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EmblemHealth 2012 Pharmacy Services Formulary Summary This is a list of the most commonly prescribed preferred drugs for members of EmblemHealth, GHI, HIP and Vytra Commercial benefit plans with prescription drug coverage. Drugs marked with an asterisk will become non- preferred when a generic equivalent product becomes available. Make sure to ask your doctor to prescribe generic drugs whenever appropriate; this may lower your out-of-pocket expenses.
NOTE: Not all drugs listed are covered by all pharmacy benefit programs, so coverage is not guaranteed. Please use the formulary search at, or check your benefit materials, to find out if a specific
drug is covered under your pharmacy benefit. You should also check your benefit materials for the copay and any other responsibilities you may have under your pharmacy benefit. For additional questions about your prescription drug coverage, please call the phone number printed on your ID card.
EmblemHealth 2012 Pharmacy Services Formulary Summary (continued) See Key on next page.
Capital letters
Prior Authorization – Prescriber needs to obtain EmblemHealth approval for coverage of this drug (as outlined in the member’s plan).
Quantity Level Limit – Quantities dispensed may be limited.
Step Therapy – Drug is part of a program where drug options are organized in a series of steps (as outlined in the member’s plan).
For the member: Generic medications contain the same active ingredients as the corresponding brand name medications, but may differ in color or shape. They have been FDA approved
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.
You can get more information about our formularies and our Pharmacy Services program at
Formulary Disclaimer
Please refer to your benefit materials for specific coverage information. Your benefit design determines what is covered for you and what your copayment will be. The presence of a medication on
this formulary does not guarantee that you as a plan member will be covered for that drug. Additionally, these medications may be subject to Prior Authorization. Coverage for some drugs may be
limited to specific dosage forms and/or strengths. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EmblemHealth’s Pharmacy
Services. As new generics become available, the corresponding brand name drug will no longer be considered a preferred agent.
Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
EGH_MB_OTH_9088_Commercial 2012 Pharmacy Formulary 03-12



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