy (ST) must be followed where indicated on the formulary prior to coverage of the requested product.
Specific step sequences and prior agents are defined in the payer's authorization system or product-specific policy; see the product Requirements/Limits for ST entries such as FETZIMA, FETZIMA titration pack, FLUOXETINE DR, FANAPT titration packs, RISPERIDONE ODT, gabapentin formulations and HORIZANT.
| Summary |
|---|
| Step therapy (ST) may require trial of specified alternative drugs before coverage of another agent; follow the 'ST' annotation shown next to drug names. |
| Summary |
|---|
| No explicit step-therapy sequences or required prior agents are listed in this segment for the included products (entries show LA/SP but not ST sequences). |
| Summary |
|---|
| Some products list LA in addition to PA and QL (e.g., pemigatinib, PIQRAY, POMALYST) in their Requirements/Limits; specific step-therapy (ST) details are not enumerated in these lines. |
| Summary |
|---|
| Certain products include LA (site/limited access), PA, QL and SP flags (e.g., PALFORZIA entries show LA, SP; several oncology entries show LA/PA/QL/SP), but no explicit step edits are shown in these excerpts. |
| Summary |
|---|
| Some specialty antidiabetic agents (e.g., MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) are annotated with PA and QL and may be subject to step edits in the payer system, though specific step sequences are not listed here. |
| Summary |
|---|
| KERENDIA (finerenone) is listed in the formulary entries and noted in the brief as having an ST designation (ST/site indicated alongside QL/PA where applicable). |
| Summary |
|---|
| High‑cost agents such as PCSK9 inhibitors (example: REPATHA/evolocumab) are listed with quantity limits (QL) and may be subject to utilization management including step therapy in the payer system, although explicit ST steps are not provided here. |
| Summary |
|---|
| Tiered inhaled agents and combination inhalers (e.g., BREO ELLIPTA, BREZTRI, DULERA) have quantity limits and tier assignments that may imply preferred alternatives; explicit step-therapy rules are not stated in these excerpts. |
| Product |
|---|
| AUVELITY — dextromethorphan-bupropion |
| FETZIMA — levomilnacipran (including titration pack) |
| FLUOXETINE DR — fluoxetine delayed-release 90 mg |
| Summary |
|---|
| Step therapy is required for selected medications (examples in the formulary include AUVELITY, FANAPT titration packs, and certain strengths of risperidone ODT), but the specific prior agents or step sequences are not listed in these excerpts. |
| Product |
|---|
| Gabapentin (once-daily formulations — Gralise) — marked ST |
| HORIZANT (gabapentin enacarbil) — marked ST |
| Summary |
|---|
| Multiple biologic and biosimilar products (e.g., adalimumab biosimilars) are flagged with PA and QL and carry specialty pharmacy (SP) designations; explicit step-therapy specifications are not provided in these chunks but administrative controls are implied. |
Quantity Limits by Product
Specialty Pharmacy, Infusion, and Limited-Access Settings
Policy Background and Scope
Background: This document is a payer Prescription Drug List for EmblemHealth that identifies covered outpatient prescription drugs, their drug tiers, and plan‑level annotations such as PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), LA (Limited Availability) and SP (Specialty Pharmacy). It is intended to guide prescribing and benefit expectations for members of the EmblemHealth Large Group ASO NRA Preferred plan. The formulary notes that coverage depends on the member’s Certificate of Coverage, that not all drugs listed are paid for by all plans, and that utilization controls shown in the Requirements/Limits field must be satisfied for coverage to be provided.
Abbreviations and Terms
Biosimilars and Related Rules
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