Prior Authorization, Documentation and Billing Requirements

Prior Authorization Required. Certain drugs and supplies listed in this formulary require prior authorization (PA) before the plan will cover them. If prior authorization is not obtained, the claim may be denied.

• Examples of drugs requiring PA: mifepristone (PA, QL, SP), MOUNJARO (PA, QL), OZEMPIC (PA, QL), TRULICITY (PA indicated where listed), many GLP agents
• Specialty or limited-access products (flagged SP or LA) may have additional PA criteria (e.g., extended-release buprenorphine products such as BRIXADI are LA and SP)
• Prior authorization is required for specified insulin pumps and pump kits (e.g., ILET pump and starter kits, OMNIPOD intro kits, OMNIPOD 5 kits, TWIIST starter kit)
• V-GO disposable pump kits (V-GO 20/30/40) require PA and are subject to quantity limits (PA, QL — typically QL (30 systems/30 days) or as listed)
• PA applies to other specialty injectable or extended-release formulations as indicated on the formulary rows

Prior authorization / Quantity limit triggers

Prior authorization and Quantity Limits (QL). Requests that exceed published quantity limits or that lack required PA documentation may be denied. Follow the Requirements/Limits field on each formulary row when submitting claims or PA requests.

• Examples of QL enforcement: FARXIGA (QL 30 tablets/30 days), JANUMET/XR (QL 60 or 30 tablets/30 days), insulin pens/cartridges (various QL values), CGM supplies (e.g., test strips QL 204/30 days)
• Pump/kits QL examples: ILET pump (PA, QL 1 kits/720 days), OMNIPOD intro kits (PA, QL 1 kit/720 days), OMNIPOD pods (PA, QL 30 pods/30 days), V-GO kits (PA, QL 30 systems/30 days)
• GLP and tirzepatide agents show PA plus pen/pen-count QLs (MOUNJARO: PA, QL 4 pens/28 or 180 days; OZEMPIC: PA, QL 1–3 pens/28 days depending on strength)

Documentation expectations for PA/QL/LA/SP items

Documentation expectations for PA/QL/LA/SP items. When a formulary entry lists PA, QL, LA (Limited Access) or SP (Specialty), provide clinical justification and supporting documentation with the PA submission. Use the plan's PA forms and include relevant clinical notes, prior therapies tried, and dosing/quantity rationale.

• Include diagnosis, prior treatment history, and reason for the requested drug or device; for specialty drugs include monitoring plan and handling requirements
• For QL exceptions or requests exceeding the stated limit, provide rationale and supporting clinical information
• For LA/SP products, include documentation that the member requires the specialty formulation or product and that standard alternatives are inappropriate or contraindicated

Claims and PA documentation

Claims and PA documentation. Pharmacy claims must include accurate NDC and days' supply consistent with the formulary QL. When 'PA' is indicated on the formulary row, ensure PA fields are populated on the claim or a PA has been submitted and approved prior to dispensing.

• Populate PA fields on the claim when a formulary row indicates 'PA' to avoid adjudication failure
• Verify NDC, quantity, and days' supply match the approved PA; mismatches may result in denial or reversal
• For device/supply items billed under medical benefit, include HCPCS/CPT as appropriate and attach PA approval when filing claims

PA required for pumps/kits

Required documentation for PA for pumps and pump kits. Prior authorization submissions for insulin pumps and disposable pump kits must include clinical justification, history of insulin therapy, evidence of frequent glucose monitoring or hypoglycemia as applicable, and prior therapy attempts when requested.

• Specific pump/kits requiring PA: ILET insulin pump and starter kits (PA, QL), OMNIPOD DASH/OMNIPOD 5 kits and pods (PA, QL), OMNIPOD INTRO KIT, TWIIST starter kit (PA where listed)
• Supply frequency and device replacement intervals are governed by QL (e.g., 1 kit/720 days for many pumps; pods often QL 30 pods/30 days)
• Include physician order, pump training plan, and supplier details with PA submission

Special program requirements

Special program requirements and specialty/limited-access flags. Products flagged with 'SP' (Specialty) or 'LA' (Limited Access) may require enrollment in a specialty program, specialty pharmacy dispensing, or additional monitoring and documentation.

• BRIXADI buprenorphine extended-release products are flagged LA and SP and have special handling and dispensing requirements
• Some agents (e.g., certain injectable or extended-release formulations) may only be available through contracted specialty pharmacies

Prior authorization indicated; Quantity limit enforcement

Quantity limit enforcement and PA indicated. Dispensing beyond stated quantity limits or without required PA may result in denial. Review the Requirements/Limits column for each product and obtain PA when 'PA' is shown.

• Examples: test strips often limited to 204 strips/30 days; many insulins have pen/cartridge QLs; GLP agents and tirzepatide have pen-count QLs tied to strength
• V-GO kits and OMNIPOD kits explicitly list both PA and QL — ensure both approval and correct quantity to avoid denial

No explicit authorization or denial rule

No explicit authorization or denial rules in some formulary rows. Certain segments of the formulary simply list product names, tiers, or OTC status without an explicit PA, QL, ST, LA or SP indicator; these entries do not imply PA is required unless noted elsewhere.

• When a product row does not list PA, QL, LA or SP, standard coverage rules and the member's Certificate of Coverage apply
• If in doubt, verify coverage and authorization requirements by contacting Member Services or checking plan-specific documents

Step therapy not specified / Step therapy flags

Step therapy and step-therapy flags. While many formulary rows do not specify step therapy sequences, some device/sensor items are marked 'ST' indicating step therapy requirements; absent an ST flag, step therapy is not specified in that segment.

• Examples: Dexcom G6/G7 receivers, sensors and transmitters include ST flags along with QLs (e.g., QL limits for receivers/sensors/transmitters and ST designation)
• Most drug rows in the provided segments do not list step therapy sequences — follow the Requirements/Limits field and plan documents for any ST rules

Contact for assistance

How to get help. For plan-specific coverage, PA forms, or assistance with prior authorization submissions, contact EmblemHealth Member Services. The member's Certificate of Coverage remains the definitive source for benefit details.

• EmblemHealth Member Services: 833-998-5430 (TTY: 711) — 24/7 assistance
• Refer to the member portal (my.emblemhealth.com) and the Certificate of Coverage for plan-specific details and PA form access