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  • Pharmacy Services > Medicare Prescription Drug Plans

    We offer Medicare Advantage plans with Part D benefits (MAPD) under the EmblemHealth Medicare HMO and EmblemHealth Medicare PPO programs. We also offer a stand-alone Medicare Part D prescription drug plan (PDP): EmblemHealth Medicare PDP. These plans are defined in the Medicare Product Summary section of the Provider Networks and Member Benefit Plans chapter.

    EmblemHealth Medicare Prescription Drug Plan

    EmblemHealth Medicare PDP is a free-standing Medicare Part D plan available to Medicare members in New York State who do not have prescription drug coverage through another Medicare Advantage prescription drug plan.

    More information about the prescription drug benefits covered by this plan and the Medicare PDP formulary can be found at www.emblemhealth.com/Our-Plans/Medicare/Pharmacy-for-Medicare/Search-for-Medications.aspx.

    For prior approval of prescription drugs for members in our Medicare PDP, please call 1-877-362-5670.

    For prior approval of prescription drugs for members in our Medicare PDP (City of New York), please call 1-888-447-8175.

    You can get the plan's Summary of Benefits at:
    www.emblemhealth.com/~/media/Files/PDF/Medicare/2014%20Medicare/Summary%20of%20Benefits%202014/PDP_SOB1_2014.pdf

    Additional information is also available at:
    www.emblemhealth.com/Our-Plans/Medicare/Plans/2014-EmblemHealth-Prescription-Drug-Plan/EmblemHealth-Medicare-Prescription-Drug-Plan-Downstate.aspx#phcontent_1_plan_description

    Identification Card

    Members should provide their ID card to access Medicare Part D benefits. The card contains important information the pharmacy needs to process the claim.

    Coverage Determinations

    A coverage determination is a decision:

    • Not to provide or pay for a Part D drug because the drug is either not medically necessary, not obtained from a participating pharmacy or not on our formulary
    • About an exceptions request from the tiering structure
    • About an exceptions request for a non-formulary Part D drug
    • About the amount of cost sharing for a drug

    Failure to make a decision about one of the above in a timely manner when a delay would adversely affect the health of the enrollee is also considered a coverage determination.

    Coverage determinations may be requested by a member of our Medicare plans, the prescribing physician or other prescriber, or an officially designated representative (as filed with EmblemHealth).

    For standard requests, we will notify the member (and prescribing physician or other prescriber, as appropriate) of the determination no later than 72 hours after receipt of the request and/or physician's supporting statement.

    For expedited requests, we will notify all parties within 24 hours of receipt of the request and/or physician's supporting statement. If the expedited request is denied, we will contact all parties to:

    • Explain our standard process
    • Provide instructions about our grievance process and its time frames
    • Inform the member of the right to file expedited grievance
    • Inform the member of the right to resubmit the request with a physician's supporting documentation

    Note: Expedited coverage determinations are not permitted for payment requests.

    Exception Requests

    Exception requests fall under coverage determination process. Practitioners may request an exception in the following instances:

    • If the formulary tiering structure has changed mid-year and an enrollee is adversely affected by the change
    • When a formulary drug would not be as effective (or has been ineffective) as a non-formulary drug
    • When a formulary drug would have adverse effects and a non-formulary drug is available

    For an exception to be evaluated, the practitioner must provide supporting documentation of the diagnosis and a supporting statement that must indicate that the preferred drug for the treatment of the enrollee's condition would not be as effective as the requested non-preferred drug and/or would have adverse effects. All drugs approved under the exceptions process must meet the definition of a Part D drug.

    Members will be notified of changes to the formulary (including cost-sharing changes) as they occur. Updates to the EmblemHealth Medicare formulary can be found on EmblemHealth's Clinical Corner at www.emblemhealth.com/Providers/Provider-Resources/Clinical-Corner/Formulary-Updates.aspx.

    Grievance and Appeal (Redetermination) Procedures

    See the Dispute Resolution - Medicare chapter.

    Medicare Prescription Drug Plans - Contacts

    Medicare Prescription Drug Plans - Contacts
    Benefit Plans All Correspondence
    (e.g., claims, billing and member ID card questions)
    Pharmaceutical Coverage Determinations Exceptions
    (e.g., drugs not listed in formulary requiring prior approval)

    EmblemHealth
    Medicare HMO

     

    EmblemHealth Medicare HMO
    Attn: Customer Service
    55 Water St.
    New York, NY 10041-8190
    Call 1-800-447-8255
    Fax 1-631-719-0911

     

    EmblemHealth Medicare HMO
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-877-444-7097
    Fax 1-877-300-9695

     

    Pharmacy Services
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-877-444-7097
    Fax 1-877-300-9695

     

    EmblemHealth
    Medicare PDP

     

    EmblemHealth Medicare PDP
    Attn: Customer Service
    PO Box 2820
    New York, NY 10116-2820
    Call 1-877-444-7241
    Fax 1-954-965-2163

     

    EmblemHealth Medicare PDP
    Pharmacy Services
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-877-444-7097
    Fax 1-877-300-9695

     

    Pharmacy Services
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-877-444-7097
    Fax 1-877-300-9695

     

    EmblemHealth
    Medicare PDP
    (City of New York)

     

    EmblemHealth Medicare PDP
    Attn: Customer Service
    PO Box 2872
    New York, NY 10117-2037
    Call 1-800-585-5786

     

    EmblemHealth Medicare PDP
    Pharmacy Services
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-888-447-8175
    Fax 1-877-300-9695

     

    EmblemHealth Medicare PDP
    Pharmacy Services
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-888-447-8175
    Fax 1-877-300-9695

     

    EmblemHealth
    Medicare PPO
    EmblemHealth Medicare PPO
    Attn: Customer Service
    PO Box 2807
    New York, NY 10017-2807
    Call 1-866-557-7300
    Fax 1-888-382-1031
    EmblemHealth Medicare PPO
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-877-444-7097
    Fax 1-877-300-9695

    Pharmacy Services
    PO Box 1520
    JAF Station
    New York, NY 10116-1520
    Call 1-877-444-7097
    Fax 1-877-300-9695

     

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    Glossary terms found on this page:

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    A general term for the deductible, copayment and coinsurance provisions in the member's plan.

    An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

    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.

    A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

    A card that allows the subscriber to identify himself or his covered dependents to a provider for health care services.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    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.

    Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

    • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
    • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
    • It is in accordance with accepted standards of good medical practice in the community.
    • It is furnished in a setting commensurate with the member's medical needs and condition.
    • It cannot be omitted under the standards referenced above.
    • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
    • It is not furnished primarily for the convenience of the member, the member's family or the provider.
    • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

    The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

    Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

    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.

    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. Also known as MA.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

    Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    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.

    A set of providers contracted with a health plan to provide services to the enrollees.

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