CurrentEmblemHealthPolicy N/A

2026 Medicare Prescription Drug Formulary - EmblemHealth

This document is EmblemHealth's 2026 Medicare formulary listing covered prescription drugs, tiers, and common plan-level restrictions (prior authorization, quantity limits, step therapy, specialty). It affects EmblemHealth Medicare prescription drug plan members, their prescribers, and pharmacies.

Policy Summary

PayerEmblemHealth

Policy2026 Medicare Prescription Drug Formulary - EmblemHealth

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization when a drug is marked LA or SP and ensure prescriptions comply with stated quantity limits (QL).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-04-01formulary effective/updated date

U86Minternal formulary identifier

Tiers 1-2drug tiering shown

PA / QL / SP / LAcommon restrictions listed

SPspecialty designation present

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Coverage Criteria and Formulary Rules

inv-01: General coverage conditions

Formulary coverage is tiered and may be subject to plan-level restrictions; coverage requires adherence to plan requirements.

Formulary coverage conditions: Drug is listed on the formulary AND any listed restriction (PA, QL, ST, LA, SP) is satisfied per plan rules

Providers/patients must follow authorization and quantity rules or request exceptions via member services.

inv-02: Formulary inclusion with tiering and QL

Coverage and utilization controls for listed outpatient drugs

Formulary coverage: Drugs listed are included on the EmblemHealth formulary with an assigned Drug Tier; coverage subject to any stated Requirements/Limits and quantity limits (QL).

Specific prior authorization requirements are not detailed in this excerpt; QL values provided must be observed.

inv-03: Formulary listing and special handling

Coverage and handling notes inferred from flags in list

Formulary coverage and handling: Drugs listed include tier assignments (1 or 2) and may include requirement flags 'SP' (specialty), 'LA' (limited access), or 'QL' (quantity limit).

Specific prior authorization criteria are not present in these chunks; presence of SP/LA/QL implies additional PBM rules.

inv-04: Formulary coverage indicators

Coverage varies by product; many specialty/biologic agents have utilization controls.

Formulary coverage and controls: Drugs are listed with Drug Tier and Requirements/Limits indicators (examples: LA, SP, QL, OTC). Coverage requires adherence to those requirements; explicit medical necessity criteria not provided in this section.

See full policy for detailed prior authorization/medical necessity criteria.

inv-05: Formulary coverage summary

Medications listed with Drug Tier and, where provided, Requirements/Limits (e.g., QL, SP, LA). Covered when dispensed within listed tier and quantity/program constraints.

Formulary coverage conditions: Coverage applies according to the drug tier listed; where Requirements/Limits indicate QL, prescriptions must not exceed the stated quantity per period; where Requirements/Limits indicate SP or LA, prior authorization or specialty pharmacy enrollment is required.

This node summarizes the operational coverage stance present in the excerpt.

inv-06: General formulary coverage logic

Coverage and dispensing are governed by formulary tier and requirement flags

Formulary dispensing rules: Drug must be on formulary listing with tier assignment; if Requirements/Limits includes QL, SP, or LA, dispensing is subject to the listed limit or specialty/prior authorization processes

Applies to each product line as listed

inv-07: Prior authorization/Quantity limit indicators

Coverage and utilization management indicators shown in this segment

Formulary management indicators: Drugs marked with 'SP' or 'LA' require special program routing or prior authorization per the plan; drugs with 'QL' have explicit quantity limits; OTC indicates over-the-counter availability.

Exact PA criteria and step edits are not specified in these chunks.

Coverage for drugs listed in this formulary depends on the member's specific benefit plan. A listing in the guide does not guarantee payment; members and providers must consult the member's Certificate of Coverage and member ID card for plan-specific coverage, cost-sharing, and any additional requirements. Not all drugs in this list are paid for by all drug benefit plans, and prior authorization, quantity limits, specialty routing, or other plan rules may apply.

Within the excerpted formulary pages there are no explicit product exclusions listed. Entries show drug names, tier assignments, and any Requirements/Limits fields provided; absence of an explicit exclusion in this excerpt does not imply universal coverage — refer to plan documents for exclusions that may appear elsewhere.

No explicit exclusions are shown in these formulary fragments. The listings include tiers and Requirements/Limits flags (for example, LA or SP) for some products but do not present product-level exclusion statements in the provided excerpt.

