Posted in Insurance, Training, Updates

EmblemHealth (NY) – Pharmacy Utilization Management Update for 2021

As of 01/01/2021-there are two main changes that will take effect:

  1. Express Scripts will take over utilization management for drugs (medication) – this will apply to ALL lines of business including Medicaid and Medicare plans. The utilization management will include: prior authorizations, quantity limits and step therapy.
  2. New Century Health (NCH) will authorize most oncology related chemotherapy drugs and supportive agents, when these services are performed (delivered) in physician’s office, outpatient hospital, or ambulatory setting.

Note: #2 Change DOES NOT APPLY to Montefiore CMO, EmblemHealth Inc. (formerly GHI), members managed by HealthCareParners, or members under 18 years of age.

For complete list of formulary: EmblemHealth, GHI, HIP and Vytra Commercial benefit plans please click here.

For complete list of drug formulary: Medicare Plans, click here

Note: Updates to the Commercial formulary apply to EmblemHealth, GHI, HIP and Vytra benefit plans. Updates to the Medicare formulary apply to EmblemHealth and ConnectiCare benefit plans. Exceptions will be noted.

#EmblemHealth, #HealthCarePartners, #Expressscripts, #NCH


My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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