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2022 EmblemHealth Formulary Changes
Effective Date: Jan. 1, 2022
The table below describes all formulary changes going into effect for our Medicare and Medicaid members in 2022. For our Commercial members, this table highlights the most highly impacted drugs. See the applicable 2022 plan formularies for all coverage rules:
Affected members were notified of these changes separately.
Key:
Medicaid = Medicaid and HARP
Medicare Advantage Plans = EmblemHealth Plan, Inc. (formerly GHI) and HIP
Medicare CNY PDP = City Retirees’ Prescription Drug Plan Only
Commercial See: 2022 Summary of Companies, Lines of Business, Networks & Benefit Plans
| Affected Members | Drug | Change | Alterative(s) |
|---|---|---|---|
Medicaid |
Perforomist |
Brand Removal |
FORMOTEROL FUMARATE |
Medicaid |
Remodulin |
Brand Removal |
TREPROSTINIL |
Medicare Advantage Plans |
Incruse Ellipta |
Removed from Formulary |
SPIRIVA HANDIHALER & SPIRIVA RESPIMAT |
Medicare Advantage Plans |
Saphris |
Brand Removal |
ASENAPINE (generic) |
Medicare Advantage Plans |
Tecfidera |
Brand Removal |
DIMETHYL FUMARATE (generic) |
Medicare Advantage Plans |
Zytiga |
Brand Removal |
ABIRATERONE ACETATE (generic) |
Medicare Advantage Plans |
Lubiprosotone |
Needs Step Therapy |
LINZESS & MOVANTIK |
Medicare Advantage Plans |
Trulance |
Tier Increase to T4 |
LINZESS |
Medicare Advantage Plans |
Ciprodex |
Removed from Formulary |
CIPROFLOXACIN/DEXAMETHASONE (generic) |
Medicare Advantage Plans |
Pazeo |
Removed from Formulary |
AZELASTINE, OLOPATADINE & CROMOLYN SODIUM |
Medicare Advantage Plans |
Atripla |
Removed from Formulary |
EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE (generic) |
Medicare Advantage Plans |
Truvada |
Removed from Formulary |
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE (generic) |
Medicare Advantage Plans |
Tier Increase to T4 |
n/a |
|
Medicare - CNY PDP |
Anoro Ellipta |
Step Therapy Added or Updated |
STIOLTO RESPIMAT |
Medicare - CNY PDP |
Incruse Ellipta |
Step Therapy Added or Updated |
SPIRIVA HANDIHALER & SPIRIVA RESPIMAT |
Medicare - CNY PDP |
Budesonide-Formoterol |
Step Therapy Added or Updated |
SYMBICORT, DULERA, BREO |
Medicare - CNY PDP |
Invokana |
Step Therapy Added or Updated |
FARXIGA, JARDIANCE, STEGLATRO |
Medicare - CNY PDP |
NovoLog |
Step Therapy Added or Updated |
HUMALOG |
Medicare - CNY PDP |
Tradjenta |
Step Therapy Added or Updated |
JANUVIA, ONGLYZA, KOMBIGLYZE |
Medicare - CNY PDP |
Xiidra Ophthalmic |
Step Therapy Added or Updated |
RESTASIS |
Medicare - CNY PDP |
Cabometyx |
New Quantity Limit: 30/30 Days |
n/a |
Medicare - CNY PDP |
Sevelamer Carbonate |
New Quantity Limit: 9/Days |
n/a |
Medicare - CNY PDP |
Vimpat |
New Quantity Limit: 60/30 Days |
n/a |
Medicare - CNY PDP |
Invega Sustenna |
New Quantity Limit: 1/Fill |
n/a |
Medicare - CNY PDP |
Cinacalcet tablets |
Preauthorization Requirement Added or Updated |
n/a |
Medicare - CNY PDP |
Cimzia |
Preauthorization Requirement Added or Updated |
n/a |
Medicare - CNY PDP |
Octreotide |
Preauthorization Requirement Added or Updated |
n/a |
City of NY PPO |
Tradjenta |
Removed from Formulary |
JANUVIA |
City of NY PPO |
Ventolin HFA |
Removed from Formulary |
ALBUTEROL SULFATE HFA |
City of NY PPO |
Jentadueto/Jentadueto XR |
Removed from Formulary |
JANUMET, JANUMET XR |
City of NY PPO |
ProAir HFA/ProAir RespiClick |
Removed from Formulary |
ALBUTEROL SULFATE HFA |
City of NY PPO |
Invokana |
Removed from Formulary |
FARXIGA, JARDIANCE, STEGLATRO |
