Additional Pharmacy Information

Learn more about what our over-the-counter debit card covers, how to get money back for a drug, our Medication Management Therapy Program, how to get help paying for part D drugs in the Extra Help program (as known as Low Income Subsidy) and much more.

Extra Help also called Low Income Subsidy (LIS) is a Medicare Program to help people with limited income and resources pay for Part D drug plan costs. It can help you pay for monthly premium fees (the amount you pay for your insurance every month), deductibles (the amount you pay before your plan starts to pay), and coinsurance (the percentage you pay for health services).

You can get Extra Help if:

  • You have full Medicaid coverage.
  • You get help from your state Medicaid program to pay your part B premiums in a Medicare Savings Program.
  • You get Supplemental Security Income (SSI) Benefits.

To see if you qualify for Extra Help:

  • Call Medicare: 1-800-MEDICARE (1-800-633-4227). If you use a TTY, please call 1-877-486-2048, 24 hours a day, seven days a week;
  • Call Social Security: 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. If you use a TTY, please call 1-800-325-0778 or
  • Your State Medicaid Office.

If you get Extra Help, what you pay for the plan and what you pay at the pharmacy will be lower.

The chart below shows what you would pay monthly for the plan if you get Extra Help.

HMO LIS Premium Summary

Nondiscrimination Policy

The MTM Program is a free service for EmblemHealth Medicare plan members with a Part D prescription drug coverage who have certain health conditions and who take seven or more chronic medications.

Learn More

You, your representative or your prescriber can also start a coverage determination (exception) and coverage redetermination (appeal) request for Part D prescription drugs by sending us an email. Please see Grievance and Appeal Information page for more information.

Notice of Nondiscrimination Policy

EmblemHealth’s goal is to make changes that occur each new benefit year as seamless as possible. EmblemHealth’s transition policy meets the immediate needs of our members and allows them time to work with their prescribing doctor to switch to another medication that is on the formulary to treat the member’s condition or ask for an exception.

Who is Eligible for a Temporary Supply?

During the first 90 days of membership, we offer a temporary supply of medications to:

  • New members on January 1 following the Annual Election Period
  • Newly eligible Medicare beneficiaries
  • Existing members impacted by a negative formulary change from the prior year
  • Members switching Medicare Part D plans after January 1
  • Members residing in long-term care (LTC) facilities

Our transition policy applies to:

Part D medications that are not on EmblemHealth’s formulary and Part D medications that are on EmblemHealth’s formulary but may require:

  • Prior authorization(PA) (Approval in advance to get services or certain drugs that may or may not be on our formulary.),
  • Step therapy (ST) (A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.) or
  • Quantity limitations (QA) (Limits may be on the amount of the drug that we cover per prescription or for a defined period of time)

Getting Medication from a Participating Network Pharmacy

For each medication that is not on our formulary or is subject to PA, ST or QA EmblemHealth will cover a temporary 30 day supply of medications (unless the prescription was written for fewer days) when taken to a network pharmacy during the transition period. After the first 30 day supply, EmblemHealth will not pay for these medications, even if the member has been in the plan less than 90 days.

How is a Prescription filled in Long-Term Care Facilities?

For members in long-term care facilities prescription refills will be provided up to a 98 day transition supply (unless the prescription was written for fewer days). We will cover more than one refill of these medications for the first 90 days as a member of our plan.

If a medication is needed that is not on our formulary or if the member’s ability to get medications is limited, but the member is past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that medication (unless a prescription was written for fewer days) while a formulary exception is requested.

How is a Member is Notified about the Transition Supply?

All members (and their doctors) getting a temporary supply of a medication will be sent a letter about the member’s transition fill and the transition process. This letter will be sent within three business days of the temporary fill.

The notice will include:

  • An explanation of the transition supply that the member received;
  • How to work with EmblemHealth and the member’s prescriber to find another medication that is on the formulary to treat the member’s condition;
  • An explanation of the member’s right to ask for a formulary exception; and
  • A description of the formulary exception process.

