UnitedHealthcare Empire Plan Formulary Update

Medications and products that are listed as excluded are not covered under the prescription benefit; the enrollee will be responsible for the full cost of any excluded medication unless a request for a medical exception is approved.

Fenofibrate is generally listed as excluded with two specific exceptions called out: the policy excludes fenofibrate except fenofibrate capsule 50 mg and 130 mg and fenofibrate tablet 40 mg and 120 mg, indicating those specific strengths/forms are treated differently in the formulary listing.

Isosorbide dinitrate is included on the excluded list with a specific strength exception: the formulary notes isosorbide dinitrate (except isosorbide dinitrate tablet 40 mg), meaning the 40 mg tablet is not treated as excluded.

The document enumerates multiple entries under the heading EXCLUDED DRUG NAME(S), listing specific brand and generic products that are not covered and for which preferred alternatives are provided elsewhere in the formulary.

Examples of excluded drug names in the list include cardiovascular and specialty products such as BALCOLTRA, BASAGLAR, BETAPACE (and BETAPACE AF BINOSTO), BRAVELLE, and other items; the formulary provides preferred alternatives next to many excluded entries.

Additional excluded names shown include gastrointestinal and ophthalmic products and related preferred alternatives, for example CARAC, CARAFATE, DIOVAN HCT, dorzolamide-timolol pf, with preferred alternative options listed in adjacent entries.

The excluded list also contains dermatologic and antihypertensive entries such as EPIDUO, ergotamine-caffeine, EXFORGE, and explicitly lists fenofibrate exclusions alongside the fenofibrate exceptions called out elsewhere.

Further excluded items include musculoskeletal and respiratory products like EXFORGE HCT, EXTAVIA, FABIOR, and additional fenofibrate/formulation entries plus other named topical and systemic medications.

The excluded-drug sections repeatedly list products across therapeutic areas and explicitly call out fenofibrate strengths/forms (referenced as exceptions) alongside other excluded names, underscoring that specific strengths/forms (e.g., fenofibrate capsule 50 mg, 130 mg and tablet 40 mg, 120 mg) are handled distinctly in the formulary.

Explicit excluded drug names in these chunks include high-profile products across classes such as IDACIO; imiquimod cream 3.75%; INDOCIN oral suspension; INNOPRAN XL; multiple insulin products (INSULIN ASPART, INSULIN DEGLUDEC, INSULIN GLARGINE, INSULIN LISPRO, etc.); isosorbide dinitrate 40 mg; RETIN-A MICRO; SEMGLEE and others named directly in the excluded lists.

Provider Actions & Authorization Rules

Note

Prior authorization not specified in excerpts

Prior authorization is not consistently specified in the excerpted formulary listings; many entries are plain formulary listings without explicit PA instructions. Providers should verify PA requirements for specific products prior to prescribing or dispensing.

Log in to www.empireplanrxprogram.com to check coverage and copay information for a specific medicine.
When in doubt about PA/QL status, contact the benefit administrator or pharmacy vendor (CVS Caremark).

Documentation Required

Formulary qualifiers (quantity limit / prior authorization)

Formulary qualifiers shown in the list indicate utilization controls: QL = Quantity Limit, PA = Prior Authorization, PA/QL = Prior Authorization then Quantity Limit, QL/PA = Quantity Limit with PA for additional quantities, SGM = Specialty Guideline Management, B4G = Brand-for-Generic. These flags mean the drug may require prior approval, have dispensing quantity limits, or be managed via specialty processes.

SGM may include specialty quantity limits based on FDA dosing guidelines.
B4G affects substitution and cost-sharing (brand dispensed at generic copay).

Prior Authorization

Prior authorization requirements

Many drugs in the excerpts are annotated with PA, PA/QL, QL/PA or SGM indicating prior authorization or specialty management is required; prescriptions for these products may be denied at point of sale without an approved authorization.

Examples: incretin mimetics and antiobesity agents (liraglutide, MOUNJARO, OZEMPIC, CONTRAVE, WEGOVY) are marked PA.
Opioid long-acting agents (fentanyl transdermal, methadone, morphine ext-rel) appear with QL/PA or PA/QL flags.

