Prior Authorization requirement — Some drugs are subject to Prior Authorization (PA)

Some drugs listed in the formulary require prior authorization (PA) before the plan will cover them. Providers or members must obtain plan approval in advance; failure to obtain PA may result in claim denial. PA flags appear next to products in the formulary and may be combined with other flags (QL, SP, ACA, LA, ST).

• Check the member's Certificate of Coverage and plan benefits for specific PA, coverage, and cost-sharing rules.
• If a drug is marked PA in the formulary, submit a prior authorization request per EmblemHealth procedures before dispensing.

Prior authorization required for select formulations

Certain specific formulations (oral solutions, suspensions, capsules, tabs, and strength-specific products) are labeled with PA in the formulary. Examples include nystatin tablets 500, voriconazole (tabs and susp), itraconazole oral solution, and multiple antiretroviral liquid formulations. When a formulation is marked PA, authorization must be obtained for that formulation even if other formulations of the same drug may not require PA.

• Review the Requirements/Limits column for formulation-level flags (e.g., PA next to a specific strength or formulation).
• Document medical necessity for the specific formulation when submitting PA (e.g., swallowing difficulty requiring suspension).

Prior authorization required for PA-designated drugs

Many oncology, specialty oral agents, and certain injectables are designated PA (often with SP and/or QL). Examples include abiraterone (PA, QL, SP), temozolomide (PA, SP), bexarotene (PA, SP), and various antineoplastics. These PA-designated drugs frequently require clinical documentation and specialty pharmacy handling.

• When Requirements/Limits shows PA or SP for antineoplastics, include diagnosis, prior therapies, and treatment intent with the PA request.
• Quantity limits listed (e.g., abiraterone QL 120 tablets/30 days) must be adhered to unless an override is authorized.

Prior authorization for select antidiabetic injectables and orals

Select antidiabetic agents — including GLP-1/GIP receptor agonists and related products — are marked PA and often have quantity limits. Examples include MOUNJARO (tirzepatide), OZEMPIC/RYBELSUS (semaglutide), TRULICITY, and liraglutide (Saxenda for weight management). These require PA and may have specific pen/kit limits.

• MOUNJARO: PA, QL (4 pens/180 days for some strengths; 4 pens/28 days for others).
• OZEMPIC: PA, QL (1 pen/28 days or 3 pens/28 days depending on strength).
• RYBELSUS: PA, QL (30 tablets/30–180 days depending on strength).
• Liraglutide (Saxenda) for weight management: PA, QL (15 mls/30 days).

Prior authorization and quantity limits

Some products combine prior authorization (PA) with quantity limits (QL) and/or specialty (SP) designation. When multiple flags appear, PA must be obtained and dispensing must comply with the QL unless an exception is authorized.

• Examples: abiraterone (PA, QL, SP); pirfenidone (PA, QL, SP); teriparatide (PA, QL, SP).
• Follow the QL numeric limits on the formulary (e.g., pirfenidone caps 180 capsules/30 days) when submitting claims.

PA required for pirfenidone — Esbriet formulations

Pirfenidone (Esbriet) formulations require prior authorization and are subject to quantity limits and specialty designation. Dispense only after PA approval and within stated QL.

• Pirfenidone cap/tab 267 mg: PA, QL (180 capsules/tablets/30 days) and SP.
• Higher-strength tablet formulations (e.g., 801 mg) have separate QL (90 tablets/30 days).

Prior authorization required for select agents and listed products

Multiple listed products across therapeutic classes are flagged PA (and often SP/QL). Examples include tasimelteon, liraglutide (weight mgmt), phentermine products, cladribine, sodium oxybate, tetrabenazine, and others. Obtain PA and supporting documentation as required.

• Check Requirements/Limits for PA, SP, LA, ACA flags on individual products before dispensing.
• High-cost specialty or program-flagged items require supporting clinical documentation (diagnosis, prior therapy, labs) with the PA request.

