EmblemHealth Prior Authorization Lookup
Latest EmblemHealth prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-05-08Lyme Disease Intravenous TreatmentDefines medical necessity criteria, acceptable agents, exclusions, and coding for IV antibiotic therapy for members with confirmed Lyme disease; applies to providers requesting preauthorization from EmblemHealth.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-012026 Formulary (XCHG) — Drug List, Tiers, and Utilization ManagementThis document is the EmblemHealth formulary listing covered drugs, tiers, and utilization management rules (e.g., prior authorization, step therapy, quantity limits) for members and providers in the plan. It applies to members using the XCHG formulary as of May 1, 2026.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Formulary — Covered Outpatient Drugs (CHP)This document lists outpatient prescription drugs covered under EmblemHealth CHP plans (formulary updated May 1, 2026) and explains coverage features such as prior authorization, quantity limits, step therapy, specialty designation, and how members/providers can get help.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Medical Technologies Database — Investigational, Unproven, HDE, and Transplant Case Management Coverage CriteriaThis document lists medical technologies, devices, and procedures that EmblemHealth considers investigational, unproven, or subject to special handling (including HDE and FEHB notes) and describes program-level transplant case management; it affects providers submitting precertification/coverage requests for EmblemHealth members, including transplant program referrals.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 EmblemHealth Formulary (Large Group LG) — Drug Coverage and Utilization ManagementThis document is the plan formulary listing covered drugs, tiers, and utilization management rules for EmblemHealth large group plans; it informs members and providers which drugs are covered and any prior authorization, quantity limits, or step therapy requirements.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 EmblemHealth Formulary (US86) — Coverage CriteriaThis document lists covered prescription drugs, tiers, and formulary rules for EmblemHealth members and explains prior authorization, quantity limits, step therapy, and how to use the formulary.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 EmblemHealth Large Group ASO NRA Preferred Formulary (covered drugs list)Defines the list of covered outpatient prescription drugs, tiers, and common benefit restrictions (e.g., prior authorization, quantity limits, step therapy, specialty drug handling) for EmblemHealth Large Group ASO NRA Preferred members as of Apr 1, 2026.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 EmblemHealth PPO Formulary (PPOF) — Prescription Drug Coverage & Utilization ManagementThis document lists covered prescription drugs, tier assignments, and utilization management rules (e.g., prior authorization, quantity limits, step therapy) for EmblemHealth PPO members and their providers. It governs coverage and pharmacy benefit operations for members whose ID cards indicate the PPOF formulary.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 Formulary (List of Covered Drugs)This document is EmblemHealth's 2026 formulary listing covered prescription and OTC drugs, formulary rules (e.g., prior authorization, quantity limits, step therapy), and plan contact information; it affects EmblemHealth members and their prescribing providers.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 Formulary (List of Covered Drugs) — EmblemHealthThis document lists covered outpatient prescription drugs, tiers, and utilization management (e.g., prior authorization, quantity limits, step therapy) for EmblemHealth plans and explains how members and providers use the formulary.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 Formulary (List of Covered Drugs) — Part 2 (drugs, vaccines, biologics; tiers and requirements/limits)This document lists drugs, vaccines, biologics and associated benefit design attributes (Drug Tier and Requirements/Limits such as PA, QL, ACA, LA, SP, OTC, FF). It is a formulary/drug list excerpt (part of a larger formulary), not standalone prior authorization criteria.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-012026 Medicare Prescription Drug Formulary - EmblemHealthThis 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.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Large Group Generic Drug List (Formulary) — 2026This document lists covered drugs, tiers, and utilization management (e.g., prior authorization, quantity limits, step therapy) for EmblemHealth large-group plans and informs members and providers which drugs are included and any restrictions.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Local-246 Prescription Drug Formulary — Covered Drugs, Tiers, and Utilization ManagementThis document is the EmblemHealth Local 246 2026 prescription drug formulary describing covered drugs, tiers, and plan-level utilization management requirements (e.g., prior authorization, quantity limits, step therapy, specialty designation) for affected members and their providers.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Medical technologies and investigational transplant-related devices/servicesLists investigational, investigational-with-exceptions, and coverage notes for medical devices and technologies relevant to transplant program case management and other services; applies to EmblemHealth members and providers requesting review or pre-certification.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01PPO Preferred Plan Formulary — Drugs Covered (Formulary — PPOB)This document is the EmblemHealth PPO Preferred Plan drug formulary (list of covered drugs) as of Apr 1, 2026 and explains coverage tiers, limits, prior authorization, and how members/providers can use the formulary. It affects members and providers covered under the PPOB formulary.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Prior Authorization Criteria Formulary EmblemhealthThis document is the first part of EmblemHealth's 2026 Prior Authorization (PA) Criteria formulary listing medications that may require prior authorization for EmblemHealth Medicare HMO/PPO plans. It includes introductory policy text and a Table of Contents listing covered drugs and their page locations (partial list in this part).All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Prior Authorization Criteria — Pharmacy & Specialty Drugs (Medicare PA List)This document lists drugs requiring prior authorization for EmblemHealth Medicare HMO/PPO plans and specifies requirements providers must meet for approval, including medications that may be covered under Medicare Part B or D depending on use and administration.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-012026 Formulary (List of Covered Drugs)This document lists covered drugs, tiers, and formulary rules (prior authorization, step therapy, quantity limits, specialty, limited distribution) for EmblemHealth members; it is intended for members and providers using EmblemHealth plans.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-23Penile ImplantsMedical necessity and coverage criteria for surgical implantation, repair, removal, or replacement of penile prostheses for EmblemHealth members, and documentation/prior authorization expectations for providers.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-012026 Formulary (List of Covered Drugs) — EmblemHealth Uniformed Sanitationmen's Association (US86)This document is the EmblemHealth formulary (US86) describing covered prescription drugs, tiers, utilization management (prior authorization, quantity limits, step therapy), and member services for the EmblemHealth Uniformed Sanitationmen's Association plan; it affects plan members, prescribing providers, and pharmacies.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01EmblemHealth 2026 Drug List (Large Group Generic Formulary) — Coverage CriteriaGoverns the covered prescription drugs, tiers, and utilization management (e.g., prior authorization, quantity limits, step therapy) for EmblemHealth large group plans; affects members, prescribing providers, and pharmacies using the plan's drug list.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01EmblemHealth Large Group ASO NRA Preferred Formulary (2026)This document lists covered prescription drugs, formulary tiers, and common plan restrictions (e.g., prior authorization, quantity limits, step therapy, specialty pharmacy) for EmblemHealth Large Group ASO NRA Preferred members as of Jan. 1, 2026 and informs members and providers how to use the formulary.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01EmblemHealth Large Group NRA Preferred Formulary — Formulary ID - LG (Preferred Drug Formulary)This document is the EmblemHealth Large Group NRA preferred drug formulary describing covered drugs, tiers, utilization management (e.g., prior authorization, step therapy, quantity limits), member services and how to use the formulary for plan members and providers.All EmblemHealth updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01EmblemHealth Local 246 Medicare Prescription Drug Formulary (partial)This document is the plan formulary describing covered prescription drugs, tiers, utilization management (e.g., prior authorization, quantity limits, step therapy), and member services for EmblemHealth Local 246 Medicare prescription drug plan. It affects plan members, prescribing providers, and pharmacies participating with EmblemHealth.All EmblemHealth updates
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Tool Description
Search EmblemHealthprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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