Prior Authorization

Prior authorization/management indicated for annotated drugs

Drugs annotated with SGM, PA, QL, or PA/QL in the formulary should be treated as subject to utilization management; check the specific annotation when selecting therapy.

SGM entries (e.g., many specialty agents, severe asthma and biologics) indicate specialty guideline management and may require specialty prior authorization workflows.
PA next to dermatology agents (e.g., certain tazarotenes, tretinoin) indicates prior authorization for those products.

Prior Authorization

Prior authorization requirements for some alternatives

Preferred-alternative listings often note PA or QL for their alternatives; some non-preferred agents list preferred alternatives that themselves carry PA/QL flags, so prior authorization may be required for both non-preferred and alternative agents.

Example: Several Level 3 non-preferred diabetes agents list preferred alternatives that are also PA-designated (GLP-1 agonists).
Preferred alternative substitution may still trigger utilization controls when alternatives are PA-flagged.

Prior Authorization

Prior authorization / quantity-limit flags

Multiple entries include combined QL/PA or PA/QL flags; these indicate an initial quantity limit with PA required for additional amounts or PA followed by a quantity limit — documentation will typically be required to justify overrides.

Opioid listings frequently carry QL/PA or PA/QL.
Antivirals and antiviral combinations may be noted as QL/PA (e.g., oseltamivir, valacyclovir entries).

Denial Risk

Enrollee cost responsibility

Enrollees will be responsible for the full cost of excluded medications unless a medical exception is approved. Prescribe preferred alternatives when appropriate to avoid enrollee financial liability.

Medications recently approved by FDA may be excluded until added to coverage.
Ancillary Charge may apply when a brand is dispensed in place of a newly available generic.

Note

No explicit prior authorization or denial triggers in these excerpts

Some segments of the source are pure formulary listings without explicit PA or denial triggers; treat those listings as informational but verify coverage rules before prescribing.

Examples: miscellaneous oncology SGM listings and many cardiovascular listings lack explicit PA statements in these excerpts.

Note

This segment provides formulary category and agent names only

This segment provides formulary category and drug name listings; it is not a complete policy and lacks operational PA criteria, so providers must consult the plan portal for actionable prior authorization forms and clinical criteria.

Use the plan/vendor website to access PA forms and documentation requirements.
Formulary lists do not replace the official PA policy or coverage criteria.

Denial Risk

No denial triggers specified in these excerpts

No explicit denial triggers are specified within these excerpted fragments beyond the general rule that prescriptions lacking required PA may be denied at point of sale; check payer guidance for specific denial reasons and appeal pathways.

Denials commonly occur for missing PA, exceeding QL without authorization, or prescribing excluded products.
If coverage is denied, consider submitting a medical exception request per plan procedures.

Prior Authorization

Triptan utilization controls

Triptan agents show utilization controls in the listing — many triptans are annotated QL or QL/PA which may restrict quantity or require PA for coverage.

Eletriptan, naratriptan, sumatriptan, zolmitriptan and others are listed with QL/PA or QL flags.
Preferred alternative lists reference triptan QL/PA designations — verify when prescribing for migraines.

Prior Authorization

Narcolepsy agent controls

Narcolepsy and wakefulness agents in the excerpt are specifically marked PA (armodafinil, modafinil) or SGM for specialty products, indicating PA or specialty review is required prior to coverage.

Armodafinil and modafinil are PA-designated.
Other narcolepsy products (LUMRYZ, SUNOSI, WAKIX, XYWAV) are SGM-designated and may follow specialty workflows.

Prior Authorization

Prior authorization required for PA-designated drugs

PA-designated drug classes in the excerpts (for example GLP-1 agonists, GLP-1/antidiabetic agents, and antiobesity drugs) require prior authorization per the formulary annotations; obtain PA before dispensing to prevent claim denial.

Incretin mimetic agents (liraglutide, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) are marked PA.
Antiobesity agents (CONTRAVE, SAXENDA, WEGOVY, ZEPBOUND) are marked PA.

Note

Listing-only segments — no operational PA criteria included

Some fragments are strictly listing material without operational PA rules or appeal instructions; use the formulary as a directional reference only and retrieve PA criteria from the plan portal.

Listing-only segments include vitamin D analogs, some anticoagulants and other categories shown without PA text.

