This chapter contains information regarding pharmacy benefit services and prescription drug coverage, including pharmacy benefit designs, our Specialty Pharmacy Program, Medication Therapy Management program and home delivery.
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Chapter 10: Pharmacy Services
| Clinical Pharmacy Services (Providers) |
| EmblemHealth: (877) 362-5670, Monday through Friday, 8 a.m. to 6 p.m. |
Express Scripts, Inc. (ESI): |
| Specialty Pharmacy Program: (888) 447-0295, Monday through Friday, 8:30 a.m. to 5 p.m. |
| Accredo: 855-216-2166, Monday to Friday, 8 a.m. to 11 p.m.; Saturdays, 8 a.m. to 5 p.m. |
Go to the Pharmacy Services section of the Directory chapter for additional contact information.
Although prescriptions can be filled at one of our participating pharmacies, we encourage members to use our home delivery drug program as a more cost-effective method of medication management. Covered drugs are subject to the patients' applicable copay(s) as defined by their pharmacy coverage.
Pharmacy contact numbers are listed in the Pharmacy Benefit Services Telephone Contacts section of this chapter and in the Directory chapter.
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.
Formulary Searches
Title |
Description |
Location |
Commercial Drug Formularies
|
EmblemHealth, GHI, HIP and Vytra commercial benefit plans and EmblemHealth Child Health Plus |
Pharmacy
|
Medicare Part D Formulary |
E mblemHealth Medicare HMO, EmblemHealth Medicare PPO and EmblemHealth Medicare PDP |
|
Medicaid Formulary |
EmblemHealth Medicaid
|
http://www.emblemhealth.com/~/media/Files/PDF
|
ConnectiCare VIP Medicare Formulary |
ConnectiCare VIP (HMO) and ConnectiCare VIP (HMO-POS) plans |
www.connecticare.com/medicare/PDF/FORMULARY.pdf
|
We offer several pharmacy benefit designs, which determine coverage of certain drugs as well as copay amounts for our members. Each pharmacy benefit plan is subject to regulations, state and federal laws, clinical guidelines, a prior approval process and quantity limitations, unless otherwise specified. Covered pharmacy services must be listed on the Commercial or Medicare formularies, unless the member's benefit includes nonformulary/nonpreferred drugs. (The drug formularies may describe drugs as either "formulary" or "preferred" or "nonformulary" or "nonpreferred.")
Generic Versus Brand Medications
Our prescription benefit design is formatted into three categories of prescription medications. Due to the number of drugs on the market, the continuous introduction of new drugs, new applications of existing drugs and new information regarding safety, the design is continually revised.
Tier 1 - Preferred Generic Drugs
Generic drugs (tier 1) are chemically identical to brand drugs, but are priced at a fraction of the cost and offer an excellent value to the member. To gain FDA approval, a generic drug must:
- Contain the same active ingredients as the branded drug (inactive ingredients may vary).
- Be identical to the brand drug in strength, dosage form, safety and route of administration.
- Be of the same quality, performance characteristics and use indications.
- Be manufactured under the same strict standards of the FDA's good manufacturing practice regulations required for branded products.
If a generic is chosen, the practitioner must leave blank the "DAW" (Dispense As Written) box. This way, the pharmacist will fill the prescription with the generic drug.
Tier 2 - Preferred Brand Drugs
We have identified a listing of formulary brand drugs (tier 2) available at a lower copay than drugs in the nonpreferred drug category. This generally happens when there are several equally effective, FDA-approved brand name drugs by different manufacturers for treatment of a particular condition. (Some plans also include single source generics in Tier 2.)
Tier 3 - Nonpreferred Brand and Generic Drugs
Drugs in the nonpreferred category (tier 3) generally have a similar, more cost effective drug available in either the preferred generic drug category (tier 1) or the preferred brand drug category (tier 2).
Most new FDA-approved drugs are initially placed in tier 3 for about excluded from coverage for up to six months until the P&T Committee reviews them for safety, efficacy and clinical comparisons.