Prior authorization / specialty flags and other program flags

Products marked with program flags (PA, SP, LA, ACA, FF, ST) trigger utilization management controls. These flags indicate that prior authorization, specialty pharmacy handling, limited availability, Affordable Care Act coverage, frozen formulary implications, or step therapy may apply.

• ACA = may be covered with no member cost-share when applicable.
• FF = Frozen Formulary — coverage or utilization may change at plan-year boundaries.
• LA = Limited Availability — obtainable at select pharmacies only.

PA and QL required for select pumps and kits

Specific insulin pumps, starter kits, disposable pod reservoirs, and infusion systems require prior authorization and have quantity limits noted. Requests for these devices should include clinical indication and justification for the specific pump or kit.

• ILET insulin infusion kit/pump/starter kits: PA, QL (1 kit/720 days or 1 kit/30 days as shown).
• OMNIPOD Dash and OMNIPOD 5 kits/pods: PA, QL (1 kit/720 days; 30 pods/30 days).
• V-GO disposable pump kits: PA, QL (30 systems/30 days).

Prior Authorization Not Specified in Segment — some listings are index-only

This segment primarily lists formulary products and flags; not every line specifies prior authorization. Absence of a PA flag in this segment does not guarantee coverage — consult plan details.

• If Requirements/Limits is blank for a product, confirm coverage and any program rules via the member's plan or prior authorization resources.
• Some sections are index/listing material and do not include operational PA rules; see plan documents for full requirements.

Potential triggers for denial — obtain PA and follow limits

Potential triggers for denial include: absence of required prior authorization, exceeding quantity limits, failing step therapy requirements, or not meeting specialty program criteria. Claims submitted without proper PA or documentation may be denied or delayed.

• Denials commonly occur when PA is required but not obtained prior to dispensing.
• Claims exceeding QL (e.g., topiramate ER QL 30–60 capsules/30 days; insulin pump kit QL limits) may be denied without documented exception.

PA-marked products may require prior authorization

Products marked 'PA' in the formulary may be denied if prior authorization is not obtained. Examples: nystatin tab 500000 unit (PA), voriconazole formulations (PA). Always verify PA status before dispensing.

• When you see 'PA' next to a product, do not assume coverage at point of sale without approval.
• Contact EmblemHealth or use the provider portal to initiate PA prior to claim submission.

Quantity limits and specialty/ACA flags — enforce both PA and QL

Some products combine Quantity Limits (QL) with specialty or ACA flags. Antiretrovirals and other specialty agents often list QL and ACA/SP indicators; these require adherence to both coverage and numerical limits.

• Examples: abacavir solutions/tabs with QL values; DESCOVY with ACA and QL (30 tablets/30 days); YEZTUGO with ACA, QL (4 tablets/365 days), SP.
• When ACA or ACA+QL is listed, ensure eligibility rules for ACA apply to the member and that QL is enforced.

Utilization management flags — follow indicated controls

Utilization management flags on the formulary (PA, QL, SP, ST, ACA, FF, LA) indicate controls that affect coverage and dispensing. Providers must review flags and follow the corresponding operational steps (PA submission, QL enforcement, step therapy documentation).

• ST (Step Therapy): when present, document prior trials per the ST requirements before requesting non-preferred therapies.
• SP (Specialty): specialty pharmacy handling and additional monitoring may be required; follow SP routing instructions.

Prior authorization required for select antidiabetics — PA and QL enforcement

Several high-cost antidiabetic agents are flagged PA (see antidiabetic callout). Quantity limits and PA enforcement are applied to control dispensing frequency and supply amounts.

• Enforce QL exactly as listed (e.g., MOUNJARO pens QL 4 pens/28 or 180 days depending on strength).
• PA requirements may include documentation of diagnosis (type 2 diabetes), prior therapies, and weight indication for weight-management products.

Documentation required when PA/QL present — include clinical justification

When a product lists PA or QL (or both), the provider must include documentation supporting medical necessity, indication, prior treatment history, and dosing. PA submissions lacking required documentation risk denial.

