Pharmacy Policy Criteria for EmblemHealth Members
These preauthorization criteria apply to EmblemHealth’s members when they obtain prescription drugs covered by retail or specialty
pharmacy benefits. These criteria also apply to most ConnectiCare commercial members. ConnectiCare members with Large Group Select plans follow their own criteria, as do ConnectiCare’s Medicare members.
This page is under construction. More policy criteria are being prepared and will be added to the table soon.
| Title | Download (PDF) |
|---|---|
| Allergen Immunotherapy Grass Pollen Sublingual Products | Download (PDF) |
| Allergen Immunotherapy Odactra | Download (PDF) |
| Allergen Immunotherapy Palforzia | Download (PDF) |
| Allergen Immunotherapy Ragwitek | Download (PDF) |
| Alpha1 Proteinase Inhibitor Products | Download (PDF) |
| Amifampridine Products | Download (PDF) |
| Amyloidosis Onpattro | Download (PDF) |
| Antibiotics (Inhaled) Arikayce | Download (PDF) |
| Antibiotics (Inhaled) TOBI Podhaler | Download (PDF) |
| Antibiotics (Inhaled) Tobramycin Inhalation Solution | Download (PDF) |
| Antibiotics Linezolid (Zyvox) Sivextro | Download (PDF) |
| Antibiotics Vancomycin Capsules | Download (PDF) |
| Anticoagulants Savaysa | Download (PDF) |
| Antiepileptics Banzel | Download (PDF) |
| Antiepileptics Clobazam Products | Download (PDF) |
| Antiepileptics Fintepla |
Download (PDF) |
| Antiepileptics Nayzilam |
Download (PDF) |
| Antiepileptics Vigabatrin |
Download (PDF) |
| Antifungals (Azoles) Intravenous Products |
Download (PDF) |
| Antifungals Cresemba (Oral) | Download (PDF) |