The following table outlines the more common benefit structures with regards to copayment.
| Copay Designs | |
| Benefit Levels | Benefit Structure |
Single Tier Copay (with or without a deductible) |
|
Two-Tier Copay (with or without a deductible) |
|
Three-Tier Copay (with or without a deductible) |
|
Percentage Coinsurance (with or without a deductible) |
|
Members must pay a copay and/or deductible (as specified on their ID card) for each supply of medicine received at a participating pharmacy or through an affiliated mail order pharmacy.
Note: EmblemHealth Medicaid members cannot be denied health care services based on their inability to pay the copay at the time of service. However, providers may bill these members or take other action to collect the owed copay amount.
Prior approval and/or quantity limits apply to certain medications. Please read the Nonpreferred Drugs section of this chapter for more details.
Depending on the specifics of a member's pharmacy plan, a 90-day supply mail order prescription drug service may be available. Please read the Home Delivery Pharmacy Program section in this chapter for more information.
Practitioners prescribing an FDA-approved nonpreferred (tier 3) drug for a member whose benefit does not cover nonpreferred drugs should contact Pharmacy Benefit Services at 1-877-362-5670.
The requesting practitioner and an EmblemHealth clinical pharmacist will discuss the parameters to determine whether the member requires a nonpreferred medication. Practitioners must submit proper documentation and, if appropriate criteria are met, a physician's prior approval (PPA) number will be issued while the member is in the practitioner's office (whenever possible). If the prior approval criteria are not met, the EmblemHealth clinical pharmacist will contact an EmblemHealth medical director for approval/denial of the request. If our medical director denies the request, the practitioner will be notified and a denial letter issued to the member. For information on disputing a denial, please refer to the Dispute Resolution chapters.
Practitioners requesting a non-FDA-approved drug or an approved drug for a non-FDA-approved usage must complete and submit a Non-FDA-Approved Drug Use and/or Dose Request Form via fax to 1-877-300-9695 or mail to:
EmblemHealth
Pharmacy Benefit Services
Attn: Pharmacy Services
55 Water Street
New York, NY 10041
The request is evaluated by an EmblemHealth medical director to determine if an expedited review is necessary. If the prescribing physician requests an expedited review, it will be processed as such. EmblemHealth Pharmacy Benefit Services will notify the requesting practitioner of the decision.
Following the introduction of any new drug in the U.S. market, the P&T Committee will typically allow for at least a six-month period of study before any final decision is made on inclusion of the drug to the formulary. During this time, the P&T Committee carefully observes the use and experience of the newly marketed drug in the general population, with regard to its efficacy, safety and drug interactions, and evaluates members' needs to determine whether there are any advantages of the new drugs over the existing formulary drugs. After this study period, a final recommendation will be made.
Practitioners who would like to request the inclusion of a drug in the Commercial Formulary can complete an Addition to Formulary Request Form. Such requests must be completed and submitted with pertinent clinical data and/or literature justifying the addition of the drug to the formulary. The requests will be reviewed by the appropriate specialty subcommittee(s) for their recommendation and then sent to the P&T Committee for a final decision. Completed Addition to Formulary Request Forms can be submitted via fax to 1-877-300-9695 or mail to:
EmblemHealth
Pharmacy Benefit Services
Attn: Formulary Management Team
55 Water Street
New York, NY 10041
Under this program, EmblemHealth promotes the use of less expensive, equally effective prescription drugs when medically appropriate. EmblemHealth Medicaid members must use pharmacies that will accept their benefit ID card; pharmacies must comply with all applicable Medicaid program requirements.
We cover the following pharmacy services for members with EmblemHealth Medicaid coverage:
- As of October 1, 2011, EmblemHealth covers pharmacy benefit services for all EmblemHealth Medicaid members. The benefit includes prescription drugs, all Medicaid covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.
- EmblemHealth covers medical/surgical supplies routinely furnished or administered as part of an office visit for EmblemHealth Medicaid members. Note: Medical/surgical supplies dispensed in a doctor's office or other non-inpatient setting, or by a certified home health aide as part of an at-home visit, are not covered as separate billable items.