This segment of the formulary does not contain explicit exclusions. Product rows list the drug formulation, assigned Drug Tier, and any Requirements/Limits values; where an exclusion applies it would be documented elsewhere in plan materials.

Some listed products are designated OTC in the Requirements/Limits field (for example, aspirin 81 mg and certain levonorgestrel formulations). OTC designation indicates the product is available without a prescription and coverage and billing rules may differ from prescription drugs; confirm benefit plan rules before billing.

No clinical exclusion statements (medical necessity denials) are included in the provided excerpt. The entries are limited to product names, tiers, and Requirements/Limits flags; clinical coverage criteria and exclusions, if any, are maintained in other sections of the plan documentation.

The excerpt does not show any items explicitly designated as 'not medically necessary.' Instead, entries present Drug Tier and Requirements/Limits flags (e.g., QL, SP, LA) which indicate utilization controls rather than explicit NMN determinations in this fragment.

The provided pages do not include formal 'not medically necessary' determinations. Where utilization controls are present (e.g., LA, SP), they signal prior authorization or specialty handling may be required, but no NMN rulings are specified in this excerpt.

No conditions or product listings in this excerpt are labeled as 'not medically necessary.' The listing format focuses on tier assignments and Requirements/Limits indicators; clinical NMN decisions are not part of the visible content here.

Entries in this portion of the formulary primarily display Drug Tier and Requirements/Limits tags such as QL, SP, or LA. The excerpt does not include standalone clinical exclusion or 'not medically necessary' statements; instead it shows quantity limits and program flags that drive dispensing and authorization processes.

Drug Listings, Codes, and Quantity Designations

CARDIOVASCULAR - Calcium channel blockers / AntiarrhythmicsmixedCovered

verapamil_hcl_cap_er_24hr_360_mg	verapamil hcl cap er 24hr 360 mg (Verelan) - included
verapamil_hcl_cap_er_24hr_120_mg	verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg - included
verapamil_hcl_tab_er_120_180_240_mg	verapamil hcl tab er 120 mg, 180 mg, 240 mg - included
verapamil_hcl_tab_40_80_120_mg	verapamil hcl tab 40 mg, 80 mg, 120 mg - included
verapamil_hcl_cap_er_100_200_300_mg	verapamil hcl cap er 24hr 100 mg, 200 mg, 300 mg - noted (E formulation)
amiodarone_hcl_tab_100_200_400_mg	amiodarone hcl tab 100 mg, 200 mg, 400 mg - included
amiodarone_hcl_inj_150mg_450mg_900mg	amiodarone hcl inj 150 mg/3ml, 450 mg/9ml, 900 mg/18ml (50 mg/ml) - included
lidocaine_iv_infusion_d5w_4mgml_8mgml	lidocaine iv infusion in d5w inj 4 mg/ml, 8 mg/ml - included
lidocaine_hcl_iv_pf_soln_100mg5ml_50mg5ml	lidocaine hcl (cardiac) iv pf soln 100 mg/5ml (2%), pref syr 50 mg/5ml (1%), etc. - included
captopril_tab_12.5_25_50_100_mg	captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg - included

1–10 of 14

1/2

ANTIVIRALS / Selected entriesmixedCovered

STRIBILD_tab_150-150-200-300_mg	STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg (QL as noted)
valacyclovir_tab_500_1000_mg	valacyclovir hcl tab 500 mg, 1 gm (Valtrex)
tenofovir_disoproxil_tab_150_200_250_300_mg	tenofovir disoproxil fumarate tab 150 mg, 200 mg, 250 mg, 300 mg (Viread)
valganciclovir_soln_50_mg_ml	valganciclovir hcl for soln 50 mg/ml (Valcyte) and tab 450 mg

ANTIMALARIALS / AntiparasiticsmixedCovered

hydroxychloroquine_tab_100_200_300_400_mg	hydroxychloroquine sulfate tab 100 mg, 200 mg, 300 mg, 400 mg (Plaquenil)
chloroquine_tab_250_500_mg	chloroquine phosphate tab 250 mg; tab 500 mg
atovaquone-proguanil_tab_Malarone	atovaquone-proguanil hcl tab (Malarone)
primaquine_tab_26.3_mg	primaquine phosphate tab 26.3 mg (15 mg base)

