Pharmacy Services and Specialty Pharmacy

This program contains information regarding our pharmacy network, formularies, benefit designs, preauthorization requirements, and specialty pharmacy.

You will also find information about our Home Delivery program which offers our members cost savings and convenience.

Pharmacy contact numbers are listed in the Directory chapter of the Provider Manual.

We provide information about our pharmaceutical management procedures and formularies at least annually and whenever we make changes. These updates may include the following:

• Pharmacy benefit designs.
• Formulary changes.
• Preauthorization criteria.
• Procedures for generic substitution, therapeutic interchange, step therapy, or other management methods impacting the practitioner's prescribing decisions.
• Any other requirements, restrictions, limitations, or incentives that apply to the use of certain pharmaceuticals.

If you require printed copies or have any questions regarding our pharmaceutical management procedures, contact the respective pharmacy preauthorization vendor as listed in the Directory chapter.

Claims Submission

For instructions on submitting claims, see the Directory and Claims chapters of the Provider Manual. Claims submitted without obtaining a required preauthorization number will be denied, and the member cannot be billed. Claims must also include National Drug Code numbers and Taxonomy Codes.

Billing for Drug Waste

The portion of the drug administered should be submitted on one line. The JW modifier must be submitted on a separate claim line with the discarded amount. The JW modifier should only be used on the claim line with the discarded amount.

Reimbursement Methodology for Injectables and In-Office Medications

EmblemHealth periodically reviews and adjusts reimbursement levels to reflect changes in market prices for acquiring and administering drugs.

Reimbursement Methodology for Radiopharmaceuticals

With respect to the radiopharmaceutical codes below, defined by Healthcare Common Procedure Coding System (HCPCS), EmblemHealth pays health care professionals the Average Sales Price (ASP) plus 15%. If ASP is not available, the reimbursement rate is Average Wholesale Pricing (AWP) minus 15%.

• A9500-A9700
• A4641-A4647
• Q9949-Q9969

EmblemHealth Formularies

The EmblemHealth formularies cover many brand-name and generic pharmaceuticals for members who have prescription drug coverage, as defined by their benefit plan. Experimental or investigational drugs (i.e., non-FDA approved) are excluded from coverage. 

EmblemHealth Pharmacy and Therapeutics (P&T) Committee

The EmblemHealth Pharmacy and Therapeutics (P&T) Committee reviews and finalizes recommendations from the specialty subcommittees when selecting medications for inclusion in our formularies. Together, these committees review safety, efficacy, and cost to identify the pharmaceuticals that provide optimal results for our members. Members of the P&T and specialty committees include participating doctors (primary care and specialists), pharmacists, and administrators. The committees meet regularly to keep the drug formularies current.

Additions to the Formulary

Following the introduction of any new drug in the U.S. market, the P&T Committee typically allows for an up to six-month period of study before any final decision is made on inclusion of the drug to the formulary. During this time, the P&T Committee carefully observes the use and experience of the newly marketed drug in the general population. They examine its efficacy, safety, and drug interactions, and evaluate member needs to determine whether there are any advantages of the new drugs over the existing formulary drugs. A final recommendation is made after this study period.

We offer several pharmacy benefit designs. Each design determines drug coverage and members’ copay amounts. Each pharmacy benefit plan is subject to regulations, state and federal laws, clinical guidelines, a prior approval process, and quantity limitations, unless otherwise specified. Covered pharmacy services must be listed on the Commercial, or Medicare formularies, unless the member's benefit includes nonformulary/nonpreferred drugs (the drug formularies may describe drugs as either "formulary" or "preferred," or "nonformulary" or "nonpreferred").

Generic Versus Brand 

Our prescription benefit designs are configured into three categories of prescription medications. Due to the number of drugs on the market, the continuous introduction of new drugs, new applications of existing drugs, and new information regarding safety, the designs are continually revised.

