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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 BC Select Drug List (3-Tier)PDFDownload
Empire BCBS Select Drug List (3-Tier)PDFDownload
Empire BC Select Drug List (3-Tier)-SpanishPDFDownload
Empire BCBS Select Drug List (3-Tier)-SpanishPDFDownload
Prescription Drug Claim FormPDFDownload
Prescription Home Delivery Order FormPDFDownload
Prescription Home Delivery Order Form (Spanish)PDFDownload
Empire BC Upstate National Alpha Drug List (English)PDFDownload
Empire BC Upstate National Alpha Drug List (Spanish)PDFDownload
Empire BCBS Upstate National Alpha Drug List (English)PDFDownload
Empire BC Upstate National Alpha Drug List (Spanish)PDFDownload
Empire BC Upstate National 3 Tier Drug List (English)PDFDownload
Empire BC Upstate National 3 Tier Drug List (Spanish)PDFDownload
Empire BCBS Downstate National 3 Tier Drug List (English)PDFDownload
Empire BCBS Downstate National 3 Tier Drug List (Spanish)PDFDownload
Drug List/Formulary: Generic Premium – DownstatePDFDownload
Drug List/Formulary: Generic Premium – UpstatePDFDownload
Drug List: SSB – Child Health Plus – UpstatePDFDownload
Drug List: SSB – Child Health Plus – DownstatePDFDownload
Drug List: Healthy New York – UpstatePDFDownload
Drug List: Healthy New York – DownstatePDFDownload
Empire Maintenance Drug ListPDFDownload
Specialty Drug List - Empire BlueCross BlueShieldPDFDownload
Specialty Drug List-Empire BlueCrossPDFDownload
Medical provider-administered specialty drug listPDFDownload
Formulary UpdatePDFDownload
Retail Pharmacy NetworkPDFDownload
Specialty Pharmacy Network List – UpstatePDFDownload
Specialty Pharmacy Network List – DownstatePDFDownload
Empire BC Saving with Drug List, Generics and OTC Drugs.PDFDownload
Empire BCBS Saving with Drug List, Generics and OTC Drugs.PDFDownload

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