ANTI-INFECTIVE - MiscellaneousmixedCovered

clindamycin_caps_75_150_300_mg	clindamycin hcl cap 75 mg, 150 mg, 300 mg (Cleocin)
linezolid_tab_600mg_susp	linezolid tab 600 mg; suspension 100 mg/5ml (Zyvox)
vancomycin_oral_iv_entries	vancomycin hcl cap 125 mg, 250 mg; iv soln 500 mg, 1 gm, 5 gm, 10 gm; oral soln 25 mg/ml, 50 mg/ml (Vancocin, Firvanq)
sulfamethoxazole-trimethoprim_tab_iv_susp	sulfamethoxazole-trimethoprim tab 400-80 mg, ds 800-160 mg; iv soln and susp forms

SPECIFIC ANTIBACTERIAL AGENTSmixedCovered

amoxicillin_tabs_caps_susp_strengths	amoxicillin (trihydrate) chew tabs 125 mg, 250 mg; caps 250 mg, 500 mg; tabs 500 mg, 875 mg; suspensions 125/5ml, 200/5ml, 250/5ml, 400/5ml
amoxicillin_k_clavulanate_tabs_susp_er	amoxicillin & k clavulanate susp and tabs including ES-600 and ER 12hr 1000-62.5 mg and standard strengths 250-125, 500-125, 875-125 mg
ampicillin_entries	ampicillin cap 500 mg; sodium for inj/iv soln various strengths

VACCINES / PASSIVE IMMUNIZING / BIOLOGICALS / SELECTED SPECIALTYmixedCovered

vaccine_list_excerpts	Extensive vaccine and passive immunizing agent list (e.g., ABRYSVO, AREXVY, GARDASIL9, PNEUMOVAX 23, PREVNAR 20, SHINGRIX, COVID-19 vaccines, etc.)
BEYFORTUS_nirsevimab	BEYFORTUS - nirsevimab-alip prefilled syringe 50 mg/0.5ml, 100 mg/ml (SP)
selected_oncology_specialty_entries	Selected antineoplastics and biologics entries appear in this section (e.g., AFINITOR, ABIRATERONE, many LA/SP designations)

FORMULARY STRENGTHS & FORMS (Excerpt)mixed

drug_strengths_examples	Formulary includes specific strengths and forms across classes (injectable vials, pref syringes, tabs, caps, suspensions, ER/CR formulations) as listed throughout the formulary
quantity_limit_examples	Many entries include quantity limits (QL) where noted — examples shown in antiviral, endocrine, gastrointestinal sections

Prior Authorization, Documentation, and Dispensing Guidance

Documentation Required

Special-authority or specialty product flags

Some drugs listed in this formulary may require prior authorization (PA), be designated Limited Availability (LA), or be classified as Specialty (SP) products. These flags indicate additional routing, documentation, or dispensing requirements and may affect where and how a prescription is filled.

Claims must match formulary entries (drug name, strength, form) — mismatches can trigger denials.
Prescription documentation: prescriber name, diagnosis, and treatment history may be requested with PA.
Quantity-limit documentation: when a QL is listed (eg, “QL (30 tablets/30 days)”) supporting clinical rationale may be required for larger quantities.
Documentation placeholders: when a Requirements/Limits field is blank, additional documentation may still be requested per plan rules.
Special program / limited-access documentation: LA or program-specific drugs often require routing through designated specialty channels or programs.
LA/SP authorization notes: Limited Availability (LA) and Specialty (SP) flags commonly indicate prior authorization and/or specialty pharmacy dispensing.
Documentation for restricted products: many LA/SP agents (especially injectable or infused biologics and oncology agents) require clinical notes, prior therapy history, and dosing schedule.

Explicit Quantity Limits and Examples

inv-152: abacavir sulfate soln 20 mg/ml — 960 mls

Productabacavir sulfate solution 20 mg/mL

Quantity limit960 mL per 30 days

TierDrug Tier = 1

inv-153: Many antiretroviral combination tablets — 30 tablets

Product examplesAntiretroviral combination tablets (e.g., BIKTARVY, STRIBILD, GENVOYA, DESCOVY)

Quantity limit30 tablets per 30 days (per listed product)

Typical tierDrug Tier = 2 for many combination products

Specialty Pharmacy, Infusion, and Site-of-Care Notes

Note

Coordinate with infusion center or specialty pharmacy

Some products flagged LA or SP imply limited site‑of‑care or specialty pharmacy distribution; coordinate with the specialty pharmacy or infusion center to ensure correct routing and authorization.

