Pharmacy Services > The EmblemHealth Drug Formularies
The EmblemHealth formularies are compilations of brand name and generic pharmaceuticals covered under our benefit plans.
Experimental or investigational drugs (i.e., non-FDA approved) are excluded from coverage. The medications listed in EmblemHealth's formularies are covered for members who have prescription drug coverage, as defined by their benefit plan. EmblemHealth Child Health Plus members are covered for both formulary prescription drugs and a select list of nonprescription drugs (that are not listed on the Commercial formulary) when prescribed by a licensed healthcare professional.
EmblemHealth contracts with the Centers for Medicare & Medicaid Services (CMS) to provide drug coverage for Medicare Part D members using the Medicare Part D Drug Formulary, utilization management programs and pricing structure.
Effective October 1, 2011, EmblemHealth Medicaid members can receive pharmacy benefits directly from EmblemHealth rather than from New York State Medicaid.
Medications selected for inclusion in our formularies are chosen by specialty subcommittees whose recommendations are reviewed and finalized by the Pharmacy and Therapeutics (P&T) Committee. Members of the P&T and specialty committees include participating specialists, pharmacists and administrators. Together, these committees identify the pharmaceuticals that will provide optimal results for our members while controlling the cost of drug therapy. The committees meet regularly to keep the drug formularies current.
Visit the webpages listed in the following table to determine whether a drug is covered by a member's benefit plan.
Glossary terms found on this page:
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.
The government agency responsible for administering the Medicare and Medicaid programs.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
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.
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.
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.
A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.
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 jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
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 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.
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.
A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.