City of NY PPO |
Invokamet/Invokamet XR |
Removed from Formulary |
SEGLUROMET, SYNJARDY XR |
City of NY PPO |
Praluent pen |
Removed from Formulary |
REPATHA SURECLICK |
City of NY PPO |
Synthroid |
Removed from Formulary |
EUTHYROX, LEVO-T, LEVOTHYROXTINE SODIUM |
City of NY PPO |
NovoLog products |
Removed from Formulary |
HUMALOG PRODUCTS |
City of NY PPO |
Victoza |
Removed from Formulary |
BYDUREON, BYETTA, OZEMPIC |
City of NY PPO |
Synthroid |
Removed from Formulary |
EUTHYROX, LEVO-T, LEVOTHYROXINE SODIUM |
City of NY PPO |
Novolin products |
Removed from Formulary |
HUMULIN PRODUCTS |
City of NY PPO |
Lo Loestrin FE 1-10 |
Removed from Formulary |
BLISOVI FE, HAILEY FE |
City of NY PPO |
Invokana |
Removed from Formulary |
FARXIGA, JARDIANCE, STEGLATRO |
Synthroid |
Preauthorization Requirement Added |
EUTHYROX, LEVOTHYROXINE SODIUM, LEVOXYL |
|
Small Group/Essential/Individual Plans |
Ventolin HFA |
Preauthorization Requirement Added |
ALBUTEROL SULFATE HFA |
Small Group/Essential/Individual Plans |
Lo Loestrin FE 1-10 |
Preauthorization Requirement Added |
BLISOVI 24 FE, HAILEY FE, JUNEL FE |
Small Group/Essential/Individual Plans |
NovoLog |
Preauthorization Requirement Added |
HUMALOG |
Small Group/Essential/Individual Plans |
Onglyza |
Preauthorization Requirement Added |
JANUVIA |
Small Group/Essential/Individual Plans |
Bystolic |
Preauthorization Requirement Added |
ATENOLOL, CARVEDILOL, METOPROLOL SUCCINATE |
Small Group/Essential/Individual Plans |
Preauthorization Requirement Added |
FARXIGA, JARDIANCE, STEGLATRO |
|
Small Group/Essential/Individual Plans |
Victoza |
Preauthorization Requirement Added |
BYDUREON, BYETTA, OZEMPIC, TRULICITY |
Small Group/Essential/Individual Plans |
Lumigan |
Preauthorization Requirement Added |
BIMATOPROST, LATANOPROST, TRAVOPROST |
Small Group/Essential/Individual Plans |
Praluent |
Preauthorization Requirement Added |
REPATHA |
Small Group/Essential/Individual Plans |
Advair |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Arnuity |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Incruse Ellipta |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Dulera |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Ajovy |
New Quantity Limit: 2/Month (3ML Total) |
n/a |
Small Group/Essential/Individual Plans |
Emgality |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Copaxone |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Duloxetine |
New Quantity Limit: 30/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Buproprion XL |
New Quantity Limit: 30/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Escitalopram |
New Quantity Limit: 30/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Venlafaxine |
New Quantity Limit: 30/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Desvenlafaxine |
New Quantity Limit: 30/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Ozempic |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Trulicity |
New Quantity Limit: 1/Month |
n/a |
Small Group/Essential/Individual Plans |
Valacyclovir |
New Quantity Limit: 30/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Zolpidem |
New Quantity Limit: 15/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Eszopiclone |
New Quantity Limit: 15/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Belsomra |
New Quantity Limit: 15/30 Days |
n/a |
Small Group/Essential/Individual Plans |
Ventolin HFA |
Moving to Non-Preferred Tier |
ALBUTEROL SULFATE HFA |
Small Group/Essential/Individual Plans |
Combigan |
Moving to Non-Preferred Tier |
