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  • Pharmacy Services > Pharmaceutical Management Procedures

    We provide information about our pharmaceutical management procedures and our formularies at least annually and whenever we make changes. These updates may include the following:

    • Pharmacy benefit designs
    • Formulary changes
    • Prior approval criteria
    • Procedures for generic substitution, therapeutic interchange, step therapy or other management methods the practitioner's prescribing decisions are subject to
    • Any other requirements, restrictions, limitations or incentives that apply to the use of certain pharmaceuticals

    For the latest updates to our Commercial and Medicare formularies, please go to Formulary Updates on Clinical Corner at www.emblemhealth.com/Providers/Provider-Resources/Clinical-Corner/Formulary-Updates.aspx.

    If you require printed copies or have any questions regarding our pharmaceutical management procedures, please call Clinical Pharmacy Services at 1-877-362-5670.

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    Glossary terms found on this page:

    A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Also called a drug formulary.

    Specific circumstances or services listed in the contract for which benefits will be limited.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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