For more details on coverage of medical/surgical supplies, please refer to Appendix B in the Provider Networks and Member Benefit Plans chapter.
Effective January 1, 2017, our Medicaid/HARP members will no longer be able to fill prescriptions at CVS or Target. When writing prescriptions for these members, especially when ePrescribing or prescribing controlled substances, please ask them to designate a new pharmacy. Although members can arrange to have certain prescriptions moved from CVS or Target to a new pharmacy, if you are able to have the prescription sent to the right place, it will improve the member’s experience and increase the likelihood of medication compliance.
Use the Medicaid Pharmacy Locator to find alternate pharmacies to recommend to your Medicaid members.
NYSDOH Medicaid Prior Authorization Request Form for Prescriptions
The New York State Department of Health (NYSDOH) has created a New York State Medicaid Prior Authorization Request Form for Prescriptions to streamline managed care organizations' prior approval procedures for medications prescribed to members covered by Medicaid. EmblemHealth is complying with NYSDOH's requirement to use this form.
If the drug you want to prescribe to your EmblemHealth Medicaid patient requires prior approval, please download and complete the New York State Medicaid Prior Authorization Request Form for Prescriptions and fax it to 1-877-300-9695.
The member may also download this form and present it to you for completion. Please fill out the form and fax it to the number above.
Prior approval is required for:
- Non-preferred medications (except for typical anti-psychotics, anti-depressants, anti-rejection drugs and anti-retroviral drugs used for HIV/AIDS)
- Drugs with coverage limitations (e.g., frequency, quantity, duration limits)
- Drugs that require clinical review (e.g., step protocols, certificate of medical necessity)
- Generics when the cost of the brand name is less than the generic
Prior approvals may be obtained by calling 1-866-447-9717. Prior approvals are valid for up to six months, with a maximum of five refills.
The EmblemHealth Medicaid Formulary excludes medications used for:
- Weight loss
- Erectile dysfunction
- Promotion of fertility
- Cosmetic purposes
It also excludes drugs without a National Drug Code (NDC). In addition, under the Mandatory Generic Program, coverage for brand name medications is excluded when the FDA has approved an A-rated generic equivalent, unless a prior approval is obtained or the drug is exempted.
For more information on the EmblemHealth Medicaid Formulary click here.
EmblemHealth requires all eligible Child Health Plus (CHPlus) and Medicaid providers to participate in the Vaccines for Children (VFC) Program. The VFC Program is a New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYCDOHMH) program that distributes free vaccines to eligible providers that serve CHPlus/Medicaid members under 19 years of age within New York City (Bronx, Kings, New York, Queens, Richmond counties) and Nassau, Suffolk and Westchester counties. Members that meet these criteria are commonly referred to as VFC-eligible members.
Although vaccinations are a covered benefit for CHPlus/Medicaid members, EmblemHealth is not responsible for the cost of the vaccines available through the VFC Program.
EmblemHealth will only reimburse Providers for the cost of administering vaccines to VFC-eligible members. Providers are required to bill vaccine administration code 90460 for administration of vaccines supplied by VFC, including influenza and pneumococcal administration. For reimbursement purposes, the administration of the components of a combination vaccine continues to be considered as one vaccine administration. More than one vaccine administration is reimbursable under vaccine administration code 90460 on a single date of service.
The following is a list of the CPT codes for vaccines that will be auto-denied when administered to any VFC-eligible members under the age of 19 years: 90633, 90636, 90647, 90648, 90649, 90650, 90670, 90672, 90680, 90681, 90685, 90686, 90696, 90698, 90700, 90707, 90710, 90713, 90715, 90716, 90718, 90723, 90732, 90734, 90744, 90748.
Regulations Regarding Known Sex Offenders in Government Programs
As per government legislation, we do not cover supplies for the treatment of erectile dysfunction (ED) for sex offenders enrolled in any state-sponsored programs.
For more information regarding the prior approval program created by the New York State Department of Health for Medicaid members for the provision of ED procedures and supplies, see Prior Approval for Procedures, Supplies and Drugs for Erectile Dysfunction Treatment in the Care Management chapter.
