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Drug List

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  1. Home
  2. Member Resources
  3. Pharmacy
  4. Drugs Covered

Which Drugs Are Covered by My Plan?

To see the list of drugs covered by your EmblemHealth plan — also known as a formulary — locate your plan name or the letter identifiers in the “Formulary” section on the front of your member ID card, which will match the options below.
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  • Small Group (SG), Essential Plan, and Qualified Health Plan (QHP)

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Drug Management Programs

For the safe and cost-effective use of prescription medicines, plans include programs for preauthorization, drug quantity management, step therapy, and specialty drugs.

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Preauthorization

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Step Therapy

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Drug Quantity Management

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Specialty Pharmacy Program

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Preauthorization

Preauthorization is when some prescribed drugs must be authorized before they can be covered. Your prescribing doctor must give proof of the medical necessity of the drug for you and your diagnosis.

If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, preauthorization will be approved for your prescription to be filled.

Step Therapy

A Step Therapy program is a two-step process. The first step is the use of a first-line or generic drug before a second-line drug is approved. The drugs used as the first step are well-established treatments. In most cases, these drugs are preferred therapy over second-line therapies. First-line drugs may be filled without calling EmblemHealth Pharmacy Benefit Services. The second step is if the first-line drug is not effective for you. In this case, second-line drugs can be prescribed. To do this, your doctor must call EmblemHealth’s Pharmacy Clinical Department.

If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, preauthorization will be approved for your prescription to be filled.

Drug Quantity Management

A Drug Quantity Management (DQM) program is when some drugs have quantity limits — meaning you can get only a certain amount at one time. The DQM program decides the number of doses to be included in each prescription for certain drugs. At the pharmacy, you might be told that your prescription is written for a larger amount than your plan covers. You can ask your pharmacist to give you the amount that your plan covers or, if your doctor doesn’t agree with the limit, he or she can call EmblemHealth’s Pharmacy Clinical Department to find out if you can get a greater quantity.

If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, preauthorization will be approved for your prescription to be filled. Review our list of covered drugs to find out if a drug has a quantity limit.

Specialty Injectable Pharmacy Program

Specialty drugs are most often injectable drugs for conditions such as multiple sclerosis, growth deficiencies, fertility issues, and hepatitis C. Members who use specialty drugs must get their prescriptions filled through Accredo, EmblemHealth’s Specialty Pharmacy vendor.

You may not fill specialty drug prescriptions at a retail pharmacy or through Express Scripts home delivery. Some noninjectable drugs used in combination with self-injectables are also on hand through Accredo.

Accredo fills your prescriptions and delivers them directly to your home. For approvals, call Accredo at 855-216-2166 (TTY: 711) from 8 a.m. to 11 p.m., Monday through Friday and 8 a.m. to 5 p.m. on Saturday.

You may also call EmblemHealth about your specialty pharmacy services at 888-447-0295 (TTY: 711).

Additional Resources

Learn about your pharmacy coverage, download prescription drug claim forms, and more.

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Common Insurance Terms

Find the definition of copays, deductibles, coinsurance, and more in our helpful glossary.

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Pharmacy Prescription Drug Claim Form

A form to submit claims for EmblemHealth prescriptions.

Download Your Claim Form
Glossary

Deductible: The amount you must pay before the plan starts to pay for your prescriptions.

Coinsurance: After you pay your deductible, you and your plan may share the cost of your prescriptions. The percentage you pay is called coinsurance.

Copay: The out-of-pocket amount you pay the retail pharmacy or the mail order pharmacy for home delivery. You pay one copay per prescription. This fee is most often less than the actual price of the prescription and can vary based on the type of drug and your benefits. Usually, generic drugs have a lower copay than brand-name drugs. If the price of the prescription is less than the copay, then you will pay the lower price.

Tiered Copay: To give quality and affordable drug coverage, most EmblemHealth drug programs have a three-tiered drug formulary benefit. The three tiers, with different levels of coverage are:

Tier 1: Generic Drugs — Generic drugs have the lowest copay.

Tier 2: Formulary or Preferred Brand-Name Drugs — Brand-name drugs have higher copays than generic drugs.

Tier 3: Non-Formulary or Non-Preferred Brand-Name Drugs — These are drugs for which there may be a similar generic drug or preferred brand-name drug on hand. You will pay more for these drugs.

Please note: Some plans include multiple-source generic drugs in Tier 1 and single-source generics in Tier 2.

PHARMACY SUPPORT

Questions? We’re here to help.

Call EmblemHealth Customer Service at the number on your member ID card.

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Also of Interest: 
Pharmacy   |   Medicare Formularies   |   Delivery & Refills
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Any information provided on this website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care professional. If you have any concerns about your health, please contact your health care professional's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.

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