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  • Pharmacy Services > Nonpreferred Drugs

    FDA-Approved

    Practitioners prescribing an FDA-approved nonpreferred (tier 3) drug for a member whose benefit does not cover nonpreferred drugs should contact Pharmacy Benefit Services at 1-877-362-5670.

    The requesting practitioner and an EmblemHealth clinical pharmacist will discuss the parameters to determine whether the member requires a nonpreferred medication. Practitioners must submit proper documentation and, if appropriate criteria are met, a physician's prior approval (PPA) number will be issued while the member is in the practitioner's office (whenever possible). If the prior approval criteria are not met, the EmblemHealth clinical pharmacist will contact an EmblemHealth medical director for approval/denial of the request. If our medical director denies the request, the practitioner will be notified and a denial letter issued to the member. For information on disputing a denial, please refer to the Dispute Resolution chapters.

    Non-FDA-Approved

    Practitioners requesting a non-FDA-approved drug or an approved drug for a non-FDA-approved usage must complete and submit a Non-FDA-Approved Drug Use and/or Dose Request Form via fax to 1-877-300-9695 or mail to:

    EmblemHealth
    Pharmacy Benefit Services
    Attn: Clinical Department
    441 Ninth Avenue
    New York, NY 10001

    The request is evaluated by an EmblemHealth medical director to determine if an expedited review is necessary. If the prescribing physician requests an expedited review, it will be processed as such. EmblemHealth Pharmacy Benefit Services will notify the requesting practitioner of the decision.

    Additions to the Formulary

    Following the introduction of any new drug in the U.S. market, the P&T Committee will typically allow for at least a six-month period of study before any final decision is made on inclusion of the drug to the formulary. During this time, the P&T Committee carefully observes the use and experience of the newly marketed drug in the general population, with regard to its efficacy, safety and drug interactions, and evaluates members' needs to determine whether there are any advantages of the new drugs over the existing formulary drugs. After this study period, a final recommendation will be made.

    Practitioners who would like to request the inclusion of a drug in the Commercial Formulary can complete an Addition to Formulary Request Form. Such requests must be completed and submitted with pertinent clinical data and/or literature justifying the addition of the drug to the formulary. The requests will be reviewed by the appropriate specialty subcommittee(s) for their recommendation and then sent to the P&T Committee for a final decision. Completed Addition to Formulary Request Forms can be submitted via fax to 1-877-300-9695 or mail to:

    EmblemHealth
    Pharmacy Benefit Services
    Attn: Director of Clinical Pharmacy Programs
    441 Ninth Avenue
    New York, NY 10001

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    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.

    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 doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

    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.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    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.

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