Learn about your pharmacy benefits, download prescription drug claim forms, view additional programs, and more.
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For the safe and cost-effective use of drugs, plans include programs for Prior Authorization, Drug Quantity Management and Step Therapy.
Prior Authorization
Prior authorization is when some prescribed drugs must be authorized before they can be covered. Your prescribing doctor must give proof of the medical necessity of the drug for you and your diagnosis.
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.
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 EmblemHealth Pharmacy Benefit Services. 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 EmblemHealth's Pharmacy Clinical Department.
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.
Drug Quantity Management
A Drug Quantity Management (DQM) program is when some drugs have quantity limits — meaning you can get only a certain amount at one time. The DQM program decides 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 EmblemHealth's Pharmacy Clinical Department 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 approved for your prescription to be filled. Review our list of covered drugs to find out if a drug has a quantity limit.
Specialty Injectable Pharmacy Program
Specialty drugs are most often injectable drugs for conditions such as multiple sclerosis, growth deficiencies, fertility issues and hepatitis C. Members who use specialty drugs must get their prescriptions filled through Accredo, EmblemHealth’s Specialty Pharmacy vendor.
You may not fill specialty drug prescriptions at a retail pharmacy or through Express Scripts home delivery. Some noninjectable drugs used in combination with self-injectables are also on hand through Accredo.
Accredo fills your prescriptions and delivers them directly to your home. For approvals, call Accredo at 855-216-2166. Their hours are Monday to Friday, 8 a.m. to 11 p.m., and Saturdays, 8 a.m. to 5 p.m..
You may also call EmblemHealth about your specialty pharmacy services at 888-447-0295.
A formulary is a list of drugs covered by your prescription plan. This list is made 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 below for descriptions) that have been approved by the US Food and Drug Administration (FDA). The formulary applies to prescription drugs that are dispensed in retail pharmacies and those delivered to your home through a home delivery pharmacy. If a drug is not on our formulary, it may have one or more FDA-approved alternatives that are covered by your prescription plan.
Review our list of covered drugs to check the formulary status of a drug.
Generic Drugs
The FDA approves both brand-name and generic drugs. Generic drugs have the same active ingredients, dosage form and strength, and must be absorbed in the body the same way as brand-name drugs.
Generic drugs can be classified as single source or multiple source.
Single Source Generics
These include brand-name drugs that are going off patent and a single manufacturer has exclusive rights to make the drug for a period of time.
Multiple Source Generics
These drugs are defined by the Centers for Medicare and Medicaid Services (CMS) as products with three or more versions of the product related therapeutically equal (A–rated) no matter what the ratings of other versions (B–rated) and at least three suppliers are listed in the current editions of published national compendia.
Brand-Name Drugs
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 make it. For this reason, brand-name drugs most often cost more than generic drugs. Once a patent runs out, other companies may make a generic equal.
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 most often 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.
Tiered Copayment
To give quality and affordable drug coverage, most EmblemHealth drug programs have a three-tiered drug formulary benefit. The three tiers, with different levels of coverage are:
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 drugs for which there may be a similar generic drug or preferred brand-name drug on hand. You will pay more for these drugs.
Please note: Some plans include multiple source generic drugs in Tier 1 and single source generics in Tier 2.
Pharmacy Benefit Services Prescription Drug Claim Form
This form allows you to submit claims for EmblemHealth 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.
formulary
Drugs Covered
Find the list of drugs covered by your EmblemHealth plan (also known as a “formulary”).
your prescriptions
Delivery and Refills
Find out how to set up home delivery or a get a prescription refill.
KNOW YOUR RIGHTS
Grievances and Appeals
Find out how to file a grievance or an appeal, request coverage decisions and determinations, and more.