BRIMONIDINE, TIMOLOL |
Small Group/Essential/Individual Plans |
Multaq |
Moving to Non-Preferred Tier |
AMIODARONE, DOFETILIDE, FLECAINIDE |
Small Group/Essential/Individual Plans |
Synthroid |
Moving to Non-Preferred Tier |
EUTHYROX, LEVOTHYROXINE, LEVOXYL |
Small Group/Essential/Individual Plans |
Bystolic |
Moving to Non-Preferred Tier |
ATENOLOL, CARVEDILOL, METOPROLOL |
Small Group/Essential/Individual Plans |
Invokana |
Moving to Non-Preferred Tier |
FARXIGA, JARDIANCE, STEGLATRO |
Small Group/Essential/Individual Plans |
Lumigan |
Moving to Non-Preferred Tier |
BIMATOPROST, LATANOPROST, TRAVOPROST |
Small Group/Essential/Individual Plans |
Alphagan P |
Moving to Non-Preferred Tier |
BRIMONIDINE TARTRATE |
Large Group |
Ventolin HFA |
Preauthorization Requirement Added |
ALBUTEROL SULFATE HFA |
Large Group |
Synthroid |
Preauthorization Requirement Added |
EUTHYROX, LEVOTHYROXINE, LEVOXYL |
Large Group |
Advair |
Preauthorization Requirement Added |
FLUTICASONE-SALMETEROL, WIXELA INHUB |
Large Group |
NovoLog |
Preauthorization Requirement Added |
HUMALOG |
Large Group |
Bystolic |
Preauthorization Requirement Added |
ATENOLOL, CARVEDILOL, METOPROLOL SUCCINATE |
Large Group |
Invokana |
Preauthorization Requirement Added |
FARXIGA, JARDIANCE, STEGLATRO |
Large Group |
Lo Loestrin FE 1-10 |
Preauthorization Requirement Added |
BLISOVI 24 FE, HAILEY FE, JUNEL FE |
Large Group |
Lumigan |
Preauthorization Requirement Added |
BIMATOPROST, LATANOPROST, TRAVOPROST |
Large Group |
Advair |
New Quantity Limit: 1/Month |
n/a |
Large Group |
Arnuity |
New Quantity Limit: 1/Month |
n/a |
Large Group |
Incruse Ellipta |
New Quantity Limit: 1/Month |
n/a |
Large Group |
Dulera |
New Quantity Limit: 1/Month |
n/a |
Large Group |
Ajovy |
New Quantity Limit: 2/Month (3ML Total) |
n/a |
Large Group |
Emgality |
New Quantity Limit: 1/Month |
n/a |
Large Group |
Copaxone |
New Quantity Limit: 1/Month |
n/a |
Large Group |
Duloxetine |
New Quantity Limit: 30/30 Days |
n/a |
Large Group |
Buproprion XL |
New Quantity Limit: 30/30 Days |
n/a |
Large Group |
Escitalopram |
New Quantity Limit: 30/30 Days |
n/a |
Large Group |
Venlafaxine |
New Quantity Limit: 30/30 Days |
n/a |
Large Group |
Desvenlafaxine |
New Quantity Limit: 30/30 Days |
n/a |
Large Group |
Invokana |
New Quantity Limit: 30/30 Days |
n/a |
Large Group |
Onglyza |
New Quantity Limit: 60/30 Days |
n/a |
Large Group |
Ozempic |
New Quantity Limit: 1/Month |
n/a |
Large Group |
Zolpidem |
New Quantity Limit: 15/30 Days |
n/a |
Large Group |
Eszopiclone |
New Quantity Limit: 15/30 Days |
n/a |
Large Group |
Temazepam |
New Quantity Limit: 15/30 Days |
n/a |
Large Group |
Ventolin HFA |
Moving to Non-Preferred Tier |
ALBUTEROL SULFATE HFA |
Large Group |
Adderall XR |
Moving to Non-Preferred Tier |
DEXTROAMPHETAMINE-AMPHETAMINE ER |
Large Group |
NovoLog |
Moving to Non-Preferred Tier |
HUMALOG |
Large Group |
Synthroid |
Moving to Non-Preferred Tier |
EUTHYROX, LEVOTHYROXINE, LEVOXYL |
Large Group |
Praluent |
Moving to Non-Preferred Tier |
REPATHA |
Large Group |
Combigan |
Moving to Non-Preferred Tier |
BRIMONIDINE TARTRATE, TIMOLOL MALEATE |
Large Group |
Victoza |
Moving to Non-Preferred Tier |
BYDUREON, BYETTA, OZEMPIC, TRULICITY |
Large Group |
Invokana |
Moving to Non-Preferred Tier |
FARXIGA, JARDIANCE, STEGLATRO |
Large Group |
Lumigan |
Moving to Non-Preferred Tier |
BIMATOPROST, LATANOPROST, TRAVOPROST |
Large Group |
Lo Loestrin FE 1-10 |
Moving to Non-Preferred Tier |
BLISOVI FE, HAILEY FE, JUNEL FE |
JP56804:12/14