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EmblemHealth Local 246 Prescription Drug Formulary (Coverage Criteria)

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This document is the EmblemHealth Local 246 prescription drug formulary describing covered drugs, tiers, utilization management (e.g., prior authorization, quantity limits, step therapy), and member/provider resources for plan members and prescribing providers.

Policy Summary

PayerEmblemHealth

PolicyLocal 246 Prescription Drug Formulary (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Last ReviewJan 1, 2026

Next Review Date

Key ActionObtain prior authorization and submit required documentation when a drug entry is annotated with PA, LA, QL or SP to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-01-01formulary effective/updated date

Local 246formulary identifier / group

PA/QL/LA/SPutilization flags present

QL presentquantity limits noted

Tier 1–2tiers used

Formulary Coverage and Utilization Management

Formulary coverage with utilization management

Formulary lists drugs with tier assignments and may include Requirements/Limits per product; coverage depends on plan benefits and any listed utilization controls.

Formulary coverage: Drugs are listed with a Drug Tier and may have Requirements/Limits (e.g., PA, QL, ST, LA, SP). Coverage depends on plan-specific benefit rules and any listed requirements.

See product entries for specific limits or prior authorization requirements.

Product-level coverage controls

Each listed product includes tiering and may include program flags and numeric quantity limits; coverage requires adherence to the product-level controls shown.

Formulary entry: Each listed product includes a Drug Tier and may include requirement codes (LA, PA, QL, SP) and numeric quantity limits as specified per product entry.

See individual product entries for exact QL values

Policy Summary

PayerEmblemHealth

PolicyLocal 246 Prescription Drug Formulary (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Last ReviewJan 1, 2026

Next Review Date

Key ActionObtain prior authorization and submit required documentation when a drug entry is annotated with PA, LA, QL or SP to avoid coverage denial.

SourceLink

On This Page

Drug Listings, Codes and Quantity Examples

Sample listed drug products (Antibiotics / Penicillins / Cephalosporins)mixed

amoxicillin (trihydrate) chew tab 125 mg, 250 mg	AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg, 250 mg
amoxicillin (trihydrate) cap 250 mg, 500 mg	amoxicillin (trihydrate) cap 250 mg, 500 mg
amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml	amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
amoxicillin (trihydrate) tab 500 mg, 875 mg	amoxicillin (trihydrate) tab 500 mg, 875 mg
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml	amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)	amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)
amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg	amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg, 875-125 mg
amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg	AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg
ampicillin cap 500 mg	ampicillin cap 500 mg
AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml	AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml

1–10 of 16

1/2

Formulary drug entries (excerpt)mixed

oseltamivir phosphate cap 45 mg	Tamiflu; QL (40 capsules/120 days) listed
oseltamivir phosphate cap 75 mg	Tamiflu; QL (20 capsules/120 days) listed
oseltamivir phosphate for susp 6 mg/ml	Tamiflu suspension; QL (300 mls/120 days)
nirmatrelvir tab 6 x 150 mg & ritonavir tab 5 x 100 mg pak	PAXLOVID; QL (11 tablets/30 days)
nirmatrelvir tab 10 x 150 mg & ritonavir tab 10 x 100 mg pak	PAXLOVID; QL (20 tablets/30 days)
nirmatrelvir tab 20 x 150 mg & ritonavir tab 10 x 100 mg pak	PAXLOVID; QL (30 tablets/30 days)
letermovir tab 240 mg, 480 mg	PREVYMIS; QL (200 tablets/365 days)
letermovir pellet pack 20 mg, 120 mg	PREVYMIS; QL (800 packets/365 days)
darunavir-cobicistat tab 675-150 mg, 800-150 mg	PREZCOBIX; QL (30 tablets/30 days)
darunavir oral susp 100 mg/ml	PREZISTA; QL (400 mls/30 days)

1–10 of 40

1/4

Examples from cardiopulmonary/specialty listmixed

UPTRAVI TITRATION PACK	selexipag tab therapy pack 200 mcg (140) & 800 mcg (60)
VERQUVO	vericiguat tab 2.5 mg, 5 mg, 10 mg
VYNDAMAX	tafamidis cap 61 mg
VYNDAQEL	tafamidis meglumine (cardiac) cap 20 mg

