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Empire Plan prescription drug savings options
 The cost of prescription drugs is one of the fastest growing components of health care costs in the United States.
The Empire Plan’s prescription drug benefit is designed to help manage drug costs and establish copayment levels that are more in line with the relative cost of various drugs to the Plan.
Each January, Empire Plan enrollees are sent the “Empire Plan at a Glance,” which is a summary of benefits available under the Empire Plan, and also includes applicable copayment(s). Copayments are not the only component that impacts overall health insurance costs.
To keep out-of-pocket prescription drug costs as low as possible, speak with your doctor about alternative drugs that may be available for your treatment and become aware of programs that can help you save money.
The Empire Plan Prescription Drug Program uses the Advanced Flexible Formulary to provide CSEA enrollees and dependents with the best value in prescription drug spending. All drugs included on the formularies have been approved by the FDA. The list is developed by a committee of pharmacists and physicians and are subject to change each January.
The Empire Plan Advanced
Flexible Formulary uses a three-level copayment schedule – level 1 has the lowest copayment and most generic prescription drugs fall within this level.
Empire Plan Mail Service Pharmacy
One of the most cost-effective ways to receive your prescription drugs is through the CVS Caremark Mail Service Pharmacy.
Empire Plan enrollees/dependents
can order up to a 90-day supply of medication shipped directly to your home. Once a prescription is on file at the Mail Service Pharmacy, ordering refills is easy: by mail, phone or online. You download the mail service pharmacy order form at forms/CVSCM_MailServiceOrderForm. pdf.
Questions about the Empire Plan Mail Service Pharmacy program can
be directed to the Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447). Press or say 4 for the Prescription Drug Program.
Specialty Pharmacy Program
The Empire Plan Specialty Pharmacy Program offers enhanced services to individuals using specialty drugs. Most specialty drugs will only be covered when dispensed by The Empire Plan’s designated specialty pharmacy, CVS Caremark Specialty Pharmacy. Prior authorization is required for some specialty drugs.
Specialty drugs are used to treat complex conditions and usually require special handling, special administration or intensive patient monitoring.
The program provides enrollees
with enhanced services that
include disease and drug education, compliance management and side- effect management, safety management, expedited and scheduled delivery of prescription drugs at no additional charge, refill reminder calls and all necessary supplies, such as needles and syringes applicable to the prescription drug.
Questions regarding specialty drugs can be directed to CVS Caremark
at 1-877-7-NYSHIP (1-877-769-7447). Press or say 4 for the Prescription Drug Program and ask to speak with
a representative from the Specialty Pharmacy Program.
Cost saving ideas
• Talk with your doctor about
using over-the-counter drugs. • Prescription drugs occasionally
move to the over-the-counter
market and become available
without a prescription. An over- the-counter drug may be an
alternative to save you money
over prescription options.
administration or business services center if you are eligible to participate in New York State’s Health Care Spending Account, which allows you to set aside part of your salary before taxes to pay for eligible health-related expenses. To learn more, visit
If you have a workers’ compensation injury, do not use the Empire Plan Prescription Drug Program for drugs to
treat it. These claims should be covered in full through workers’ compensation.
For More Information
Understanding Empire Plan benefits: Preventive, Diagnostic and Routine Care
Preventive, diagnostic, and routine care benefits are common types of health care you may receive under The Empire Plan.
Understanding the difference between them is not always easy, but it is important. Coverage and out-of-pocket expenses can vary, depending on which type of service you receive.
Be sure to discuss with your provider why a test or service is being ordered. The same test or service can be considered preventive, diagnostic or routine, depending on the description of why it is being performed. As a result, an enrollee’s out-of-pocket costs may change based on why the service is requested.
Preventive care benefits and services covered by The Empire Plan follow numerous guidelines and standards,
including recommendations by the U.S. Preventive Services Task Force (USPSTF), the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) as well as requirements of the U.S. Patient Protection and Affordable Care Act (PPACA).
The goal of preventive care is
to detect potentially serious health conditions before symptoms develop and get early treatment.
Preventive care can include annual exams, screenings and immunizations. Common examples of adult preventive care include annual wellness visits, screenings for cholesterol, high blood pressure and diabetes and cancer screenings such as colonoscopies and
Common examples of yearly pediatric
preventive care (well-child) can include growth and body mass measurements, developmental screenings, behavioral assessments and immunizations.
Many preventive services are covered in full when using an Empire Plan participating provider.
Diagnostic care helps diagnose risk factors or treat symptoms that are already present. Diagnostic care would involve following up with your provider to treat or monitor issues. When a preventive visit becomes diagnostic, a copayment would apply when using a participating provider.
Routine care describes care that occurs on a regular basis, but it is not preventive. Routine care is used to
prevent a condition from becoming worse and to help manage symptoms.
Common illnesses that often require routine care include asthma, hypertension, and diabetes. Because routine care is not preventive, a copayment would apply when using a participating provider.
Please review the 2023 Empire Plan Preventive Care Coverage Guide for more details regarding preventive, diagnostic and routine care.
You should review your Explanation of Benefits Statement (EOB) regularly. The EOB can provide a better understanding of how the services are billed, what
the Plan pays and your out-of-pocket costs. If you have specific coverage questions or need assistance finding a participating provider, call the Empire Plan 1-877-7-NYSHIP (1-877-769-7447).
September 2023
The Work Force 17
• When your doctor starts you
on a maintenance prescription drug, you may want to have
it filled for a 30-day supply to ensure the drug is right for your condition before you pay a higher copayment for a 31-to-90-day supply.
• Ask your agency’s health benefits
Additional online resources
are available on the Empire Plan’s
CVS Caremark website. Visit and select the CVS Caremark link or call The Empire Plan toll free at 1-877-7-NYHIP (1-877-769-7447) and press 4 for the Prescription Drug Program.

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