Tier 1 - Preferred Generic Drugs

Generic drugs (Tier 1) are chemically identical to brand drugs but are priced at a fraction of the cost and offer an excellent value to the member. To gain FDA approval, generic drugs must:

• Contain the same active ingredients as the branded drug (inactive ingredients may vary).
• Be identical to the brand drug in strength, dosage form, safety, and route of administration.
• Be of the same quality, performance characteristics, and use indications.
• Be manufactured under the same strict standards of the FDA's good manufacturing practice regulations required for branded products.

When writing for generic drugs, remember to leave the “DAW” field blank to ensure the generic version of the drugs are dispensed.

Tier 2 - Preferred Brand Drugs

Our preferred brand drugs are on Tier 2 and offer our members brand drugs at a lower copay or cost-share than nonpreferred drugs. 

Tier 3 - Nonpreferred Brand and Generic Drugs

Drugs placed in Tier 3 generally have a similar, more cost-effective option available in either the preferred generic drug category (Tier 1) or the preferred brand drug category (Tier 2).

Most new FDA-approved drugs are initially placed in Tier 3 and excluded from coverage for up to six months until the P&T Committee reviews them for safety, efficacy, and clinical comparisons.

Copay Designs 

The Copay Designs Table outlines the more common benefit structures with regards to copayment.

As of April 1, 2023, all Medicaid members enrolled in EmblemHealth Enhanced Care (Medicaid) and Enhanced Care Plus (HARP) receive their prescription drugs through NYRx, the Medicaid Pharmacy Program. General information about NYRx, the Medicaid Pharmacy Program, can be found HERE along with information for Members and Providers.

We offer Medicare Advantage plans with Part D benefits under the EmblemHealth Medicare HMO and EmblemHealth Medicare PPO programs.

Participating Retail Network Pharmacies 

EmblemHealth offers its members more than 65,000 independent and chain pharmacies nationwide through Prime Therapeutics. To find a network pharmacy, go to emblemhealth.com/resources/pharmacy. 

Home Delivery Pharmacy Program  

Starting Jan. 1, 2026, EmblemHealth works with Amazon Pharmacy to provide convenient and cost-effective home delivery pharmacy services for all of our commercial members.

Child Health Plus members will continue to receive home delivery from Express Scripts, Inc.’s (ESI) Mail Order Pharmacy.

Medicare members will have the option to move to Amazon Pharmacy or stay with ESI Mail Order Pharmacy.

To place orders directly to:

• Amazon home delivery pharmacy:  e-prescribe or call 855-206-3605 for instructions on how to fax a prescription to Amazon.
• ESI Mail Order Pharmacy:  
  • Child Health Plus members, call 866-469-5661.
  • Medicare members, call 866-325-5263. 

FlexPreference Program

Starting Jan. 1, 2026, the EmblemHealth pharmacy network coverage through Prime Therapeutics will include a program called FlexPreference. Members may choose either Walgreens or CVS to be their large pharmacy chain. Walgreens is the default unless claims or a geographic mapping program shows CVS is a more appropriate option. Whichever is selected (Walgreens or CVS), the other is considered outside the member’s pharmacy network. Each covered family member can pick a different option. This choice does not change other in-network pharmacies or home delivery through Amazon Pharmacy.  Members do not have to utilize the chosen chain, they may continue to fill their prescriptions at any in-network pharmacy.

Ordering Extended Day Supplies

Getting a single three-month or 90-day supply saves members money compared to purchasing three one-month supplies. Members make fewer trips to the pharmacy and are less likely to miss a dose since they do not have to refill as often.  

Maintenance Medications

Members can fill a three-month supply of long-term maintenance medications from any in-network pharmacy that is contracted to provide more than a 30-day supply, as well as their selected chain pharmacy, or the home delivery pharmacy. 

90DayMyWay Program

Prime Therapeutics 90DayMyWay will replace the EmblemHealth Smart90™ program administered by Express Scripts. This is a mandatory, 90-day program for City of New York commercial members and EmblemHealth employees that requires the member obtain a 90-day supply of maintenance medications with each fill.  This can be done through any extended-day supply, in-network pharmacy, or by using home delivery. 