Antihistamines and nasal agentsmixed

azelastine hcl nasal spray 0.1%	137 mcg/spray
fluticasone propionate nasal susp 50 mcg/act
XHANCE	fluticasone propionate nasal exhaler susp 93 mcg/act

Antiasthmatic and bronchodilator agentsmixed

ADVAIR HFA	fluticasone-salmeterol inhal aerosol 45-21 mcg/act, 115-21 mcg/act, 230-21 mcg/act
albuterol sulfate inhal aero 108 mcg/act	90 mcg base equiv
ANORO ELLIPTA	umeclidinium-vilanterol aero powd ba 62.5-25 mcg/act
TRELEGY ELLIPTA	fluticasone-umeclidinium-vilanterol aepb (various strengths)

CFTR modulator agents (cystic fibrosis specialty)mixed

ALYFTREK	vanzacaftor-tezacaftor-deutivacaftor (various strengths)
KALYDECO	ivacaftor tab/packet
TRIKAFTA	elexacaftor-tezacaftor-ivacaftor with ivacaftor (various strengths/formulations)

Pulmonary fibrosis and related specialty agentsmixed

PIRFENIDONE / Esbriet	pirfenidone formulations (various strengths)
OFEV	nintedanib esylate cap 100 mg, 150 mg
PULMOZYME	dornase alfa inhal soln 2.5 mg/2.5 ml

Gastrointestinal and digestive aidsmixed

CREON	pancrelipase dr cap (multiple unit strengths)
VOQUEZNA	vonoprazan fumarate tab 10 mg, 20 mg
BONJESTA / Diclegis	doxylamine-pyridoxine formulations

Listed drugs and strengths (no billing codes provided)mixed

NDC/HCPCS not listed

The document lists drug products and strengths but does not provide numeric billing codes in these chunks.

Formulary drug listing (no procedure/diagnosis codes)mixed

no procedure codes

This segment lists drug product names, strengths and formulary flags rather than CPT/HCPCS/ICD codes

Index entries (drug names and formulations)mixed

No codes listed

inv-16: Example quantity limits — common QL examples (30/30, 60/30, 365, etc.)

30 tablets/30 daysCommon short-term oral QL used for many single-tablet regimens and chronic tablets

60 tablets/30 daysUsed for some maintenance or higher-dose tablet therapies (e.g., certain antiviral or cardiovascular agents)

40 capsules/120 daysExample packaging-based QL shown for oseltamivir (Tamiflu) 45 mg capsules

4 tablets/365 daysAnnual QL example used for long-interval therapy packs (e.g., some long-acting HIV therapy pack counts)

300 mls/30 daysExample liquid QL shown for specialty oral solutions (e.g., VITRAKVI oral solution)

inv-17: Quantity limits examples — varied QL examples across different products

330 mls/30 daysARBLI (losartan oral suspension 10 mg/ml) QL

1200 mls/30 daysEpaned (enalapril oral solution) and DIURIL (chlorothiazide suspension) example liquid QL

30 tablets/30 daysNEXLETOL / NEXLIZET QL example for tablet agents

90 tablets/30 daysADEMPAS (riociguat) QL example for cardiac/pulmonary therapy

112 tablets/28 daysATTRUBY (acoramidis) QL example showing non-30-day interval

inv-18: Examples of quantity limits — additional QL examples

56 packets/28 daysTRIKAFTA formulation QL example (pack-based limit)

84 or 56 tablets/28 daysALYFTREK QL varies by strength (examples shown)

30 tablets/30 daysMultiple specialty and non-specialty agents (VERQUVO, many single-tablet regimens) use this common monthly QL

inv-19: Quantity limits (examples) — QL values shown in product listings

QL (30 tablets/30 days)Standard monthly tablet limit shown across many product listings

QL (60 tablets/30 days)Higher monthly tablet limit used for some maintenance therapies

QL (360 mls/30 days)Example large-volume liquid QL shown for select oral solutions

Prescriber and Pharmacy Actions — Prior Authorization, Step Therapy, Documentation

Prior Authorization

Prior Authorization and Related Access Controls

Prior authorization (PA), limited access (LA), quantity limits (QL), specialty (SP), and step therapy (ST) flags shown throughout the drug listings indicate utilization controls that may affect coverage. Drugs marked PA or LA require approval prior to dispensing; failure to obtain required authorization may result in non‑coverage or claim denial. LA and SP designations may also restrict where or how a product is dispensed. Many specialty and specialty‑accessible products (examples: SUNLENCA, BRUKINSA, KOSELUGO, VITRAKVI, TRIKAFTA, VYNDAQEL, OFEV, KALYDECO, ALYFTREK) require PA and are subject to program review.