• Documentation implied by PA/QL: diagnosis, prior therapy failures/intolerances, treatment plan, labs where applicable.
• For specialty products (SP), include any required enrollment or monitoring documentation with PA.

General documentation note for PA/QL flagged products

General documentation expectations for flagged products: provide indication, prior therapy trials and dates, relevant lab results, and planned dosing. Pharmacy claims should reflect the drug name, strength, form, and quantity to match QL limits.

• Ensure claim lines match the formulary-listed strength and form to permit automated QL checks.
• If requesting an override to a QL or PA, include rationale and supporting clinical records.

Prescription information for QL enforcement — follow QL when dispensing

When a quantity limit (QL) is listed, dispense according to the numeric limit (e.g., mls/30 days, tablets/30 days). Pharmacy claims must include complete prescription details to allow QL enforcement.

• Examples: abacavir soln QL 960 mls/30 days; citalopram solution QL 600 mls/30 days; rizatriptan QL 18 tablets/30 days.
• If a prescription exceeds QL, submit PA with clinical justification prior to dispensing.

Documentation for PA/SP — submit required clinical support

Prescribers and pharmacists must provide documentation to support PA or specialty (SP) requests per EmblemHealth procedures. This includes clinical notes, prior therapy history, and any program enrollment forms required for SP drugs.

• For PA/SP requests, include: diagnosis, prior treatments/trials, duration of therapy tried, and relevant diagnostic tests or lab values.
• Follow payer-specific submission channels (provider portal, fax, or special pharmacy) for SP items.

Program-flagged products — operational follow-up required

Program-flagged products (PA, SP, LA, ACA, FF, ST) require following the payer's operational rules. These flags may trigger specialty pharmacy routing, limited pharmacy availability, or ACA coverage rules.

• Confirm whether LA (Limited Availability) requires dispensing at specific pharmacies.
• ACA-marked drugs may have different cost-sharing — verify member eligibility and plan applicability.

Quantity limit and status documentation for devices and supplies

Quantity limits, status indicators, and program flags must be observed when submitting claims for devices and supplies (e.g., CGM sensors, pump kits). Claims not matching QL or program status may be denied or subject to retrospective review.

• DEXCOM sensors: QL (2–3 sensors/30 days) and may have ST or other program flags.
• Pump kits: QL (1 kit/720 days) for some devices; verify device-specific QL before billing.

Required documentation/PA indication — submit complete PA requests

Submit PA requests with the documentation indicated by the formulary flag. Where PA is required, include all requested clinical information; incomplete submissions delay review and may lead to denial.

• Use EmblemHealth's PA submission instructions and include all clinical records specified on the PA form.
• Track PA approvals and authorization numbers; include them on claims per payer guidelines.

This segment does not include full PA submission documentation — consult payer resources

This segment is largely a product listing with flags; it does not contain full operational prior authorization forms, timelines, or appeal procedures. Providers should use EmblemHealth's provider resources for detailed PA submission steps and required forms.

• For full PA criteria, forms, and turnaround times, consult the EmblemHealth provider portal or call the number on the member ID card.
• Do not rely solely on the printed formulary listing for operational PA instructions.

Step Therapy requirement — Step/other utilization flags noted

Step Therapy (ST) may apply to some products in the formulary; flags will indicate when ST is required. The document includes items with ST noted (e.g., CGM sensors) but does not provide step-therapy protocols in this segment.

• When ST is flagged, document prior trials of preferred agents and durations per plan policy.
• If no ST details are listed in this segment, obtain ST protocol details from the plan's clinical policy or PA criteria.

No explicit step therapy rules are presented in this segment — consult plan documents

This section does not specify step therapy rules or detailed protocols. Providers must consult plan-specific clinical policies or the Certificate of Coverage for step therapy requirements and exception processes.

• If a drug is marked ST but no protocol is present here, request ST criteria from EmblemHealth prior to PA submission.
• Document failed trials of first-line agents when seeking exceptions to ST.