Part 1 of the EmblemHealth NYSHIP No-Rx Formulary (Formulary ID -NYS1) listing covered drugs, tiers, and requirements/limits (e.g., ACA, PA, QL, SP, LA, OTC) as of Jan 1, 2026. This part includes introductory material, member contact/language/access notices, nondiscrimination, and the beginning of the alphabetical formulary entries (Anti-infective agents, Biologicals, Vaccines, Toxoids, Passive immunizing agents, Antineoplastics, Endocrine/Contraceptives, Antidiabetics) with tier and requirement annotations.
Policy Summary
PayerEmblemHealth
Policynyship-no-rx-formulary-2026-emblemhealth
Policy CodePolicy Formulary ID -NYS1
Change TypeNo material change
Effective DateJan 1, 2026
Next Review Date
Key ActionProviders/pharmacies must verify the member's specific plan formulary and tier using the member ID/formulary letter and may need to obtain prior authorization or follow quantity limits/step therapy as annotated (PA, QL, ST, SP).
No material clinical or coverage changes reported in this update (has_material_change=false).
manyDrugs listed in Part 1
100+Line items in partial extract
MultipleProducts with PA requirement
MultipleProducts with QL limits
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ACAACA preventive tier entries
Coverage Summary
Part 1 of the EmblemHealth NYSHIP No‑Rx Formulary (Formulary ID -NYS1) lists covered drugs, tiers, and requirement/limit annotations and is effective as of 2026-01-01 (last reviewed 2026-01-01). This extract provides the introductory material and the start of the alphabetical formulary entries (e.g., anti-infectives, biologicals, vaccines, antineoplastics, endocrine/contraceptives, antidiabetics) with tier and requirement annotations such as ACA, PA, QL, SP, LA, and OTC.
Formulary Annotations & How to Use
Background: This Part 1 formulary lists covered drugs and selected medical devices and supplies for EmblemHealth NYSHIP members. It is current as of the Effective Date 2026-01-01 and describes coverage tiers, common utilization management tools (prior authorization, step therapy, quantity limits), and where to get help. Member services are available at 800-447-8255 (TTY: 711), Monday–Friday, 8 a.m.–6 p.m. If a prescribed drug or device is not listed, members should call member services for next steps. Members may request exceptions to restrictions; clinical documentation from the prescribing provider may be required.
Member resources and language assistance: Members can view the full drug list and search the formulary online at emblemhealth.com under Member Resources > Drugs Covered or sign in to the member portal at my.emblemhealth.com. Free language assistance services and auxiliary aids and services are available in multiple languages and accessible formats; call 877-411-3625 (TTY: 711) for assistance.
Nondiscrimination notice summary: EmblemHealth complies with federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, gender identity, intersex traits, and related conditions). Reasonable modifications and free auxiliary aids and services (e.g., qualified sign language interpreters, written information in alternative formats) are available to people with disabilities upon request.
Formulary Annotationsmixed
ACA
Affordable Care Act: $0 cost-share preventive drugs when clinically appropriate
FF
Frozen Formulary: coverage/copay/utilization may change per mandate
LA
Limited Availability: available only at select pharmacies
OTC
Over the Counter: non-prescription product
PA
Prior Authorization: plan approval required before coverage
QL
Quantity Limit: coverage limited to specified amount
SP
Specialty: may require special handling, monitoring, or education
ST
Step Therapy: must try specified alternative(s) first
Glossary:
anastrozole 1 mg: Aromatase inhibitor used in hormone receptor–positive breast cancer (generic anastrozole).
exemestane 25 mg: Steroidal aromatase inhibitor for certain breast cancer indications (generic exemestane).
tamoxifen (Soltamox); tamoxifen citrate tab 10 mg, 20 mg: Selective estrogen receptor modulator used in breast cancer prevention and treatment (includes brand Soltamox and generic tamoxifen citrate).
KETONE TEST STRIPS / KETOSTIX - acetone (urine) test strip; RELION KETONE TEST STRIPS - acetone (urine) test strip: Urine ketone test strips for ketone monitoring.
PRECISION XTRA BLOOD GLUC - glucose blood test strip; PRECISION XTRA BLOOD GLUC: Blood glucose test strips for home glucose monitoring.
RELION GLUCOSE; RELION KETONE TEST STRIPS: Over-the-counter brand lines for glucose and ketone home testing supplies.