Examples of PA/LA/QL/SP entries: SUNLENCA (LA, QL, SP); BRUKINSA (LA, PA, QL, SP); KOSELUGO (LA, PA, QL, SP); VITRAKVI (LA, PA, QL, SP); ZOKINVY (LA, PA, QL, SP).
Bempedoic acid agents (NEXLETOL/NEXLIZET) are listed with PA and QL.
Pulmonary/cardiac specialty agents (e.g., ADEMPAS/CAMZYOS, CORLANOR, ENTRESTO, OPSUMIT, ORENITRAM, TYVASO, UPTRAVI) are flagged LA/PA/QL/SP and have specified quantity limits.
Many high‑cost specialty and non‑specialty drugs require PA and QL (examples: TRIKAFTA, VYNDAQEL, OFEV).
Certain products are LA plus PA (e.g., MAVENCLAD, LUMRYZ, VYLEESI) and will require both limited‑access routing and prior approval.

Documentation Required

How Flags Affect Prescribing and Dispensing

The Requirements/Limits field on each listing identifies the operational flags (PA, LA, QL, SP, ST). These flags are intended to prompt prescribers and pharmacies to obtain necessary approvals and to ensure claims conform to quantity and specialty program rules. When a QL is present, dispensing must not exceed the listed quantity for the specified time period unless an approved override is obtained.

QL examples: abacavir (QL 60 tablets/30 days), oseltamivir (QL by days/mL), many oral suspensions with specific mL limits.
PA + QL example: MYFEMBREE (PA, QL 30 tablets/30 days).
Claims submitted without required PA or with quantities exceeding QL may be denied.
Specialty program review may apply for items flagged SP; these may require specialty pharmacy dispensing and additional clinical documentation.

Documentation Required

Documentation Requirements and Risk of Denial

Documentation must be submitted per EmblemHealth processes to support prior authorization and overrides of limits. PA requests should include clinical rationale, prior therapy history (for ST or PA‑required drugs), relevant labs or tests, and any supporting specialty pharmacy enrollment information. For products with LA or SP designations, the prescriber may need to use a specific dispensing channel or specialty pharmacy.

PA documentation is required for items flagged PA/LA/SP (examples: GALAFOLD, CRENESSITY, TRIKAFTA).
Quantity limit documentation: when requesting an exception to a QL, include justification and expected duration; many liquid formulations list mL limits (e.g., ARBLI, DIURIL, enalapril oral solution).
For specialty products, include monitoring plans and specialty enrollment forms when applicable.
Follow the member’s Certificate of Coverage and contact the member services number on the ID card for plan‑specific requirements.

Step Therapy

Step Therapy — what prescribers should know

Step therapy (ST) is noted on select listings but explicit step sequences are not shown in these listing chunks. Where ST appears (for example: KERENDIA, FANAPT, certain gabapentin products), prescribers should verify the required prior medications and document treatment history in PA submissions. If no ST rules are shown in the index or listing, contact EmblemHealth for the specific step requirements before assuming coverage.

ST flagged examples: KERENDIA (ST noted), FANAPT (ST), gabapentin‑related products (ST).
If the listing or alphabetical index does not specify PA/ST rules, the absence does not guarantee no authorization; always confirm with the plan.
Prescribers may request an exception when clinical need justifies bypassing step therapy.

Note

Confirm Member Coverage Before Prescribing

Member coverage varies by plan. Always confirm benefits and requirements using the member's Certificate of Coverage and the member portal (my.emblemhealth.com) or by calling the phone number on the back of the member ID card. Not all drugs listed are covered under every drug benefit plan.

Check the member’s plan for copay, prior authorization, specialty pharmacy, and any frozen formulary (FF) impacts.
Drugs with a ‘*’ next to the tier denote group‑specific coverage — verify group eligibility.

Key Terms and Abbreviations

inv-89: PA — Prior Authorization definition

DefinitionPrior Authorization (PA) — the plan requires you or your provider to get approval from the plan before filling the prescription; claims submitted without required PA may not be covered.

PurposeUsed to confirm medical necessity, appropriate prescriber, dose and duration before coverage is approved.

