Empire Plan Drug Lists
The drug formulary shows whether a prescription drug is covered or not. It also lists the tier or drug level, which affects costs. The formulary is updated quarterly.
Drug information is split between five documents.
Preferred Drug List
Commonly prescribed prescription drugs covered by The Empire Plan. The list includes both generic and brand-name drugs, based on their availability and tier placement.
Prior Authorization Drug List
Medications that needs prior authorization from The Empire Plan before benefits are available. Prior authorization review and approval is required before The Empire Plan provides coverage.
Specialty Pharmacy Drug List
Medications that can only be received from a Designated Specialty Pharmacy.
Excluded Drug List
Medications that are not covered by The Empire Plan, plus available alternatives that the plan does cover.
Comprehensive Formulary
A full list of drugs covered by The Empire Plan, their tier/drug level and any specific limits.
How It Works
The Empire Plan groups covered prescription drugs in three levels. These levels determine your copayment. Some drugs have no copayment, no matter which level they are in.
Your copayment depends on two factors:
Drug levels
- Level 1, Generic Drugs
- Level 2, Preferred Drugs, or Compound Drugs
- Level 3, Non-Preferred Drugs, certain Generic Drugs
Where the prescription is filled
- 30-day supply at a Network Pharmacy
- 31- to 90-day supply at a Network Pharmacy
- 31- to 90-day supply through a Mail Service Pharmacy or the Designated Specialty Pharmacy
- Oral chemotherapy drugs, when prescribed for cancer treatment
- Generic oral contraceptive drugs and devices or brand-name contraceptive drugs/devices without a generic equivalent (single-source brand-name drugs/devices)
- Medications used for emergency contraception and pregnancy termination
- Tamoxifen, raloxifene (for patients age 35 and older), anastrozole and exemestane when prescribed for the primary prevention of breast cancer
- Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP), when prescribed for enrollees who are at high risk of acquiring HIV
- Covered prescription insulin drugs
- Certain prescription and over-the-counter medications considered preventive without cost sharing and have in effect a rating of “A” or “B” in the current recommendations of the U.S. Preventive Services Task Force (USPSTF)
Some prescription drugs may have additional limits or restrictions. Check the formulary to find out specific requirements.
You can fill covered prescriptions at non-network pharmacies and submit a claim. However, you will pay more than your usual copayment and the plan will not reimburse you for the full cost.
Costs
| Up to a 30-day supply from a Network, Specialty, or Mail Service Pharmacy | Copayment |
|---|---|
| Level 1 Drugs or for most Generic Drugs | $5 |
| Level 2 Drugs, Preferred Drugs, or Compound Drugs | $25 |
| Level 3 Drugs or Non-preferred Drugs | $45 |
| 31- to 90-day supply from a Network Pharmacy | Copayment |
|---|---|
| Level 1 Drugs or for most Generic Drugs | $10 |
| Level 2 Drugs, Preferred Drugs, or Compound Drugs | $50 |
| Level 3 Drugs or Non-preferred Drugs | $90 |
| 31- to 90-day supply from a Specialty or Mail Service Pharmacy | Copayment |
|---|---|
| Level 1 Drugs or for most Generic Drugs | $5 |
| Level 2 Drugs, Preferred Drugs, or Compound Drugs | $50 |
| Level 3 Drugs or Non-preferred Drugs | $90 |
Medicare
When you become Medicare-primary, your prescription drug benefits will change. Refer to Medicare and NYSHIP for more information.
Related Publications
Each HMO maintains their own drug formulary. Go to their respective website to see which prescription drugs are covered, as well as other benefits.