Medicaid

Choose Empire BlueCross BlueShield HealthPlus for your Medicaid benefits.

We’re proud to serve eligible Medicaid members in New York. We’ll help arrange for you and your family to get the benefits you need to get and stay healthy.

The Empire medical director and the doctors in our plans review new medical advances or changes to technology in:

  • Behavioral health
  • Certain behavioral health services like skills training
  • Devices
  • Medical treatment
  • Prescription drugs

They also look at scientific findings to see if these new medical advances and treatments:

  • Are considered safe and effective by the government.
  • Give equal or better outcomes than the treatment or therapy that exists now.

They do this to see if these new changes in technology should be part of the benefits in our plans.

What you get with Empire Medicaid

We help you live your healthiest life by offering:

Care that’s about you

You come first, so we built your health plan around you. You can go to doctors and pick up your prescriptions close to home. You can also get answers about your benefits straight from us, because we’re right in your neighborhood! Visit any of our offices to talk with associates in your preferred language.

Care when you need it

We’re here for you anytime, day or night! Simply call our 24/7 NurseLine to get answers from our nurses.

Care for our community

We believe a healthier community makes a happier, healthier you. That’s why our associates volunteer with local organizations to build up our area. This year, we’re fighting hunger with the food bank. We’re also delivering clothing and supplies to nearby shelters. And we’re hosting neighborhood health fairs and food workshops to bring healthier choices to those in need.

Get Medicaid benefits to help you meet your health goals like:

  • A primary care provider (PCP) to help you get the care you need
  • Prescriptions*
  • Wellness visits and immunizations
  • Dental and vision care
  • Mental health services
  • Substance use treatment
  • Psychiatric services
  • Specialty physician services
  • Disease management for asthma, diabetes and more
  • Smoking cessation
  • Maternal depression screening
  • Coping and life skills training
  • Family support training
  • Stress management
  • Crisis prevention

*Copays may apply for medications. There are no copays for services that are part of your benefits.

When you need a referral or preapproval

Referrals

For some services, you’ll need a referral from your primary care provider (PCP) before getting care. When you need a referral, your PCP will sign a referral form and send you to a doctor in your plan. You will need to see your PCP before:

  • Going to a hospital for nonemergency care
  • Getting medicine your PCP can’t give you

Get these services from Empire BlueCross BlueShield HealthPlus without a referral

For most services, you'll go to your PCP or another doctor in your plan. Even if you get some services from a doctor who isn’t in your plan, we’ll pay for some services, including:

  • Family planning
  • Pregnancy services
  • Emergency services
  • School-based health center services
  • Adult dental care (ages 21 and over)
  • Behavioral health and substance use disorder services
  • Certain doctors for children with special health care needs

We'll also pay for the lab work and medicine related to these services.

Family planning services

You can choose to go to a doctor who isn’t in your plan for any of these family planning services:

  • Family planning office visit
  • Pap smear
  • Special contraceptive supplies
  • Diaphragm fitting
  • IUD insertion and removal
  • FDA-approved contraceptives, as well as emergency contraceptives

Pregnancy services

You can choose to keep seeing a doctor that isn’t in your plan if you:

  • Were pregnant when you joined Empire.
  • Saw a doctor who isn’t in your plan for at least one complete prenatal checkup.

As long as the doctor agrees, you can keep seeing this doctor for:

  • Checkups and prenatal care throughout your pregnancy.
  • Delivery.
  • Follow-up care for up to two months after the baby is born.

Emergency services

If you have a medical emergency, you don’t need a referral to go to the emergency room. A medical emergency is a condition that could end in death or very serious bodily harm. If you’re not sure if you should go to the emergency room, call your PCP for help. You can also speak to a registered nurse if you call the 24/7 NurseLine at 1-800-300-8181.

After you’ve been treated for an emergency condition, you may need extra services to make sure the emergency condition doesn’t return (these are called post-stabilization services). We’ll work with the hospital staff to decide if you need these services. If you would like to know more about how we make this decision, call Member Services at 1-800-300-8181 (TTY 711).