ConsequenceFailure to obtain PA when required may result in denial of coverage for the drug.

inv-90: QL — Quantity Limit definition

DefinitionQuantity Limit (QL) — a maximum quantity or frequency the plan will cover for a drug within a specified time period (e.g., tablets per 30 days, mLs per 30 days).

ExamplesCommon examples include 30 tablets/30 days, 60 tablets/30 days, and liquid limits such as 300 mls/30 days or 1200 mls/30 days.

EnforcementPharmacy claims exceeding the listed QL may be denied unless prior authorization or exception is approved.

inv-91: ST — Step Therapy definition

DefinitionStep Therapy (ST) — a requirement to try specified lower-line or preferred drugs first before the plan will cover an alternative drug for the same condition.

ApplicationSome products are annotated 'ST' (e.g., KERENDIA, FANAPT, certain ODTs) indicating step requirements may apply per product listing.

ExceptionMembers/providers can request an exception when step therapy would be inappropriate; follow PA/appeals process as needed.

inv-92: SP — Specialty Drugs definition

DefinitionSpecialty Drugs (SP) — drugs that may require special handling, monitoring, or distribution through specialty pharmacy channels and often have utilization controls (LA, PA, QL).

CharacteristicsOften high-cost, limited-distribution, may require patient education, refrigeration, or complex administration.

Program impactProducts designated SP may trigger specialty program review or channeling to specialty pharmacy for dispensing.

inv-93: Tier — definition of drug tiering and cost-sharing

DefinitionTier — a classification indicating cost-sharing level under a plan (e.g., Tier 1 generally generics, Tier 2 brand drugs).

UseTier determines member copay/coinsurance and preferred products; formulary displays tier next to each product.

VariationSpecific tier assignments may vary by plan; refer to member Certificate of Coverage for plan-level cost-sharing details.

inv-94: SP (alternate) — specialty designation noted in listings

Specialty designationSP — indicates product designated as specialty and may require specialty pharmacy dispensing and program review.

ExamplesMany LA/PA/QL products are also marked SP (e.g., ADEMPAS, ATTRUBY, TYVASO) showing specialty channeling.

ImplicationSP designation often accompanies PA/LA/QL and can affect site-of-care or distribution requirements.

inv-95: PA (alternate) — prior authorization definition from examples

Prior Authorization (PA)Payer authorization required before coverage is approved for listed products annotated 'PA' (e.g., ARBLI, Epaned, DIURIL, NEXLETOL).

ExamplesARBLI (PA, QL 330 mls/30 days); Epaned (PA, QL 1200 mls/30 days); DIURIL (PA, QL 1200 mls/30 days).

RiskClaims submitted without required PA for these products risk denial.

inv-96: QL (alternate) — quantity limit definition with examples

Quantity Limit (QL)Maximum quantity covered per time period as shown per product (e.g., tablets/30 days, mLs/30 days, packets/28 days).

ExamplesCommon examples in listings include 30 tablets/30 days, 60 tablets/30 days, 360 mls/30 days, and pack-specific limits such as 56 packets/28 days.

EnforcementExceeding listed QL without prior authorization or exception may result in claim denial.

inv-97: LA — Limited Access definition

Limited Access (LA)Restricted distribution or additional access controls beyond standard prior authorization; may limit where a drug can be obtained.

When usedApplied to products with constrained supply or restricted distribution (often shown alongside PA and SP).

ExamplesSeveral specialty agents are listed with LA indicating limited availability (see product rows).

inv-98: PA (repeated) — definition placeholder for other chunks

Prior Authorization (PA)When 'PA' appears next to a product, coverage requires plan approval before dispensing; lack of PA may result in non-coverage.

Provider actionPrescribers must submit PA requests and supporting documentation per EmblemHealth procedures for PA drugs.

ReferenceSee product Requirements/Limits for PA annotations and required documentation.

inv-99: QL (repeated) — definition placeholder for other chunks

Quantity Limit (QL)A numeric cap on quantity per timeframe shown with products (e.g., 'QL (60 tablets/30 days)').

FormatsShown as tablets/30 days, capsules/28 days, mLs/30 days, packets/28 days, or other pack-dependent intervals in listings.

