Notification: Pharmacy Utilization Management Services Starting January 1, 2021

In July, we informed you that Express Scripts (ESI) will perform most drug utilization management services starting in August for all Commercial and Health Exchange EmblemHealth plan members.

We want to let you know about two additional updates to our utilization management process:

- Starting Jan. 1, 2021, ESI will perform drug utilization management services for all lines of business, including Medicaid (until March 31, 2023) and Medicare.

- The services include preauthorizations, quantity limits, and step therapy.

- Starting Jan. 1, 2021, New Century Health (NCH) will authorize most oncology-related chemotherapeutic drugs and supportive agents when delivered in the physician’s office, outpatient hospital, or ambulatory setting.

- This will not apply to EmblemHealth Plan, Inc. (formerly GHI) members, members managed by HealthCare Partners and Montefiore CMO (until March 31, 2023), or members under 18 years of age. See the drug preauthorization overview chart below for details. Visit our Frequently Asked Questions page to learn more.

We encourage you to take advantage of ESI’s electronic prior authorization (ePA) option. ePA is fast, secure, and simple. Any authorized personnel, including nurses and office staff, can use your electronic health record (EHR) or sign in to an online portal. You save time, and patients get their medications faster.


You can also use these phone and fax numbers for preauthorization requests for Medicaid (until March 31, 2023) and Medicare members.

Medicaid

• Pharmacy Drug Reviews: call 888-281-5539, 24/7/365 or fax to 877-251-5896
• Medical Drug Reviews: call 877-681-9866, 8 a.m. to 7 p.m., Monday through Friday or fax to 866‑896‑1209

Medicare

• Pharmacy Drug Reviews: call 877-920-1470, 24/7/365 or fax to 877-251-5896
• Medical Drug Reviews: call 877-681-9866, 8 a.m. to 7 p.m., Monday through Friday or fax to 866‑896‑1209

NCH preauthorization process for most adult chemotherapy and supportive agents

Beginning Jan. 1, 2021, you can complete a preauthorization request online in the NCH provider portal. To get started, register online at my.newcenturyhealth.com.

You can also call NCH at 888-999-7713, option 6, between the hours of 8 a.m. and 8 p.m., Monday through Friday, or fax the preauthorization form that’s in the provider portal to 877-624-8602.

All preauthorizations issued by EmblemHealth before Jan. 1, 2021 will remain valid until they expire. 

This move is part of EmblemHealth’s continuing transformation and desire to partner with our providers on delivering care to our members. If you have any questions, call EmblemHealth Provider Services at 866‑447‑9717. Our hours are 8 a.m. to 6 p.m., Monday to Friday. A representative will be happy to help.