Billing Rule

Do not dispense retail when SP/LA requires specialty routing

Certain products designated 'SP' or 'LA, SP' indicate specialty pharmacy or limited access site‑of‑care requirements; do not dispense via retail when specialty routing is required.

Billing Rule

Route oncology/biologics to specialty pharmacy

Several oncology and biologic agents are designated Requirements/Limits = SP, indicating they are managed through specialty pharmacy channels and may require specialty handling and authorization.

Abbreviations and Formulary Flags

Step Therapy Indicators and Notes

Step therapy note
Step therapy (ST) may require that a member try specified preferred or lower‑tier drugs first before a non‑preferred drug will be covered; exceptions can be requested through member services.

Step therapy sequences
No explicit step therapy sequences are detailed in the provided formulary excerpts; tiering and QL flags suggest utilization controls but do not define ordered steps.

Step therapy sequences (fragment)
The fragment lists many products with Requirements/Limits (e.g., QL, SP, LA) but does not provide explicit step‑therapy sequences or required prior agents to be tried first.

LA flag implication
Entries annotated with LA (Limited Availability) may indicate limited access that often accompanies prior authorization or a requirement to meet prior step conditions before coverage, although specific step rules are not listed.

Explicit step-therapy steps listed?
No explicit step‑therapy steps are listed in this excerpt of the formulary.

SP/LA specialty routing requirement
Products marked SP or LA are noted as requiring specialty pharmacy handling or limited access authorization prior to coverage, which may functionally require specialty routing before benefit approval.

Quantity limits and step edits
Quantity limits (QL) and tier assignments shown for inhaled controllers and other agents (examples: ADVAIR HFA QL 1 inhaler/30 days; ASMANEX HFA QL 1 canister/30 days) suggest these products may be subject to step edits or quantity‑based program controls.

SP/LA annotations and step implication
Specialty/LA annotations on many biologic and specialty agents (e.g., OMVOH, mirikizumab) imply these products are managed via specialty programs and may be subject to step or programmatic routing, though specific step sequences are not provided.

Specialty pharmacy / prior authorization handling
Some limited‑availability or specialty agents (e.g., ZYMFENTRA, NUPLAZID) are managed through specialty pharmacy channels and require prior authorization or program enrollment before coverage is provided.

Explicit step sequences provided?
No explicit step‑therapy sequences are provided in the excerpts reviewed; the document lists requirement flags and QL values but does not enumerate ordered step requirements.

LA/SP designation implication
LA or SP designations indicate limited access or specialty program management that often implies additional authorization or routing (and may be associated with step or site‑of‑care requirements), even though explicit step rules are not shown.

SP/LA subject to step edits or PA?
Drugs marked SP or LA are typically subject to utilization management such as prior authorization, specialty pharmacy routing, or step edits; the formulary excerpts show these flags but do not list specific step sequences.

Background and Scope

Background: This formulary shows both brand-name and generic products and indicates tier placement plus common utilization controls. Listings include Drug Tier assignments and a Requirements/Limits field that may show QL (quantity limit), SP (specialty program/site or specialty pharmacy), or LA (limited access). These flags denote operational controls: QLs specify maximum quantities per period, and SP/LA entries indicate specialty routing or prior authorization processes that must be satisfied for coverage.

Policy Revision History

2026-04-01policy_effectiveLatest

Formulary was updated and is effective as of April 1, 2026.

2026-04-26document_publication

Document contains EmblemHealth contact and Formulary ID U86M with publication reference dated April 26, 2026.

Policy Summary

PayerEmblemHealth

Policy2026 Medicare Prescription Drug Formulary - EmblemHealth

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization when a drug is marked LA or SP and ensure prescriptions comply with stated quantity limits (QL).