School-based health center services

For children who go to schools with health centers, there are some services they can get without a referral:

  • Office visits and treatment for acute or urgent physical illness, along with needed medicine
  • Follow-up visits to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) visits when needed
  • Family planning services listed on the previous page

Adult dental care (age 21 and over)

Dental services don’t need a referral from your PCP. Empire offers services managed by Healthplex. Call 1-800-468-9868 (TTY 1-800-662-1220) for more information. The state provides dental care for individuals under 21 years old.

Adult vision care (age 21 and over)

Vision services don’t need a referral from your PCP. Empire offers services managed by Superior Vision. Call 1-800-879-6901 for more information. Vision services for individuals under 21 years old require preapproval.

Certain doctors for children with special health care needs

To keep getting the right plan of care, children with special health care needs may go to a doctor outside of their plan if the child’s doctor gives the plan of care to us for review and approval within 30 days of the child’s effective date.

A child may ask for a specific doctor outside of the plan if:

  • He or she is already enrolled in Empire when diagnosed as having a special health care need.
  • His or her need calls for a plan of care that includes specific types of services.

We’ll approve your request unless we have a local specialty doctor in the plan with the same training and skills that is reasonably on hand and gives the same services.

Preapproval

Some Empire services and benefits require preapproval. This means that you and/or your doctor must ask Empire to approve those services or benefits before you get them. Empire requires preapproval for these services:

  • Ambulance transportation (emergency air and nonemergency)
  • Chiropractic services
  • Diagnostic testing
  • Durable medical equipment
  • End-stage renal disease services
  • Eye/vision care and services for people age 20 and younger
  • Home health extended services for people age 20 and younger
  • Home health services for people age 21 and over: registered/skilled nurse, physical therapy, occupational therapy, speech therapy, home health aide and IV therapy
  • Hospice services: inpatient, home and hospice facility
  • Inpatient acute care hospitalization
  • Medicines (See the Empire Preferred Drug List. Low copays for over-the-counter medicine require a prescription from your doctor.)
  • Mental health rehab services: family therapy, crisis stabilization, assertive community treatment
  • Nurse-midwifery services
  • Organ transplant services
  • Outpatient hospital services: physical therapy, occupational therapy, speech therapy and surgical procedures
  • Pediatric Day Health Care (PDHC) for people ages 20 and older
  • Personal Care Services (PCS) for people ages 20 and older
  • Physician services: medical assessments, treatments and surgical services (includes behavioral health physicians)
  • Podiatry services
  • Post-stabilization care services: from doctors inside or outside the Empire plan
  • Radiology services
  • Rehabilitation services: physical therapy, occupational therapy and speech therapy
  • Transportation services
  • If you live in NYC, nonemergency transportation is provided through the state’s vendor, Medical Answering Services (MAS). To set up a ride, please call MAS at 1-800-850-5340.
  • For members who live in Nassau, please call LogistiCare at 1-844-678-1103 (TTY 1-866-288-3133).
  • All other counties, please call Medical Answering Services at 1-800-850-5340.

For more information, call Member Services at 1-800-300-8181 (TTY 711). All services from doctors outside of your plan require preapproval from Empire.

Call Member Services at 1-800-300-8181 (TTY 711) to learn more about qualifying for Medicaid and getting your benefits through Empire.

To learn more about applying for health insurance including Child Health Plus and Medicaid through NY State of Health, The Official Health Plan Marketplace, visit nystateofhealth.ny.gov or call 1-855-355-5777.

Plus, Extra Benefits at No Cost!
  • 24/7 NurseLine — Our nurses are ready to answer your questions 24 hours a day, every day
  • New Baby, New LifeSM, a special care program for pregnant women
  • Comprehensive programs for chronic conditions like diabetes, asthma, hypertension and more
Empire Healthy Rewards

New Baby, New Life℠ Empire BlueCross BlueShield HealthPlus Healthy Rewards Incentives

  • $25 incentive for prenatal visit in the first trimester or within 42 days of enrollment into Empire
  • $25 incentive for attending postpartum visit 21 to 56 days after delivery
  • $25 incentive for attending at least six prenatal care visits
  • $25 incentive for baby’s 2-week checkup
  • $25 incentive for attending at least six well-child checkups by 15 months of age

For more information, check online at mss.empireblue.com/healthyrewards or call 1-877-868-2004.

