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)



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.


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Last Updated 10/01/2021

Y0026_201700 Accepted 9/24/21