PurposeHelps manage utilization and dosing safety; exceeding QL may require PA to be covered.

inv-100: SP (repeated) — specialty definition placeholder

Specialty (SP)Product designated 'SP' indicates specialty pharmacy handling/distribution, often with LA/PA/QL requirements.

ImplicationMay limit dispensing channel and require specialty program review or monitoring.

ExamplesMany complex biologic or rare-disease therapies are marked SP in the formulary listings.

inv-101: LA (repeated) — limited access definition placeholder

Limited Access (LA)Designation indicating restricted distribution or additional access controls beyond PA; may limit where and how product is dispensed.

Common pairingOften appears with PA and SP flags for high-cost or limited-distribution therapies.

Provider noteRequests for LA products typically need PA and documentation of clinical need.

Step Therapy Notes and Instances

Note
No explicit step therapy sequences are provided in the available formulary excerpts; product lines display tier and utilization flags (PA, LA, QL, SP) but no multi-step algorithms are listed.

Product	Flags / Notes
Multiple products show utilization flags without explicit step sequences (e.g., ARIKAYCE: LA, PA, QL, SP)	Flags present: PA (prior authorization), LA (limited access), QL (quantity limit), SP (specialty). No step-by-step ST sequences shown in these excerpts.

Drug	Step Therapy (ST) Annotation
KERENDIA (finerenone) 10 mg, 20 mg	Requirements/Limits: QL (30 tablets/30 days), ST indicated — step therapy may apply as annotated in product line.

Product / Category	Utilization Controls
Selected specialty/brand products	Require Limited Access (LA) and Prior Authorization (PA) prior to coverage; explicit step sequences not provided in these chunks.

Agent / Group	Controls Noted
CFTR modulators (e.g., TRIKAFTA, KALYDECO, ALYFTREK)	Designated LA, PA and QL in product entries; specialty agents subject to these controls prior to coverage (no step sequences shown).

Example Product	Step Therapy (ST) / QL
FANAPT (iloperidone)	Requirements/Limits = QL (60 tablets/30 days); annotated ST (step therapy) — titration packs also ST.
risperidone ODT / risperidone solution	Requirements/Limits include QL (various); some formulations noted in segments with ST annotations for select products.
SECUADO (asenapine TD patch)	Requirements/Limits = QL (30 patches/30 days); ST indicated for the product line.
VERSACLOZ (clozapine suspension)	Requirements/Limits = QL (540 mls/30 days); ST annotated for clozapine products.

Drug / Formulation	Step Therapy (ST) / QL
gabapentin once-daily formulations (Gralise)	Requirements/Limits = QL (30–90 tablets/30 days depending on strength); annotated ST for once-daily gabapentin products.
HORIZANT (gabapentin enacarbil ER)	Requirements/Limits = QL (60 tablets/30 days); ST indicated in product entry.

Entry	Notes
Various agents show PA and QL flags (examples: tramadol ER, XTAMPZA ER, select anticonvulsants)	Product lines list PA and QL but do not include explicit step therapy sequences in these excerpts.

Agent / Group	Program Flags (LA / PA / SP)
Selected branded specialty agents (e.g., DAYBUE, CERDELGA, DOPTELET, miglustat, enoxaparin formulations)	Annotated with LA, PA, and often SP — indicating utilization management and specialty program review prior to coverage; explicit step sequences not provided.

Note
This segment contains product entries with QL and PA flags but contains no explicit step therapy sequences — information is informational/index listing.

Quantity Limits by Product

inv-112: abacavir sulfate soln 20 mg/ml — QL 960 mls

Abacavir sulfate oral solution 20 mg/mlQuantity Limit = 960 mls per 30 days

Source exampleListed in formulary antiviral/anti-infective section with explicit liquid QL

inv-113: Biktarvy; other single-tablet regimens — QL (30 tablets)

Biktarvy and other single-tablet regimensQuantity Limit = 30 tablets per 30 days

ContextSingle-tablet antiretroviral regimens commonly limited to 30 tablets/30 days in listing

inv-114: emtricitabine soln — QL 680 mls

Emtricitabine oral solutionQuantity Limit = 680 mls (listed)

ContextLiquid formulation QL noted in antiviral product listings

inv-115: Paxlovid (nirmatrelvir/ritonavir packs) — QL examples

Paxlovid (nirmatrelvir/ritonavir packs)Quantity Limit = QL (11–30 tablets/30 days) depending on pack size

