Apoyo farmacéutico

Learn about your pharmacy benefits, download prescription drug claim forms, view additional programs, and more.

For the safe and cost-effective use of drugs, plans include programs for Prior Authorization, Drug Quantity Management and Step Therapy.

Autorización previa
La autorización previa hace referencia al requisito de autorización de algunos medicamentos recetados antes de que se puedan cubrir. Your prescribing doctor must give proof of the medical necessity of the drug for you and your diagnosis.

Si la evaluación de su médico cumple con las pautas aprobadas para ese medicamento y está cubierto por su plan, se aprobará la autorización previa para surtir su receta.

Tratamiento escalonado
Un programa de terapia escalonada es un proceso de dos pasos. El primer paso es usar un medicamento genérico o de primera línea antes de que se apruebe uno de segunda línea. Los medicamentos que se usan como el "primer paso" responden a tratamientos consolidados. En la mayoría de los casos, se prefieren estos medicamentos antes que las terapias de segunda línea. First-line drugs may be filled without calling EmblemHealth Pharmacy Benefit Services. El segundo paso es para aquellos casos en los que el medicamento de primera línea no le resulta efectivo. En este caso, se pueden recetar medicamentos de segunda línea. To do this, your doctor must call EmblemHealth's Pharmacy Clinical Department.

Si la evaluación de su médico cumple con las pautas aprobadas para ese medicamento y está cubierto por su plan, se aprobará la autorización previa para surtir su receta.

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. En la farmacia es posible que le digan que la receta incluye una cantidad mayor que la que cubre su plan. 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.

Si la evaluación de su médico cumple con las pautas aprobadas para ese medicamento y está cubierto por su plan, se aprobará la autorización previa para surtir su receta. 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 ICORE Pharmacy Services, 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 ICORE.

ICORE Pharmacy Services fills the prescriptions and delivers them directly to your home. You must join by calling ICORE at 866-554-2673.

For more information, call ICORE Pharmacy Services at the number above. You may also call EmblemHealth about your specialty pharmacy services at 888-447-0295.

Un formulario es una lista de medicamentos cubiertos por su plan. This list is made by doctors and pharmacists after reviewing clinical studies. Evalúan qué medicamentos son los más seguros y efectivos y maximizan el ahorro de costos. The formulary has a range of generic and brand-name drugs (see below for descriptions) that have been approved by the US Food and Drug Administration (FDA). The formulary applies to prescription drugs that are dispensed in retail pharmacies and those delivered to your home through a home delivery pharmacy. Si algún medicamento no se encuentra en nuestro formulario, puede tener una o más alternativas aprobadas por la FDA que están cubiertas por su plan de medicamentos.

Review our list of covered drugs to check the formulary status of a drug.

Medicamentos genéricos
The FDA approves both brand-name and generic drugs. Generic drugs have the same active ingredients, dosage form and strength, and must be absorbed in the body the same way as brand-name drugs.

Generic drugs can be classified as single source or multiple source.

Single Source Generics
These include brand-name drugs that are going off patent and a single manufacturer has exclusive rights to make the drug for a period of time.

Multiple Source Generics
These drugs are defined by the Centers for Medicare and Medicaid Services (CMS) as products with three or more versions of the product related therapeutically equal (A–rated) no matter what the ratings of other versions (B–rated) and at least three suppliers are listed in the current editions of published national compendia.

Medicamentos de marca
Un medicamento de marca es el nombre comercial bajo el cual se promociona y vende un medicamento. A new drug is protected by a patent, so only one manufacturer can make it. For this reason, brand-name drugs most often cost more than generic drugs. Once a patent runs out, other companies may make a generic equal.

Un copago es la cantidad de desembolso que debe abonar un miembro a la farmacia de venta minorista o al servicio de la farmacia para pedidos de envío por correo. El miembro paga un copago por receta. This fee is most often less than the actual price of the prescription and can vary based on the type of drug and the member’s benefits. Por lo general, los medicamentos genéricos implican un copago menor que los de marca. Si el precio de la receta es menor que el copago, entonces el miembro pagará el precio menor.

Copago en niveles
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 copayment.

Tier 2: Formulary or Preferred Brand-Name Drugs — Brand-name drugs have higher copayments 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. Tendrá que pagar más por ellos.

Tenga en cuenta: Some plans include multiple source generic drugs in Tier 1 and single source generics in Tier 2.

Online Prior Approvals With PromptPA

The PromptPA website lets you and your health care providers submit prior approval/Coverage Determination requests online for your prescription drugs. You can also see the status and outcome of these requests on the site.

To get started, simply click on the “Members” link at PromptPA and follow the directions. You do not need to register.

Pharmacy Benefit Services Prescription Drug Claim Form

This form allows you to submit claims for EmblemHealth prescriptions. Todas las reclamaciones deben hacerse con la siguiente información: nombre del paciente, concentración y cantidad de cada medicamento, número de receta de cada medicamento, nombre y dirección de la farmacia, nombre del médico recetador y facturas de las recetas.

formulario

Medicamentos cubiertos

Find the list of drugs covered by your EmblemHealth plan (also known as a “formulary”).

Sus medicamentos con receta

Entrega a domicilio y resurtido

Averigüe cómo coordinar la entrega a domicilio o cómo obtener un resurtido de receta.

CONOZCA SUS DERECHOS

Reclamos y apelaciones

Averigüe cómo presentar un reclamo o una apelación, cómo solicitar decisiones y determinaciones de cobertura, y más.