MEDICAL DEVICES (general): Durable medical equipment and related supplies that may be covered under the medical benefit or pharmacy benefit depending on product and indication.
Listed products (alphabetical entries in this document segment)mixed
HUMALOG MIX 75/25 KWIKPEN
listed (references: Humalog insulin entries)
HUMALOG TEMPO PEN
listed
HUMULIN 70/30
listed
HUMULIN 70/30 KWIKPEN
listed
HUMULIN N
listed
HUMULIN N KWIKPEN
listed
HUMULIN R
listed
HUMULIN R U-500 KWIKPEN
listed
levonorgestrel tab 1.5 mg
listed
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
listed
1–10 of 74
1/8
Provider Requirements & Billing Rules
Prior Authorization
Prior authorization required when annotated
Drugs annotated with 'PA' require the plan's prior authorization before coverage; failure to obtain PA may result in noncoverage.
Documentation Required
Use formulary index and check plan-specific coverage
Providers/pharmacies must verify the member's specific plan formulary and tier using the member ID/formulary letter and may need to obtain prior authorization or follow quantity limits/step therapy as annotated (PA, QL, ST, SP).
Quantity Limits & Thresholds (Selected Items)
Interpretation note: QL annotations and other inline requirements shown after each formulary entry indicate the plan's claim‑editing or coverage limits and must be applied as listed (for example, QL values such as 30 tablets/30 days or device limits like 1 receiver/365 days). Providers and pharmacies should verify member plan details, obtain required prior authorizations where PA is annotated, and apply step therapy (ST) and specialty (SP) handling per the formulary instructions.
Clinical Evidence & Notes
This Part 1 extract is a formulary listing and reference that provides covered products, tiers, and utilization annotations; it does not include discrete clinical trial or evidence metrics in this segment. Clinical‑evidence summaries are not provided in Part 1 of the extract.
Revision History
2026-01-01EffectiveLatest
Formulary effective date / Part 1 published (Formulary updated on Jan. 1, 2026). Last review: 2026-01-01
Policy Summary
PayerEmblemHealth
Policynyship-no-rx-formulary-2026-emblemhealth
Policy CodePolicy Formulary ID -NYS1
Change TypeNo material change
Effective DateJan 1, 2026
Next Review Date
Key ActionProviders/pharmacies must verify the member's specific plan formulary and tier using the member ID/formulary letter and may need to obtain prior authorization or follow quantity limits/step therapy as annotated (PA, QL, ST, SP).
AUTOSOFT XC/30/90 INFUSION SET - infusion set: Infusion set options for insulin pump therapy (different cannula lengths and wear-times).
CONDOMS MALE - VARIOUS; VCF VAGINAL CONTRACEPTIVE: Barrier contraceptive products covered per benefit design.
CONTOUR BLOOD GLUCOSE MON - blood glucose monitoring devices: Blood glucose meters for home use, subject to benefit rules for meters and supplies.
DEXCOM G6 RECEIVER; DEXCOM G6 SENSOR; DEXCOM G6 TRANSMITTER: Components of the Dexcom G6 continuous glucose monitoring system (receiver, disposable sensor, transmitter).
EXTENDED INFUSION SET 23" / 32": Longer-length infusion sets for insulin pump therapy when clinically indicated.
MINIMED SENSOR - glucose monitoring sensor noninvasive device; MINIMED QUICK SET / RESERVOIR / SILHOUETTE INFUSION SETS; SILHOUETTE INFUSION SET 1; SILHOUETTE INFUSION SET 2; SILHOUETTE INFUSION SET 4; PARADIGM SILHOUETTE INFUS - Insulin pump sensors and infusion set families compatible with MiniMed/Paradigm systems.
ILET STARTER KIT; T:SLIM X2 3 ML CARTRIDGE; T:FLEX T:LOCK INSULIN CAR; TWIIST REFILL KIT / INFUSIO - insulin infusion disposable pump reservoir/infus set kit: Starter and refill kits for various pump platforms.
OMNIPOD DASH INTRO KIT (G); OMNIPOD 5 DEXCOM G7G6 POD - pods; OMNIPOD 5 LIBRE2 PLUS G6 - pump kit/pods; V-GO 20 / 30 / 40 - insulin infusion disposable pump kit (20/30/40 unit/24hr): Pod-based and patch pump systems and related kits.
