Pharmacy Benefits

Important note: If you experience difficulty filling a prescription at an EmblemHealth network pharmacy, contact Pharmacy Customer Services at 1-888-447-7364, Monday through Friday, 8:00 am – 6:00 pm and Saturday and Sunday, 10:00 am – 1:00 pm.

Medicaid Managed Care pharmacy benefit includes:

  • Prescription drugs
  • Over-the-counter medicines (OTC)
  • Insulin and diabetic supplies
  • Smoking cessation agents, including OTC products
  • Hearing aid batteries
  • Enteral formula
  • Emergency contraception (6 per calendar year)
  • Medical and surgical supplies

Medicaid Managed Care Copayments

Prescription Item Copayment Amount
Brand-name prescription drugs $3.00
Preferred brand-name prescription drugs $1.00
Generic prescription drugs $1.00
Over-the-counter medications (e.g., for smoking cessation and diabetes) $0.50 per medication

Note: One copay charge for each new prescription and each refill regardless of the number of days’ supply of the prescription.

Services to which Copayments DO NOT Apply

  • Emergency room visits for needed emergency care
  • Family planning services, drugs, and supplies like birth control pills and condoms
  • Mental health clinic visits
  • Chemical dependency clinic visits
  • Drugs to treat mental illness (psychotropic)
  • Drugs to treat tuberculosis
  • Prescription drugs for residents of Adult Care Facilities

Note: One copay charge for each new prescription and each refill

Members to which Copayments DO NOT Apply

  • Members under age 21
  • Pregnant women (though 60 days postpartum)
  • Residents of community-based residential facilities licensed by the Office of Mental Health or the Office of People with Developmental Disability
  • Members in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination program
  • Members in an OMH or OPWDD Home and Community Based Services (HCBS) Waiver program
  • Members in a DOH HCBS Waiver program for Persons with Traumatic Brain Injury (TBI)
  • Members who are financially unable to make copayments at any time who tell the provider that they are unable to pay

You will not be denied health care services based on your inability to pay the copayment at the time of service. However, you will still owe the unpaid copay to the provider, and the provider may bill you or take other action to collect the owed amount.

If you are required to pay a copay you are responsible for a maximum of $200 per calendar year. If you transfer from one health plan to another during the calendar year, keep your receipts as proof of your copayments or you may request proof of paid copayments from your pharmacy. You will need to give a copy to your new plan.

Family Health Plus (FHPlus) pharmacy benefit includes:

  • Prescription drugs
  • Select over-the-counter (OTC) medicines such as Prilosec OTC, Loratadine, Zyrtec
  • Smoking cessation products, including over-the-counter (OTC) products
  • Hearing aid batteries
  • Vitamins necessary to treat an illness or condition
  • Insulin and diabetic supplies
  • Enteral formula
  • Emergency Contraception (6 per calendar year)

Note: Medical supplies, other than diabetic supplies and smoking cessation products, are not covered.

Services to Which Copayments DO NOT Apply

  • Emergency room visits for needed emergency care
  • Family planning services, drugs, and supplies
  • Mental health clinic visits
  • Chemical dependency clinic visits
  • Drugs to treat mental illness (psychotropic)
  • Drugs to treat tuberculosis
  • Prescription drugs for residents of Adult Care Facilities

You will not be denied health care services based on your inability to pay the copayment at the time of service. However, you will still owe the unpaid copay to the provider, and the provider may bill you or take other action to collect the owed amount.

Members who do not have to make Copayments

  • Children under age 21
  • Pregnant women (through 60 days postpartum)
  • Members who are financially unable to make copayments at any time and who tell the provider that they are unable to pay
  • A resident in a community based residential facility licensed by the Office of Mental Health or the Office of People with Developmental Disability

You will not be denied health care services based on your inability to pay the copayment at the time of service. However, you will still owe the unpaid copay to the provider, and the provider may bill you or take other action to collect the owed amount.

FHPlus Copayments

Prescription Item Copayment Amount
Brand-name prescription drugs $6.00
Generic prescription drugs $3.00
Over-the counter medications (e.g., for smoking cessation and diabetes) $0.50 per medication

Note: There will be one copay charge for each new prescription and each refill regardless of the number of days’ supply of the prescription.

Services to which Copayments DO NOT Apply

  • Emergency room visits for needed emergency care
  • Family planning services, drugs, and supplies
  • Mental health clinic visits
  • Chemical dependency clinic visits
  • Drugs to treat mental illness (psychotropic)
  • Drugs to treat tuberculosis
  • Prescription drugs for residents of Adult Care Facilities

You will not be denied health care services based on your inability to pay the copayment at the time of service. However, you will still owe the unpaid copay to the provider, and the provider may bill you or take other action to collect the owed amount.

Members who do not have to make Copayments

  • Members under age 21
  • Pregnant women (though 60 days postpartum)
  • Members who are financially unable to make copayments at any time who tell the provider that they are unable to pay
  • A resident in a community-based residential facility licensed by the Office of Mental Health or the Office of People with Developmental Disability

You will not be denied health care services based on your inability to pay the copayment at the time of service. However, you will still owe the unpaid copay to the provider, and the provider may bill you or take other action to collect the owed amount.