SourceLink

On This Page

Prior Authorization

Prior Authorization Required

Prior authorization or other approval is required for many Specialty (SP) and Limited Availability (LA) products, and for select biologic and specialty agents. Authorization flags in the formulary indicate that a PA may be required to avoid denial.

Prior Authorization Required: PA is often required for SP/LA products — examples in the formulary include many oncology, biologic, and infusion/injectable therapies.
Prior authorization may be required for QL or specialty-tier drugs: exceeding a listed QL or selecting a specialty-tier alternative can trigger PA.
Authorization flags indicate potential denial risk: when a drug record shows LA or SP (or PA), claims submitted without prior approval are at risk of denial.

Prior Authorization

Specialty/Authorization requirement

Many oncology agents and other high-cost specialty therapies are marked LA and/or SP and are routed through specialty pharmacy channels or require limited‑access routing. Prescribers should expect utilization management at point of dispensing.

LA or SP required for many oncology agents: formulary entries for agents such as AFINITOR, ALECENSA, AYVAKIT, and multiple chemotherapy/intravenous agents list LA, SP.
Specialty/limited access routing: drugs marked LA or SP may need to be dispensed by a designated specialty pharmacy or through an infusion clinic contracted with the plan.
LA/SP utilization management: prior authorization, step requirements, site-of-care restrictions, and mandated specialty pharmacy use are examples of utilization controls applied to these agents.

Note

Prior authorization may be required

Prior authorization decisions and specialty pharmacy requirements vary by drug and by plan. The formulary does not list every possible PA condition; absence of explicit PA text in a drug row does not guarantee PA will not be required.

Prior authorization may be required: absence of a PA label in a single entry does not mean the product is exempt from PA under other program rules.
Prior authorization not enumerated in this segment: many entries show only LA/SP/QL flags — check the plan’s PA criteria for details.
Denial triggers not specified here: this section highlights risk areas but is not an exhaustive list of denial triggers; consult PA policies and the Certificate of Coverage.

Prior Authorization

Prior authorization / specialty pharmacy

Specialty pharmacy, limited-access routing, and prior authorization flags are common drivers of claim routing and potential denials. Providers should follow plan instructions for submitting PA requests and documentation.

Prior authorization / specialty pharmacy: many SP drugs (eg, injectables, biologics) require dispensing via a specialty pharmacy and an approved PA prior to fill.
Specialty / Limited Access and Quantity Limit Denials: submitting claims that exceed QLs or that do not include required PA/authorization for LA/SP drugs may be denied.
Quantity limit enforcement: QLs shown (for example QL (30 tablets/30 days), QL (60 tablets/30 days), QL (360 capsules/30 days)) are actively enforced; exceeding these can prompt PA requests or claim denial.

Step Therapy

Step/Program indicators

Step therapy and step/program indicators are used in some cases but are not detailed for every drug in this segment. Where step therapy applies, it will be noted as ST or described in the plan’s PA criteria.

Step/quantity considerations: some products are subject to both step therapy and QLs; providers should review plan criteria before prescribing.
Step/site-of-care noted but details absent: the formulary may flag site-of-care or step requirements without full operational detail — consult the PA policy.
Step therapy not detailed: if a drug is subject to ST, specific step requirements and allowable alternatives are maintained in the plan’s PA guidelines.

Denial Risk

Requirements/Limits and denial risk

Follow the Requirements/Limits tags in each formulary row. When a Requirements/Limits field shows LA, SP, QL, or PA, be prepared to supply supporting clinical documentation and to use designated dispensing channels when required.

Requirements/Limits may trigger denial: claims that do not comply with the listed Requirements/Limits (LA, SP, QL, PA) are at risk of denial.
Limited access / specialty flag may trigger prior authorization: LA and SP entries commonly trigger PA workflows.
Authorization flags indicate potential denial risk: an LA or SP marker is a signal to initiate PA before dispensing.

inv-154: ritonavir (Norvir) — 360 tablets

Productritonavir (Norvir) 100 mg tablets

Quantity limit360 tablets per 30 days

TierDrug Tier = 1

inv-155: emtriva soln — 680 mls

ProductEMTRIVA (emtricitabine) oral solution 10 mg/mL

Quantity limit680 mL per 28 days

TierDrug Tier = 2

inv-156: oseltamivir — 40 capsules

Productoseltamivir phosphate capsules (Tamiflu)