EmblemHealth engages in several initiatives to manage the use of opioid drugs. EmblemHealth formularies include opioid analgesics and access to non-opioid analgesics as treatment alternatives, including nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, and anticonvulsants.

Opioid Case Management 

EmblemHealth identifies members for outreach who are on multiple opioids or are receiving high doses of opioids for a long period of time. As part of the Case Management process, EmblemHealth Clinical Pharmacists call each member and their prescriber to discuss the member’s use of opioids.

Fraud, Waste, and Abuse Program

To help improve coordination of care and promote the safe use of controlled substances, a member may be locked in to a single provider and a single pharmacy if evidence of fraud or opioid misuse is substantiated.

The program uses techniques to identify drug-seeking behavior, use of opioids in tandem with drug treatment medications, stockpiling medications, dangerous combinations of medications, frequent emergency department prescriptions, using multiple pharmacies, and excessive dosing based on morphine equivalent doses, among other concerning drug seeking behaviors

Opioid Management Solution

Starting Jan. 1, 2026, EmblemHealth will participate in the Prime Therapeutics GuidedHealth program focused on opioid education throughout a continuum of patient care.

Practitioners must obtain preauthorization when:

• Prescribing an FDA-approved nonpreferred (Tier 3) drug for a member whose benefit does not cover nonpreferred drugs.
• Requesting a non-FDA-approved drug or an approved drug for a non-FDA-approved usage for members.

The easiest way to determine whether a drug requires preauthorization is to check on Prime Therapeutic’s GateWayPA site for medical benefit drugs and Prime Central for pharmacy benefit drugs.

Starting Jan. 1, 2026, Prime Therapeutics performs utilization management services for all drugs, including home infusion therapy, specialty pharmacy, chemotherapy, and supportive agents. The services include preauthorization, quantity limits, and step therapy for all members who are not managed by HealthCare Partners. Only codes that are included on the Medical Drug Preauthorization list hosted on Prime Therapeutic’s GatewayPA site will require preauthorization for Home Infusion. Any other home infusion therapy code not listed will not require preauthorization. All preauthorizations issued by Prime Therapeutics are added to member benefit records.

Some specialty pharmacy medications are complex to administer and often involve frequent dosage adjustments, severe side effects, and special storage or handling instructions. They may have a narrow therapeutic range and require periodic lab or diagnostic testing. 
 

Specialty pharmacy medications may be covered as either a medical or pharmacy benefit depending on the diagnosis, specific formulations, and administration setting and method.
 

Medical Benefits (for medication shipped to provider's office)

1. A prescriber can either:
   • Buy and Bill: Purchase, and bill EmblemHealth for, an inventory of specialty medications directly from the manufacturer or willing licensed pharmacy and store them in the office for administration to patients. The billed amount must equal the price paid for the drug; invoices may be requested.  
   • Use a Specialty Pharmacy Provider: Submit prescriptions for specialty medications to the member’s specialty pharmacy provider who will ship the medication directly to the prescriber's office for administration to the patient. 
   • Single-Case Agreement: If the administering provider is out of network, that provider may request a single-case agreement directly from EmblemHealth AFTER obtaining a preauthorization through Prime Therapeutics Medical Pharmacy Solutions program. A single-case agreement can also be issued to an infusion provider for a drug that has a new J-code that has not been added to the current contract or has limited distribution. 

Pharmacy Benefits (for medication shipped to patient from a pharmacy)

• Send prescriptions for specialty medications to the member’s specialty pharmacy provider and have it shipped directly to the patient. 
• Once received, your patient can properly store the specialty medication until office administration.

Starting Jan. 1, 2026 medications that are shipped directly to a member from a specialty pharmacy provider will fall into one of the following categories:

1. Accredo or;
2. Advocate+ Pharmacy Match Program

Specialty Pharmacy Medications – Accredo

Accredo provider for :

• Medicare members.
• NYCE PPO.
• Local 246.
• NYPD Line of Duty Injury (LODI).
• Uniformed Sanitationmen's Association (USA).
• HIP HMO Preferred.

