Learn more about what our over-the-counter benefit covers, how to get money back for a drug, our Medication Therapy Management Program, how to get help paying for Part D drugs in the Extra Help program (also known as Low-Income Subsidy), and much more.
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Medicare: Additional Pharmacy Information
Over-the-Counter (OTC) Benefit
If your EmblemHealth Medicare plan includes an OTC benefit, you can get coverage for items like hand sanitizer, cold medicines, vitamins, dental care items, and more.
Over-the-Counter Items
Extra Help, also called Low-Income Subsidy (LIS), is a Medicare Program to help people with limited income and resources pay for Part D drug plan costs. It can help you pay for monthly premium fees (the amount you pay for your insurance every month), deductibles (the amount you pay before your plan starts to pay), and coinsurance (the percentage you pay for health services).
You can get Extra Help if:
- You have full Medicaid coverage.
- You get help from your state Medicaid program to pay your Part B premiums in a Medicare Savings Program.
- You get Supplemental Security Income (SSI) Benefits
To see if you qualify for Extra Help:
- Call Medicare: 1-800-MEDICARE (1-800-633-4227). If you use a TTY, please call 1-877-486-2048, 24 hours a day, seven days a week;
- Call Social Security: 800-772-1213 between 8 a.m. and 7 p.m., Monday through Friday. If you use a TTY, please call 800-325-0778; or
- Your State Medicaid Office.
Elderly Pharmaceutical Insurance Coverage (EPIC) Program:
You can also get Extra Help with Elderly Pharmaceutical Insurance Coverage (EPIC) Program. It is the New York State program that helps people with their Medicare Part D drug plan costs. You can qualify for this program based on your income. You can apply for EPIC at any time of the year. For more information or to apply, call 800-332-3742 (TTY: 800-290-9138). Or, go online at health.ny.gov/health_care/epic.
If you get Extra Help, what you pay for the plan and what you pay at the pharmacy will be lower.
2025 HMO LIS Premium Summary (EmblemHealth Medicare HMO plans)
2024 HMO LIS Premium Summary (EmblemHealth Medicare HMO plans)
Medicare provides "Extra Help" to pay for prescription drug costs for people who have limited income and resources. If you qualify, you will receive help paying for your drug copays. EmblemHealth accepts several forms of evidence to establish your eligibility to receive help to lower your cost for your prescription drugs. That evidence may be provided by the beneficiary or the beneficiary’s pharmacist, advocate, representative, family member or other individual acting on behalf of the beneficiary. For more information, please view the best available evidence (BAE) policy. View more information on this policy.
If you have any questions please call our Customer Service at 877-344-7364 (TTY: 711). From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.
The MTM Program is a free service for EmblemHealth Medicare plan members with Part D prescription drug coverage who have certain health conditions and who take a certain number of chronic medications.
EmblemHealth’s goal is to make changes that occur each new benefit year as seamless as possible. EmblemHealth’s transition policy meets the immediate needs of our members and allows them time to work with their prescribing doctor to switch to another medication that is on the formulary to treat the member’s condition or ask for an exception.
Who is Eligible for a Temporary Supply?
During the first 90 days of membership, we offer a temporary supply of medications to:
- New members on January 1 following the Annual Election Period
- Newly eligible Medicare beneficiaries
- Existing members impacted by a negative formulary change from the prior year
- Members switching Medicare Part D plans after January 1
- Members residing in long-term care (LTC) facilities
- In some cases, enrollees who change treatment settings due to a change in level of care
Our transition policy applies to:
Part D medications that are not on EmblemHealth’s formulary and Part D medications that are on EmblemHealth’s formulary but may require:
- Prior authorization (PA) These are drugs that may or may not be included in our drug list that need to be approved in advance before we will cover it.
- Step therapy (ST) In these cases, we require your doctor to first try certain drugs to treat a medical condition before we will cover another drug.
- Quantity limitations (QL) These are drugs that we limit to a certain amount over a certain time period. If your doctor thinks you need to receive more, you can ask us for an exception.
Getting Medication from a Participating Network Pharmacy
For each medication that is not on our formulary or is subject to prior authorization, step therapy or quantity limits. EmblemHealth will cover a temporary one-time supply for at least a month's supply of medications (unless the prescription was written for fewer days) when you get it filled from a network pharmacy during the transition period. After the first month’s supply, you will need to request an exception for coverage, otherwise EmblemHealth will not pay for these medications, even if the member has been in the plan less than 90 days.
How is a Prescription Filled in Long-Term Care Facilities?
For members in long-term care facilities, prescription refills will be provided up to a month’s supply (unless the prescription was written for fewer days). We will cover more than one refill of these medications for the first 90 days as a member of our plan.
