Please encourage interested patients to view our Medicare Advantage plans.
Medicare Advantage Plans
MEDICARE ADVANTAGE PLANS
Sample Member ID Cards for 2026
Provider Networks and Member Benefits
Checking a Provider’s Network Status for a Member
VIP Medicare Plans Have Primary Care Providers
2026 Plan Changes
Coordinating Care for Members
Health Survey for Medicare and Special Needs Plan Members
EmblemHealth Member Rewards Program
Care Management Plans for D-SNP Members
Do Not Bill Dual Eligible and QMB Members for Any Medicare Cost-Sharing
Formularies
Encouraging Medication Adherence
Pharmacy Billing for EmblemHealth Dual-Eligible Members
Fraud, Waste, and Abuse
Sample Member ID Cards for 2026
The Sample ID Cards section of the EmblemHealth Provider Manual features representative ID cards for all plan types.
Each card indicates whether a referral is required for specialist visits. Plans that do not need a referral are clearly marked "No Referral Required” on the ID card.
Provider Networks and Member Benefits
For plan details and a complete list of the Medicare plans offered, see: Summary of Lines of Business, Networks, and Plans.
Reciprocity With ConnectiCare Ending In 2026
Beginning Jan. 1, 2026, because of the ConnectiCare sale to Molina Healthcare, ConnectiCare’s Medicare network will no longer be available to EmblemHealth Medicare members. Likewise, EmblemHealth providers will no longer be required to treat ConnectiCare members.
Through Dec. 31, 2025, reciprocity between the two networks remains in effect. Please continue to accept covered members through the end of the year.
Checking a Provider’s Network Status for a Member
To confirm whether you or a provider you manage is in-network for an EmblemHealth member, use the Check Provider Network Status tool in the Member Management section of the provider portal.
VIP Medicare Plans Have Primary Care Providers
All VIP Medicare plan members need to select a primary care provider (PCP). If a member does not select a PCP, EmblemHealth will assign one. The assigned PCP may appear on the member’s ID card and can also be viewed on the Member Details page in the provider portal.
Providers can generate a PCP Member Panel Report through the portal to see all assigned members.
2026 Plan Changes
Pharmacy Benefit Manager (PBM) Change
Starting Jan. 1, 2026, Prime Therapeutics will serve as EmblemHealth’s new pharmacy benefit manager, expanding member access to more than 65,000 independent and chain pharmacies nationwide. Prime Therapeutics will also manage pharmacy medical benefits.
Members should review the updated formulary and pharmacy network to confirm whether their medications or preferred pharmacies are affected. New member ID cards with pharmacy details will be mailed to members.
Find a network pharmacy:
Visit emblemhealth.com/resources/pharmacy to find a network pharmacy.
Starting in 2026, Medicare plans will no longer have preferred retail pharmacy networks or preferred cost-sharing arrangements. Copays and coinsurance will be the same at all in-network retail pharmacies.
Home delivery options
Members can continue to receive discounts on 90-day supplies for most maintenance medications through preferred mail order pharmacies. There are other long-term supply and mail-order pharmacies available in our network.
Preferred home delivery pharmacy information:
Amazon Pharmacy Home Delivery Service
4500 S. Pleasant Valley Road, Suite 201
Austin, TX 78744
Customer Service: 855-445-1459
Express Scripts Home Delivery Service
P.O. Box 66577
St. Louis, MO 63166-6577
Customer Service: 866-325-5236
Changes to Prescription Drug Coverage for Medicare Members
Plan benefits and cost sharing change each year. In 2026, the out-of-pocket limit will increase to $2,100, after which all covered prescription drugs will be available at $0 copay. See 2026 Formulary Changes for details.
Medicare Prescription Payment Plan
The 2025 payment option for members with high out-of-pocket prescription drug costs will continue to be available in 2026. Renewing members who signed up for this in 2025, will continue with payment plan in 2026. Prime Therapeutics contracted with CapitalRx to administer the Medicare Prescription Payment Plan on behalf of our plans.
Coordinating Care for Members
To support your efforts in coordinating care for EmblemHealth members, see Clinical Corner and the Utilization and Care Management chapter of the EmblemHealth Provider Manual.
For ConnectiCare members, see Clinical Information and Coverage Guidelines.
Health Survey for Medicare and Special Needs Plan Members
EmblemHealth conducts health assessments (HAs) with Medicare Special Needs Plan members to help our Care Management team identify and address care needs.
Members may receive a call from EmblemHealth inviting them to complete the HA. Please encourage your patients to participate. Completing this survey helps us better connect them with care and support services.
Members can complete their HA online by signing in to the member portal. They may also qualify for EmblemHealth’s Member Rewards Program when completing their HA within the first 90 days of enrollment. D-SNP members may also be eligible for a reward when completing their annual HA within 365 days from the last HA completed.
EmblemHealth Member Rewards Program
In 2026, EmblemHealth will continue offering the Member Rewards Program to encourage Medicare Advantage and Special Needs Plan members to get important primary care and preventive screenings.