EmblemHealth expanded the Behavioral Health Benefit offered to Medicaid members. The Behavioral Health Pharmacy services previously covered under Fee-for-Service Medicaid through SSI will now be covered through EmblemHealth.
Emergency Pharmacy for Members with a Behavioral Health Condition
Except where otherwise prohibited by law:
- EmblemHealth allows immediate access without prior authorizations to a seventy-two (72) hour emergency supply of the prescribed drug or medication for an individual with a behavioral condition experiencing an emergency condition as defined in the Medicaid Managed Care Model Contract.
- EmblemHealth will immediately authorize a seven day supply of a prescribed drug or medication associated with the management of opioid withdrawal and/or stabilization.
Injectable Anti-Psychotic Agent Access
Medicaid members are entitled to obtain injectable anti-psychotic agents through their medical or pharmacy benefit.
Medical Benefit Process
- Buy and Bill - A prescriber can purchase, and bill for, an inventory of injectable anti-psychotic agents directly from the manufacturer or willing licensed pharmacy and store them in the office for administration to patients.
- Voluntary Specialty Pharmacy Program - A prescriber can request injectable anti-psychotic agents through Specialty Pharmacy Services. After the prescriber satisfies any existing prior approval (PA) criteria, Specialty Pharmacy Services will issue a prior approval and the prescription can be sent directly to Accredo, our contracted medical provider, who will ship the anti-psychotic agent to the prescriber’s office for administration to the patient at no additional cost to the prescriber.
Pharmacy Benefit Prior Approval Process
Medicaid members may obtain first-generation injectable anti-psychotic agents from any network retail pharmacy that participates in our Specialty Pharmacy Network without prior approval. Medicaid members may require prior approval for selected second-generation injectable anti-psychotic agents.
Requesting Injectable Anti-Psychotics
Please review the EmblemHealth Medicaid Behavioral Health Injectable Medication Procedures below for detailed instructions on how to request injectable anti-psychotics.
Note: Injectable anti-psychotic agents cannot be obtained without a valid prescription.
For additional information on EmblemHealth’s Specialty Pharmacy Program please call: 1-888-447-0295, Monday through Friday, 8:30 am to 5 pm.
Drugs Used for the Treatment of Substance Use Disorder
Medicaid members are entitled to obtain naloxone vials, naloxone prefilled syringes, and extended-release naltrexone through the medical or pharmacy benefit. In addition, at least one formulation of buprenorphine and buprenorphine/naloxone are to be maintained on the Medicaid Formulary.
Medical Benefit Process
- Buy and Bill - A prescriber can purchase, and bill for, an inventory of naloxone vials, naloxone prefilled syringes, and extended-release naltrexone directly from the manufacturer or willing licensed pharmacy and store them in the office for administration to patients.
- Voluntary Specialty Pharmacy Program - A prescriber can request extended-release injectable naltrexone, without prior approval, by contacting Accredo, our contracted medical provider. They will ship the opioid antagonist to the prescriber’s office for administration to the patient at no additional cost to the prescriber.
Pharmacy Benefit Process
Medicaid members may obtain naloxone vials, and naloxone prefilled syringes from any network retail pharmacy without prior approval. Extended-release injectable naltrexone may be obtained from any pharmacy that participates in our Specialty Pharmacy Network without prior approval.
Prior approval is no longer required for generic buprenorphine/naloxone, however, select branded buprenorphine/naloxone products may still require prior approval. Both may be obtained from any network retail pharmacy.
Requesting Naloxone and Vivitrol
Please review the EmblemHealth Medicaid Behavioral Health Injectable Medication Procedures for formulary status and detailed instructions on how to request naloxone and vivitrol.
Note: Buprenorphine, buprenorphine/naloxone, naloxone vials, naloxone syringes, and extended-release naltrexone cannot be obtained without a valid prescription.
For additional information on EmblemHealth’s Specialty Pharmacy Program please call: 1-888-447-0295, Monday through Friday, 8:30 am to 5 pm.