Quantity limit40 capsules per 120 days

TierDrug Tier = 1

inv-157: oseltamivir suspension — 300 mls

Productoseltamivir phosphate suspension (Tamiflu) 6 mg/mL

Quantity limit300 mL per 120 days

TierDrug Tier = 1

inv-158: zidovudine syrup — 1920 mls

Productzidovudine syrup (Retrovir) 10 mg/mL

Quantity limit1920 mL per 30 days

TierDrug Tier = 1

inv-159: STRIBILD — 30

ProductSTRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir) tablets

Quantity limit30 tablets per 30 days

TierDrug Tier = 2

inv-160: VIREAD — 30

ProductVIREAD (tenofovir disoproxil fumarate) 300 mg tablets

Quantity limit30 tablets per 30 days

TierDrug Tier = 1

inv-161: zidovudine syrup (Retrovir) — 1920

Productzidovudine syrup (Retrovir) 10 mg/mL

Quantity limit1920 mL per 30 days

TierDrug Tier = 1

inv-162: zidovudine capsules (Retrovir) — 180

Productzidovudine capsules (Retrovir) 100 mg

Quantity limit180 capsules per 30 days

TierDrug Tier = 1

inv-163: nitazoxanide — 12

Productnitazoxanide tablets

Quantity limit12 tablets per 90 days

TierDrug Tier indicated in listing

inv-164: CLIMARA PRO - estradiol-levonorgestrel td patch — 4

ProductCLIMARA PRO (estradiol-levonorgestrel) transdermal patch

Quantity limit4 patches per 28 days

TierDrug Tier = 2

inv-165: Divigel estradiol td gel packets — 30

ProductDivigel estradiol topical gel packets

Quantity limit30 packets per 30 days

TierDrug Tier = 1

inv-166: Divigel estradiol td gel (37.5 g) — 37.5

ProductDivigel estradiol topical gel (37.5 g) bottle/packet

Quantity limit37.5 grams per 30 days

TierDrug Tier = 1

inv-167: COMBIPATCH — 8

ProductCOMBIPATCH (estradiol-norethindrone) transdermal patch

Quantity limit8 patches per 28 days

TierDrug Tier = 2

inv-168: FARXIGA (dapagliflozin) — 30

ProductFARXIGA (dapagliflozin)

Quantity limit30 tablets per 30 days

TierDrug Tier = 2

inv-169: JANUVIA (sitagliptin) — 30

ProductJANUVIA (sitagliptin)

Quantity limit30 tablets per 30 days

TierDrug Tier = 2

inv-170: TRULICITY (dulaglutide) — 33

ProductTRULICITY (dulaglutide) auto-injector pens

Quantity limit33 pens per 30 days

TierDrug Tier = 2

inv-171: FIASP (insulin aspart) — 10

ProductFIASP (insulin aspart) vials

Quantity limit10 vials per 30 days

TierDrug Tier = 2

inv-172: FIASP FLEXTOUCH — 33

ProductFIASP FLEXTOUCH (insulin aspart) pen devices

Quantity limit33 pens per 30 days

TierDrug Tier = 2

inv-173: NOVOLOG MIX 70/30 — 10

ProductNOVOLOG MIX 70/30 vials

Quantity limit10 vials per 30 days

TierDrug Tier = 2

inv-174: NOVOLOG MIX 70/30 PREFILL — 33

ProductNOVOLOG MIX 70/30 Prefill (pens)

Quantity limit33 pens per 30 days

TierDrug Tier = 2

inv-175: XULTOPHY 100/3.6 — 5

ProductXULTOPHY 100/3.6 (insulin degludec/liraglutide) pens

Quantity limit5 pens per 30 days

TierDrug Tier = 2

inv-176: Combination SGLT2/Metformin and others — 30 or 60

ProductCombination SGLT2/Metformin products (e.g., INVOKAMET, SYNJARDY, TRIJARDY XR, XIGDUO XR)

Quantity limit30 or 60 tablets per 30 days depending on formulation

TierDrug Tier = 2 (varies by product)

inv-177: tolvaptan (Samsca) — 15 mg: 30 tablets/365 days; 30 mg: 60 tablets/365 days

Producttolvaptan (Samsca)