NotesFormulary lists pack-specific QLs (11, 20, 30 tablets per 30 days) for different Paxlovid packaging

inv-116: oseltamivir formulations — QL examples

Oseltamivir formulationsQuantity Limits vary by formulation: 45 mg cap QL 40 (120-day period), 75 mg cap QL 20 (120 days), suspension QL 300 mls/120 days

ContextExamples shown in antiviral section for Tamiflu capsules and suspension

inv-117: oseltamivir phosphate cap 45 mg — QL 40

Oseltamivir phosphate cap 45 mgQuantity Limit = 40 (capsules) per 120 days

SourceListed as Tamiflu capsule QL in formulary excerpt

inv-118: oseltamivir phosphate cap 75 mg — QL 20

Oseltamivir phosphate cap 75 mgQuantity Limit = 20 (capsules) per 120 days

SourceFormulary lists 75 mg capsule QL in antiviral section

inv-119: lenacapavir sodium tab 300 mg — QL 4

Lenacapavir sodium tab 300 mg (SUNLENCA)Quantity Limit = 4 tablets per 365 days

Access flagsAlso listed with LA and SP designations in formulary

inv-120: BRUKINSA - zanubrutinib tab 160 mg — QL 60

BRUKINSA - zanubrutinib 160 mg tabQuantity Limit = 60 tablets per 30 days

RequirementsListed with LA, PA, QL and SP flags in formulary

inv-121: VITRAKVI - larotrectinib oral soln 20 mg/ml — QL 300

VITRAKVI - larotrectinib oral solution 20 mg/mlQuantity Limit = 300 mls per 30 days

Packaging noteLiquid QL specified for specialty oral solution formulation

inv-122: CRENESSITY — QL 60 caps/30 days and 120 mL/30 days

CRENESSITYQuantity Limits = 60 capsules/30 days (caps) and 120 mL/30 days (oral solution)

AccessListed with LA, PA, QL and SP flags

inv-123: GALAFOLD — QL 14 caps/28 days

GALAFOLD (migalastat)Quantity Limit = 14 capsules per 28 days

Access flagsListed with LA, PA, QL and SP in formulary

inv-124: JYNARQUE — pack-dependent QL examples

JYNARQUE (tolvaptan)Quantity Limits vary by pack — examples include 56 tablets/28 days or 60 tablets/30 days depending on presentation

AccessListed with LA, PA, QL and SP flags

inv-125: ISTURISA — 240-300 tablets/30 days depending on strength

ISTURISA (osilodrostat)Quantity Limits = 240–300 tablets per 30 days depending on strength (formulation-specific)

AccessListed with LA, PA, QL and SP flags

inv-126: OPFOLDA — QL 8 capsules/28 days

OPFOLDA (miglustat) cap 65 mgQuantity Limit = 8 capsules per 28 days

AccessListed with LA, PA, QL and SP flags

inv-127: ARBLI (losartan oral suspension 10 mg/ml) — QL 330 mls

ARBLI (losartan oral suspension 10 mg/ml)Quantity Limit = 330 mls per 30 days

AuthorizationListing shows PA and QL for this liquid formulation

inv-128: Epaned (enalapril oral solution 1 mg/ml) — QL 1200 mls

Epaned (enalapril oral solution 1 mg/ml)Quantity Limit = 1200 mls per 30 days

AuthorizationListed with PA and QL in formulary

inv-129: DIURIL (chlorothiazide suspension 250 mg/5ml) — QL 1200 mls

DIURIL (chlorothiazide suspension 250 mg/5ml)Quantity Limit = 1200 mls per 30 days

AuthorizationListed with PA and QL

inv-130: NEXLETOL / NEXLIZET — QL 30 tablets

NEXLETOL / NEXLIZETQuantity Limit = 30 tablets per 30 days

AuthorizationListed with PA and QL in formulary

inv-131: ADEMPAS (riociguat) — QL 90 tablets

ADEMPAS (riociguat)Quantity Limit = 90 tablets per 30 days

AccessListed with LA, PA, QL and SP flags

inv-132: ATTRUBY (acoramidis) — QL 112 tablets

ATTRUBY (acoramidis)Quantity Limit = 112 tablets per 28 days

AccessListed with LA, PA, QL and SP flags

inv-133: ORENITRAM TITRATION KIT M — QL 1 pack

ORENITRAM TITRATION KIT MQuantity Limit = 1 pack per 180 days

AccessListed with LA, PA, QL and SP

inv-134: TYVASO and related kits — QL varies by kit (examples provided)

