Important Plan Documents

Members 2021 Important Plan Documents

Your important plan documents below include coverage and costs for medical product and services and prescription drugs that will start on January 2021.

Click here to view 2020 Important Plan Documents.

What are you looking for?

  • Medicare Pharmacy Directory (Broad Network)

    (VIP Dual (HMO D-SNP), VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP), and VIP Dual Reserve (HMO D-SNP), National Drug Plan (PDP), select EmblemHealth Group Access Rx (PPO) plans and VIP Premier (HMO) group plans with standard pharmacy benefit)

  • Medicare Pharmacy Directory (Value Network)

    (VIP Value (HMO), VIP Part B Saver (HMO), VIP Essential (HMO), VIP Rx Saver (HMO), VIP Go (HMO-POS), VIP Gold (HMO), VIP Gold Plus (HMO), VIP Passport (HMO), VIP Passport NYC (HMO), VIP Rx (PDP), VIP Rx Plus (PDP), VIP Reserve (HMO) and select VIP Premier (HMO) Group Plans)


List of Covered Drugs

  • 2021 EmblemHealth HMO and PDP Drug Formulary

  • 2021 EmblemHealth VIP Dual (HMO D-SNP) Drug Formulary

  • 2021 Recent Changes to EmblemHealth's HMO and PDP Drug Formulary

  • 2021 Recent Changes to EmblemHealth's HMO D-SNP Drug Formulary

Prior Authorization

Prior Authorization means that you will need to get approval from your plan before you fill your prescriptions. If you do not get an approval, your plan may not cover the drug. Below is a list of drugs that require prior-authorization.

  • 2021 EmblemHealth Medicare Part D Prior Authorization (HMO)

Step Therapy

Step Therapy means you may need to try a different or more common drug first. Below is a list of drugs that require Step Therapy.

  • 2021 EmblemHealth Medicare Part D Step Therapy

  • EmblemHealth VIP Rx Carveout (HMO) – Group

  • EmblemHealth VIP Premier (HMO) – Group

  • EmblemHealth Group PPO- Group Access Rx/Access Rx National (PPO)

  • EmblemHealth National Drug Plan (PDP) CNY/ EmblemHealth National Drug Plan (PDP)

Thank you for your interest in EmblemHealth. To request a Formulary, EOC, or Provider/Pharmacy Directory, please call Customer Service at 877-344-7364 (TTY: 711). We are open seven days a week from 8 am to 8 pm. We will be happy to help you.


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Last Updated 10/01/2020

Y0026_200570 Accepted 9/29/20