CommercialAdministrativeHigh impact
New Pharmacy Benefit Manager: Prime Therapeutics
EmblemHealth·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Starting January 1, 2026, Prime Therapeutics will replace Express Scripts and Evolent as the new pharmacy benefit manager for all EmblemHealth plans, handling preauthorization for pharmacy drugs and medical specialty drugs. All existing preauthorizations from previous managers remain valid until their end dates, but new requests must go through Prime with new phone numbers and processes.
Action Required
By December 22, 2025: Update billing workflows and staff training for new preauthorization contacts. Replace Express Scripts/Evolent contact info with Prime Therapeutics numbers: Commercial pharmacy (866-799-7919), Medicare pharmacy (866-799-7781), Medical drugs (833-519-4548, 8am-6pm M-F). Register staff for mandatory web training sessions on Dec 11 or Dec 17. Update prior auth request processes for specialty drugs in physician office (POS 11), patient home (POS 12), outpatient facility (POS 19, 22), and inpatient (POS 21) settings. Failure to use correct contacts after Jan 1, 2026 will delay approvals and potentially deny claims.