Medicaid members with a diagnosis of mental illness or substance use disorder are entitled to obtain unlimited courses of smoking cessation therapy and are permitted the concomitant utilization of two smoking cessation products.
The EmblemHealth Medicaid Formulary currently includes all categories of smoking cessation products. Medicaid members have access to these products without prior approval criteria or quantity limits.
EmblemHealth Medicaid Formulary
For more information on the EmblemHealth Medicaid Formulary, visit express-scripts.com.
EmblemHealth Medicaid Behavioral Health Injectable Medication Procedures
For patient pick-up at a retail pharmacy (PHARMACY BENEFIT):
Long-Acting Injectable First Generation Antipsychotics, Extended-Release Injectable Naltrexone, and Injectable Naloxone:
- Send the prescription to a retail pharmacy that participates in our Specialty Pharmacy Network.
- Injectable Naloxone may be obtained from any retail pharmacy.
- Once filled, your patient can pick up the medication from the retail pharmacy for proper storage until office administration.
Select Long-Acting Injectable Second Generation Antipsychotics:
- Submit the Medicaid Behavioral Health Injectable Form to EmblemHealth's Specialty Pharmacy Services via fax to 1-877-243-4812. The prescriber can also call Specialty Pharmacy Services directly at 1-888-447-0295 to submit the request telephonically.
- Please be sure to indicate you are requesting this medication as part of your patient’s pharmacy benefit and submit all relevant information including, but not limited to, medication, dose, frequency, diagnosis in words, ICD-10 code and relevant medication history.
- Once approved, send the prescription to a retail pharmacy that participates in our Specialty Pharmacy Network.
- Once filled, your patient can pick up the medication from the retail pharmacy for proper storage until office administration.
If you want the medication shipped to your office (MEDICAL BENEFIT):
Long-Acting Injectable First Generation Antipsychotics, Extended-Release Injectable Naltrexone, and Injectable Naloxone:
- Prescriptions should be submitted directly to Accredo, our contracted medical provider, via phone at 855-216-2166.
- Accredo will then call to schedule delivery to your office.
Select Long-Acting Injectable Second Generation Antipsychotics:
- Submit the Medicaid behavioral health injectable form to EmblemHealth's Specialty Pharmacy Services via fax to 1-877-243-4812.
- Please be sure to indicate you are requesting this medication as part of your patient’s medical benefit and submit all relevant information including, but not limited to, drug, dose, frequency, diagnosis in words, ICD-10 code and relevant medication history.
- Once approved, submit the prescription to Accredo, our contracted medical provider, via phone at 855-216-2166.
- Accredo will then call your office to schedule delivery.
*NOTE: Long-Acting Injectable First Generation Antipsychotics, Extended-Release Injectable Naltrexone, and Injectable Naloxone DO NOT REQUIRE PRIOR APPROVAL.
EmblemHealth offers the Medication Therapy Management (MTM) program to EmblemHealth Medicare members who meet all of the following criteria:
Take seven or more chronic medications
Have high medication costs
Have at least three of the five conditions:
- Rheumatoid arthritis
- Chronic heart failure
- Chronic obstructive pulmonary disease (COPD)
- Diabetes
- High cholesterol
The MTM program helps EmblemHealth Medicare members better manage their conditions by providing a telephonic medication review as follows:
- A pharmacist will review the member's prescription medicines, over-the-counter drugs and any herbal supplements to ensure they are safe and working.
- A personal medication list will be mailed to the member after the call. The personal medication list includes all medicine the member is taking and explains how and why the medication is taken. The member will also receive a medication action plan to remind the member what was talked about during the call and what the member needs to do.
- The member will receive educational material on his or her chronic condition.
- A pharmacist will answer any questions or concerns the member has about his or her medications.
- A pharmacist will monitor the member's progress and may provide drug alerts or recommendations to the practitioner to optimize therapy.
For more information about the MTM program, call 1-888-447-0321, Monday through Friday, from 9 am to 5 pm.
