Empire MediBlue Access (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Empire MediBlue Access (PPO) by Empire Healthchoice Assurance, Inc. 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 Empire MediBlue Access (PPO)(H3342-023) plan has a $310 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. Empire Healthchoice Assurance, Inc 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:Empire MediBlue Access (PPO)
Plan ID: H3342-023
Provider: Empire Healthchoice Assurance, Inc
Plan Year:2023
Premium:$44.30
Deductible:$310
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H3342-023


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
3Y$38$43NANN
Edarbi
4Y$88$93NANY
Edarbyclor
4Y$88$93NANN
Edurant
528%28%NA30/30NN
Efavirenz
4Y$88$93NA30/30NN
Efavirenz, Emtricitabine And Tenofovir Disoproxil
528%28%NA30/30NN
Efavirenz, Lamivudine And Tenofovir Disoproxil Fum
528%28%NA30/30NN
Egrifta Sv
528%28%NAYN
Eliquis
3Y$38$43NA74/180NN
Elmiron
4Y$88$93NANN
Eluryng
4Y$88$93NANN
Emcyt
528%28%NANN
Emend
3Y$38$43NA15/30YN
Emgality
528%28%NA3/28YN
Emsam
528%28%NA30/30YN
Emtricitabine
4Y$88$93NA30/30NN
Emtricitabine And Tenofovir Disoproxil Fumarate
528%28%NA30/30NN
Emtriva
4Y$88$93NA850/30NN
Enalapril Maleate And Hydrochlorothiazide
6N$0$0NANN
Enbrel
528%28%NA8/28YN
Endocet
4Y$88$93NA180/30NN
Engerix-b
3Y$38$43NAYN
Enoxaparin Sodium
4Y$88$93NA56/28NN
Enpresse
3Y$38$43NANN
Enskyce
3Y$38$43NANN
Entacapone
4Y$88$93NANN
Entecavir
4Y$88$93NAYN
Entresto
3Y$38$43NANN
Enulose
2N$10$15NANN
Envarsus
4Y$88$93NAYN
Epclusa
528%28%NA30/30YN
Epidiolex
528%28%NAYN
Epinastine Hydrochloride
3Y$38$43NANN
Epinephrine
3Y$38$43NA2/28NN
Epitol
1N$3$8NANN
Epivir
3Y$38$43NANN
Eplerenone
4Y$88$93NANN
Eprontia
4Y$88$93NANN
Equetro
4Y$88$93NA180/30NN
Ergoloid Mesylates
4Y$88$93NAYN
Ergotamine Tartrate And Caffeine
3Y$38$43NANN
Erivedge
528%28%NA30/30YN
Erleada
528%28%NAYN
Erlotinib
528%28%NA90/30YN
Errin
3Y$38$43NANN
Ertapenem
4Y$88$93NANN
Ery
3Y$38$43NANN
Ery-tab
4Y$88$93NANN
Erythrocin Lactobionate
4Y$88$93NANN
Erythrocin Stearate
3Y$38$43NANN
Erythromycin
2N$10$15NANN
Erythromycin Ethylsuccinate
3Y$38$43NANN
Esbriet
528%28%NA90/30YN
Escitalopram
2N$10$15NA120/30NN
Escitalopram Oxalate
4Y$88$93NA600/30NN
Estarylla
3Y$38$43NANN
Estradiol
1N$3$8NANN
Estradiol / Norethindrone Acetate
4Y$88$93NAYN
Estradiol Transdermal System
3Y$38$43NA4/28YN
Estradiol Valerate
4Y$88$93NANN
Estring
4Y$88$93NA1/90NN
Eszopiclone
4Y$88$93NA30/30NN
Ethambutol Hydrochloride
4Y$88$93NANN
Ethosuximide
4Y$88$93NANN
Ethynodiol Diacetate And Ethinyl Estradiol
3Y$38$43NANN
Etodolac
3Y$38$43NANN
Etonogestrel/ethinyl Estradiol
4Y$88$93NANN
Etravirine
528%28%NA60/30NN
Euthyrox
1N$3$8NANN
Everolimus
528%28%NAYN
Evotaz
528%28%NA30/30NN
Exemestane
4Y$88$93NA60/30NN
Exkivity
528%28%NA120/30YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3342-023

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $310. 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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