2026 Medicare Prescription Drug Formulary - EmblemHealth
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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.
No material clinical or coverage changes in this revision.
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.
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
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
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.
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.
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
Applies to each product line as listed
inv-07: Prior authorization/Quantity limit indicators
Coverage and utilization management indicators shown in this segment
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
| 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 |
| 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 |
| 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) |
| 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 |
| 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 |
| 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) |
| 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
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.
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.
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.
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 / 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/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.
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.
Explicit Quantity Limits and Examples
Specialty Pharmacy, Infusion, and Site-of-Care Notes
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.
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.
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.
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.
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.
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.
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.
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.
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
Formulary was updated and is effective as of April 1, 2026.
Document contains EmblemHealth contact and Formulary ID U86M with publication reference dated April 26, 2026.
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