Tag: #ExpressScripts

Posted in Insurance, Training, Updates

EmblemHealth (NY) – Pharmacy Utilization Management Update for 2021

Posted on by KR2Medical Billing

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

Posted in Training, Updates

EmblemHealth Commercial and Exchange Plans – order Prior Auths through Express Scripts

Posted on by KR2Medical Billing

Just a reminder to all of providers that accept EmblemHealth Commercial and Exchange Plans- starting 08/03/2020 Express Scripts will be responsible for utilization management of most specialty and step therapy drugs (specialty medications).

This change does NOT apply to EmblemHealth Medicaid and Medicare Plans or adult chemotherapy and supportive agents. Providers should follow the prior authorization guidelines through EmblemHealth. (Please see below)

EmblemHealth Commercial and Exchange Plans– Requesting an EPA (electronic Prior Authorization) Steps:

1. If your practice utilizes an EHR, you would be able to order it electronically.

2. You may also utilize: Covermymeds, Surescipts or ExpressPath- here you are able to create a free account and request an ePA.

Request Prior Auth by Phone & Fax:

1. Pharmacy Drug Reviews- phone 844-516-3324 (available 24/7/365) or by fax#: 877-251-5896

2. Medical Drug Reviews- phone 877-681-9866 (available 8am to 7pm EST) Monday through Friday, or by fax#: 866-896-1209

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Requesting Prior Authorizations for EmblemHealth Medicaid and Medicare Plans:

1. Specialty Drugs- phone 888-447-0295 (available 8am to 6pm, Monday through Friday), or fax# 877-243-4812

2. Pharmacy Drugs- phone 877-362-5670 (available 8am to 6pm, Monday through Friday) or fax# 877-300-9695

IMPORTANT: if your patient has received an Authorization Approval prior to 08/03/2020, from EmblemHealth- it is valid until the expiration date of the authorization. Subsequent requests have to go through Express Scripts NOT EmblemHealth. (Your claims will be denied if you do not request an authorization from Express Scripts after 08/03/2020 and beyond)

For the full provider announcement, please see the slideshow below.