2026 Formulary (List of Covered Drugs)
A Medicare prescription drug formulary listing covered drugs, tiers, and requirements/limits (prior authorization PA, quantity limits QL, step therapy ST, limited availability LA, special program SP, ACA). Applies to EmblemHealth members as of the formulary update date and provides contact information and instructions for exceptions.
No material clinical or coverage changes in this update.
Coverage Summary
Utilization Management & Provider Actions
Prior Authorization / Quantity Limits / Step Therapy / Other Requirements
Covered when plan requirements met:
ALL of the following
- Prior Authorization (PA): The plan requires approval before coverage; prescriptions without approval may be denied.
Operational: Prior authorization requests should include clinical rationale, relevant diagnostics, prior medication history when applicable.
- Quantity Limits (QL): Coverage may be limited to a specified quantity or dosing interval. Claims exceeding limits may be rejected or require PA.
Examples and numeric limits appear in billing_rule callouts below.
- Step Therapy (ST): The plan may require trial of specified preferred agents before non-preferred drugs are covered.
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