TYVASO and related kitsQuantity Limits vary by kit (examples: 7 packages/28 days; 112 cartridges/28 days; 1 kit/28 days); product listings show LA, PA, QL, SP

NoteMultiple kit/package QLs used for inhalation systems and refill kits

inv-135: UPTRAVI — QL 60 tablets

UPTRAVI (selexipag)Quantity Limit = 60 tablets per 30 days

AccessListed with LA, PA, QL and SP flags

inv-136: VERQUVO (vericiguat) — QL 30 tablets

VERQUVO (vericiguat)Quantity Limit = 30 tablets per 30 days

AuthorizationListed with PA and QL in formulary

inv-137: VYNDAMAX / VYNDAQEL (tafamidis) — QL 30 / 120 capsules

VYNDAMAX / VYNDAQEL (tafamidis)Quantity Limits = 30 / 120 capsules per 30 days depending on formulation

AccessListed with PA, QL and SP flags

inv-138: tadalafil 2.5 mg, 5 mg — QL 30 tablets

Tadalafil 2.5 mg, 5 mgQuantity Limit = 30 tablets per 30 days

ContextED treatment tablets commonly limited to 30/30 in formulary listings

inv-139: UPTRAVI TITRATION PACK — QL 1 package/180 days

UPTRAVI TITRATION PACKQuantity Limit = 1 package per 180 days (titration pack)

NoteTitration packs may use longer interval QLs compared to maintenance packs

inv-140: VERQUVO — QL 30 tablets/30 days

VERQUVOQuantity Limit = 30 tablets per 30 days (repeat listing)

SourceListed in cardiopulmonary specialty section with PA and QL

inv-141: TRIKAFTA formulations — QL 56 packets/28 days; 90 tablets/30 days depending on formulation

TRIKAFTA formulationsQuantity Limits = 56 packets per 28 days or 90 tablets per 30 days depending on formulation; listings show LA, PA, QL, SP

Pack vs tabletPackets (granules) and tablet presentations have distinct QLs per product row

inv-142: pirfenidone (Esbriet) — QL examples

Pirfenidone (Esbriet)Quantity Limits = 180 capsules/30 days or 90 tablets/30 days depending on formulation

AccessListed with PA, QL and SP flags in pulmonary fibrosis section

inv-143: ALYFTREK — QL 84 or 56 tablets/28 days depending on strength

ALYFTREKQuantity Limits = 84 tablets/28 days or 56 tablets/28 days depending on strength

AccessListed with LA, PA, QL and SP for CFTR-related therapy

inv-144: fluoxetine hcl capsule 10 mg — QL 240

Fluoxetine HCl capsule 10 mgQuantity Limit = 240 (tablets) per 30 days

Formulation noteOral tablets have specific monthly QLs in listing

inv-145: fluoxetine hcl capsule 20 mg — QL 120

Fluoxetine HCl capsule 20 mgQuantity Limit = 120 (tablets) per 30 days

SourceListed in antidepressant section with QL

inv-146: fluoxetine hcl solution 20 mg/5ml — QL 600

Fluoxetine HCl solution 20 mg/5mlQuantity Limit = 600 mls per 30 days

Liquid formulationLarge-volume oral solution QL shown for pediatric/liquid needs

inv-147: trintellix (vortioxetine) tablets — QL 30

Trintellix (vortioxetine) tabletsQuantity Limit = 30 tablets per 30 days

AdditionalListed with ST in some presentations

inv-148: zuranolone (Zurzuvae) 20/25 mg — QL 28

Zuranolone (Zurzuvae) 20/25 mgQuantity Limit = 28 capsules per 365 days

NoteLong-interval QL (annual) used for certain short-course therapies

inv-149: zuranolone (Zurzuvae) 30 mg — QL 14

Zuranolone (Zurzuvae) 30 mgQuantity Limit = 14 capsules per 365 days

ContextSmaller annual QL for alternative strength presentation

inv-150: aripiprazole oral solution 1 mg/ml — QL 900

Aripiprazole oral solution 1 mg/mlQuantity Limit = 900 mls per 30 days

Formulation noteLarge-volume liquid QL for oral solution presentation

inv-151: aripiprazole ODT 10 mg, 15 mg — QL 60

Aripiprazole ODT 10 mg, 15 mgQuantity Limit = 60 tablets per 30 days

PresentationOrally disintegrating tablet QL typical for psychotropic ODT forms

inv-152: clozapine ODT 12.5 mg — QL 90

Clozapine ODT 12.5 mgQuantity Limit = 90 tablets per 30 days

MonitoringClozapine products are QL- and monitoring-sensitive; listings may include ST