Note

No explicit authorization or denial rules included

No explicit authorization or denial rules are provided in these excerpts; do not infer clinical criteria from the list — consult the payer resources for formal coverage criteria and required documentation.

Severe asthma biologics are SGM-marked and will have specialty criteria separate from this listing.

Step Therapy

No explicit step therapy requirements are included in this segment

None of the provided fragments contain a full step-therapy algorithm. The excerpted lists reference preferred alternatives and tiering but do not define enforced step sequences; verify step therapy requirements on the plan site.

B4G notation and preferred-alternative listings imply substitution and step preference but are not a replacement for documented step therapy rules.
Where a preferred alternative is listed, the plan may require trial of that alternative prior to non-preferred coverage.

Note

Specialty/guideline management tags

Specialty/guideline management tags (SGM) indicate specialty products are subject to managed access or specialty review and may require different PA workflows than standard drugs.

Examples: oncology PARP inhibitors, proteasome inhibitors, severe asthma and many biologics are SGM-designated.
SGM products often follow specialty pharmacy dispensing and may have specialty quantity limits based on FDA dosing.

Step Therapy

Step/Preference notes

Step/preference notes are implied where preferred alternatives are listed next to non-preferred drugs; in many cases the plan expects use of preferred alternatives before authorizing non-preferred agents.

Level 3/non-preferred listings include preferred alternatives that may be required prior to coverage of the non-preferred product.
Preferred alternatives themselves may carry PA or QL designations — check each agent's requirements.

Note

No step therapy rules are defined in this excerpt

No detailed step therapy rules are defined in these excerpts — the lists reference preferred alternatives and tiering (B4G) but do not include operational step counts, timelines, or trial-length criteria.

Consult the plan portal for step therapy criteria and required documentation before pursuing PA for non-preferred agents.

Step Therapy

Step/quantity edits referenced

Step therapy and quantity edits are referenced via flags (QL, PA/QL, QL/PA, B4G); these annotations indicate edits will be enforced at point of sale or via prior authorization workflows.

B4G may trigger brand-for-generic substitution rules affecting cost-sharing and step preference.
Quantity limits (QL) may require documented justification for overrides or PA for larger quantities.

Step Therapy

Preferred-alternative driven step therapy

Preferred-alternative driven step therapy is implied throughout the Level 3/non-preferred lists — where a preferred alternative is named, the plan may require use of that drug before authorizing the non-preferred product.

Providers should attempt prescribing preferred alternatives when clinically appropriate to minimize PA requirements and patient out-of-pocket costs.

Documentation Required

Documentation hints

Documentation hints: drugs marked QL/PA or PA may require supporting clinical documentation (diagnosis, prior trial history, dosing rationale) when submitting PA or quantity-limit override requests.

Medications with QL may require documentation to justify quantities beyond limits.
PA requests typically need prior-therapy history, clinical rationale, and attestation of medical necessity.

Documentation Required

Quantity Limit Documentation

Quantity limit documentation: where a QL is present, authorization for amounts beyond the stated limit usually requires chart notes or supporting documentation demonstrating medical necessity.

Opioid long-acting agents and certain antivirals are called out with QL/PA flags; expect to supply dosing history for override requests.

Prior Authorization

PA indicated for dermatologic products

PA is indicated for many dermatologic products in the excerpts (e.g., adapalene exceptions, certain tazarotene and tretinoin formulations); verify PA requirements and provide required clinical documentation to avoid denials.

Some topical agents (tazarotene cream/gel, tretinoin formulations, AKLIEF, WINLEVI) are annotated PA.
Preferred alternative lists often propose non-PA topical agents as substitutes.

Note

SGM (Specialty Guideline Management) may apply to specialty products

SGM (Specialty Guideline Management) may apply to specialty products and includes specialty quantity limits and management processes based on FDA dosing and specialty pharmacy workflows.

SGM-designated agents (oncology, biologics, pulmonary hypertension, severe asthma) typically require specialty pharmacy enrollment.
SGM may include specific clinical criteria distinct from standard PA forms.

Documentation Required

Utilization annotation implication

Utilization annotation implication: QL, PA and SGM annotations in the formulary indicate administrative controls that affect prescribing, dispensing, and coverage decisions — always confirm via the payer/vendor portal.

