Pharmacy Policy Criteria

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Pharmacy Policy Criteria

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)