If a medication is needed that is not on our formulary or if the member’s ability to get medications is limited, but the member is past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that medication (unless a prescription was written for fewer days) while a formulary exception is requested.
How is a Member Notified about the Transition Supply?
All members (and their doctors) getting a temporary supply of a medication will be sent a letter about the member’s transition fill and the transition process. This letter will be sent within three business days of the temporary fill.
The notice will include:
- An explanation of the transition supply that the member received;
- How to work with EmblemHealth and the member’s prescriber to find another medication that is on the formulary to treat the member’s condition;
- An explanation of the member’s right to ask for a formulary exception; and
- A description of the formulary exception process.
What is the Copay for Temporary Medication?
The copay for the approved temporary medication will be based on one of our approved formulary tiers. The cost-sharing for a non-formulary drug provided during the transition period will be the same as the cost-sharing charged for non-formulary medications that are approved under a coverage exception. The cost share for formulary drugs that require prior authorization, step therapy or quantity limits approvals that are provided during the transition will be the same cost share after the prior approval criteria are met.
Copays for members who are eligible for “Extra Help” (a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance) during the transition period will never exceed the copay maximums set by the Centers for Medicare & Medicaid Services for low-income members.
As part of our commitment to patient safety, we have taken steps to ensure that prescription drugs are used safely and effectively by our Medicare Part D members. Members can be at risk for drug errors and drug-related problems since they often get prescriptions from more than one doctor. We make sure drugs are used safely by:
- Screening for drug interaction: Using prescription-tracking software, we screen each member’s drug profile for possible harmful interactions with other drugs the member may be taking.
- Making sure drugs are right for members: We check if a drug has a warning for certain age groups. We have added drugs to our formulary (list of covered drugs) that are safe for our members and removed drugs that are not as safe. We also educate our doctors about their prescribing patterns and about drugs that may not be right for members.
- Ensuring dosages are safe: To prevent a possible overdose, we review each member’s drug profile to decide if a drug is filled above FDA dosing guidelines.
- Avoiding drug duplication: We screen each member’s drug profile to see if the same or similar drug is already in the member’s drug profile.
- Sending pharmacy reports to doctors: We review each member’s drug profile to see if they are being prescribed more drugs than they need. This report is shared with prescribing doctors. The doctor then decides on the right therapy, if needed.
If you have any questions, please call Customer Service at the phone numbers below. From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.
EmblemHealth Medicare HMO: 877-344-7364
EmblemHealth Medicare PPO: 866-557-7300
If you have a TTY, please call: 711
EmblemHealth Pharmacy Benefit Services completes quality assurance reviews of the medicines our members take to avoid medication errors and harmful drug reactions and improve medication use. EmblemHealth Pharmacy Benefit Services also oversees the use of prescription drugs and checks each prescription filled based on these criteria:
- Dosing: We check how much of each drug you take to find out if it is within established dosage ranges, meaning not too high or too low.
- Gender/Age: We screen a prescribed drug to find out if it is right for a member’s gender and age.
- Proper Medication Use: We look at the time frame for refills and new fills. We do this to make sure that members take their prescribed drugs as directed and follow established dosing guidelines for controlled and non-controlled substances.
- Drug-Drug and Drug-Disease Interaction: We look at medication profiles to find any potential interactions between prescribed drugs and a member’s health conditions.
- Medication Duplication: We screen each member profile to make sure that newly prescribed drugs are not the same as other prescribed drugs the member is taking.
- FDA-issued Warnings: We review FDA-issued warnings about any harmful reactions to medications, new dosage formulations and how the drug is administered (orally, injectable, topically, etc.) We re-evaluate the formulary (list of covered drugs) to make improvements based on our reviews.
If you have any questions or concerns, please call Customer Service at the phone numbers below,From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.
EmblemHealth Medicare HMO: 877-344-7364
EmblemHealth Medicare PPO: 866-557-7300
If you have a TTY, please call: 711
Reimbursement Forms
Complete this form to seek reimbursement for prescription drug costs you paid above the cost-share amounts outlined under your plan’s prescription drug benefits.
Reimbursement Form – HMO and PPO
English | Español | 中文
Reimbursement Form – City of New York PDP
English | Español | 中文
Medicare Prescription Drug Coverage Determination Request Form
EmblemHealth Medicare HMO, PPO and PDP (City of New York)
English | Español | 中文
Medicare Prescription Drug Coverage Redetermination Request Form
EmblemHealth Medicare HMO and PPO
English | Español | 中文
EmblemHealth Medicare PDP (City of New York)
English | Español | 中文
Last Updated 10/01/2024
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