Current Drug Lists
SEHP uses The Empire Plan Advanced Flexible Formulary for prescription drugs.
The drug formulary documents list out if a prescription drug is covered or not covered, and their tier/drug level (which determines costs). The documents are updated quarterly.
Drug information is split between five documents.
Preferred Drug List
Commonly prescribed prescription drugs covered by the 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 plan before benefits are available. Prior authorization review and approval is required before the 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 plan, plus available alternatives that the plan does cover.
Comprehensive Formulary
A full list of drugs covered by the plan, their tier/drug level and any specific limits.
How It Works
Prescription drugs that are covered by the plan are categorized into three levels. These levels determine your copayment. There are also some drugs that are not subject to copayment, no matter their level.
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
At certain SUNY Campus Student Health Centers, SUNY SEHP enrollees and/or their enrolled dependents can fill prescriptions for a $7 copayment for up to a 30-day supply. (This does not apply to CUNY SEHP enrollees.) Speak with your HBA for more information.
- 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)
There may be additional limits or restrictions, depending on the prescription drug.
Covered prescription drugs filled at a non-network pharmacy are eligible for reimbursement. However, in almost all cases, you will not be reimbursed for the full cost, and you will likely pay more than usual copayments.
Medicare
When you become Medicare-primary, your prescription drug benefits will change. Refer to Medicare and NYSHIP for more information.