Annotations drive prior authorization, quantity limits, specialty management, and step-preference enforcement.
Failure to follow required workflows may lead to claim denial or enrollee financial responsibility.

Billing Rule

Brand-for-generic designation

Brand-for-generic (B4G) designation affects substitution and benefit/cost-sharing: a brand dispensed under B4G is charged at the generic copay and may be subject to step or substitution rules.

B4G entries (e.g., certain SGLT2 combinations and SGLT2 inhibitors) influence preferred-alternative selection and cost to the enrollee.

Note

Provider actions — check plan portal and support

Providers should log in to www.empireplanrxprogram.com or contact 1-877-7-NYSHIP for specific coverage, prior authorization forms, clinical criteria, and copay information prior to prescribing products that may be PA/QL/SGM-designated.

Use the plan/vendor website to retrieve PA forms and current utilization management rules.
Call the plan support line for urgent benefit questions and claims assistance.

Definitions & Abbreviations

B4G — Brand for Generic

DefinitionB4G = Brand for Generic medication; brand-name product is dispensed at the generic copayment.

ImplicationUsed in formulary listings to indicate brand product may be charged at the generic (lower) copayment when applicable.

ExampleSGLT2 entries: SYNJARDY B4G, SYNJARDY XR B4G, XIGDUO XR B4G (B4G appears adjacent to these products in the list).

PA — Prior Authorization

DefinitionPA = Prior Authorization — medication requires approval prior to coverage.

ScopePA flags appear adjacent to specific agents in the formulary indicating coverage requires prior authorization (e.g., liraglutide PA, MOUNJARO PA).

Denial riskPrescriptions for medications labeled PA may be denied at point of service or claim adjudication if authorization is not obtained.

QL — Quantity Limit

DefinitionQL = Quantity Limit — restrictions on the amount of medication that may be dispensed within a time period.

ExamplesOpioids and opioid-related products are commonly marked with QL or QL/PA (e.g., codeine-acetaminophen QL; fentanyl transdermal QL/PA).

Formulary useQL annotations in the quick reference indicate the plan enforces maximum permitted quantities and may require documentation for higher quantities.

SGM — Specialty Guideline Management

DefinitionSGM = Specialty Guideline Management — specialty medication management which may include specialty quantity limits based on FDA dosing guidelines.

UsageSGM appears next to many specialty agents (e.g., LYNPARZA SGM; DUPIXENT SGM) indicating specialty oversight or management pathways.

ImplicationMay denote specialty review, site-of-care or additional administrative controls for these agents.

SGM acronym occurrence

ObservationThe abbreviation 'SGM' appears after certain brand names in the formulary (e.g., LYNPARZA SGM; ambrisentan SGM).

NoteThe document excerpt shows the annotation but does not include an in-line definition in those positions — definition is provided in the legend instead.

ReferSee legend (LEGEND) for the full SGM definition and details on specialty quantity limits and guidelines.

Specialty designation (SGM)

ObservationProducts listed with the 'SGM' tag are designated as specialty in the formulary (e.g., LYNPARZA SGM; DUPIXENT SGM).

ImplicationSGM-marked products are treated as specialty agents and may be subject to specialty management procedures and limits.

ExamplesLYNPARZA SGM; ZEJULA SGM; DUPIXENT SGM; FASENRA SGM

B4G / SGM / PA shorthand

Formulary shorthandB4G, SGM and PA are used as inline modifiers throughout the drug list to indicate brand-for-generic status, specialty management, and prior authorization respectively.

Practical effectThese shorthand flags guide coverage rules, copay tiering, and utilization management for listed products.

ExamplesSYNJARDY B4G (B4G); LYNPARZA SGM (SGM); liraglutide PA (PA).

Preferred Drug List segment

Segment descriptionPreferred Drug List segment presents therapeutic categories and agents, intended to show preferred formulary products and alternatives.

LimitationsThis fragment lists products and preferred alternatives but does not include full coverage criteria or authorization workflows in-line.

UseProviders should use the list to identify preferred alternatives and check plan materials or portal for specific coverage rules.

