Forms and Other Important Downloads

Below is information on a number of important pharmacy-related topics and access to forms you may need for your plan. A note about forms: Not all forms are required for all plans. Please follow the instructions specific to each form to submit and/or supply supporting documents.

Pharmacy Benefit Services Prescription Drug Claim Form

This form allows you to submit claims for EmblemHealth prescriptions. All claims must be filed with the following information: the name of the patient; the strength and quantity of each drug; the prescription number of each drug; the name and address of the pharmacy; the name of the prescribing physician; and prescription receipts.

Looking to Set Up Home Delivery?

Here are instructions  on how to set up the delivery of your approved long-term medications (maintenance drugs).

Online Prior Approvals With PromptPA

The PromptPA website lets you and your health care providers submit prior approval/Coverage Determination requests online for your prescription drugs. You can also see the status and outcome of these requests on the site.

To get started, simply click on the “Members” link at PromptPA and follow the directions. You do not need to register.

Pharmacy at Your Fingertips