Policy Updates That Impact Where Members Get Care

At EmblemHealth, our members’ health is our highest priority. This means we stay on top of best practices and adopt the ones we believe can help them get and stay healthy in an affordable way. As part of this ongoing effort, we review how our members get their care. When we find a better way of doing something, we update our policies. You may already know about some of these changes, but we were notified by the New York State Department of Financial Services (DFS) that we did not properly let you know. 

Site of Service Medical Policy – Infusions and Injectables Policy

This policy was changed on July 14, 2024, to help our members take advantage of some of the region’s best infusion centers and care offered in their doctor’s office or even in their own homes for injectable and/or intravenous medications that can safely be administered outside of a hospital setting. 

EmblemHealth works with multiple organizations that will recommend the most medically appropriate, convenient, and cost-effective options for your EmblemHealth patients.

Prior authorization requests should be submitted to Prime Therapeutics by one of the following methods:

Fax: 888-656-6671
Telephone: 833-519-4548, 8 a.m. to 6 p.m., Monday through Friday
Online: gatewaypa.com

Prime Therapeutics may direct a member to a setting other than the one you and/or they prefer for these services. You have the right to request a real-time clinical peer-to-peer discussion as part of the Prior Authorization process by calling 833-519-4548. If you disagree with Prime Therapeutics' decision, you have the right to file an appeal. Prime Therapeutics’ decision will include information about how to file an appeal.   

Services the policy covers: Specialty pharmacy infusions and specialty pharmacy injections administered by a health care professional. To see all services the policy covers, view the full Site of Service Medical Policy – Infusions and Injectables Policy.