EmblemHealth's has more than 60,000 independent, chain and corporately owned participating pharmacies nationwide. The following list includes the participating nationwide chain pharmacies with stores in the New York area:
- Duane Reade
- King Kullen
- Medicine Shoppe Pharmacies
- Pathmark
- Price Club/Costco
- Rite Aid
- ShopRite
- Target
- Walgreens
Note: Medicaid members can fill their prescriptions only at Medicaid-approved pharmacies.
For EmblemHealth, GHI, HIP and Vytra Plans
We contract with Express Scripts, Inc. (ESI), a home delivery vendor, to serve our EmblemHealth, GHI, HIP and Vytra plan members. Practitioners may call 1-888-327-9791 for instructions on how to fax a prescription to ESI.
Members may order medications taken on a regular basis from ESI in three ways:
- Online - Register at www.StartHomeDelivery.com.
- Mail - Send the order form included in your member packet, along with your 90-day prescription and copayment to ESI.
- Phone - Commercial members: 1-877-866-5798; Medicare members: 1-877-866-5828; Medicaid members: 1-877-866-4165.
We have also teamed up with ESI to provide prescriptions through our website, allowing members to fill their prescriptions from any location with Internet access.
Home delivery and Internet pharmacy programs are especially convenient for individuals on maintenance prescription medications that treat long-term conditions such as high blood pressure, diabetes or thyroid disorders. Additionally, members using the mail order pharmacy program may receive a reduction in their formulary prescription copayments of up to 50 percent.
For GHI City of New York Group Plans
We contract with Express Scripts, Inc. (ESI) to provide home delivery services to our GHI City of New York group plans. Practitioners may call 1-888-327-9791 for instructions on how to fax a prescription to ESI. This line is available seven days a week, from 8 am to 8:30 pm. Users of TTY/TDD can call 1-800-899-2114, 24 hours a day, seven days a week.
GHI City of New York members may also request their medications. Commercial plan members can call 1-877-534-3682. Medicare members can call 1-800-585-5786, 24 hours a day, seven days a week.
EmblemHealth’s Drug Quantity Management program establishes and monitors appropriate levels of use for selected drugs or drug categories that are high-cost and/or prone to overuse, misuse, waste or abuse.
Medications in this program include*:
- Erectile dysfunction therapy
- Caverject
- Edex
- Muse
- Viagra
- Migraine medications
- Relenza
- Smoking cessation aids
- Smoking cessation therapy
- Bupropion sustained-release tablet
- Nicotine inhalation system
- Nicotine nasal spray
- Nicotine transdermal patch
- Nicotine polacrilex gum
- Tamiflu
*This is not a comprehensive list.
EmblemHealth works with Magellan Rx, a leading specialty pharmacy, to administer complex specialty pharmacy medications through our Specialty Pharmacy Program. Network practitioners may also order medical benefit injectables — which are routinely administered in their office or clinical setting — from Magellan Rx. Other vendors may be used for limited distribution of specialty drugs not available from Magellan Rx.
Practitioners must complete the Physician Specialty Program Enrollment Form, which appears at the end of this chapter, and submit it to EmblemHealth’s Specialty Pharmacy department, either before or when placing an order for the first time.
For more information, please refer to the Injectables and Specialty Pharmacy Program chapter or contact our Specialty Pharmacy Program at 1-888-447-0295.
We offer Medicare Advantage plans with Part D benefits (MAPD) under the EmblemHealth Medicare HMO and EmblemHealth Medicare PPO programs. We also offer a stand-alone Medicare Part D prescription drug plan (PDP): EmblemHealth Medicare PDP. These plans are defined in the Medicare Product Summary section of the Provider Networks and Member Benefit Plans chapter.
EmblemHealth Medicare Prescription Drug Plan
EmblemHealth Medicare PDP is a free-standing Medicare Part D plan available to Medicare members in New York State who do not have prescription drug coverage through another Medicare Advantage prescription drug plan.
More information about the prescription drug benefits covered by this plan and the Medicare PDP formulary can be found here.
For prior approval of prescription drugs for members in our Medicare PDP, please call 1-877-362-5670.
