Members 2023 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 2023.

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2023 EmblemHealth Annual Notice of Changes


Evidence of Coverage


Comprehensive and Preventive Dental Benefits


Medicare HMO Provider Directory - VIP Bold Network


Medicare HMO Provider Directory - VIP Reserve Network


Medicare HMO Provider Directory - VIP Prime Network


Dental Directory


Pharmacy Directory

  • Medicare Pharmacy Directory (Broad Performance Network)

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

  • Medicare Pharmacy Directory (Preferred Value Network)

    (VIP Essential (HMO), VIP Rx Saver (HMO), VIP Gold (HMO), VIP Gold Plus (HMO), VIP Reserve Classic (HMO) and select VIP Premier (HMO) group plans)



List of Covered Drugs

  • 2023 EmblemHealth HMO and D-SNP Drug Formulary

  • 2023 Recent Changes to EmblemHealth's HMO 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.

  • 2023 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.


Evidence of Coverage for Group Plans

  • 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)


Enrollment Applications