Quantity limits15 mg: 30 tablets per 365 days; 30 mg: 60 tablets per 365 days

TierDrug Tier = 1; Requirements/Limits = QL and SP

inv-178: ADVAIR HFA / various inhalers — examples include 1 inhaler/30 days, 2 inhalers/30 days, 60 blisters/30 days

Product examplesADVAIR HFA and various inhaler controllers

Quantity limitsExamples include 1 inhaler/30 days, 2 inhalers/30 days, or 60 blisters/30 days depending on product

TierDrug Tier = 2 for many inhaled controllers

inv-179: SPIRIVA HANDIHALER — 30 capsules/30 days

ProductSPIRIVA HANDIHALER (tiotropium capsules)

Quantity limit30 capsules per 30 days

TierDrug Tier = 1

inv-180: dexlansoprazole 30 mg — 60 capsules

Productdexlansoprazole 30 mg (Dexilant)

Quantity limit60 capsules per 30 days

TierDrug Tier = 1

inv-181: lanthanum carbonate chewable — 270 tablets

Productlanthanum carbonate chewable (Fosrenol)

Quantity limit270 tablets per 30 days

TierDrug Tier = 1

inv-182: sevelamer carbonate packet — 510 packets

Productsevelamer carbonate packets (Renvela)

Quantity limit510 packets per 30 days

TierDrug Tier = 1

inv-183: oxybutynin chloride solution — 600 mL

Productoxybutynin chloride solution 5 mg/5 mL

Quantity limit600 mL per 30 days

TierDrug Tier = 1

inv-184: MYRBETRIQ - mirabegron ER — 30 tablets

ProductMYRBETRIQ (mirabegron) ER tablets

Quantity limit30 tablets per 30 days

TierDrug Tier = 2

inv-185: oxybutynin chloride solution — 600 mls

Productoxybutynin chloride solution 5 mg/5 mL

Quantity limit600 mL per 30 days

TierDrug Tier = 1

inv-186: oxybutynin chloride ER 10 mg,15 mg — 60 tablets

Productoxybutynin chloride ER 10 mg, 15 mg

Quantity limit60 tablets per 30 days

TierDrug Tier = 1

inv-187: oxybutynin chloride 5 mg — 120 tablets

Productoxybutynin chloride 5 mg tablets

Quantity limit120 tablets per 30 days

TierDrug Tier = 1

inv-188: solifenacin succinate (Vesicare) — 30 tablets

Productsolifenacin succinate (Vesicare)

Quantity limit30 tablets per 30 days

TierDrug Tier = 1

inv-189: tolterodine tartrate ER — 30 capsules

Producttolterodine tartrate ER capsules

Quantity limit30 capsules per 30 days

TierDrug Tier = 1

inv-190: tolterodine tartrate tab 1 mg — 60 tablets

Producttolterodine tartrate tablets 1 mg

Quantity limit60 tablets per 30 days

TierDrug Tier = 1

inv-191: trospium chloride ER 60 mg — 30 capsules

Producttrospium chloride ER 60 mg capsules

Quantity limit30 capsules per 30 days

TierDrug Tier = 1

inv-192: trospium chloride 20 mg — 60 tablets

Producttrospium chloride 20 mg tablets

Quantity limit60 tablets per 30 days

TierDrug Tier = 1

inv-193: estradiol vaginal cream (Estrace) — 255 grams

Productestradiol vaginal cream (Estrace)

Quantity limit255 grams per 365 days

TierDrug Tier indicated in listing

inv-194: ESTRING - estradiol vaginal ring — 1 ring

ProductESTRING (estradiol vaginal ring)

Quantity limit1 ring per 90 days

TierDrug Tier = 2

inv-195: Amphetamine-dextroamphetamine examples — various QL values (180 tablets/30 days, 60 capsules/30 days, 30 capsules/30 days)

Product classamphetamine-dextroamphetamine formulations (various strengths/brands)

Quantity limitsExamples include 180 tablets/30 days, 60 capsules/30 days, 30 capsules/30 days depending on formulation

TierDrug Tier varies by product (listed in entries)

inv-196: Methylphenidate examples — QL 60 tablets/30 days, 30 capsules/30 days, 360 tablets/30 days

Product classmethylphenidate formulations (multiple forms)

