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Medicare Formularies

Pharmacist holding a tabley and a bottle of medicine

 

At EmblemHealth, we offer Medicare plans that cover a wide range of prescription drugs. Below is a complete list of all covered drugs in our comprehensive formularies. This list includes both generic and brand-name drugs. Most formularies list drugs in levels or “tiers”, based on cost. The lower the level or tier, the lower your cost for the drug will be.

 

Formulary

List of Covered Drugs
 

Employer Group Formulary

List of Covered Drugs

  • 2025 City of New York PDP Drug Formulary

  • 2025 HMO Employer Group 4 Tier Drug Formulary

  • 2025 HMO and PPO Employer Group 5 Tier 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.

  • 2025 EmblemHealth Medicare Part D Prior Authorization

  • 2025 City of New York Prior Authorization Criteria

In addition, you can request prior approval by completing a Coverage Determination Form or by calling Customer Service.

 

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.

  • 2025 EmblemHealth Medicare Part D Step Therapy

  • 2025 EmblemHealth Medicare Part B Step Therapy

  • 2025 City of New York Step Therapy Criteria

    The drugs on this list require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that needs step therapy pre-approval.
 

Formulary

List of Covered Drugs

  • 2024 EmblemHealth HMO and D-SNP Drug Formulary

    Last Updated: 12/01/2024
 

Employer Group Formulary

List of Covered Drugs

  • 2024 City of New York PDP Drug Formulary

    Last Updated: 12/01/2024

  • 2024 HMO Employer Group 4 Tier Drug Formulary

    Last Updated: 12/01/2024

  • 2024 HMO and PPO Employer Group 5 Tier Drug Formulary

    Last Updated: 12/01/2024
 

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.

  • 2024 EmblemHealth Medicare Part D Prior Authorization

  • 2024 City of New York Prior Authorization Criteria

In addition, you can request prior approval by completing a Coverage Determination Form or by calling Customer Service.

 

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.

  • 2024 EmblemHealth Medicare Part D Step Therapy

  • 2024 EmblemHealth Medicare Part B Step Therapy

  • 2024 City of New York Step Therapy Criteria

    The drugs on this list require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that needs step therapy pre-approval.

Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan is a new payment option for 2025 that works with your current Part D drug coverage to help you manage your out-of-pocket prescription costs by spreading them across the calendar year (January through December). Those who have high cost-share amounts for prescription drugs earlier in the plan year are more likely to benefit from the program. This voluntary program is free to join and there are no fees or interest charged under the payment plan.

This option doesn’t save you money or lower your maximum out-of-pocket drug cost ($2,000 in 2025). If you receive extra help paying for prescription drugs or have low drug costs, this payment option is not the best choice for you. Learn more about Extra Help here.

How is the monthly payment calculated? 

The following resources provide examples of how the payment is calculated and tell you about other ways to save on prescription drug costs:

You can also calculate your monthly payment plan amounts here.

How can I opt in or out of the program? 

Contact ExpressScripts to opt in or out of the program.

When does the payment plan go into effect?

If you are new to the plan, we will process your request within:

  • 10 calendar days of receipt of your election form.
  • If your enrollment in our plan will start sooner than 10 days from when we receive your election form, we will process your election before your enrollment in our plan starts so that you will be enrolled in the program on the same day that your plan starts.

If you are currently a member:

  • We will process your request within 24 hours, but enrollment will be effective on the date we receive your completed request.
  • If you paid any cost-share for an urgently needed prescription before we processed your election, we may make your election effective before we receive it. This can happen if you meet the following criteria:
    • You believe that taking 24 hours to process your request may seriously jeopardize your life, health, or ability to regain maximum function.
    • You request a retroactive election within 72 hours of the date and time you paid and received your urgently needed prescription. 

You must pay your monthly payments to stay enrolled. If you do not pay within a grace period of two months, we will remove you from the Medicare Prescription Payment Plan.

For information on how to file a complaint and grievance, please click here.

your prescriptions

Delivery and Refills

Find out how to set up home delivery or get a prescription refill.

Female pharmacist smiling and putting hand on customer's shoulder.

MTM Program

Medication Therapy Management

Find out if you qualify for this service, which is free for EmblemHealth Medicare plan members with Part D prescription drug coverage.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances.

Medicare Pharmacy

Additional Pharmacy Information

Learn more about what our over-the-counter debit benefit covers, how to get money back for a drug and more.

Pharmacist smiling at male customer.

Last Updated 10/01/2024

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Also of Interest: 
Pharmacy   |   Drugs Covered   |   Medicare Important Plan Documents