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Forms designated "Upstate" are for residents of Albany, Clinton, Essex, Fulton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Washington and Warren counties.
Forms designated "Downstate" are for residents of Bronx, Columbia, Delaware, Dutchess, Greene, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster and Westchester counties.
 
Pharmacy
Document NameType

 

Empire Drug ListsHTMLDownload
Prescription Drug Claim FormPDFDownload
Prescription Home Delivery Order FormPDFDownload
Prescription Home Delivery Order Form (Spanish)PDFDownload
Specialty Pharmacy Exception Form-Empire BlueCrossPDFDownload
Specialty Pharmacy Exception Form-Empire BlueCross BlueShield PDFDownload

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