Quantity limitsExamples include QL 60 tablets/30 days, 30 capsules/30 days, up to 360 tablets/30 days for some formulations

TierDrug Tier varies by formulation

inv-197: pregabalin ER (Lyrica CR) — QL 30 tablets/30 days (82.5/165 mg) and QL 60 tablets/30 days (330 mg)

Productpregabalin ER (Lyrica CR) 82.5 mg, 165 mg, 330 mg

Quantity limits82.5/165 mg: QL 30 tablets/30 days; 330 mg: QL 60 tablets/30 days

TierDrug Tier = 1

inv-198: pregabalin ER 82.5 mg, 165 mg — 30

Product strengthspregabalin ER 82.5 mg, 165 mg

Quantity limit30 tablets per 30 days (per listing)

TierDrug Tier = 1

inv-199: SAVELLA (milnacipran) tablets — 60

ProductSAVELLA (milnacipran) tablets

Quantity limit60 tablets per 30 days

TierDrug Tier = 2

inv-200: butalbital-acetaminophen — 180

Productbutalbital-acetaminophen formulations

Quantity limit180 capsules/tablets per 30 days

TierDrug Tier = 1

inv-201: buprenorphine-naloxone films/tabs — varies (60-120)

Productbuprenorphine-naloxone films/tabs (Suboxone and others)

Quantity limitExamples vary by formulation (QLs listed: 60–120 per 30 days)

TierDrug Tier = 1

inv-202: methadone and morphine oral solutions — examples 900 mls/30 days, 2700 mls/30 days

Product classmethadone and morphine oral solutions

Quantity limitsExamples include 900 mL/30 days and 2700 mL/30 days depending on formulation

TierVarious tiers as listed

inv-203: morphine sulfate oral soln 10 mg/5ml — 2700

Productmorphine sulfate oral solution 10 mg/5 mL

Quantity limit2700 mL per 30 days

TierDrug Tier listed in formulary entries

inv-204: morphine sulfate oral soln 20 mg/5ml — 1350

Productmorphine sulfate oral solution 20 mg/5 mL

Quantity limit1350 mL per 30 days

TierDrug Tier listed in formulary entries

inv-205: oxycodone w/ acetaminophen tab 7.5-300 mg — 240

Productoxycodone w/ acetaminophen 7.5/300 mg tablets

Quantity limit240 tablets per 30 days

TierDrug Tier = 2

inv-206: oxycodone soln 5 mg/5ml — 5400

Productoxycodone oral solution 5 mg/5 mL

Quantity limit5400 mL per 30 days

TierDrug Tier = 1

inv-207: oxycodone tab 5 mg — 360

Productoxycodone tablets 5 mg

Quantity limit360 tablets per 30 days

TierDrug Tier = 1

inv-208: pregabalin (various strengths) — 360; 270; 180; 90; 60 capsules per 30 days; solution 900 mL/30 days

Product classpregabalin (various strengths) — Lyrica and formulations

Quantity limitsExamples: 360, 270, 180, 90, 60 capsules per 30 days depending on strength; solution 900 mL/30 days

TierDrug Tier = 1 (as listed)

Note

Verify infusion vs. specialty pharmacy site for IV biologics

Certain IV biologics and specialty agents indicate SP and LA which implies administration in an infusion center or managed distribution through specialty pharmacy — verify site and authorization prior to administration.

Note

Manage SP/LA agents via specialty or limited‑access channels

Some specialty agents are designated SP/LA and typically require management through specialty pharmacy or limited‑access channels; coordinate home infusion or clinic administration as indicated by the program.

Billing Rule

Use specialty pharmacy for SP/LA products

Products flagged 'SP' or 'LA' are handled via specialty pharmacy or limited‑access channels and will require prior authorization and program enrollment before dispensing.

Note

Confirm administration site for injectable biologics

Some IV/subcutaneous biologic products list Requirements/Limits = SP or LA which may route administration to infusion center, office, or specialty pharmacy; confirm site‑of‑care and authorization prior to scheduling.

Billing Rule

Adalimumab biosimilars require specialty program routing

Multiple adalimumab biosimilars are listed with Requirements/Limits = SP, indicating biosimilars are managed through specialty program/prior authorization routing similar to reference products.