Prescription Drugs

Empire works with Express Scripts to provide your pharmacy benefit. We cover a wide range of prescriptions and many over-the-counter medicines. Starting May 1, Rite Aid is no longer a pharmacy in your plan. Go to Express Scripts to find a plan pharmacy near you.

Your copays are:

  • $3 for brand-name drugs
  • $1 for generic drugs

Preferred Drug List

Empire has a preferred drugs list (PDL), also called a formulary. It includes all medicines covered by Medicaid and Child Health Plus (CHPlus). Your doctor may need to get approval from us for certain drugs. This is known as prior authorization. Your doctor’s request for approval should include why a specific drug is required and how much is needed. For these drugs, your doctor must get approval from us before you can fill your prescription. When there is a generic drug available, it will be covered. Generic drugs are equal to brand-name drugs and approved by the Food and Drug Administration. Requests for brand-name drugs when generics are available will need prior authorization. You can email and ask us for an exception at wrkgp-submitmyexceptionreq@anthem.com

If you have any questions about your pharmacy benefit, please call our Member Services department at 1-800-300-8181 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m.

Searchable Formulary

Search for name brand and generic drugs that are on the formulary. You can search for your drug by:

  • Typing the name (at least first three letters) of the drug in the search box
  • Using the A-Z list to search by the first letter of your drug
    • OR
  • Clicking on therapeutic class of the drug
Searchable Formulary

Drug Interactions and Side Effects

Learn more about drug interactions or side effects on the ESI Drug Information website.

Getting your prescription filled is easy!

Simply present the written prescription from your doctor to a participating network pharmacy. Or your doctor can call in the prescription to your local participating pharmacy. You will also need to show the pharmacy your Empire ID card to have a prescription filled.
It is good to use the same pharmacy each time. This way, your pharmacist will know about problems that may occur when you are taking more than one prescription. If you use another pharmacy, you should tell the pharmacist about any medicines you are taking.

You can use the links below to get more pharmacy information:

Half Tablet Program Preferred Drug List

New York HealthPlus Preferred Drug List (PDL)

Common Over-the-Counter (OTC) Medicines

ESI Online Registration Instructions

ESI Mail Order Form

Eligibility

Empire BlueCross BlueShield HealthPlus is a New York Managed Care Organization (MCO) that offers New York State-sponsored Medicaid programs. With us, you get the New York Medicaid benefits you need: doctor care, hospital care, prescription drugs and more. We help answer your questions and guide you through the system.

With Empire, you get extra benefits like:

  • A 24/7 NurseLine to answer health questions
  • New Baby, New LifeSM, a special care program for pregnant women
  • Comprehensive programs for chronic conditions like diabetes, asthma, hypertension and more
  • And much more!

You may be covered by Medicaid if:

  • You live in Brooklyn, the Bronx, Queens, Manhattan, Staten Island, Nassau County or Putnam County
  • You have high medical bills
  • You receive Supplemental Security Income (SSI — see below)
  • You meet certain income, resource, age or disability requirements

You may be eligible for SSI if you:

  • Are elderly
  • Are blind
  • Have a disability
  • Have a behavioral health condition

Find out more about income and resources limitations.

You can also call New York State of Health, The Official Health Plan Marketplace at 1-855-355-5777.

For help with enrolling or if you have questions, call us at 1-888-809-8009 (TTY 711). You can also visit one of our office locations.

Already a member, and have questions?

Call Member Services at 1-800-300-8181 (TTY 711). Member Services is open Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m. We are happy to help you with your health care!

