CommercialCoverageHigh impact
New Specialty Pharmacy Reimbursement Policy
EmblemHealth·Pharmacy
Effective date
Jul 14, 2025
We identified it
Jun 20, 2026
Summary
EmblemHealth now requires outpatient providers to obtain certain specialty drugs from specific designated pharmacies, with the pharmacy billing EmblemHealth directly. Providers can only bill for drug administration services, not for the medications themselves.
Action Required
By July 14, 2025: Billing team must identify all specialty drugs covered by EmblemHealth's new policy and update workflows to source these medications only from designated specialty pharmacies. Update billing system to prevent charging patients for covered specialty medications - only bill for administration services. Review the Specialty Pharmacy Requirements Drug List to determine which drugs and pharmacies apply to your practice. Failure to comply will result in claim denials and potential member billing violations.