Inflammatory Bowel Disease — listed agents

CategoryInflammatory Bowel Disease (IBD) — agents listed include balsalazide; budesonide delayed-release capsule; budesonide extended-release tablet; hydrocortisone enema; mesalamine formulations; sulfasalazine; CORTIFOAM.

ScopeThe IBD section lists topical and systemic 5-ASA derivatives and corticosteroid preparations among other IBD-specific formulations.

ReferenceUse the IBD listing to identify formulary-preferred agents when selecting therapy; check utilization flags in the quick reference for QL/PA/SGM annotations.

SGM / PA / QL inline usage

ObservationDrugs are annotated with multiple utilization flags inline — SGM (specialty), PA (prior authorization), and QL (quantity limit) are used together where applicable.

Examplesfentanyl buccal tablet PA/QL; tramadol QL/PA; DUPIXENT SGM; tadalafil QL/PA.

ImplicationThese combined annotations indicate plans may require both specialty management and prior authorization and/or enforce quantity limits for specific products.

PA — Prior Authorization (definition)

DefinitionPrior Authorization (PA) — medication requires approval prior to coverage.

Formulary indicatorPA appears in the legend and adjacent to specific drugs in the quick reference and drug lists to indicate authorization requirement.

Action for providersObtain prior authorization per plan procedures before prescribing PA-marked agents to avoid claim denial.

QL — Quantity Limit (definition)

DefinitionQuantity Limit (QL) — restrictions on the amount of medication that may be dispensed within a time period.

ExamplesCodeine-acetaminophen QL; tramadol QL/PA; fentanyl transdermal QL/PA are shown in the formulary list.

Provider noteDocumentation may be required to justify quantities beyond the listed limit; check plan resources for limit specifics.

SGM — Specialty/segment designation

DefinitionSGM — Specialty/segment designation used in the formulary to denote specialty medications or internal categorization.

ManifestationSGM is listed in the legend and appears beside many specialty agents in the quick reference (e.g., ambrisentan SGM, teriparatide SGM).

ImplicationSGM designation may trigger specialty management workflows and different prior authorization handling.

B4G — Buy for Generic

DefinitionB4G — Buy/Brand for Generic indicating a brand is dispensed at the generic copayment or designated in a generic-first program.

Formulary examplesSYNJARDY B4G, FARXIGA B4G, JARDIANCE B4G illustrate B4G use in the SGLT2 listings.

EffectB4G flags indicate the plan prefers generic-first or biosimilar-first approaches; documentation required if requesting non-preferred brand.

Level 3 / Non-Preferred

Tier definitionLevel 3 or Non-Preferred — a formulary tier indicating drugs that are non-preferred; alternatives are recommended and utilization management may apply.

GuidancePreferred alternatives are listed next to many Level 3 drugs; prescribers may be expected to use listed preferred agents prior to coverage of non-preferred drugs.

Denial riskNon-preferred designation may trigger prior authorization, step edits, or higher member cost-sharing.

Excluded Drugs

DefinitionExcluded Drugs — medications listed as excluded are not covered under the formulary; members must pay full cost unless a medical exception is approved.

ExamplesExcluded entries include ACTICLATE; ADALIMUMAB biosimilar listings; BASAGLAR; many specified insulin and other branded products (see excluded list).

Provider actionWhen an excluded drug is prescribed, consider recommended preferred alternatives listed or request a medical exception if clinically necessary.

QL/PA — Quantity Limit with Prior Authorization

DefinitionQL/PA — combined designation indicating a Quantity Limit is applied and Prior Authorization may also be required for additional quantity or coverage.

ExamplesOpioid long-acting products and select analgesics show QL/PA (e.g., methadone QL/PA; morphine ext-rel QL/PA; tramadol QL/PA).

Operational noteEntries marked QL/PA in the quick reference signal both quantity controls and authorization processes will apply per formulary rules.

OpenPayer

Empire Plan Flexible Formulary Preferred Drug List (partial)

Coverage Criteria

Coding

Provider Actions & Authorization Rules

Background

Definitions & Abbreviations

Step Therapy & Preference Rules

Quantity Limits

Biosimilars & Reference Biologics

QL	Quantity Limit (formulary qualifier shown beside drug)
PA	Prior Authorization (formulary qualifier shown beside drug)