Member Handbooks

Your member handbook is your go-to guide for health services. It tells you how you can get the most from Empire BlueCross BlueShield HealthPlus. You’ll find answers to these items:

  • Your benefits
  • How to get help after your doctor’s office closes
  • How to choose a primary care provider
  • Renewing your coverage
  • How to reach Member Services if you have a question

Member Handbooks

Notice of Privacy Practices

Frequently Asked Questions

Frequently Asked Questions about Your Pharmacy Benefit


How can I find out what pharmacies are in the Empire network?

Please call Member Services at 1-800-300-8181 (TTY 711) or ask your local pharmacy for help.

Are over-the-counter (OTC) products covered, and do I need a prescription?

We cover many OTC products, including pain relievers, antacids, contraceptives and some vitamins. All OTC products require a written prescription from your doctor and can be filled at any network pharmacy.

How does my doctor request prior authorization?

Your doctor can request prior authorization on medicines by calling our Pharmacy department at 1-800-454-3730.

What if a copayment is required and I am unable to pay it?

If you don’t have the copayment for your medicine, your pharmacy should still provide the medicine. If the pharmacy allows you to take the medicine without paying the required copayment, you will have to pay the copayment at a later time.

How do I get my medicine if I am traveling?

We have network pharmacies in all 50 states. Most chain pharmacies as well as many independent and grocery store pharmacies participate. If you need a refill while on vacation, contact your doctor for a new prescription to take with you or fax it to the closest network pharmacy where you are.

What happens if my medicines are lost or stolen?

If your medicines are lost or stolen, you should contact your doctor to authorize the pharmacy to refill your prescription early. The pharmacy may have to contact us for prior approval. Replacement of lost or stolen medicines will be reviewed on a case-by-case basis.

What if I paid out of pocket for a medicine and want to be reimbursed?

If you had to pay for a medicine, you may submit a request for reimbursement. You’ll need to mail a completed reimbursement request form along with any receipts to:
Express Scripts
P.O. Box 14711
Lexington, KY 40512

Will I be able to receive my enteral nutrition, diapers and medical supplies through a pharmacy?

Enteral nutrition, diapers and durable medical equipment can be obtained through your Durable Medical Equipment (DME) benefit. Some medical supplies can be obtained from your local pharmacy, like bandages, insulin syringes and diabetic glucose test strips.

General Frequently Asked Questions


How do I get help after my primary care provider’s (PCP) office closes?

Call your PCP for advice on how to get urgent care. The number is listed on your member ID card. You can also call our Member Services department at 1-800-300-8181 (TTY 711) or our 24/7 NurseLine at the same number.

Can I call my specialist’s office directly to set up an appointment if my PCP says I need to see a specialist regarding my health care?

Your PCP will refer you to a specialist. If you need specialist services that you can’t get from a doctor in the Empire network, we will work with your PCP to refer you to an out-of-network specialist. Your PCP must call Empire at 1-800-450-8753 to request authorization for an out-of-network referral.

How do I get a ride to my doctor appointment?

You or your provider should call LogistiCare at 1-866-481-9488 (TTY-1-866-288-3133). If possible, you should call LogistiCare at least three days before your medical appointment. Be ready to provide the following information:

  • Empire ID number
  • Appointment date and time
  • Address where you are going
  • The name of the doctor you are seeing

You can also call the Member Services department at 1-800-300-8181 (TTY 711) to schedule transportation.*

*Routine and nonemergency transportation includes taxi, ambulette or public transportation.

How do I choose a dentist?

If you need to find a dentist or change your dentist, please call Healthplex toll free at 1-800-468-9868 (TTY 1-800-662-1220) Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m. You can also call the Member Services department at 1-800-300-8181 (TTY 711). When you visit your dentist, you should show your plan ID card.

How do I get a copy of my provider directory?

You can call the Member Services department at 1-800-300-8181 (TTY 711) and request one. You can also download a free mobile app and search for Empire on your Android or iPhone. Then simply enter the name of your PCP.

If you want to see a doctor who is not in the Empire network, can you?

Please call the Member Services department at 1-800-300-8181 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m. with questions.