The documents below include coverage information, forms, and costs for covered products and services.
Medicare Advantage
Important Plan Documents
Important Plan Documents
- 2027
- 2026
Annual Notice of Changes
Individual Plans
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EmblemHealth VIP Gold (HMO)
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Dental
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Covered Dental Services
Coming soon
Enrollment Application and Forms
Enrollment Application
Forms
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To submit claims for medical care and services.
Evidence of Coverage
Individual Plans
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EmblemHealth VIP Gold (HMO)
Coming soon
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EmblemHealth VIP Gold Plus (HMO)
Coming soon
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EmblemHealth VIP Value (HMO)
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Bronx, Kings, Nassau, Queens, and Suffolk
Coming soon
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Westchester
Coming soon
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EmblemHealth VIP Saver (HMO)
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Bronx, Kings, Nassau, Queens, and Suffolk
Coming soon
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Westchester
Coming soon
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EmblemHealth VIP Core (HMO)
Coming soon
Employer Group Plans
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EmblemHealth VIP Rx Carveout (HMO) – Group
Coming soon
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EmblemHealth VIP Premier (HMO) – Group
Coming soon
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EmblemHealth Group PPO – Group Access Rx/Access Rx National (PPO)
Coming soon
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EmblemHealth National Drug Plan (PDP) CNY/EmblemHealth National Drug Plan (PDP)
Coming soon
Pharmacy
Directory
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EmblemHealth VIP Gold (HMO), EmblemHealth VIP Gold Plus (HMO), EmblemHealth VIP Value (HMO), EmblemHealth VIP Saver (HMO), EmblemHealth VIP Core (HMO), EmblemHealth VIP Premier (HMO), EmblemHealth National Drug Plan (PDP), and EmblemHealth Group Access Rx (PPO) plans.
Formularies
Prior Authorization
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EmblemHealth Medicare Part D Prior Authorization (HMO)
Coming soon
Step Therapy
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EmblemHealth Medicare Part B Step Therapy
Coming soon
Provider Directories
VIP Bold Network
VIP Prime Network
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(Albany, Broome, Columbia, Delaware, Greene, Rensselaer, Saratoga, Schenectady, Warren and Washington)
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(Dutchess, Orange, Rockland, Putnam, Sullivan, Ulster and Westchester)
Star Ratings
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Medicare Advantage HMO Star Ratings (H3330)
Coming soon
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Medicare Advantage HMO Star Ratings (H5991)
Coming soon
Annual Notice of Changes
Individual Plans
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EmblemHealth VIP Gold (HMO)
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EmblemHealth VIP Dual (HMO D-SNP)
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EmblemHealth VIP Dual Enhanced (HMO D-SNP)
Dental
Enrollment Applications and Forms
Enrollment Applications
Forms
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To submit claims for medical care and services.
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Reimbursement for OTC purchases in extraordinary circumstances.
Evidence of Coverage
Individual Plans
Employer Group Plans
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Last Updated: 10/24/2025
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Last Updated: 10/24/2025
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Last Updated: 10/24/2025
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Last Updated: 06/03/2026
Pharmacy
Directory
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EmblemHealth VIP Gold (HMO), EmblemHealth VIP Gold Plus (HMO) , EmblemHealth VIP Value (HMO-POS), EmblemHealth VIP Dual (HMO D-SNP), EmblemHealth VIP Dual Enhanced (HMO D-SNP) EmblemHealth VIP Dual Reserve (HMO D-SNP), EmblemHealth VIP Premier (HMO), EmblemHealth National Drug Plan (PDP), and EmblemHealth Group Access Rx (PPO) plans.
Last Updated: 09/10/2026
Formularies
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Last Updated: 10/01/2026
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Last Updated: 10/01/2026
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Last Updated: 10/01/2026
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Last Updated: 10/01/2026
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Last Updated: 10/01/2026
Prior Authorization
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Last Updated: 10/01/2026
Step Therapy
Provider Directories
VIP Bold Network
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Last Updated: 08/28/2026
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Last Updated: 08/28/2026
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Last Updated: 08/28/2026
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Last Updated: 08/28/2026
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Last Updated: 08/28/2026
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Last Updated: 08/28/2026
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Last Updated: 08/28/2026
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(Albany, Broome, Columbia, Delaware, Greene, Rensselaer, Saratoga, Schenectady, Warren and Washington)
Last Updated: 08/28/2026 -
(Dutchess, Orange, Rockland, Putnam, Sullivan, Ulster and Westchester)
Last Updated: 08/28/2026
VIP Reserve Network
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Last Updated: 08/27/2026
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Last Updated: 08/27/2026
VIP Prime Network
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Last Updated: 08/27/2026
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Last Updated: 08/27/2026
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Last Updated: 08/27/2026
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Last Updated: 08/27/2026
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Last Updated: 08/27/2026
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Last Updated: 08/27/2026
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Last Updated: 08/27/2026
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(Albany, Broome, Columbia, Delaware, Greene, Rensselaer, Saratoga, Schenectady, Warren and Washington)
Last Updated: 08/27/2026 -
(Dutchess, Orange, Rockland, Putnam, Sullivan, Ulster and Westchester)
Last Updated: 08/27/2026
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Thank you for your interest in EmblemHealth. To request a Formulary, Evidence of Coverage, or Provider/Pharmacy Directory, please call Customer Service at 877-344-7364 (TTY: 711). From Oct. 1 to March 31, you can call us seven days a week from 8 a.m. to 8 p.m. From April 1 to Sept. 30, you can call us Monday through Saturday from 8 a.m. to 8 p.m. We will be happy to help you.
Last Updated: 10/01/2026
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