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Medicare Advantage Plan
Frequently Asked Questions (FAQs)
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We want you to make the most of your health plan. Here are some answers to questions you may have.
There are many preventive services that Medicare and EmblemHealth cover at no extra cost to you, including:
- Flu shot
- Breast cancer screening
- Diabetes screening
- Annual “Wellness” visit (this is different than the annual exam)
- Annual physical exam (an annual physical at $0 is covered on most Medicare plans)
For more information on preventive services covered at no cost to you, see your Medicare plan’s Evidence of Coverage (EOC).
No referrals are required on individual Medicare plans. Please check the front of your ID card for more information.
To learn more, please refer to the Cost Sharing Guide on the member portal or see your Medicare plan’s Evidence of Coverage (EOC).
- You can find your list of covered drugs through our Rx Cost Calculator.
- The Cost Sharing Guide is available on the secure member portal.
- In some cases, you can get a temporary supply of the drug while you work with your doctor to change to another drug or file a request to have the drug covered.
- You can ask your provider to change to a drug that is on your plan’s formulary.
- You can request an exception and ask the plan to cover the drug or remove restrictions from the drug. Your doctor must support the request. EmblemHealth will review and respond to your request.
- Call the pharmacy number on the back of your member ID card for more information.
To learn more, click here.
Preferred pharmacies are network pharmacies where you can save on prescription drugs. Check our Pharmacy Locator to find a local pharmacy and their preferred status. Some preferred pharmacies we work with include Rite Aid, Costco, Walgreens/Duane Reade, Sam's Club, Price Chopper Pharmacy, and Safeway.
- Quest Diagnostics and LabCorp are participating laboratories. Quest and LabCorp have locations nationwide. There are other specialty labs also available in our network.
- Ask your provider to use Quest or LabCorp when they take your bloodwork for analysis.
- Copays may vary depending on locations (doctor’s office or free-standing facility versus all other locations).
For more information, or to find the nearest lab here.
- All medically necessary Medicare-covered services are covered by EmblemHealth, including MRIs.
- Your provider will have to get an approval (also known as “prior authorization”) for the service to be covered. EmblemHealth will review it and respond to your request.
Most of our plans include dental services, but the type of dental (preventive only; comprehensive only; preventive and comprehensive) varies by plan and whether you’ve purchased an optional rider. Find participating dentists here. Some services may require a prior authorization. Your dentist is responsible for submitting the request.
For more information on services covered, see your Medicare plan’s Evidence of Coverage (EOC) or the Cost Sharing Guide on the member portal.
Our Medicare plans cover medically necessary durable medical equipment and supplies that are covered by Medicare.
Covered items include:
- Oxygen equipment and supplies
- Wheelchairs
- Walkers
- Powered mattress systems
- Crutches
- Diabetic supplies
- Speech generating devices
- IV infusion pumps
- Nebulizers
- Hospital beds ordered by a provider for use in the home
Please note certain items will have to be returned and some will be owned by you, such as prosthetics
If you have an emergency while outside the country:
- You will first have to pay out-of-pocket for expenses.
- You can submit a request for reimbursement to EmblemHealth.
- EmblemHealth reviews the information submitted and decides on coverage and payment.
- If the request is approved, EmblemHealth will send you a check.
Yes, it’s always a good idea to choose a primary care doctor to coordinate your care and help you when you need to see a specialist. At EmblemHealth, we will select a primary care doctor for you if one is not chosen.
EmblemHealth recommends that you schedule your first primary care doctor visit within the first 90 days of being a member. This way, your doctor can get to know you and your medical history and can recommend preventive care and screenings. Also, once you are a patient, it will be easier for you to schedule a sick visit if you need one.
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Last Updated: 10/01/2024
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