EmblemHealth prior authorization criteria
Submission criteria, documentation packets, and P2P prep by drug — for prescribers and PA staff. 30-day standard PA decision.
EmblemHealth reviews prior-authorization requests against its published medical policies — diagnosis with ICD-10 code, documented step-therapy history, and prescriber attestation of medical necessity. Standard PA decisions return in 30 days; if denied, prescribers and members have 180 days to appeal. Criteria by drug below.
Prior authorization criteria by drug
Each page covers EmblemHealth's submission criteria, the documentation packet, and peer-to-peer prep for that drug.
- Adalimumab at EmblemHealth →
- Aflibercept at EmblemHealth →
- Apixaban at EmblemHealth →
- Atezolizumab at EmblemHealth →
- Atogepant at EmblemHealth →
- Benralizumab at EmblemHealth →
- Bevacizumab at EmblemHealth →
- Bictegravir at EmblemHealth →
- Buprenorphine at EmblemHealth →
- Dapagliflozin at EmblemHealth →
- Dulaglutide at EmblemHealth →
- Dupilumab at EmblemHealth →
- Eculizumab at EmblemHealth →
- Elexacaftor Tezacaftor Ivacaftor at EmblemHealth →
- Empagliflozin at EmblemHealth →
- Erenumab at EmblemHealth →
- Evolocumab at EmblemHealth →
- Faricimab at EmblemHealth →
- Fingolimod at EmblemHealth →
- Fremanezumab at EmblemHealth →
- Galcanezumab at EmblemHealth →
- Glecaprevir Pibrentasvir at EmblemHealth →
- Guselkumab at EmblemHealth →
- Ibrutinib at EmblemHealth →
- Imatinib at EmblemHealth →
- Inclisiran at EmblemHealth →
- Infliximab at EmblemHealth →
- Ixekizumab at EmblemHealth →
- Lenalidomide at EmblemHealth →
- Liraglutide at EmblemHealth →
- Lisdexamfetamine at EmblemHealth →
- Mepolizumab at EmblemHealth →
- Methylphenidate at EmblemHealth →
- Naltrexone at EmblemHealth →
- Natalizumab at EmblemHealth →
- Nintedanib at EmblemHealth →
- Nivolumab at EmblemHealth →
- Nusinersen at EmblemHealth →
- Ocrelizumab at EmblemHealth →
- Ofatumumab at EmblemHealth →
- Omalizumab at EmblemHealth →
- Ozanimod at EmblemHealth →
- Palbociclib at EmblemHealth →
- Pembrolizumab at EmblemHealth →
- Pirfenidone at EmblemHealth →
- Ribociclib at EmblemHealth →
- Rimegepant at EmblemHealth →
- Risankizumab at EmblemHealth →
- Rituximab at EmblemHealth →
- Rivaroxaban at EmblemHealth →
- Sacubitril Valsartan at EmblemHealth →
- Secukinumab at EmblemHealth →
- Semaglutide at EmblemHealth →
- Sofosbuvir at EmblemHealth →
- Tafamidis at EmblemHealth →
- Tenofovir Alafenamide at EmblemHealth →
- Tezepelumab at EmblemHealth →
- Tirzepatide at EmblemHealth →
- Tofacitinib at EmblemHealth →
- Trastuzumab at EmblemHealth →
- Upadacitinib at EmblemHealth →
- Ustekinumab at EmblemHealth →
Generate a EmblemHealth PA packet
Open ApprovalHelp — generate a prior-auth packet tailored to EmblemHealth's criteria, with prescriber attestation and step-therapy documentation pre-filled.
Get started →Contact: hello@approvalhelp.com