Medicare Formularies
and Rx Cost Calculator

Pharmacy Benefits

Our Medicare Advantage plans cover a wide range of prescription medicines and give you access to a large network of conveniently located pharmacies. Whether you want to find a network pharmacy, check if your drug is covered, or explore ways to save, you’re in the right place.

2026
2025

2026 Rx Cost Calculator and Pharmacy Locator

With more than 60,000 pharmacies in our network, including major retail chains and independent pharmacies, it’s easy to find one near you.

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Individual Plan Members
If you're enrolled in one of the individual plans below, you can use our cost calculator and pharmacy locator tool (administered through Prime Therapeutics™) to estimate your prescription drug costs at network pharmacies:

VIP Gold (HMO), VIP Gold Plus (HMO), and VIP Value (HMO-POS).
VIP Dual (HMO D-SNP), VIP Dual Enhanced (HMO D-SNP), and VIP Dual Reserve (HMO D-SNP).

Employer Group Members
If you're enrolled in a group plan, such as VIP Premier (HMO) or National Drug Plan (PDP), you can use the drug and pharmacy locator tool to check if your prescription drug is on the formulary and find a network pharmacy.

Get personalized information about your pharmacy coverage and manage all your benefits in one place in the secure member portal.

2026 Formularies

Below is a complete list of drugs covered by your plan — also known as a formulary — including both generic and brand-name drugs. Most formularies list drugs in levels or tiers based on cost. The lower the tier, the lower your cost will be.

Looking for our non-Medicare drug lists?

Individual Plans

Employer Group Plans

2025 Rx Cost Calculator and Pharmacy Locator

With more than 60,000 pharmacies — and 27,000 preferred pharmacies — in our network, including major retail chains and independent pharmacies, it’s easy to find one near you. You will usually pay less if you use a preferred pharmacy. Our pharmacy locator tool indicates which pharmacies are preferred.

Use our cost calculator/pharmacy locator tool (administered through ExpressScripts) to estimate your prescription drug costs at network pharmacies:

Get personalized information about your pharmacy coverage and manage all your benefits in one place in the secure member portal.

2025 Formularies

Looking for our non-Medicare drug lists?

Individual Plans

Employer Group Plans

Paying for Prescription Drugs

Learn about programs that may help you save on your prescription medicines or better manage your out-of-pocket costs.

Extra Help
(Low-Income Subsidy)

A program to help people with limited income pay for drug costs.

Learn More >

Best Available Evidence Policy

Information on qualifying for the low-income subsidy program.

Learn More >

Elderly Pharmaceutical Insurance Coverage

A New York state program to help with Part D drug plan costs.

Learn More >

Medicare Prescription Payment Plan

A new option to help manage your out-of-pocket costs.

Learn More >

2026
2025

The Medicare Prescription Payment Plan is a payment option that works with your current Part D drug coverage to help you manage your out-of-pocket prescription costs by spreading them across the calendar year (January through December). Those who have high cost-share amounts for prescription drugs earlier in the plan year are more likely to benefit from the program. This voluntary program is free to join and there are no fees or interest charged under the payment plan. EmblemHealth works with Capital Rx (a third-party supplier) to offer the Medicare Prescription Payment Plan, including providing a website to sign up, view your account, schedule and make payments, and review payment history.

This option doesn’t save you money or lower your maximum out-of-pocket drug cost ($2,100 in 2026). If you receive Extra Help to pay for prescription drugs or have low drug costs, this payment option is not the best choice for you. Learn more about Extra Help.

How is the monthly payment calculated?
The following resources provide examples of how the payment is calculated and tell you about other ways to save on prescription drug costs:

enrollment.cap-rx.com/emblemhealthmppp | medicare.gov.
Or review this fact sheet. (English | Spanish | Chinese)
You can also calculate your monthly payment plan amounts.

How can I opt in or out of the program?
Contact Capital Rx to opt in or out of the program.

Call 833-746-5914 (TTY – 711), 24 hours a day, 7 days a week.
Visit enrollment.cap-rx.com/emblemhealthmppp.
Mail your completed participation request form to:
Capital Rx
Attn: M3P Selections
9450 SW Gemini Dr., Suite 87234
Beaverton, Oregon 97008-7015

When does the payment plan go into effect?
If you are new to the plan we will process your request within 10 calendar days of receipt of your election form.If your plan starts sooner than 10 days from when we receive your election form, we will process your election before your enrollment in our plan starts so that you will be enrolled in the program on the same day that your plan starts.

If you are currently a member we will process your request within 24 hours, but enrollment will be effective on the date we receive your completed request. If you paid any cost share for an urgently needed prescription before we processed your election, we may make your election effective before we receive it. This can happen if you meet the following criteria:

You believe that taking 24 hours to process your request may seriously jeopardize your life, health, or ability to regain maximum function.
You request a retroactive election within 72 hours of the date and time you paid and received your urgently needed prescription.
You must pay your monthly payments to remain active in the Medicare Prescription Payment Plan. If you do not pay within a grace period of two months, we will remove you from the Medicare Prescription Payment Plan.

View information on how to file a complaint and grievance.

The Medicare Prescription Payment Plan (MPPP) is a new payment option for 2025 that works with your current Part D drug coverage to help you manage your out-of-pocket prescription costs by spreading them across the calendar year (January through December). Those who have high cost-share amounts for prescription drugs earlier in the plan year are more likely to benefit from the program. This voluntary program is free to join and there are no fees or interest charged under the payment plan.