What is the Copay for Temporary Medication?

The copay for the approved temporary medication will be based on one of our approved formulary tiers. The cost sharing for a non-formulary drug provided during the transition period will be the same as the cost-sharing charged for non-formulary medications that are approved under a coverage exception. Cost sharing for formulary drugs subject to PA, ST or QA that are provided during the transition will be provided at the same cost sharing that would apply once the PA, ST or QA is met.

Copays for members who are eligible for “Extra Help” (A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance) during the transition period, will never exceed the copay maximums set by Centers for Medicare & Medicaid Services for low-income members.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

EmblemHealth Pharmacy Benefit Services has steps to make sure that prescription drugs are used safely and effectively by our Medicare Part D members. Members can be at risk for drug errors and drug-related problems, since they often get prescriptions from more than one doctor. We make sure drugs are used safely by:

  • Screening for drug interaction: Using prescription-tracking software, we screen each member’s drug profile for possible harmful interactions with other drugs the member may be taking.
  • Making sure drugs are right for members: We screen each member’s drug profile to see if a drug has a warning for certain age groups. We have added drugs to our formulary (list of covered drugs) that are safe for our members and removed drugs that are not as safe. We also educate our doctors about their prescribing patterns and about drugs that may not be right for members.
  • Making sure dosages are safe: To prevent a possible overdose, we look at each member’s drug profile to decide if a drug is filled above FDA dosing guidelines.  Avoiding drug duplication: We screen each member’s drug profile to see if the same or similar drug is already in the member’s drug profile.
  • Sending pharmacy reports to doctors: We review each member’s drug profile to see if they are being prescribed more drugs than they need. This report is shared with prescribing doctors. The doctor then decides on the right therapy, if needed.

If you have any questions, please call Customer Service at the phone number below, Monday through Sunday, 8 am to 8 pm.

EmblemHealth Medicare HMO: 1-877-344-7364

EmblemHealth Medicare PPO: 1-866-557-7300

EmblemHealth Medicare PDP: 1-877-444-7241

If you have a TTY please call: 711

EmblemHealth Pharmacy Benefit Services completes quality assurance reviews of the medicines our members take to avoid medication errors, harmful drug reactions and improve medication use. EmblemHealth Pharmacy Benefit Services also oversees the use of prescription drugs and checks each prescription filled based on these criteria:

  • Dosing: We check how much of each drug you take to find out if it is within established dosage ranges, meaning not too high or too low.
  • Gender/Age: We screen a prescribed drug to find out if it is right for a member’s gender and age.
  • Proper Medication Use: We look at the time frame for refills and new fills. We do this to make sure that members take their prescribed drugs as directed and follow established dosing guidelines for controlled and non-controlled substances.
  • Drug-Drug and Drug-Disease Interaction: We look at medication profiles to find any potential interactions between prescribed drugs and a member’s health conditions.
  • Medication Duplication: We screen each member profile to make sure that newly prescribed drugs are not the same as other prescribed drugs the member is taking.
  • FDA–issued Warnings: We review FDA-issued warnings about any harmful reactions to medications, new dosage formulations and how the drug is administered (orally, injectable, topically, etc). We re-evaluate the formulary (list of covered drugs) to make improvements based on our reviews.

If you have any questions or concerns, please call Customer Service at the phone number below, Monday through Sunday, 8 am to 8 pm.

EmblemHealth Medicare HMO: 1-877-344-7364

EmblemHealth Medicare PPO: 1-866-557-7300

EmblemHealth Medicare PDP: 1-877-444-7241

If you have a TTY please call 711.

The Best Available Evidence (BAE) policy requires Part D sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate. In certain cases, Center for Medicare & Medicaid Services (CMS) systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. View more information on this policy.

If you have any questions please call our Customer Service at 1-877-344-7364 (TTY: 711), 8 am to 8pm, seven days a week.

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