Accredo offers:

• Experience in providing specialty pharmacy services to members.
• Educational materials to support at-home administration of medications.
• Syringes and needles to members for self-administered specialty drugs at no additional cost.
• Comprehensive coordination of care, including refill reminders.
• Dedicated pharmacists and nurses are available to patients and physicians 24 hours a day, seven days a week. They provide comprehensive support to help maximize formulary compliance and improve patient outcomes.

The Accredo process will remain as follows:

• Accredo’s Patient Care Advocate calls the member to coordinate medication delivery. During this call, a specialty clinician is available to counsel the patient. Accredo dispenses and packages the prescription order with member literature on the proper administration, product usage, and appropriate ancillary supplies required for self-administration.
• For those therapies requiring nursing and administration supplies (such as pumps and tubing), a specialized nurse contacts the patient or caregiver to coordinate an appointment time for initiation of therapy and any necessary training. 
• In some cases, unless the member requests not to be contacted, a nurse or pharmacist places a follow-up call to the member for any needed counseling and training on self-administration.
• Accredo’s specialty pharmacy makes every effort to dispense the product within 24 hours of receipt of a complete referral.

Specialty Pharmacy Medications - Advocate+ Pharmacy Match Program

Starting Jan. 1, 2026, EmblemHealth will launch the Advocate+ Pharmacy Match program in collaboration with Prime Therapeutics for specialty pharmacy medications. This program enhances the experience for our members in all of our fully insured EmblemHealth plans (i.e. Child Health Plus, Essential Plan, Individual and Family, Large Group and Small Group, and NYSHIP) and all EmblemHealth/AdvantageCare employees requiring specialty medications by expanding the specialty pharmacy network and matching members with highly qualified pharmacies.

Pharmacy Match offers:

• A dedicated team of empathetic care specialists.
• Simplified onboarding.
• Patient education.
• Financial assistance support as needed.

Prior to Jan. 1, 2026, Prime will work to identify the best-matched pharmacy for members using specialty medications. Once identified, Prime will notify impacted members that there could be a change to their specialty pharmacy.

For members starting specialty medications after Jan. 1, 2026, Prime Therapeutics will contact the member via phone to notify them of the next steps in the process. Additionally, the best-matched pharmacy will reach out to the member and will follow the standard onboarding process. 

Starting your patient on a specialty medication in the program is simple.

1. To kick off the process, e-prescribe to Free Market Health (FMH) Pharmacy.

• FMH Pharmacy
  • NPI: 1366292880
  • Fax: 833-998-4435
  • Phone: 412-755-3241
  • Email: contact@fmhpharmacy.com
  • Address: 40 24th St., Suite 150, Pittsburgh, PA 15222

2.  Continue using our standard preauthorization process, if applicable.
3. Once the preauthorization is approved, FMH will assign the referral to a specialty pharmacy and transfer the prescription. You’ll receive a fax with the pharmacy assignment.

Note: Members on multiple specialty medications may be matched with more than one specialty pharmacy provider. Once a match is made refills will be handled by the matched specialty pharmacy for one year.

4. The assigned pharmacy will contact the member to begin onboarding and coordinate delivery.

FMH or the assigned pharmacy may also contact prescribers for inquiries or requests related to prior authorizations, prescription transfers, alternative medications, therapy clarifications, or other needs.

FMH Provider Assistance:

• Phone: 877-787-0520
• Email: prescribers@freemarkethealth.com

For Direct Delivery to a Member

Prime Therapeutics Pharmacy Match program facilitates the match of a member to an appropriate in-network specialty pharmacy based on a set of custom-configured rules, including clinical services, access, and dynamic market pricing for all specialty medications. Once there is a match, refills are handled with that matched pharmacy for a year. If a refill script is sent to Pharmacy Match, it would go to that matched pharmacy automatically and not go through the bidding process.

• If your patient has multiple specialty prescriptions, two different pharmacies might provide the best prices for each medication. Prime will set up each prescription with the pharmacy that offers the best pricing.
• Specialty medications will continue to be mailed to the member.