This option doesn’t save you money or lower your maximum out-of-pocket drug cost ($2,000 in 2025). If you receive Extra Help to pay for prescription drugs or have low drug costs, this payment option is not the best choice for you. Learn more about Extra Help.

How is the monthly payment calculated?
The following resources provide examples of how the payment is calculated and tell you about other ways to save on prescription drug costs:

Express-scripts.com/mppp | medicare.gov.
Or review this fact sheet. (English | Spanish | Chinese)
You can also calculate your monthly payment plan amounts.

How can I opt in or out of the program?
Contact ExpressScripts to opt in or out of the program.

Call 866-845-1803 (TTY: 800-716-3231), 24/7.
Visit express-scripts.com/mppp.
Mail your completed participation request form to:
Express Scripts MPPP
P.O. Box 801101
Kansas City, MO 64180-1101

You believe that taking 24 hours to process your request may seriously jeopardize your life, health, or ability to regain maximum function.
You request a retroactive election within 72 hours of the date and time you paid and received your urgently needed prescription.
You must pay your monthly payments to stay enrolled. If you do not pay within a grace period of two months, we will remove you from the Medicare Prescription Payment Plan.

View information on how to file a complaint and grievance.

Your Pharmacy Benefits

Make the most of your coverage and learn more about our programs for the safe and cost-effective use of prescription medicines.

EmblemHealth Medicare Part D Transition Policy
EmblemHealth’s goal is to make changes that occur each new benefit year as seamless as possible. Our transition policy is designed to meet the immediate needs of our members and allow them time to work with their prescribing doctor to switch to another medicine that is on the formulary to treat the member’s condition, or to ask for an exception.

Who is eligible for a temporary supply?
During the first 90 days of membership, we offer a temporary supply of medicines to:

New members on Jan. 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 Jan. 1.
Members residing in long-term care (LTC) facilities.
In some cases, enrollees who change treatment settings due to a change in level of care.

Our transition policy applies to Part D medicines that are not on EmblemHealth’s formulary and Part D medicines that are on EmblemHealth’s formulary but may require:

Prior authorization (PA).
Step therapy (ST) (Not applicable for 2026).
Quantity limits (QL).

Getting medicine from a participating network pharmacy
For each medicine that is not on our formulary or is subject to prior authorization, step therapy, or quantity limits, EmblemHealth will cover a temporary one-time supply for at least a month’s supply of medicines (unless the prescription was written for fewer days) when you get it filled from a network pharmacy during the transition period. After the first month’s supply, you will need to request an exception for coverage, otherwise EmblemHealth will not pay for these medicines, 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 month’s supply, unless the prescription was written for fewer days. We will cover more than one refill of these medications during the first 90 days.

If a medicine is needed that is not on our formulary or if the member’s ability to get medicine 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 medicine, unless a prescription was written for fewer days, while a formulary exception is requested.

How is a member notified about the transition supply of their medicine?
All members getting a temporary supply of a medicine, and their doctors, 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 medicine supply that the member received.
How to work with EmblemHealth and the member’s prescriber to find another medicine that is on the formulary to treat the member’s condition.
An explanation of the member’s right to ask for a formulary exception.
A description of the formulary exception process.

What is the copay for temporary medicine?
The copay for the approved temporary medicine 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 medicines that are approved under a coverage exception. The cost share for formulary drugs that require prior authorization, step therapy, or quantity limits approvals that are provided during the transition will be the same cost share after the prior approval criteria are met.

Copays for members who are eligible for Extra Help during the transition period will never exceed the copay maximums set by the Centers for Medicare & Medicaid Services (CMS) for low-income members.

Medication Safety Program
As part of our commitment to patient safety, we have taken steps to ensure 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 interactions: 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 check 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.
Ensuring dosages are safe: To prevent a possible overdose, we review 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.

Quality Assurance Program
EmblemHealth Pharmacy Benefit Services completes quality assurance reviews of the medicines our members take to avoid medication errors and harmful drug reactions and to improve medicine use. We also oversee the use of prescription drugs and check 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 and age: We screen a prescribed drug to find out if it is right for a member’s gender and age.
Proper medicine 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 noncontrolled substances.
Drug-drug and drug-disease interaction: We look at medicine profiles to find any potential interactions between prescribed drugs and a member’s health conditions.
Medicine duplication: We screen each member’s 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 medicines, new dosage formulations, and how the drug is administered (orally, injectable, topically, etc.). We reevaluate the formulary (list of covered drugs) to make improvements based on our reviews.

If you have any questions or concerns, please call Medicare Connect Concierge at the phone numbers below. From Oct. 1 through March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 through Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.

EmblemHealth Medicare HMO: 877-344-7364 (TTY: 711)
EmblemHealth Medicare PPO: 866-557-7300 (TTY: 711)

PHARMACY SUPPORT

Questions? We’re here to help.

Call EmblemHealth Customer Service at the number on your member ID card.

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In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances.

Last Updated 10/01/2025

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Medicare Formularies
and Rx Cost Calculator

Pharmacy Benefits

2026 Rx Cost Calculator and Pharmacy Locator

2026 Formularies

Individual Plans

Employer Group Plans

2025 Rx Cost Calculator and Pharmacy Locator

2025 Formularies

Individual Plans

Employer Group Plans