Eligible members can earn a $15 to $250 reward on a reloadable card for each of the qualifying services they complete.
Please encourage your patients to schedule essential visits and preventive exams. Members can view and track their earned rewards by signing in to the member portal and following prompts for Wellness Rewards. Registration is required to receive rewards.
Care Management Plans for D-SNP Members
Care Management Plans are individualized and aim to support Dual Eligible Special Needs Plan (D-SNP) members in coordinating their health care. These plans are developed in collaboration with the member, their providers, and care managers to address medical, behavioral, and social needs. Through regular communication and assessments, the Care Management team ensures that members receive appropriate services and resources tailored to their unique circumstances. Members enrolled in EmblemHealth Dual-Eligible Special Needs Plans (D-SNPs) have individualized care plans on file with our Care Management team, who can share them with the treating providers.
If you cannot locate a member’s care plan, please contact us to request a copy by:
Email: complexcasemgmt@emblemhealth.com
Phone: 800-447-0768, 9 a.m. to 5 p.m., Monday through Friday.
Do Not Bill Dual Eligible and QMB Members for Any Medicare Cost-Sharing
Members who are Medicare-Medicaid full dual eligible and Qualified Medicare Beneficiaries (QMB) are not responsible for Medicare Part A and Part B cost shares for covered services. Please do not balance bill these members.
Federal and New York state laws prohibit providers from balance billing Medicare-Medicaid dual eligible individuals for any Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments, if any, received for services provided to dual-eligible individuals must be accepted as payment in full. Providers may reference Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.
To remain compliant:
- Verify plan and Medicaid/QMB eligibility prior to providing a service.
- Do not bill the member or collect cost shares during the visit.
- Bill New York State Medicaid for the member’s cost share.
- Consider the claim as paid in full, regardless of the Medicaid or plan payment.
- Notify member in writing if you do not accept Medicaid and member is not a QMB.
Providers can confirm Medicaid or QMB status through eMedNY or by calling the New York State eMedNY call center at 800-343-9000.
Pharmacy providers may use this Pharmacy Balance Billing guide for instructions on coordinating benefits with New York State’s eMedNY program.
Encouraging Medication Adherence
Taking medicines as prescribed (medication adherence) is important for treating and controlling chronic conditions. Providers play a key role in supporting member adherence.
Here are a few ways to assist:
- Discuss the importance of taking medications on time as prescribed.
- Remind members to track their refills and make an appointment for a new prescription before they run out.
- Educate members on the side effects of the medications and how to treat them.
- Help identify and resolve barriers to members not taking their medications as prescribed.
- Consider prescribing a 90-day supply of maintenance medications.
- Consider lower-cost generic drugs or formulary brand-name options.
- Talk to the member about potential state drug assistance programs or pharmaceutical prescription assistance programs that might help with the cost of medications.
- Recommend pharmacy-based adherence tools including:
- Medication synchronization (limit the member’s trip to the pharmacy for medications).
- Compliance packing or blister packs.
- Automatic refills.
- Encourage members to use available technologies (medication reminder apps on their phone or tablet, like Prime Central).
Free pill boxes
Members who need help organizing their medications can request a free pill box. These are available to everyone, regardless of coverage.
Providers can share the EmblemHealth Pill Box Request form and educational video on medication adherence, both available on our website:
Pharmacy Billing for EmblemHealth Dual-Eligible Members
Federal and state laws protect dual-eligible members from being balance billed.
Pharmacy providers can refer to the Pharmacy Balance Billing guide for step-by-step instructions on coordinating benefits with New York State’s eMedNY program.
Fraud, Waste, and Abuse
Annual Training Requirement
EmblemHealth requires all contracted providers to complete annual training on Fraud, Waste, and Abuse (FWA) prevention. To learn about this important topic, see Medicare Learning Network’s Web-Based Training.
Recommended Centers for Medicare & Medicaid Services (CMS) trainings include:
- Combating Medicare Parts C & D Fraud, Waste, and Abuse (CMS contact hours: 30 min.)
Learn to recognize health care FWA, identify methods to prevent FWA, identify how to report FWA, recognize how to correct FWA, and recognize potential consequences and penalties associated with violations. - Medicare Fraud and Abuse: Prevent, Detect, Report (CMS contact hours: 88 min.)
Learn how to identify what Medicare considers health care fraud and abuse, the provisions and penalties, prevention methods, and recognize how to report fraud and abuse.
Reporting a Concern
To report suspected health care fraud, waste, or abuse:
- Call: 888-4KO-FRAUD
- Email: kofraud@emblemhealth.com.
To report other compliance issues:
- Call: 844-I-COMPLY (844-426-6759), toll free, 24/7
- Online: emblemhealth.mycompliancereport.com.
EmblemHealth and ConnectiCare will not retaliate against anyone who in good faith reports a compliance concern.
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