TANDEM MOBI AUTOSOFT 30; TANDEM MOBI AUTOSOFT 30 S; TANDEM MOBI AUTOSOFTXC 14; TANDEM MOBI AUTOSOFTXC 14: Tandem pump infusion set variants (Autosoft series) and related supply kits.
OMNIPOD 5 and related interoperable pods: Pod devices and starter kits subject to medical policy and supply coverage rules.
WIDE-SEAL SILICONE DIAPHRAGM (various sizes): Replacement diaphragms for insulin pump reservoirs/containers as applicable.
Numerous additional drug and device line items (alphabetical A–F shown) including vaccines, diabetics supplies, contraceptives, and common generics; members should consult the full formulary index for item-level coverage and tiering.
KINRIX; PREVNAR 20; PRIORIX; PROQUAD; QUADRACEL; RABAVERT: Selected vaccine products included on the formulary/vaccine list where applicable.
norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg; 0.8 mg-25 mcg; norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg; 1.5 mg-30 mcg; norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24); norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg (24); norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24); norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg: Oral contraceptive formulations and strengths included in the contraceptives section.
NOVAFERRUM PEDIATRIC DROP; PRENATAL; PRENATAL AND IRON; PRENATAL COMPLETE; PRENATAL MULT + DHA; PRENATAL MULTIVITAMIN; PRENATAL ONE DAILY; PRENATAL VITAMIN/IRON; PRENATAL VITAMINS; PRENATAL VITAMIN & MINERA: Prenatal vitamins and pediatric iron preparations listed under OTC or covered supplement categories as applicable.
NOVOLIN 70/30; NOVOLIN 70/30 FLEXPEN; NOVOLIN N; NOVOLIN N FLEXPEN; NOVOLIN R; NOVOLIN R FLEXPEN; NOVOLOG FLEXPEN; TOUJEO MAX SOLOSTAR; SOLIQUA 100/33; SEMGLEE: Insulin and insulin analog products and combination agents covered per formulary and medical policy.
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm; peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln 100 gm: Bowel prep/PEG solutions included where applicable.
PREFERRED PLUS GLUCOSE; RELION GLUCOSE; PRECISION XTRA BLOOD GLUC: Preferred glucose monitoring strip lines and meter supplies.
KETONE and GLUCOSE test supplies: Multiple brands of blood glucose strips and urine ketone strips are included; members should verify covered NDCs or supply SKUs in the detailed formulary index.
ZEVRX STERILE ALCOHOL PRE; SB ALCOHOL PREP PADS: Sterile alcohol prep pads listed as covered supply items where applicable.
T:SLIM X2 cartridges and other platform-specific cartridges: Platform-specific insulin cartridge supplies (e.g., T:SLIM) are included under pump supply coverage.
Vitamins w/ lipotropics tab and other specialty supplement formulations: Coverage varies by benefit; check the formulary and plan documents.
VCF VAGINAL CONTRACEPTIVE; CONDOMS MALE - VARIOUS: Contraceptive devices and supplies included per benefit design.
Note: This glossary is a brief reference. The full formulary index contains item-level codes, NDCs, device model names, and coverage annotations (ACA, FF, LA, OTC, PA, QL, SP, ST). For coverage determinations, prior authorization requirements, and exact supply quantities, consult the full formulary or call member services.
Billing Rule
OTC and ACA preventive coverage handling
Some drugs are designated ACA (preventive $0 cost share) or OTC; providers/pharmacies must apply plan benefit rules and quantity limits specified.
Example QL: 30 tablets/30 days
Prior Authorization
Prior authorization required for selected devices/kits
Certain insulin pumps and starter kits (e.g., ILET insulin pump and kits, OMNIPOD DASH, OMNIPOD 5, OMNIPOD LIBRE2 kits, TWIIST kits, V-GO systems) are subject to prior authorization (PA) as indicated in the listing.
Ilet pump
Omnipod
TWIIST
V-GO
Billing Rule
Quantity limits for supplies and devices
Quantity limits (QL) apply to many products (e.g., blood glucose test strips 204/30 days; Dexcom sensors/receivers/transmitters; Omnipod pods 30/30 days; V-GO 30 systems/30 days); claims should respect listed QL values.