inv-153: clozapine ODT 25 mg — QL 270

Clozapine ODT 25 mgQuantity Limit = 270 tablets per 30 days

ContextHigher QL for larger‑dose ODT presentation shown in listing

inv-154: Fanapt (iloperidone) tablets — QL 60

Fanapt (iloperidone) tabletsQuantity Limit = 60 tablets per 30 days

Titration packsFanapt titration packs have QL = 1 pack per 180 days

inv-155: Fanapt titration packs — QL 1

Fanapt titration packsQuantity Limit = 1 pack per 180 days

UsePack-based QL for initiation/titration presentations

inv-156: lurasidone (Latuda) tablets — QL 30

Lurasidone (Latuda) tabletsQuantity Limit = 30 tablets per 30 days

Formulary noteStandard monthly tablet QL for antipsychotic listed

inv-157: quetiapine fumarate ER (Seroquel XR) — QL 60; Rexulti — QL 30

Quetiapine fumarate ER (Seroquel XR)Quantity Limit = 60 tablets per 30 days for certain ER strengths

Rexulti (brexpiprazole)Quantity Limit = 30 tablets per 30 days (listed)

inv-159: risperidone solution 1 mg/ml — QL 480

Risperidone solution 1 mg/mlQuantity Limit = 480 mls per 30 days

ODT/solution distinctionsLiquid and ODT forms have separate QLs compared to tablet forms

inv-160: Vraylar (cariprazine) — QL 30; hypnotics general — QL 30

Vraylar (cariprazine)Quantity Limit = 30 capsules per 30 days

Hypnotics (general)General hypnotic QL example = 30 tablets per 30 days

inv-162: tasimelteon (Hetlioz) capsule 20 mg — QL 30; tasimelteon oral suspension — QL 158

Tasimelteon (Hetlioz) capsule 20 mgQuantity Limit = 30 capsules per 30 days

Tasimelteon oral suspensionQuantity Limit = 158 mls per 30 days (liquid presentation)

inv-164: Azstarys and related ADHD agent QLs

AzstarysQuantity Limit = 30 capsules per 30 days

Dextroamphetamine oral solution 5 mg/5mlQuantity Limit = 1800 mls per 30 days

Methylphenidate solutions (Methylin)Quantity Limit = 450 mls per 30 days

Quillivant XR (methylphenidate ER susp)Quantity Limit = 360 mls per 30 days

Concerta 36 mgQuantity Limit = 30 tablets per 30 days

inv-169: MAVENCLAD — cladribine therapy pack QL 8-20; VYLEESI — QL 6 pens

MAVENCLAD therapy packsQuantity Limit = 8–20 tablets depending on pack (listed as per pack size)

VYLEESI (bremelanotide)Quantity Limit = 6 pens per 30 days

inv-171: XTAMPZA ER — QL varies 60-240; common opioid combo QLs

XTAMPZA ER oxycodone capsQuantity Limit = 60–240 capsules per 30 days depending on strength

Acetaminophen/oxycodone 2.5-325 mgQuantity Limit = 360 tablets per 30 days

Oxycodone w/ acetaminophen 7.5-325 mgQuantity Limit = 240 tablets per 30 days

inv-177: eletriptan (Relpax) and migraine product QLs

Eletriptan (Relpax)Quantity Limit = 12 tablets per 30 days

ELYXYB (celecoxib oral solution)Quantity Limit = 6 bottles per 30 days

NURTEC (rimegepant)Quantity Limit = 16 tablets per 30 days

EmblemHealth Local 246 Prescription Drug Formulary (Coverage Criteria)

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Formulary Coverage and Utilization Management

Drug Listings, Codes and Quantity Examples

Prescriber and Pharmacy Actions — Prior Authorization, Step Therapy, Documentation

Policy Background and Scope

Key Terms and Abbreviations

Step Therapy Notes and Instances

Quantity Limits by Product

Dispensing Channels and Specialty Distribution