EmblemHealth VIP Dual (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from EmblemHealth VIP Dual (HMO D-SNP) by Health Insurance Plan Of Greater New York. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a New York Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This EmblemHealth VIP Dual (HMO D-SNP)(H3330-042) plan has a $505 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However, some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Health Insurance Plan Of Greater New York will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:EmblemHealth VIP Dual (HMO D-SNP)
Plan ID: H3330-042
Provider: Health Insurance Plan Of Greater New York
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H3330-045


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
E.e.s
4YNA$100NANN
Edarbi
3YNA$47NANN
Edarbyclor
3YNA$47NANN
Edurant
5NA25%NANN
Efavirenz
4YNA$100NANN
Efavirenz, Emtricitabine And Tenofovir Disoproxil
5NA25%NANN
Efavirenz, Lamivudine And Tenofovir Disoproxil Fum
5NA25%NANN
Eletriptan
4YNA$100NA18/28NN
Eletriptan Hydrobromide
4YNA$100NA18/28NN
Eliquis
3YNA$47NANN
Elmiron
3YNA$47NANN
Eluryng
4YNA$100NANN
Emcyt
5NA25%NANN
Emend
4YNA$100NAYN
Emgality
3YNA$47NA2/30YN
Emsam
5NA25%NANN
Emtricitabine
4YNA$100NANN
Emtricitabine And Tenofovir Disoproxil Fumarate
5NA25%NANN
Emtriva
3YNA$47NANN
Emverm
5NA25%NANN
Enalapril Maleate And Hydrochlorothiazide
6NNA$5NANN
Enbrel
5NA25%NA16/28YN
Endocet
3YNA$47NA360/30NN
Engerix-b
3YNA$47NAYN
Enoxaparin Sodium
4YNA$100NA28/28NN
Enpresse
2YNA$15NANN
Enskyce
2YNA$15NANN
Entacapone
4YNA$100NANN
Entecavir
4YNA$100NANN
Entresto
3YNA$47NA60/30NN
Enulose
2YNA$15NANN
Envarsus
4YNA$100NAYN
Epclusa
5NA25%NA28/28YN
Epidiolex
4YNA$100NAYN
Epinastine Hydrochloride
3YNA$47NANN
Epinephrine
3YNA$47NA2/30NN
Epitol
2YNA$15NANN
Epivir
4YNA$100NANN
Eplerenone
3YNA$47NANN
Eprontia
4YNA$100NAYN
Ergotamine Tartrate And Caffeine
3YNA$47NANN
Erivedge
5NA25%NA30/30YN
Erleada
5NA25%NA120/30YN
Erlotinib
5NA25%NA60/30YN
Errin
2YNA$15NANN
Ertapenem
4YNA$100NA14/14YN
Ery
3YNA$47NANN
Ery-tab
4YNA$100NANN
Erythrocin Stearate
4YNA$100NANN
Erythromycin
4YNA$100NANN
Erythromycin Ethylsuccinate
4YNA$100NANN
Esbriet
5NA25%NA270/30YN
Escitalopram
1YNA$5NA30/30NN
Escitalopram Oxalate
2YNA$15NANN
Estarylla
2YNA$15NANN
Estradiol
4YNA$100NAYN
Estradiol / Norethindrone Acetate
3YNA$47NAYN
Estradiol Transdermal System
3YNA$47NA4/28YN
Estradiol Valerate
4YNA$100NANN
Estring
3YNA$47NANN
Eszopiclone
4YNA$100NA30/30NN
Ethambutol Hydrochloride
3YNA$47NANN
Ethosuximide
3YNA$47NANN
Ethynodiol Diacetate And Ethinyl Estradiol
2YNA$15NANN
Etodolac
4YNA$100NANN
Etonogestrel/ethinyl Estradiol
4YNA$100NANN
Etravirine
5NA25%NANN
Euthyrox
1YNA$5NANN
Everolimus
5NA25%NA30/30YN
Evotaz
5NA25%NANN
Exemestane
4YNA$100NANN
Exkivity
5NA25%NA120/30YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3330-042

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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