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Important Plan Documents

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Members 2022 Important Plan Documents

Your important plan documents below include coverage and costs for medical product and services and prescription drugs that will start on January 2022.

What are you looking for?

 

2022 EmblemHealth Annual Notice of Changes

 

Evidence of Coverage

 

Comprehensive and Preventive Dental Benefits

 

Medicare HMO Provider Directory - VIP Bold Network

 

Medicare HMO Provider Directory - VIP Reserve Network

 

Medicare HMO Provider Directory - VIP Prime Network

 

Dental Directory

 

Pharmacy Directory

  • Medicare Pharmacy Directory (Broad Performance Network)

    (National Drug Plan (PDP), VIP Dual (HMO D-SNP), VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP), and VIP Dual Reserve (HMO D-SNP), National Drug Plan (PDP), select EmblemHealth Group Access Rx (PPO) plans and VIP Premier (HMO) group plans with standard pharmacy benefit)

  • Medicare Pharmacy Directory (Preferred Value Network)

    (VIP Value (HMO), VIP Essential (HMO), VIP Rx Saver (HMO), VIP Gold (HMO), VIP Gold Plus (HMO), VIP Passport (HMO), VIP Passport NYC (HMO), VIP Reserve (HMO) and select VIP Premier (HMO) group plans)
 

Formulary

List of Covered Drugs

 

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.

  • 2022 EmblemHealth Medicare Part D Prior Authorization (HMO)
 

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.

 

Evidence of Coverage for Group Plans

 

Enrollment Applications

Thank you for your interest in EmblemHealth. To request a Formulary, EOC, or Provider/Pharmacy Directory, please call Customer Service at 877-344-7364 (TTY: 711). We are open seven days a week from 8 am to 8 pm. We will be happy to help you.

 

To view Portable Document Format (PDF) files, you need Adobe Acrobat Reader. If you do not already have this software, you can download a free copy from Adobe®. Download the Adobe Reader® now. Follow Adobe's instructions for download and installation.

 

 

Nondiscrimination Policy for Medicare | Disaster Events Policy for Medicare

Last Updated 10/01/2021

Y0026_201700 Accepted 9/24/21

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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 provider. If you have any concerns about your health, please contact your health care provider'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.