We want to make it easy for you to make the most of your prescription drug benefits.
To use the retail pharmacy service, present your ID card at any participating pharmacy nationwide. Most major drug store chains (e.g., Walgreens, Duane Reade, CVS, Rite Aid, Target and Walmart) are part of your plan. The retail pharmacy should be used when filling a prescription for short-term (a 30-day supply or less) medications.
Set Up Home Delivery and Refills
Using ESI home delivery, you can have your approved long-term medications (maintenance drugs) mailed right to your home.
Examples of maintenance drugs are medications used for high cholesterol, high blood pressure, allergies and heartburn. There is no difference between drugs delivered by ESI and those you pick up at your walk-in pharmacy. But ordering your long-term medications from ESI is a good idea because you:
- Save on copays when you order up to a three-month supply of your medications. CBP City of New York employees and retirees can get up to a 60-day supply. The City of New York Enhanced and Standard Medicare Part D program members can get up to a 90-day supply.
- Get free shipping on all orders
- Make fewer trips to the local pharmacy
- Refill and check the status of your prescriptions online
- Talk to pharmacists, 24 hours a day, seven days a week
New to Home Delivery?
Eligible members can enroll in home delivery at Express-Scripts.com. If you have questions or need more information about your prescription drug benefits, please call ESI. CBP City of New York employees and retirees should call 1-877-534-3682. City of New York Enhanced and Standard Medicare Part D program members should call 1-800-585-5786.
Need a Refill?
Use the sign in box on the right of this page to visit myEmblemHealth. Click on the “Home Delivery” link under “Pharmacy Services.” You will be able to see a list of available prescription refills and a record of your past orders. Select the items you want to reorder and follow the on-screen prompts to complete your request.
Tip: If other members of your household are covered under your prescription drug plan and they are 18 or older, they should register for home delivery and refills, too.
Order by Phone
To place an order, CBP City of New York employees and retirees should call 1-877-534-3682. City of New York Enhanced and Standard Medicare Part D program members should call 1-800-585-5786.
Under the Exclusive Mail Order program you are allowed up to one refill per prescription at any participating retail pharmacy after the initial prescription is filled for that maintenance drug. When a new maintenance drug is prescribed, you should ask for two written prescriptions from your doctor:
- One prescription to fill immediately at a retail pharmacy (you can get only one refill)
- One prescription to mail to the mail order pharmacy (this may be up to a 90-day supply depending on your benefit)
Your doctor can fax the prescription directly to your mail order pharmacy.
If you prefer to fill your prescriptions at a retail pharmacy, you will continue to have access to virtually all major pharmacy chains and many independent pharmacies.
Prescription Drug Claim Form
This form allows you to submit claims for 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.
What is a Formulary?
A formulary is a list of drugs covered by your prescription plan. This list is created by doctors and pharmacists after reviewing clinical studies. They look at which drugs are most safe and effective, and maximize cost savings. The formulary has a range of generic and brand-name drugs (see following sections for descriptions) that have been approved by the U.S. Food and Drug Administration (FDA). The formulary applies to drugs that are filled in retail pharmacy or sent by home delivery. If a drug is not on our formulary, it may have one or more FDA-approved alternatives that are covered by your prescription plan.
A medication equal to a brand-name drug in dosage, strength and quality. The FDA regulates generic drugs with the same strict standards used for brand-name drugs. Generic drugs usually cost less and have lower or no out-of-pocket costs.
A brand name is the trade name under which the drug is advertised and sold. A new drug is protected by a patent, so only one manufacturer can produce it. For this reason, brand-name drugs usually cost more than generic drugs. Once a patent expires, other companies may manufacture a generic equivalent.
A copayment is the out-of-pocket amount a member has to pay the retail pharmacy or to the mail order pharmacy for home delivery. The member pays one copayment per prescription. This fee is usually less than the actual price of the prescription and can vary based on the type of drug and the member’s benefits. Usually, generic drugs have a lower copayment than brand-name drugs. If the price of the prescription is less than the copayment, then the member will pay the lower price.
A three-tiered copayment pharmacy benefit helps us provide quality cost-effective prescription drug coverage. This benefit gives you ways to save on your prescriptions.
Tier 1: Generic Drugs — Generic drugs have the lowest copayment.
Tier 2: Formulary or Preferred Brand-Name Drugs — Brand-name drugs have higher copayments than generic drugs.
Tier 3: Non-Formulary or Non-Preferred Brand-Name Drugs — These are brand-name drugs for which there may be a similar generic drug or preferred brand-name drug available. You will pay more for these drugs.
Drug Management Programs
For the safe and cost-effective use of prescription drugs, plans include programs for Prior Authorization, Drug Quantity Management and Step Therapy.
ESI Prior Authorization
Prior authorization is when some prescribed drugs must be authorized before they can be covered. Your prescribing doctor must provide proof of the medical necessity of the drug for you and your diagnosis. If your doctor’s diagnosis meets approved guidelines for that drug and it is covered under your plan, prior authorization will be approved and your prescription will be filled.
ESI Step Therapy
A Step Therapy program is a two-step process. The first step is the use of a first-line or generic drug before a second-line drug is approved. The drugs used as the “first step” are well-established treatments. In most cases, these drugs are preferred therapy over second-line therapies. First-line drugs may be filled without calling your pharmacy benefit manager. The second step is if the first-line drug is not effective for you. In this case, second-line drugs can be prescribed. To do this, your doctor must call your pharmacy benefit manager. If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, prior authorization will be approved for your prescription to be filled.
ESI Drug Quantity Management
A Drug Quantity Management (DQM) program is when certain prescription drugs have quantity limits — meaning you can receive only a certain amount at one time. The DQM program determines the number of doses to be included in each prescription for certain drugs. At the pharmacy, you might be told that your prescription is written for a larger amount than your plan covers. You can ask your pharmacist to give you the amount that your plan covers or, if your doctor doesn’t agree with the limit, he or she can call your pharmacy benefit manager, to find out if you can get a greater quantity. If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, prior authorization will be needed for your prescription to be filled. Your doctor should call 1-888-447-8175.