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A total health solution that helps members become more healthy, or live better with a condition, while lowering the cost of health care.
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Pharmacy - Forms and Documents

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The following forms are available online for your use:  

Click on one of the versions below to read or print the drug list/formulary:

Drug List/Formulary - Alphabetical - Empire BlueCross
Drug List/Formulary – Alphabetical (Spanish) – Empire BlueCross
Drug List/Formulary – Alphabetical - Empire BlueCross BlueShield
Drug List/Formulary – Alphabetical (Spanish) – Empire BlueCross BlueShield
Drug List/Formulary - Tiered - Empire BlueCross
Drug List/Formulary –Tiered (Spanish) – Empire BlueCross
Drug List/Formulary – Tiered - Empire BlueCross BlueShield
Drug List/Formulary –Tiered (Spanish) – Empire BlueCross BlueShield
Drug List/Formulary – Generic Premium – EmpireBlueCross BlueShield
Drug List/Formulary – Generic Premium – Empire BlueCross
Empire BlueCross SSB Drug List-Child Health Plus
Empire BlueCross BlueShield SSB Drug List-Child Health Plus
Empire BlueCross Drug List - Healthy New York
Empire BlueCross BlueShield Drug List - Healthy New York
Empire Maintenance Drug List
 
Formulary Update
Generic Alternatives to Empire’s Top Brand Medications

Check out a list of generic drugs available to you. They may save you money!

Pharmacy Forms

Prescription Drug Claim Form

Prescription Home Delivery Order Form

Prescription Home Delivery Order Form - Spanish

 
Prior Authorization Required (PAR)*

Check to see if your drugs require prior authorization by your doctor or pharmacist before a prescription can be filled.

Quantity Limitations (QL)*

Quantity limits help prevent medication overuse by establishing a maximum covered amount that you may receive within a specific time period. Coverage of a prescription claim is rejected if the amount prescribed exceeds recommended prescribing guidelines. This list outlines drugs within your network that have a quantity limit attached.

Retail Pharmacy Network

Your network includes more than 56,000 pharmacies located throughout the United States. That means you have convenient access to prescription medications no matter where you are – at home, on vacation, or on a business trip.

Specialty Drug List

Check out a list of Empire Pharmacy medications that are available through Accredo

Specialty Pharmacy Network List-Empire BlueCross
Specialty Pharmacy Network List-Empire BlueCross BlueShield
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