For prior approval of prescription drugs for members in our Medicare PDP (City of New York), please call 1-888-447-8175.
Members should provide their ID card to access Medicare Part D benefits. The card contains important information the pharmacy needs to process the claim.
A coverage determination is a decision:
- Not to provide or pay for a Part D drug because the drug is either not medically necessary, not obtained from a participating pharmacy or not on our formulary
- About an exceptions request from the tiering structure
- About an exceptions request for a non-formulary Part D drug
- About the amount of cost sharing for a drug
Failure to make a decision about one of the above in a timely manner when a delay would adversely affect the health of the enrollee is also considered a coverage determination.
Coverage determinations may be requested by a member of our Medicare plans, the prescribing physician or other prescriber, or an officially designated representative (as filed with EmblemHealth).
For standard requests, we will notify the member (and prescribing physician or other prescriber, as appropriate) of the determination no later than 72 hours after receipt of the request and/or physician's supporting statement.
For expedited requests, we will notify all parties within 24 hours of receipt of the request and/or physician's supporting statement. If the expedited request is denied, we will contact all parties to:
- Explain our standard process
- Provide instructions about our grievance process and its time frames
- Inform the member of the right to file expedited grievance
- Inform the member of the right to resubmit the request with a physician's supporting documentation
Note: Expedited coverage determinations are not permitted for payment requests.
Exception requests fall under coverage determination process. Practitioners may request an exception in the following instances:
- If the formulary tiering structure has changed mid-year and an enrollee is adversely affected by the change
- When a formulary drug would not be as effective (or has been ineffective) as a non-formulary drug
- When a formulary drug would have adverse effects and a non-formulary drug is available
For an exception to be evaluated, the practitioner must provide supporting documentation of the diagnosis and a supporting statement that must indicate that the preferred drug for the treatment of the enrollee's condition would not be as effective as the requested non-preferred drug and/or would have adverse effects. All drugs approved under the exceptions process must meet the definition of a Part D drug.
Members will be notified of changes to the formulary (including cost-sharing changes) as they occur. Updates to the EmblemHealth Medicare formulary can be found on EmblemHealth's Clinical Corner
Grievance and Appeal (Redetermination) Procedures
See the Dispute Resolution - Medicare chapter.
Medicare Prescription Drug Plans - Contacts
| Medicare Prescription Drug Plans - Contacts | |||
| Benefit Plans | All Correspondence (e.g., claims, billing and member ID card questions) |
Pharmaceutical Coverage Determinations | Exceptions (e.g., drugs not listed in formulary requiring prior approval) |
EmblemHealth
|
EmblemHealth Medicare HMO
|
EmblemHealth Medicare HMO
|
Pharmacy Services
|
EmblemHealth
|
EmblemHealth Medicare PDP
|
EmblemHealth Medicare PDP
|
Pharmacy Services
|
EmblemHealth
|
EmblemHealth Medicare PDP
|
EmblemHealth Medicare PDP
|
EmblemHealth Medicare PDP
|
| EmblemHealth Medicare PPO |
EmblemHealth Medicare PPO Attn: Customer Service PO Box 2807 New York, NY 10017-2807 Call 1-866-557-7300 Fax 1-888-382-1031 |
EmblemHealth Medicare PPO PO Box 1520 JAF Station New York, NY 10116-1520 Call 1-877-444-7097 Fax 1-877-300-9695 |
Pharmacy Services |
We provide information about our pharmaceutical management procedures and our formularies at least annually and whenever we make changes. These updates may include the following:
- Pharmacy benefit designs
- Formulary changes
- Prior approval criteria
- Procedures for generic substitution, therapeutic interchange, step therapy or other management methods the practitioner's prescribing decisions are subject to
- Any other requirements, restrictions, limitations or incentives that apply to the use of certain pharmaceuticals
For the latest updates to our Commercial and Medicare formularies, please go to Formulary Updates on Clinical Corner.
If you require printed copies or have any questions regarding our pharmaceutical management procedures, please call Clinical Pharmacy Services at 1-877-362-5670.
Please see the following pages for our pharmacy forms:
