2026 EmblemHealth Formulary Changes

10/21/2025

Effective Date: Jan. 1, 2026

The table below describes all formulary changes going into effect for our Medicare members in 2026. For our Commercial members, this table highlights the most highly impacted drugs. For a comprehensive listing of all plans see: 2026 Summary of Companies, Lines of Business, Networks & Benefit Plans.

See the applicable 2026 plan formularies for all coverage rules:

Note: Affected members were notified of these changes separately.

Medicare Advantage Plans
Medicare CNY PDP (City Retirees’ Prescription Drug Plan Only)
City of NY PPO
City of NY HMO
Commercial Small Group/Essential/Individual Plans
Commercial Large Group

Medicare Advantage Plans Drugs Moving to Non-Formulary in 2026
Drug	Alternative(s)
CYCLOSPORINE OP	RESTASIS (BRAND)
MIRABEGRON	MYRBETRIQ (BRAND)
ICOSAPENT	VASCEPA
ROCKLATAN	BETAXOLOL, BRIMONIDINE, CARTEOLOL, DORZOLOMIDE, LATANOPROST, LEVOBUNOLOL, TIMOLOL
BRILINTA	TICAGRELOR (GENERIC)
EPLERENONE	SPIRONOLACTONE
RHOPRESSA	BETAXOLOL, BRIMONIDINE, CARTEOLOL, DORZOLOMIDE, LEVOBUNOLOL, TIMOLOL
MEMANTINE ER	MEMANTINE IR
TIOTROPIUM	INCRUSE, SPIRIVA
QVAR	ARNUITY, ASMANEX
SUCRALFATE SUSP	SUCRALFATE TAB
BRIMONIDINE 0.1%	BRIMONIDINE 0.15%, BRIMONIDINE 0.2%
FEBUXOSTAT	ALLOPURINOL
TROSPIUM	MYRBETRIQ, OXYBUTYNIN, SOLIFENACIN, TOLTERODINE
SIMBRINZA	DORZOLOMIDE, BRIMONIDINE
PITAVASTATIN	ATORVASTATIN, FLUVASTATIN, LOVASTATIN, PRAVASTATIN, ROSUVASTATIN, SIMVASTATIN
SAXAGLIPTIN	JANUVIA, TRAJENTA
TRULANCE	LINZESS, LUBIPROSTONE
HUMIRA	HADLIMA, SIMLANDI
VYNDAMAX	ATTRUBY
CYCLOSPORINE OP	RESTASIS (BRAND)
MIRABEGRON	MYRBETRIQ (BRAND)

Medicare Advantage Plans

New Tier 5 Drugs

CAPLYTA CAP 10.5MG

CAPLYTA CAP 21MG

CAPLYTA CAP 42MG

ENVARSUS XR TAB 4MG

NUPLAZID CAP 34MG

REXULTI TAB 0.25MG

REXULTI TAB 0.5MG

REXULTI TAB 1MG

REXULTI TAB 2MG

REXULTI TAB 3MG

Medicare Advantage Plans

New Preauthorization Requirements for Listed Drugs in 2026

ARIPIPRAZOLE

ASENAPINE

ATOVAQUONE

BUDESONIDE

CHLORPROMAZ

CINACALCET

CLOZAPINE

CORLANOR

DICYCLOMINE

DIHYDROERGOT

DIPHEN/ATROP

EPOGEN

FLUPHENAZ

FLUPHENAZINE

GLATIRAMER

GLATOPA

HALOPER

HALOPERIDOL

IMATINIB

IMIQUIMOD

LIDO/PRILOCN

LINEZOLID

LOXAPINE

LURASIDONE

METHYLPHENID

MIEBO

OLANZAPINE

PALIPERIDONE

PERPHENAZINE

PIRFENIDONE

PROCRIT

PYRIMETHAMIN

QUETIAPINE

QUININE

REXULTI

RISPERIDONE

ROFLUMILAST

SCOPOLAMINE

TADALAFIL

TERIPARATIDE

TRETINOIN

TRIFLUOPERAZ

XIIDRA

Medicare Advantage Members New Quantity Limits for 2026
Drug	Amount/Frequency
TAMSULOSIN CAP 0.4MG	60 CAPS/30 DAYS
ALFUZOSIN TAB 10MG ER	30 TABS/30 DAYS
CELECOXIB CAP 200MG	60 CAPS/30 DAYS
DUTASTERIDE CAP 0.5MG	30 CAPS/30 DAYS
EZETIMIBE TAB 10MG	30 TABS/30 DAYS
FINASTERIDE TAB 5MG	30 TABS/30 DAYS
IBUPROFEN TAB 400MG	240 TABS/30 DAYS
IBUPROFEN TAB 600MG	150 TABS/30 DAYS
IBUPROFEN TAB 800MG	120 TABS/30 DAYS
IRBESARTAN TAB 150MG	30 TABS/30 DAYS
IRBESARTAN TAB 300MG	30 TABS/30 DAYS
LANTUS SOLOS INJ 100/ML	20 PENS/30 DAYS
LATANOPROST SOL 0.005%	15 MLS/75 DAYS
LOSARTAN POT TAB 100MG	30 TABS/30 DAYS
LOSARTAN POT TAB 25MG	60 TABS/30 DAYS
LOSARTAN POT TAB 50MG	60 TABS/30 DAYS
LOSARTAN/HCT TAB 100-12.5	30 TABS/30 DAYS
LOSARTAN/HCT TAB 100-25	30 TABS/30 DAYS
LOSARTAN/HCT TAB 50-12.5	30 TABS/30 DAYS
LUMIGAN SOL 0.01% OP	15 MLS/75 DAYS
MIRTAZAPINE TAB 15MG	45 TABS/30 DAYS
MIRTAZAPINE TAB 7.5MG	30 TABS/30 DAYS
NAPROXEN TAB 500MG	90 TABS/30 DAYS
NOVOLOG INJ FLEXPEN	20 PENS/30 DAYS
OLMESA MEDOX TAB 40MG	30 TABS/30 DAYS
OXYBUTYNIN TAB 10MG ER	90 TABS/30 DAYS
TOUJEO SOLO INJ 300/ML	60 MLS/30 DAYS
VALSARTAN TAB 160MG	60 TABS/30 DAYS
VALSARTAN TAB 320MG	30 TABS/30 DAYS
VALSARTAN TAB 80MG	60 TABS/30 DAYS
TAMSULOSIN CAP 0.4MG	60 CAPS/30 DAYS

Medicare Advantage Plans Drugs Removed from Formulary in 2026
ABACA/LAMIVU TAB 600-300	BALSALAZIDE CAP 750MG
ABIRATERONE TAB 500MG	BELBUCA MIS 900MCG
ADBRY INJ 150MG/ML	BETA DIPROP CRE 0.05%
ALPRAZOLAM TAB 0.5MG ER	BICALUTAMIDE TAB 50MG
ALVESCO AER 160MCG	BREYNA AER 160/4.5
ALVESCO AER 80MCG	BREYNA AER 80/4.5
AMLOD/ATORVA TAB 10-10MG	BRILINTA TAB 60MG
AMLOD/ATORVA TAB 2.5-40MG	BROMFENAC DRO 0.07% OP
AMLOD/ATORVA TAB 5-10MG	BUPREN/NALOX MIS 12-3MG
AMLOD/ATORVA TAB 5-20MG	BUPREN/NALOX MIS 8-2MG
AMOX/K CLAV SUS 200/5ML	BUPRENORPHIN DIS 15MCG/HR
AMOX/K CLAV SUS 400/5ML	BUPRENORPHIN DIS 5MCG/HR
AMOX/K CLAV SUS 600/5ML	BUPRENORPHIN DIS 5MCG/HR
APAP/CODEINE TAB 300-30MG	BUPRENORPHIN SUB 2MG
APTIOM TAB 200MG	BUPROPION TAB 150MG SR
ARIPIPRAZOLE TAB 10MG	BYETTA INJ 10MCG
ARIPIPRAZOLE TAB 2MG	CAPLYTA CAP 10.5MG
ARISTADA INJ 1064MG	CAPLYTA CAP 21MG
ARISTADA INJ 882MG/3	CARB/LEVO100 TAB /ENTACAP
ATROVENT HFA AER 17MCG	CARB/LEVO125 TAB /ENTACAP
CARBAMAZEPIN CAP 200MG ER	DEXAMETH PHO SOL 0.1% OP
CARBAMAZEPIN CAP 300MG ER	DEXAMETHASON TAB 1.5MG
CARBAMAZEPIN TAB 200MG	DICLOFEN POT TAB 50MG
CELECOXIB CAP 400MG	DICLOFENAC TAB 25MG DR
CEVIMELINE CAP 30MG	DILTIAZEM TAB 240MG ER
CIPRO/DEXA SUS 0.3-0.1%	DILTIAZEM TAB 300MG ER
CLINDAMYCIN LOT 1%	DIVALPROEX CAP 125MG DR
CLOBETASOL SHA 0.05%	DOPTELET TAB 20MG
CLONAZEP ODT TAB 0.25MG	DOXEPIN TAB 3MG
CLOTRIMAZOLE SOL 1%	DOXYCYC MONO TAB 100MG
CLOZAPINE TAB 200MG	DOXYCYCL HYC TAB 50MG
COLESEVELAM TAB 625MG	DOXYCYCLINE SUS 25MG/5ML
COMBIVENT AER 20-100	DUAVEE TAB 0.45-20
COMPLERA TAB	EDARBYCLOR TAB 40-12.5
CORLANOR TAB 5MG	ESZOPICLONE TAB 2MG
CRYSELLE-28 TAB 28 TABS	ESZOPICLONE TAB 3MG
CYCLOPHOSPH CAP 50MG	FAMCICLOVIR TAB 250MG
DESIPRAMINE TAB 10MG	FAMCICLOVIR TAB 500MG
DESVENLAFAX TAB 25MG ER	FASENRA PEN INJ 30MG/ML
DESVENLAFAX TAB 50MG ER	FEBUXOSTAT TAB 40MG
FENOFIBRATE CAP 200MG	LOPIN/RITON TAB 200-50MG
FLUCONAZOLE SUS 40MG/ML	MEDROXYPR AC INJ 150MG/ML
FLUTICAS HFA AER 44MCG	MEFLOQUINE TAB 250MG
FULPHILA INJ 6/0.6ML	MEMANTINE SOL 2MG/ML
GALANTAMINE TAB 12MG	METOCLOPRAM SOL 5MG/5ML
GATIFLOXACIN SOL 0.5%	METOLAZONE TAB 5MG
GATTEX KIT 5MG	MEXILETINE CAP 200MG
GAVILYTE-G SOL	MIDODRINE TAB 10MG
GLYXAMBI TAB 25-5 MG	MIDODRINE TAB 5MG
HALOPERIDOL TAB 20MG	MIRABEGRON TAB 25MG ER
HUMIRA PEN INJ 40MG/0.8	MIRABEGRON TAB 50MG ER
HUMIRA PEN INJ 80/0.8ML	MOMETASONE SPR 50MCG
ISIBLOOM TAB	MORPHINE SUL TAB 100MG ER
ISOSORB DIN TAB 5MG	MORPHINE SUL TAB 15MG
ISOSORB MONO TAB 60MG ER	MOXIFLOXACIN SOL 0.5%
LAMIVUD/ZIDO TAB 150-300	NADOLOL TAB 40MG
LAMOTRIGINE TAB 150MG	NADOLOL TAB 80MG
LAMOTRIGINE TAB 25MG	NALOXONE SPR 4MG
LEVOCETIRIZI SOL 2.5/5ML	NALOXONE HCL SPR 4MG
LIDOCAINE OIN 5%	NAPROXEN SOD TAB 275MG
NEBIVOLOL TAB 20MG	OXERVATE SOL 20MCG/ML
NEBIVOLOL TAB 5MG	OXYBUTYNIN SOL 5MG/5ML
NEUPRO DIS 2MG/24HR	OXYBUTYNIN TAB 5MG ER
NEUPRO DIS 3MG/24HR	OXYCONTIN TAB 30MG ER
NEUPRO DIS 4MG/24HR	OXYCONTIN TAB 40MG ER
NEUPRO DIS 6MG/24HR	OXYCONTIN TAB 60MG ER
NEXLETOL TAB 180MG	OXYCONTIN TAB 80MG ER
NEXLIZET TAB 180/10MG	PACERONE TAB 400MG
NIFEDIPINE TAB 60MG ER	PEG-3350 SOL ELECTROL
NITROGLYCRN SPR 400MCG	PERIOGARD SOL 0.12%
NIVESTYM INJ 300/0.5	PHENYTOIN CHW 50MG
NUCALA INJ 100MG	PITAVASTATIN TAB 2MG
NUCALA INJ 100MG/ML	PITAVASTATIN TAB 4MG
NYAMYC POW 100000	POT CHLORIDE POW 20MEQ
NYSTAT/TRIAM CRE	PREDNISOLONE SUS 1% OP
NYSTAT/TRIAM OIN	PREDNISONE CON 5MG/ML
NYSTATIN TAB 500000	PREDNISONE TAB 10MG
NYVEPRIA INJ 6/0.6ML	PREDNISONE TAB 50MG
OMEGA-3-ACID CAP 1GM	PREDNISONE TAB 5MG
OPSUMIT TAB 10MG	PREMARIN TAB 0.3MG
PREMARIN TAB 0.625MG	RIVASTIGMINE CAP 4.5MG
PRIFTIN TAB 150MG	RIZATRIPTAN TAB 10MG
PROMACTA TAB 25MG	RIZATRIPTAN TAB 10MG ODT
PROPAFENONE TAB 225MG	RIZATRIPTAN TAB 5MG
PROPRANOLOL CAP 80MG ER	ROPINIROLE TAB 6MG ER
PROPRANOLOL TAB 10MG	ROPINIROLE TAB 8MG ER
PYRIDOSTIGMI TAB ER 180MG	SAXAGLIPTIN TAB 2.5MG
QUETIAPINE TAB 200MG ER	SAXAGLIPTIN TAB 5MG
QUETIAPINE TAB 400MG ER	SELEGILINE CAP 5MG
RANOLAZINE TAB 500MG ER	SIMBRINZA SUS 1-0.2%
RETACRIT INJ 10000UNT	SODIUM CHLOR SOL 0.9% IRR
REVLIMID CAP 2.5MG	SOFOS/VELPAT TAB 400-100
REVLIMID CAP 25MG	SOTYKTU TAB 6MG
REVLIMID CAP 5MG	STEGLATRO TAB 15MG
RILUZOLE TAB 50MG	SUCRAID SOL 8500/ML
RISPERIDONE INJ 12.5MG	SUCRALFATE SUS 1GM/10ML
RISPERIDONE INJ 25MG ER	SYMPROIC TAB 0.2MG
RISPERIDONE TAB 0.25MG	TASIGNA CAP 150MG
RISPERIDONE TAB 0.5MG	TELMIS/AMLOD TAB 80-5MG
RISPERIDONE TAB 3MG	TERBUTALINE TAB 2.5MG
TERIFLUNOMID TAB 14MG	VERAPAMIL CAP 100MG ER
TESTOSTERONE SOL 30MG/ACT	VERAPAMIL CAP 120MG SR
THEOPHYLLINE SOL 80/15ML	VERAPAMIL CAP 300MG ER
THEOPHYLLINE TAB 400MG ER	VIENVA TAB 0.1-20
THEOPHYLLINE TAB 600MG ER	VILAZODONE TAB 20MG
TIOTROP BROM CAP 18MCG	XOFLUZA TAB 80MG
TOBRADEX OIN 0.3-0.1%	ZEPOSIA 7DAY CAP STR PACK
TOBRAMYCIN NEB 300/4ML	ZIPRASIDONE CAP 20MG
TOLTERODINE CAP 2MG ER	ZIPRASIDONE CAP 40MG
TOPIRAMATE CAP 25MG	ZIRGAN GEL 0.15%
TRETINOIN GEL 0.01%	ZUBSOLV SUB 5.7-1.4
TRETINOIN GEL 0.05%	VERAPAMIL CAP 100MG ER
TRIAMCINOLON PST DEN 0.1%	VERAPAMIL CAP 120MG SR
UBRELVY TAB 100MG	VERAPAMIL CAP 300MG ER
URSODIOL TAB 500MG	VILAZODONE TAB 20MG
UZEDY INJ 100MG	XOFLUZA TAB 80MG
UZEDY INJ 125MG	ZEPOSIA 7DAY CAP STR PACK
UZEDY INJ 150MG

Medicare Advantage Plans Tier Changes For 2026
Drug	Change	2025 Tier
ALBUTEROL AER HFA	Tier Increased	3
ALBUTEROL AER HFA	Tier Increased	3
AMLOD/VALSAR TAB /HCTZ	Tier Decreased	6
ANASTROZOLE TAB 1MG	Tier Decreased	1
ANASTROZOLE TAB 1MG	Tier Decreased	1
BRIMONIDINE SOL 0.15% OP	Tier Increased	4
BUDES/FORMOT AER 160-4.5	Tier Increased	4
BUDES/FORMOT AER 80-4.5	Tier Increased	4
BUPROPION TAB 150MG XL	Tier Increased	3
BUPROPION TAB 300MG XL	Tier Increased	3
COLESTIPOL TAB 1GM	Tier Decreased	3
DORZOL/TIMOL SOL 2-0.5%OP	Tier Decreased	1
DORZOL/TIMOL SOL 2-0.5%OP	Tier Decreased	1
EFAVIR/EMTRI TAB TENOFOVI	Tier Decreased	4
ESTRADIOL CRE 0.01%	Tier Decreased	3
ESTRADIOL CRE 0.01%	Tier Decreased	3
EZETIM/SIMVA TAB 10-10MG	Tier Decreased	6
EZETIM/SIMVA TAB 10-20MG	Tier Decreased	6
EZETIM/SIMVA TAB 10-40MG	Tier Decreased	6
EZETIM/SIMVA TAB 10-80MG	Tier Decreased	6
FAMOTIDINE TAB 20MG	Tier Increased	2
FAMOTIDINE TAB 40MG	Tier Increased	2
FENOFIBRATE TAB 145MG	Tier Increased	3
FENOFIBRIC CAP 135MG DR	Tier Decreased	3
FENOFIBRIC CAP 45MG DR	Tier Decreased	3
HYDROXYCHLOR TAB 200MG	Tier Increased	3
ISOSORB MONO TAB 30MG ER	Tier Increased	2
ISOSORB MONO TAB 60MG ER	Tier Increased	2
LANSOPRAZOLE CAP 15MG DR	Tier Decreased	2
LANSOPRAZOLE CAP 30MG DR	Tier Decreased	2
LUBIPROSTONE CAP 24MCG	Tier Decreased	3
LUBIPROSTONE CAP 8MCG	Tier Decreased	3
METHIMAZOLE TAB 10MG	Tier Decreased	1
METHIMAZOLE TAB 5MG	Tier Decreased	1
MONTELUKAST TAB 10MG	Tier Increased	2
NATEGLINIDE TAB 120MG	Tier Decreased	6
NATEGLINIDE TAB 60MG	Tier Decreased	6
NEBIVOLOL TAB 10MG	Tier Increased	4
NEBIVOLOL TAB 5MG	Tier Increased	4
NIFEDIPINE TAB 30MG ER	Tier Increased	3
NIFEDIPINE TAB 30MG ER	Tier Increased	3
NIFEDIPINE TAB 60MG ER	Tier Increased	3
NIFEDIPINE TAB 60MG ER	Tier Increased	3
NIFEDIPINE TAB 90MG ER	Tier Increased	3
NIFEDIPINE TAB 90MG ER	Tier Increased	3
OMEGA-3-ACID CAP 1GM	Tier Increased	3
OXYBUTYNIN TAB 10MG ER	Tier Increased	3
OXYBUTYNIN TAB 5MG ER	Tier Increased	3
PROGESTERONE CAP 100MG	Tier Decreased	2
RALOXIFENE TAB 60MG	Tier Increased	3
RANOLAZINE TAB 500MG ER	Tier Increased	4
REPAGLINIDE TAB 0.5MG	Tier Decreased	6
REPAGLINIDE TAB 1MG	Tier Decreased	6
REPAGLINIDE TAB 2MG	Tier Decreased	6
TACROLIMUS CAP 1MG	Tier Increased	4
TAMSULOSIN CAP 0.4MG	Tier Increased	2
TELMISA/HCTZ TAB 40-12.5	Tier Decreased	6
TELMISA/HCTZ TAB 80-12.5	Tier Decreased	6
TELMISA/HCTZ TAB 80-25MG	Tier Decreased	6
TRAVOPROST DRO 0.004%	Tier Increased	4

Medicare - CNY PDP New Quantity Limits for 2026
Drug	Amount/Frequency
ALFUZOSIN TAB 10MG ER	30 TABS/30 DAYS
CELECOXIB CAP 200MG	60 CAPS/30 DAYS
ELIQUIS TAB 2.5MG	60 TABS/30 DAYS
ELIQUIS TAB 5MG	74 TABS/30 DAYS
EZETIMIBE TAB 10MG	30 TABS/30 DAYS
FINASTERIDE TAB 5MG	30 TABS/30 DAYS
HUMALOG KWIK INJ 100/ML	20 PENS/30 DAYS
HYDROCORT CRE 2.5%	454 GRAMS/30 DAYS
IBUPROFEN TAB 600MG	150 TABS/30 DAYS
IBUPROFEN TAB 800MG	120 TABS/30 DAYS
LANTUS SOLOS INJ 100/ML	20 PENS/30 DAYS
LATANOPROST SOL 0.005%	15 MLS/75 DAYS
LOSARTAN POT TAB 100MG	30 TABS/30 DAYS
LOSARTAN POT TAB 25MG	60 TABS/30 DAYS
LOSARTAN POT TAB 50MG	60 TABS/30 DAYS
LOSARTAN/HCT TAB 100-25	30 TABS/30 DAYS
MELOXICAM TAB 15MG	30 TABS/30 DAYS
MIRTAZAPINE TAB 15MG	45 TABS/30 DAYS
NAPROXEN TAB 500MG	90 TABS/30 DAYS
OLMESA MEDOX TAB 20MG	30 TABS/30 DAYS
OLMESA MEDOX TAB 40MG	30 TABS/30 DAYS
OMEPRAZOLE CAP 40MG	60 CAPS/30 DAYS
OSELTAMIVIR CAP 75MG	84 CAPS/365 DAYS
PANTOPRAZOLE TAB 40MG	60 TABS/30 DAYS
SHINGRIX INJ 50/0.5ML	2 VACCNS/ LIFETI
TAMSULOSIN CAP 0.4MG	60 CAPS/30 DAYS
TRIAMCINOLON CRE 0.1%	454 GRAMS/30 DAYS
TRIAMCINOLON OIN 0.1%	454 GRAMS/30 DAYS
VALSARTAN TAB 160MG	60 TABS/30 DAYS
XARELTO TAB 20MG	30 TABS/30 DAYS

Emblem City of NY PPO Drugs Removed from Formulary In 2026
Drug Class	Non-covered	Formulary Alternatives
INFLAMMATORY BOWEL AGENTS	MESALAMINE ER CAP 500MG PENTASA	balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet
TESTOSTERONE PRODUCTS	JATENZO TESTOSTERONE	testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON), XYOSTED
ANTIARRHYTHMICS	AMIODARONE HCL 400MG	AMIODARONE HCL 200mg
BETA BLOCKERS	SOTYLIZE COREG CR TIMOLOL MALEATE	atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet
LAXATIVES: CIC, IBS-C, OIC	LACTULOSE Packets LUBIPROSTONE (generic AMITIZA) PRUCALOPRIDE (generic MOTEGRITY)	LINZESS, MOVANTIK, SYMPROIC, TRULANCE
ANTICONVULSANTS	ELEPSIA XR LAMOTRIGINE ODT	levetiracetam, levetiracetam ER, topiramate, topiramate ER, topiramate sprinkle ER, lacosamide tablet, zonisamide capsule
ANTIDIABETIC AGENTS	BYETTA CYCLOSET DAPAGLIFOZIN DAPAGLIFOZIN – METFORMIN INOVKANA INVOKANMET JENTADUETO LIRAGLUTIDE METFORMIN HYDROCHLORIDE 750mg METFORMIN HYDROCHLORIDE ER OSM PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HYDROCHLORIDE SAXAGLIPTIN HYDROCHLORIDE/METFORMIN HYDROCHLORIDE ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60	GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON, XIGDUO XR TAB 10-500MG, SYNJARDY TAB 12.5-500, SYNJARDY XR TAB 25-1000, GLYXAMBI TAB 25-5 MG, FARXIGA 10 MG, JARDIANCE 25 MG, SYNJARDY XR TAB 5-1000MG, TRIJARDY XR TAB, SYNJARDY TAB 5-1000MG, GLYXAMBI TAB 10-5 MG, FARXIGA 10MG, JARDIANCE 25 MG
ANTIGOUT	ALLOPURINOL TABLET 200mg FEBUXOSTAT	Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine
ANTILEUKOTRIENES	MONTELUKAST SODIUM oral granules packet ZILEUTON ER ZYFLO	montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate)
PARKINSON AGENTS	AMANTADINE HYDROCHLORIDE TAB NOURIANZ ONGENTYS	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet
URINARY INCONTINENCE	DARIFENACIN HYDROBROMIDE ER FESOTERODINE FUMARATE ER FLAVOXATE HCL OXYTROL	mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
ADHD AND NARCOLEPSY	ADZENYS XR-ODT AMPHETAMINE SULFATE AMPHETAMINE/DEXTROAMPHETAMINE ER (generic MYDAYIS) DESOXYN ZENZEDI COTEMPLA XR-ODT METHYLPHENIDATE METHYLPHENIDATE HCL ER (LA) METHYLPHENIDATE HCL ER (OSM) METHYLPHENIDATE HCL ER (XR) QELBREE VYVANSE	amphetamine/dextroamphetamine, amphetamine/dextroamphetamine XR, armodafinil, atomoxetine, AZSTARYS, dexmethylphenidate ER, dextroamphetamine solution, dextroamphetamine, JORNAY PM, methylphenidate, methylphenidate ER (generic CONCERTA), modafinil, QUILLICHEW ER, QUILLIVANT XR SUSPENSION, SUNOSI, LUMRYZ, SODIUM OXYBATE (authorized generic of XYREM by Hikma), XYWAV, LISDEXAMFETA CAP 30MG, LISDEXAMFETA CHW 30MG, 20MG CD, AZSTARYS CAP 52.3-10., JORNAY PM CAP 20MG ER
MENTAL HEALTH	THIORIDAZINE HYDROCHLORIDE ABILIFY MYCITE MAINTENANCE KIT NUPLAZID OLANZAPINE/FLUOXETINE SYMBYAX	aripiprazole, asenapine, lurasidone, olanzapine, quetiapine er, quetiapine fumarate, REXULTI, risperidone, VRAYLAR, ziprasidone, CAPLYTA, LYBALVI
BPH	CARDURA XL DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE	alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin
COPD & BRONCHODILATORS	YUPELRI FORMOTEROL FUMARATE (Perforomist)	INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH
CALCIUM CHANNEL BLOCKERS	ISRADIPINE NICARDIPINE HYDROCHLORIDE NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HYDROCHLORIDE ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR	amlodipine, diltiazem ER capsule (except 360mg), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr)
CARDIOVASCULAR AGENTS	ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA	enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ
CNS	FLUOXETINE HYDROCHLORIDE TAB PAROXETINE CAP (Brisdelle) PAROXETINE HCL ER TIGLUTIK VEOZAH NEFAZODONE HYDROCHLORIDE	citalopram, escitalopram, fluoxetine capsule, fluvoxamine, paroxetine, sertraline concentrate, sertraline tablet, desvenlafaxine ER, duloxetine, venlafaxine
ALZHEIMER'S AGENTS	ADLARITY ERGOLOID MESYLATES MEMANTINE HYDROCHLORIDE ER CAPS NAMZARIC	donepezil tablet, memantine tablet, memantine solution, rivastigmine patch
CYSTIC FIBROSIS AGENTS	BRONCHITOL	KALYDECO, PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20%
DIURETICS	ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML	bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide
PARKINSON'S AGENTS	PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr)
HIGH CHOLESTEROL	FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HYDROCHLORIDE OMEGA-3-ACID ETHYL ESTERS ROSZET PRALUENT	atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG, REPATHA SURE INJ 140MG/ML, REPATHA PUSH INJ 420/3.5
ELECTROLYTE/MINERAL/METAL MODIFIERS	FERRIPROX TWICE-A-DAY	DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG
FIBROMYALGIA AGENTS	SAVELLA PREGABALIN ER	duloxetine, pregabalin, GRALISE, HORIZANT
ANTICONVULSANTS: BENZODIAZEPINES	SYMPAZAN	clobazam, clonazepam
PRIMARY BILIARY CHOLANGITIS (PBC)	OCALIVA URSODIOL	URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG
GENETIC, ENZYME OR PROTEIN DISORDER	DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN	sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
H2 ANTAGONISTS	CIMETIDINE FAMOTIDINE TAB 20 MG NIZATIDINE	FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)	NOCDURNA	desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
HORMONAL AGENTS	ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE	NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB
IMMUNOLOGICAL AGENTS	TAVNEOS VELSIPITY VOYDEYA	Azathioprine, ADALIMUMAB biosimilars LOW WAC (YUFLYMA, Hyrimoz & Hadlima), ENTYVIO, OMVOH, STELARA, RINVOQ, SIMPONI 100mg, SIMLANDI, SKYRIZI, XELJANZ/XR, ZEPOSIA, CIMZIA, ZYMFENTRA
INSULINS	BASAGLAR KWIKPEN BASAGLAR TEMPO PEN INSULIN ASPART INSULIN GLARGINE-YFGN INSULIN LISPRO	HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA, HUMALOG MIX INJ 50/50KWP, HUMALOG MIX INJ 75/25KWP, NOVOLOG RELI INJ 70/30, NOVOLIN INJ 70/30 FP, NOVOLIN70/30 INJ RELION, NOVOLIN INJ 70/30, NOVOLOG MIX INJ FLEXPEN, NOVOLOG MIX INJ 70/30, NOVOLIN INJ 70/30 FP, HUMULIN INJ 70/30KWP, TOUJEO SOLO INJ 300/ML, TOUJEO MAX INJ 300/ML, SEMGLEE INJ 100U/ML, SEMGLEE INJ 100U/ML, TRESIBA INJ 100UNIT, TRESIBA FLEX INJ 200UNIT, TRESIBA FLEX INJ 100UNIT
METABOLIC BONE DISEASE	BINOSTO CALCITRIOL DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR	calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
MINERALOCORTICOID RECEPTOR ANTAGONISTS	SPIRONOLACTONE SUSP 25 MG/5ML	spironolactone tab 25 mg, 50 mg, 100 mg
MULTIPLE SCLEROSIS	BAFIERTAM PONVORY	AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg
NSAIDS	DICLOFENAC SODIUM ER FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN KETOPROFEN KETOPROFEN ER LOFENA MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM NAPROSYN NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM TOLECTIN 600 TOLMETIN SODIUm	diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg
OPHTHALMIC AGENTS	BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF MIEBO TROPICAMIDE VEVYE XIIDRA BETOPTIC-S TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING ALPHAGAN P BRINZOLAMIDE PHOSPHOLINE IODIDE BIMATOPROST TAFLUPROST TRAVOPROST	EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
PHOSPHATE BINDERS	VELPHORO CHW 500MG	calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
PHOSPHODIESTERASE INHIBITORS	THEOPHYLLINE TAB 200MG ER	theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg
PROGESTINS	MEGESTROL ACETATE SUSP 625 MG/5ML	megestrol acetate tab 20 mg, 40 mg, megestrol acetate susp 40mg/ml (Megace oral)
PROTECTANTS	SUCRALFATE SUSP 1 GM/10ML	sucralfate tablet
PROTON PUMP INHIBITORS	DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE ODT OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM	OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR
PULMONARY HTN	OPSYNVI	ambrisentan, bosentan, OPSUMIT, sildenafil suspension, sildenafil tablet, tadalafil 20mg, TRACLEER, UPTRAVI, ADEMPAS, ORENITRAM, TYVASO NEBULIZED SOLUTION, VENTAVIS, WINREVAIR
RESPIRATORY TRACT AGENTS	FASENRA NUCALA	FASENRA PEN- benralizumab subcutaneous soln auto-injector30 mg/ml, NUCALA- mepolizumab subcutaneous solution auto-injector100 mg/ml, NUCALA- mepolizumab subcutaneous solution pref syringe40 mg/0.4ml, 100 mg/ml
SSRIS/SNRIS	DESVENLAFAXINE ER DULOXETINE HCL ENTERIC COATED PELLETS CAP FLUOXETINE HCL TAB FLUVOXAMINE MALEATE ER PAXIL TRAZODONE HCL 300MG VENLAFAXINE HYDROCHLORIDE ER	DESVENLAFAXINE SUCCINATE TAB ER (PRISTIQ), DULOXETINE CAP 30MG, VENLAFAXINE CAP 150MG ER, DULOXETINE CAP 60MG, DULOXETINE CAP 30MG, VENLAFAXINE TAB 50MG, VENLAFAXINE TAB 75MG, VENLAFAXINE CAP 75MG ER, VENLAFAXINE TAB 100MG, FLUOXETINE CAP 40MG, FLUOXETINE SOL 20MG/5ML, CITALOPRAM TAB 20MG, ESCITALOPRAM TAB 10MG, PAROXETINE TAB 40MG, SERTRALINE TAB 100MG, CITALOPRAM SOL 10MG/5ML, ESCITALOPRAM SOL 5MG/5ML, SERTRALINE CON 20MG/ML, FLUVOXAMINE TAB 100MG, TRAZODONE TAB 100MG
DIABETIC MONITORING/ TESTING SUPPLIES	ONETOUCH ULTRA, ONETOUCH VERIO, FREESTYLE LIBRE READER/MONITORING SYSTEM, CEQUR SIMPLICITY INSER	CONTOUR TEST STRIP, CONTOUR NEXT TEST STRIP, CONTOUR PLUS TEST STRIP, FREESTYLE TEST STRIP, FREESTYLE LITE TEST STRIP, FREESTYLE PRECISION TEST STRIP, DEXCOM G6 SENSOR, DEXCOM G7 SENSOR, OMNIPOD DASH PODS (GEN 4), OMNIPOD 5 G7 PODS (GEN 5), OMNIPOD 5 DEXCOM G7G6 PODS (GEN 5), OMNIPOD 5 LIBRE2 PLUS G6 PODS
TRICYCLICS	AMOXAPINE IMIPRAMINE PAMOATE	imipramine hcl tab 10mg, 25mg, 50mg (Tofranil)
VASODILATORS	ISORDIL TITRADOSE 40MG	ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR

Emblem City of NY HMO Drugs Removed from Formulary In 2026
Drug Class	Non-covered	Formulary Alternatives
INFLAMMATORY BOWEL AGENTS	MESALAMINE ER CAP 500MG PENTASA	balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet
TESTOSTERONE PRODUCTS	JATENZO TESTOSTERONE	testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON), XYOSTED
ANTIARRHYTHMICS	AMIODARONE HCL 400MG	AMIODARONE HCL 200mg
BETA BLOCKERS	SOTYLIZE COREG CR TIMOLOL MALEATE	atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet
LAXATIVES: CIC, IBS-C, OIC	LACTULOSE Packets LUBIPROSTONE (generic AMITIZA) PRUCALOPRIDE (generic MOTEGRITY)	LINZESS, MOVANTIK, SYMPROIC, TRULANCE
ANTICONVULSANTS	ELEPSIA XR LAMOTRIGINE ODT	levetiracetam, levetiracetam ER, topiramate, topiramate ER, topiramate sprinkle ER, lacosamide tablet, zonisamide capsule
ANTIDIABETIC AGENTS	BYETTA CYCLOSET LIRAGLUTIDE METFORMIN HYDROCHLORIDE 750mg METFORMIN HYDROCHLORIDE ER OSM PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HYDROCHLORIDE SAXAGLIPTIN HYDROCHLORIDE/METFORMIN HYDROCHLORIDE ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60	GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON
ANTIGOUT	ALLOPURINOL TABLET 200mg FEBUXOSTAT	Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine
ANTILEUKOTRIENES	MONTELUKAST SODIUM oral granules packet ZILEUTON ER ZYFLO	montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate)
PARKINSON AGENTS	AMANTADINE HYDROCHLORIDE TAB NOURIANZ ONGENTYS	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet
URINARY INCONTINENCE	DARIFENACIN HYDROBROMIDE ER FESOTERODINE FUMARATE ER FLAVOXATE HCL OXYTROL	mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
MENTAL HEALTH	THIORIDAZINE HYDROCHLORIDE ABILIFY MYCITE MAINTENANCE KIT NUPLAZID OLANZAPINE/FLUOXETINE SYMBYAX	aripiprazole, asenapine, lurasidone, olanzapine, quetiapine er, quetiapine fumarate, REXULTI, risperidone, VRAYLAR, ziprasidone, CAPLYTA, LYBALVI
BPH	CARDURA XL DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE	alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin
COPD & BRONCHODILATORS	YUPELRI FORMOTEROL FUMARATE (Perforomist) SYMBICORT ADVAIR DISKUS	INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH, FLUTIC/SALME INH 55/14, FLUTIC/SALME INH 113/14, BREO ELLIPTA INH 100-25, ADVAIR HFA AER 45/21, TRELEGY AER 100MCG, WIXELA INHUB AER 250/50, FLUTIC/SALME AER 250/50, BUDES/FORMOT AER 80-4.5, BREZTRI AERO AER SPHERE
CALCIUM CHANNEL BLOCKERS	ISRADIPINE NICARDIPINE HYDROCHLORIDE NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HYDROCHLORIDE ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR	amlodipine, diltiazem ER capsule (except 360mg), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr)
CARDIOVASCULAR AGENTS	ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA	enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ
CNS	FLUOXETINE HYDROCHLORIDE TAB PAROXETINE CAP (Brisdelle) PAROXETINE HCL ER TIGLUTIK VEOZAH NEFAZODONE HYDROCHLORIDE	citalopram, escitalopram, fluoxetine capsule, fluvoxamine, paroxetine, sertraline concentrate, sertraline tablet, desvenlafaxine ER, duloxetine, venlafaxine
ALZHEIMER'S AGENTS	ADLARITY ERGOLOID MESYLATES MEMANTINE HYDROCHLORIDE ER CAPS NAMZARIC	donepezil tablet, memantine tablet, memantine solution, rivastigmine patch
CYSTIC FIBROSIS AGENTS	BRONCHITOL	KALYDECO, PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20%
DIURETICS	ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML	bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide
PARKINSON'S AGENTS	PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr)
HIGH CHOLESTEROL	FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HYDROCHLORIDE OMEGA-3-ACID ETHYL ESTERS ROSZET	atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG
ELECTROLYTE/MINERAL/METAL MODIFIERS	FERRIPROX TWICE-A-DAY	DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG
FIBROMYALGIA AGENTS	SAVELLA PREGABALIN ER	duloxetine, pregabalin, GRALISE, HORIZANT
ANTICONVULSANTS: BENZODIAZEPINES	SYMPAZAN	clobazam, clonazepam
PRIMARY BILIARY CHOLANGITIS (PBC)	OCALIVA URSODIOL	URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG
GENETIC, ENZYME OR PROTEIN DISORDER	DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN	sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
H2 ANTAGONISTS	CIMETIDINE FAMOTIDINE TAB 20 MG NIZATIDINE	FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)	NOCDURNA	desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
HORMONAL AGENTS	ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE	NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB
IMMUNOLOGICAL AGENTS	TAVNEOS VELSIPITY VOYDEYA TALTZ BIMZELX HUMIRA	ADALIMU-AATY KIT 40/0.4ML, HADLIMA PUSH INJ 40/0.4ML, ADALIMU-ADAZ INJ 40/0.4ML, SIMLANDI KIT 40/0.4ML, SOTYKTU TAB 6MG, TYENNE INJ 162MG, OTEZLA TAB 20MG, COSENTYX PEN INJ 150MG/ML, ENTYVIO PEN INJ 108/0.68, ENBREL SRCLK INJ 50MG/ML, STELARA INJ 90MG/ML, SKYRIZI INJ 180/1.2, TREMFYA INJ 200/2ML, XELJANZ TAB 5MG, RINVOQ TAB 15MG ER, XELJANZ XR TAB 11MG, OMVOH INJ 100MG/ML, SIMPONI INJ 100MG/ML, ZEPOSIA CAP 0.92MG
INSULINS	BASAGLAR KWIKPEN BASAGLAR TEMPO PEN	HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA
METABOLIC BONE DISEASE	BINOSTO CALCITRIOL DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR	calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
MINERALOCORTICOID RECEPTOR ANTAGONISTS	SPIRONOLACTONE SUSP 25 MG/5ML	spironolactone tab 25 mg, 50 mg, 100 mg
MULTIPLE SCLEROSIS	BAFIERTAM PONVORY	AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg
NSAIDS	DICLOFENAC SODIUM ER FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN KETOPROFEN KETOPROFEN ER LOFENA MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM NAPROSYN NAPROXEN NAPROXEN DR NAPROXEN SODIUM NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM TOLECTIN 600 TOLMETIN SODIUM	diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg
OPHTHALMIC AGENTS	BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF MIEBO TROPICAMIDE VEVYE XIIDRA BETOPTIC-S TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING ALPHAGAN P BRINZOLAMIDE PHOSPHOLINE IODIDE BIMATOPROST TAFLUPROST TRAVOPROST	EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
PHOSPHATE BINDERS	VELPHORO CHW 500MG	calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
PHOSPHODIESTERASE INHIBITORS	THEOPHYLLINE TAB 200MG ER	theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg
PROGESTINS	MEGESTROL ACETATE SUSP 625 MG/5ML	megestrol acetate tab 20 mg, 40 mg, megestrol acetate susp 40mg/ml (Megace oral)
PROTON PUMP INHIBITORS	DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE ODT OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM	OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR
PULMONARY HTN	OPSYNVI	ambrisentan, bosentan, OPSUMIT, sildenafil suspension, sildenafil tablet, tadalafil 20mg, TRACLEER, UPTRAVI ADEMPAS, ORENITRAM, TYVASO NEBULIZED SOLUTION, VENTAVIS, WINREVAIR
RESPIRATORY TRACT AGENTS	FASENRA NUCALA	FASENRA PEN- benralizumab subcutaneous soln auto-injector30 mg/ml, NUCALA- mepolizumab subcutaneous solution auto-injector100 mg/ml, NUCALA- mepolizumab subcutaneous solution pref syringe40 mg/0.4ml, 100 mg/ml
SSRIS/SNRIS	DESVENLAFAXINE ER DULOXETINE HCL ENTERIC COATED PELLETS CAP FLUOXETINE HCL TAB FLUVOXAMINE MALEATE ER PAXIL TRAZODONE HCL 300MG VENLAFAXINE HYDROCHLORIDE ER	DESVENLAFAXINE SUCCINATE TAB ER (PRISTIQ), DULOXETINE CAP 30MG, VENLAFAXINE CAP 150MG ER, DULOXETINE CAP 60MG, DULOXETINE CAP 30MG, VENLAFAXINE TAB 50MG, VENLAFAXINE TAB 75MG, VENLAFAXINE CAP 75MG ER, VENLAFAXINE TAB 100MG, FLUOXETINE CAP 40MG, FLUOXETINE SOL 20MG/5ML, CITALOPRAM TAB 20MG, ESCITALOPRAM TAB 10MG, PAROXETINE TAB 40MG, SERTRALINE TAB 100MG, CITALOPRAM SOL 10MG/5ML, ESCITALOPRAM SOL 5MG/5ML, SERTRALINE CON 20MG/ML, FLUVOXAMINE TAB 100MG, TRAZODONE TAB 100MG
TESTING SUPPLIES	ONETOUCH ULTRA, ONETOUCH VERIO, FREESTYLE LIBRE READER/MONITORING SYSTEM,	CONTOUR TEST STRIP, CONTOUR NEXT TEST STRIP, CONTOUR PLUS TEST STRIP, FREESTYLE TEST STRIP, FREESTYLE LITE TEST STRIP, FREESTYLE PRECISION TEST STRIP, DEXCOM G6 SENSOR, DEXCOM G7 SENSOR
TRICYCLICS	AMOXAPINE IMIPRAMINE PAMOATE	imipramine hcl tab 10mg, 25mg, 50mg (Tofranil)
VASODILATORS	ISORDIL TITRADOSE 40MG	ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR

Emblem Small Group/Essential/Individual Plans Drugs Removed from Formulary In 2026
Drug Class	Non-covered	Formulary Alternatives
MENTAL HEALTH	ABILIFY ABILIFY MYCITE COBENFY GEODON INVEGA LATUDA LYBALVI OLANZAPINE-FLUOXETINE OPIPZA QUETIAPINE RISPERAL SAPHRIS SEROQUEL SYMBYAX ZYPREXA	ARIPIPRAZOLE TAB 10MG, ARIPIPRAZOLE SOL 1MG/ML, ARIPIPRAZOLE TAB 10MG ODT, QUETIAPINE TAB 150MG ER, QUETIAPINE TAB 100MG, OLANZAPINE TAB 10MG, RISPERIDONE TAB 2MG, RISPERIDONE TAB 2MG ODT, PALIPERIDONE TAB ER 6MG, ASENAPINE SUB 5MG, ZIPRASIDONE CAP 40MG, OLANZAPINE TAB 15MG ODT, REXULTI TAB 2MG, VRAYLAR CAP 3MG, CAPLYTA CAP 21MG
INFLAMMATORY BOWEL AGENTS	MESALAMINE ER CAP 500MG PENTASA LIALDA DELZICOL APRISO AZULFIDINE	balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet
TESTOSTERONE PRODUCTS	TESTOSTERONE VOGELXO TESTIM	testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON)
ANTIARRHYTHMICS	AMIODARONE HCL BETAPACE RYTHMOL TIKOSYN	AMIODARONE HCL 200mg, SOTALOL AF TAB 120MG, PROPRANOLOL SOL 20MG/5ML, PROPRANOLOL TAB 80MG, PROPRANOLOL CAP 80MG ER, PINDOLOL TAB 5MG, DOFETILIDE CAP
BETA BLOCKERS	SOTYLIZE INDERAL LA INNOPRAN XL TENORMIN BETAPACE	atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet
LAXATIVES: CIC, IBS-C, OIC	LACTULOSE Packets AMITIZA LINZESS	LUBIPROSTONE CAP 24MCG, TRULANCE TAB 3MG, ENULOSE SOL 10GM/15, GENERLAC SOL 10GM/15, LACTULOSE SOL 10GM/15, CONSTULOSE SOL 10GM/15, IBSRELA TAB 50MG, MOTEGRITY TAB 1MG
ANTICONVULSANTS	APTIOM ELEPSIA XR FYCOMPA LAMOTRIGINE ODT MOTOPOLY XR ONFI	LEVETIRACETAM, LEVETIRACETAM ER, TOPIRAMATE, TOPIRAMATE ER, TOPIRAMATE SPRINKLE ER, LACOSAMIDE TABLET, ZONISAMIDE CAPSULE, PERAMPANEL TAB, CLOBAZAM SUS, FELBAMATE SUS
ALZHEIMER'S AGENTS	ERGOLOID MESYLATES MEMANTINE HCL ER CAPS NAMZARIC ADLARITY	DONEPEZIL TABLET, MEMANTINE TABLET, MEMANTINE SOLUTION, RIVASTIGMINE PATCH
ANTIDIABETIC AGENTS	BYETTA CYCLOSET LIRAGLUTIDE ONGLYZA PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HCL SAXAGLIPTIN HCL/METFORMIN HCL ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60	GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON, ALOGLIPTAN
ANTIGOUT	ALLOPURINOL 200MG ULORIC	Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine, FEBUXOSTAT
ANTILEUKOTRIENES	MONTELUKAST SODIUM GRANULES PACKET 4 MG ZYFLO	montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate)
PARKINSON AGENTS	AMANTADINE HCL TAB NOURIANZ ONGENTYS	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, ROPINORELE
URINARY INCONTINENCE	AVODART FESOTERODINE FUMARATE ER FLOMAX OXYTROL TOVIAZ	mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
ADHD AND NARCOLEPSY	ADZENYS XR-ODT AMPHETAMINE/DEXTROAMPHETAMINE ER (generic MYDAYIS) DESOXYN ZENZEDI COTEMPLA XR-ODT METHYLPHENIDATE METHYLPHENIDATE HCL ER (LA) METHYLPHENIDATE HCL ER (OSM) METHYLPHENIDATE HCL ER (XR) QELBREE	amphetamine/dextroamphetamine, amphetamine/dextroamphetamine XR, armodafinil, atomoxetine, AZSTARYS, dexmethylphenidate ER, dextroamphetamine solution, dextroamphetamine, JORNAY PM, methylphenidate, methylphenidate ER (generic CONCERTA), modafinil, QUILLICHEW ER, QUILLIVANT XR SUSPENSION, SUNOSI, LUMRYZ, SODIUM OXYBATE (authorized generic of XYREM by Hikma), XYWAV
BPH	CARDURA XL DUTASTERIDE/TAMSULOSIN HCL	alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin
COPD & BRONCHODILATORS	YUPELRI FORMOTEROL FUMARATE (Perforomist)	INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH
CALCIUM CHANNEL BLOCKERS	CARDIZEM ISRADIPINE NICARDIPINE HCL NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HCL ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR	amlodipine, diltiazem ER capsule), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr), ISOSORBIDE TABS
CARDIOVASCULAR AGENTS	ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA	enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ
CYSTIC FIBROSIS AGENTS	BRONCHITOL	PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20%
DIURETICS	ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML	bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide
PARKINSON'S AGENTS	PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr)
HIGH CHOLESTEROL	FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HCL PACKET FOR SUSP 3.75 GM OMEGA-3-ACID ETHYL ESTERS ROSZET	atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG
ELECTROLYTE/MINERAL/METAL MODIFIERS	FERRIPROX TWICE-A-DAY	DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG
FIBROMYALGIA AGENTS	SAVELLA PREGABALIN ER	duloxetine, pregabalin, GRALISE, HORIZANT
ANTICONVULSANTS: BENZODIAZEPINES	SYMPAZAN	clobazam, clonazepam
PRIMARY BILIARY CHOLANGITIS (PBC)	OCALIVA URSODIOL CAP 200MG & 400MG	URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG
GENETIC, ENZYME OR PROTEIN DISORDER	DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN	sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
H2 ANTAGONISTS	CIMETIDINE CIMETIDINE HCL SOLN 300 MG/5ML FAMOTIDINE TAB 20 MG NIZATIDINE	FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)	NGENLA NOCDURNA SEROSTIM	GENOTROPIN, OMNITROPE, SKYTROFA, desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
HORMONAL AGENTS	ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE	NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB
IMMUNOLOGICAL AGENTS	ACTEMRA TALTZ TAVNEOS VELSIPITY VOYDEYA CYLTEZO	TYENNE, ADALIMUMAB biosimilars LOW WAC (YUFLYMA, Hyrimoz & Hadlima), ENTYVIO, OMVOH, RINVOQ, SIMPONI 100mg, SKYRIZI, XELJANZ/XR, ZEPOSIA, CIMZIA, ZYMFENTRA
IMMUNOSUPPRESSANTS	RASUVO	methotrexate injection, methotrexate tablet, OTREXUP, REDITREX
INSULINS	BASAGLAR KWIKPEN BASAGLAR TEMPO PEN	HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA
METABOLIC BONE DISEASE	BINOSTO CALCITRIOL ORAL SOLN 1 MCG/ML DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR	calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
MINERALOCORTICOID RECEPTOR ANTAGONISTS	SPIRONOLACTONE SUSP 25 MG/5ML	spironolactone tab 25mg, 50mg, 100mg
MULTIPLE SCLEROSIS	BAFIERTAM PONVORY	AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg
NSAIDS	ANAPROX DS ARHTORTEC CELEBREX FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN SUPPOS 50 MG INDOMETHACIN SUSP 25 MG/5ML KETOPROFEN KETOPROFEN ER LOFENA MELOXICAM CAP NAPROXEN SUSP NAPROXEN TAB EC NAPROXEN DR NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM (generic VIMOVO) TOLECTIN 600 TOLMETIN SODIUM ZORVOLEX	diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg, KEOTROLAC
OPHTHALMIC AGENTS	ALPHAGAN P BETOPTIC-S BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HCL/TIMOLOL MALEATE PF MIEBO PHOSPHOLINE IODIDE TAFLUPROST TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING TRAVOPROST TROPICAMIDE VEVYE VERKAZYA XIIDRA	EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
PHOSPHATE BINDERS	XPHOZAH	calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
PHOSPHODIESTERASE INHIBITORS	THEOPHYLLINE TAB ER 100MG & 200MG	theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg
PROTECTANTS	SUCRALFATE SUSP 1 GM/10ML	sucralfate tablet
PROTON PUMP INHIBITORS	DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM ZEGERID	OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR
PULMONARY HTN	OPSYNVI	TADALAFIL TAB, ALYQ TAB, AMBRISENTAN TAB, BOSENTAN TAB, SILDENAFIL TAB, SILDENAFIL SUS 10MG/ML, UPTRAVI TAB
TRICYCLICS	IMIPRAMINE PAMOATE	imipramine hcl tab 10mg, 25mg, 50mg (Tofranil)
VASODILATORS	ISOSORBIDE DINITRATE NITROSTAT	ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR, NITROGLYCERIN
VITAMIN B12	cyanocobalamin nasal spray	cyanocobalamin injection
HIV	COMBIVIR EMTRIVA EPIVIR KALETRA	EMTRIC/RILPI TAB TENOF DF, ABACA/LAMIVU TAB 600-300, LAMIVUD/ZIDO TAB 150-300, TRUVADA TAB 100-150, EFAVIR/LAMIV TAB TENOFOVI, ODEFSEY TAB, BIKTARVY TAB, DELSTRIGO TAB, TRIUMEQ TAB, COMPLERA TAB

Emblem Commercial Large Group Drugs Removed from Formulary In 2026
Drug Class	Non-covered	Formulary Alternatives
MENTAL HEALTH	THIORIDAZINE HCL ABILIFY MAINTENA ABILIFY MYCITE MAINTENANCE KIT ARISTADA NUPLAZID OLANZAPINE/FLUOXETINE SYMBYAX	aripiprazole, asenapine, lurasidone, olanzapine, quetiapine er, quetiapine fumarate, REXULTI, risperidone, VRAYLAR, ziprasidone, CAPLYTA, LYBALVI
INFLAMMATORY BOWEL AGENTS	MESALAMINE ER CAP 500MG PENTASA	balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet
TESTOSTERONE PRODUCTS	JATENZO TESTOSTERONE	testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON), XYOSTED
ANTIARRHYTHMICS	AMIODARONE HCL	AMIODARONE HCL 200mg
BETA BLOCKERS	SOTYLIZE COREG CR TIMOLOL MALEATE	atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet
LAXATIVES: CIC, IBS-C, OIC	LACTULOSE Packets LUBIPROSTONE (generic AMITIZA) PRUCALOPRIDE (generic MOTEGRITY)	LINZESS, MOVANTIK, SYMPROIC, TRULANCE
ANTICONVULSANTS	ELEPSIA XR LAMOTRIGINE ODT	LEVETIRACETAM, LEVETIRACETAM ER, TOPIRAMATE, TOPIRAMATE ER, TOPIRAMATE SPRINKLE ER, LACOSAMIDE TABLET, ZONISAMIDE CAPSULE
ALZHEIMER'S AGENTS	ERGOLOID MESYLATES MEMANTINE HCL ER CAPS NAMZARIC ADLARITY	DONEPEZIL TABLET, MEMANTINE TABLET, MEMANTINE SOLUTION, RIVASTIGMINE PATCH
ANTIDIABETIC AGENTS	BYETTA CYCLOSET LIRAGLUTIDE METFORMIN HCL 750MG METFORMIN HCL ER OSM METFORMIN HCL ER MODIFIED PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HCL SAXAGLIPTIN HCL/METFORMIN HCL ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60	GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON
ANTIGOUT	ALLOPURINOL 200MG FEBUXOSTAT	Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine
ANTILEUKOTRIENES	MONTELUKAST SODIUM GRANULES PACKET 4 MG ZILEUTON ER ZYFLO	montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate)
PARKINSON AGENTS	AMANTADINE HCL TAB NOURIANZ ONGENTYS	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet
URINARY INCONTINENCE	DARIFENACIN HYDROBROMIDE ER FESOTERODINE FUMARATE ER FLAVOXATE HCL OXYTROL	mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
ADHD AND NARCOLEPSY	ADZENYS XR-ODT AMPHETAMINE SULFATE AMPHETAMINE/DEXTROAMPHETAMINE ER (generic MYDAYIS) DESOXYN ZENZEDI COTEMPLA XR-ODT METHYLPHENIDATE METHYLPHENIDATE HCL ER (LA) METHYLPHENIDATE HCL ER (OSM) METHYLPHENIDATE HCL ER (XR) QELBREE VYVANSE	amphetamine/dextroamphetamine, amphetamine/dextroamphetamine XR, armodafinil, atomoxetine, AZSTARYS, dexmethylphenidate ER, dextroamphetamine solution, dextroamphetamine, JORNAY PM, methylphenidate, methylphenidate ER (generic CONCERTA), modafinil, QUILLICHEW ER, QUILLIVANT XR SUSPENSION, SUNOSI, LUMRYZ, SODIUM OXYBATE (authorized generic of XYREM by Hikma), XYWAV, LISDEXAMFETA CAP 30MG, LISDEXAMFETA CHW 30MG, 20MG CD, AZSTARYS CAP 52.3-10., JORNAY PM CAP 20MG ER
BPH	CARDURA XL DUTASTERIDE/TAMSULOSIN HCL	alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin
COPD & BRONCHODILATORS	YUPELRI FORMOTEROL FUMARATE (Perforomist) SYMBICORT ADVAIR DISKUS	INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH, FLUTIC/SALME INH 55/14, FLUTIC/SALME INH 113/14, BREO ELLIPTA INH 100-25, ADVAIR HFA AER 45/21, TRELEGY AER 100MCG, WIXELA INHUB AER 250/50, FLUTIC/SALME AER 250/50, BUDES/FORMOT AER 80-4.5, BREZTRI AERO AER SPHERE
CALCIUM CHANNEL BLOCKERS	ISRADIPINE NICARDIPINE HCL NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HCL ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR	amlodipine, diltiazem ER capsule (except 360mg), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr)
CARDIOVASCULAR AGENTS	ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA	enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ
CNS	FLUOXETINE HCL TAB PAROXETINE CAP (Brisdelle) PAROXETINE HCL ER TAB PAROXETINE ORAL SUSP TIGLUTIK VEOZAH DESVENLAFAXINE ER TAB DULOXETINE HCL DR FLUOXETINE HCL 60MG TAB FLUVOXAMINE MALEATE ER NEFAZODONE HCL TRAZODONE HCL 300MG VENLAFAXINE HCL ER TAB	citalopram, escitalopram, fluoxetine capsule, fluvoxamine, paroxetine, sertraline concentrate, sertraline tablet, desvenlafaxine ER, duloxetine, venlafaxine, venlafaxine ER CAPS
CYSTIC FIBROSIS AGENTS	BRONCHITOL	KALYDECO, PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20%
DIURETICS	ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML	bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide
PARKINSON'S AGENTS	PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT	amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr)
HIGH CHOLESTEROL	FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HYDROCHLORIDE OMEGA-3-ACID ETHYL ESTERS ROSZET PRALUENT	atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG, REPATHA SURE INJ 140MG/ML, REPATHA PUSH INJ 420/3.5
ELECTROLYTE/MINERAL/METAL MODIFIERS	FERRIPROX TWICE-A-DAY	DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG
FIBROMYALGIA AGENTS	SAVELLA PREGABALIN ER	duloxetine, pregabalin, GRALISE, HORIZANT
ANTICONVULSANTS: BENZODIAZEPINES	SYMPAZAN	clobazam, clonazepam
PRIMARY BILIARY CHOLANGITIS (PBC)	OCALIVA URSODIOL CAP 200MG & 400MG	URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG
GENETIC, ENZYME OR PROTEIN DISORDER	DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN	sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
H2 ANTAGONISTS	CIMETIDINE CIMETIDINE HCL SOLN 300 MG/5ML FAMOTIDINE TAB 20 MG NIZATIDINE	FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML
LIPODYSTROPHY AGENTS	EGRIFTA SV	NO FORMULARY ALTERNATIVES
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)	NGENLA NOCDURNA SEROSTIM	GENOTROPIN, OMNITROPE, SKYTROFA, desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
HORMONAL AGENTS	ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE	NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB
IMMUNOLOGICAL AGENTS	TAVNEOS VELSIPITY VOYDEYA TALTZ BIMZELX HUMIRA	ADALIMU-AATY KIT 40/0.4ML, HADLIMA PUSH INJ 40/0.4ML, ADALIMU-ADAZ INJ 40/0.4ML, SIMLANDI KIT 40/0.4ML, SOTYKTU TAB 6MG, TYENNE INJ 162MG, OTEZLA TAB 20MG, COSENTYX PEN INJ 150MG/ML, ENTYVIO PEN INJ 108/0.68, ENBREL SRCLK INJ 50MG/ML, STELARA INJ 90MG/ML, SKYRIZI INJ 180/1.2, TREMFYA INJ 200/2ML, XELJANZ TAB 5MG, RINVOQ TAB 15MG ER, XELJANZ XR TAB 11MG, OMVOH INJ 100MG/ML, SIMPONI INJ 100MG/ML, ZEPOSIA CAP 0.92MG
INSULINS	BASAGLAR KWIKPEN BASAGLAR TEMPO PEN	HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA
METABOLIC BONE DISEASE	BINOSTO CALCITRIOL ORAL SOLN 1 MCG/ML DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR	calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
MINERALOCORTICOID RECEPTOR ANTAGONISTS	SPIRONOLACTONE SUSP 25 MG/5ML	spironolactone tab 25mg, 50mg, 100mg
MULTIPLE SCLEROSIS	BAFIERTAM PONVORY	AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg
NSAIDS	DICLOFENAC SODIUM ER FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN SUPPOS 50 MG INDOMETHACIN SUSP 25 MG/5ML KETOPROFEN KETOPROFEN ER LOFENA MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM CAP NAPROXEN SUSP 125 MG/5ML NAPROXEN TAB EC NAPROXEN DR NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM (generic VIMOVO) TOLECTIN 600 TOLMETIN SODIUM	diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg
OPHTHALMIC AGENTS	BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HCL/TIMOLOL MALEATE PF MIEBO TROPICAMIDE VEVYE XIIDRA BETOPTIC-S TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING ALPHAGAN P BRINZOLAMIDE PHOSPHOLINE IODIDE BIMATOPROST TAFLUPROST TRAVOPROST	EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
PHOSPHATE BINDERS	VELPHORO CHW 500MG	calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
PHOSPHODIESTERASE INHIBITORS	THEOPHYLLINE TAB ER 100MG & 200MG	theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg
PROGESTINS	MEGESTROL ACETATE SUSP 625 MG/5ML	megestrol acetate tab 20 mg, 40 mg, megestrol acetate susp 40mg/ml (Megace oral)
PROTECTANTS	SUCRALFATE SUSP 1 GM/10ML	sucralfate tablet
PROTON PUMP INHIBITORS	DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM	OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR
PULMONARY HTN	OPSYNVI TYVASO DPI MAINTENANCE KIT	ambrisentan, bosentan, OPSUMIT, sildenafil suspension, sildenafil tablet, tadalafil 20mg, TRACLEER, UPTRAVI, ADEMPAS, ORENITRAM, TYVASO NEBULIZED SOLUTION, VENTAVIS, WINREVAIR
RESPIRATORY TRACT AGENTS	FASENRA NUCALA	FASENRA PEN- benralizumab subcutaneous soln auto-injector30 mg/ml, NUCALA- mepolizumab subcutaneous solution auto-injector100 mg/ml, NUCALA- mepolizumab subcutaneous solution pref syringe40 mg/0.4ml, 100 mg/ml
TESTING SUPPLIES	ONETOUCH ULTRA, ONETOUCH VERIO, FREESTYLE LIBRE READER/MONITORING SYSTEM,	CONTOUR TEST STRIP, CONTOUR NEXT TEST STRIP, CONTOUR PLUS TEST STRIP, FREESTYLE TEST STRIP, FREESTYLE LITE TEST STRIP, FREESTYLE PRECISION TEST STRIP, DEXCOM G6 SENSOR, DEXCOM G7 SENSOR
TRICYCLICS	AMOXAPINE IMIPRAMINE PAMOATE	imipramine hcl tab 10mg, 25mg, 50mg (Tofranil)
VASODILATORS	ISOSORBIDE DINITRATE	ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR

JP69830 11/2025

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