As we have communicated to you before, EmblemHealth is changing its pharmacy benefit manager from Express Scripts to Prime Therapeutics for all its health plans. We're reaching out again to provide you with the latest updates. 

The UFT Welfare Fund will continue to provide most prescriptions to in-service members. You will only be affected by this change if you are on any Affordable Care Act or New York State-mandated drugs, such as diabetes medication or birth control, since your city health plan provides these drugs. Even then, the only change will be the home delivery service that delivers those specific prescriptions. 

Your prescription plan’s copays and benefits will remain the same. For a more detailed explanation of the change, read the following Q&A below. 

What is a pharmacy benefits manager? 

A pharmacy benefit manager, or PBM, helps employers manage drug costs and coverage. It negotiates prices with drugmakers and works with pharmacies to process prescriptions. Pharmacy benefit managers do most of their work on the “back end” of your drug plan, meaning you rarely interact with them. 

EmblemHealth made this decision independently. The change in pharmacy benefit manager was not subject to negotiations. EmblemHealth is free to select a different pharmacy benefit manager as long as it continues to administer our health plans in accordance with our city health plan agreements. This means that while the company managing EmblemHealth prescriptions may change, our plan benefits remain the same. 

What does this change mean for in-service members? 

In-service members who have all their prescriptions filled through the UFT Welfare Fund will not be affected by this change. The UFT Welfare Fund will continue to use Express Scripts as its pharmacy benefit manager, and you will continue to get those medications as usual, either through a retail pharmacy or Express Scripts home delivery. 

The PICA program for self-injectable and chemotherapy drugs is also not changing and will remain with Express Scripts. 

Your pharmacy benefit manager will change if you take any Affordable Care Act (ACA) or New York State mandated drugs. Those drugs are covered under your city health plan, and if you are enrolled in any of EmblemHealth’s plans, your pharmacy benefit manager for those medications will become Prime Therapeutics starting on Jan. 1, 2026. All your current ACA and New York State mandated prescriptions under Express Scripts will be automatically rolled over to Prime Therapeutics for you. You will continue to be able to get these medications at retail pharmacies or through mail order; however, the mail-order medications will now be delivered by Amazon Pharmacy. 

How do I know if any of my medications are ACA or New York State mandated drugs? 

ACA and New York State mandated drugs are typically zero-cost preventative care medications such as birth control or diabetes management medication. The fastest and easiest way to check would be to call your doctor and ask if any of your medications are ACA or state mandated medications. You can also call the number on the back of your medical ID card and ask EmblemHealth directly. 

What does the change to Prime Therapeutics mean for my ACA and New York State-mandated prescriptions?

Getting your prescriptions 

Retail: 

• You will still be able to pick up your prescriptions, including 30-day supplies of acute medication prescriptions and 90-day supplies of maintenance medications, at retail pharmacy networks.
• In the unlikely case that your current pharmacy is not in Prime Therapeutics’ network, you will receive a letter with instructions for finding a new pharmacy near you. 

Mail Order: 

You will now use Amazon Pharmacy only for mail-order prescriptions of ACA or New York State mandated medications: 

• Your prescriptions for ACA or NYS drugs will be automatically transferred from Express Scripts Home Delivery to Amazon Pharmacy.
• Make an account on Amazon Pharmacy after Jan. 1, 2026, just as you created an account for Express Scripts. 

See the chart below for a comprehensive look at your health plan’s prescription drug options for your Affordable Care Act or New York State mandated drugs:

What about prior authorizations for prescriptions? 

Prior authorizations are given for only a certain length of time (usually six months or a year). Once they expire, they must be renewed by your doctor and your prescription plan. Many prior authorizations are given for a calendar year and therefore expire on Jan. 1, so they would need to be renewed even if there were no change to the pharmacy benefit manager. 

If you received a letter saying you need a new prior authorization, but your current prescription has NOT expired, EmblemHealth is aware of the problem and will send a correction letter. 

Current prior authorizations for ACA and New York State mandated drugs: 

• If you currently have a prior authorization that extends into 2026, it will be automatically rolled over to Prime Therapeutics.
• There is no need for you to do anything until your existing prior authorization date is up. 

New prior authorizations for ACA and New York State mandated drugs: 

• Prescription drugs requiring prior authorization between now and the end of December will still go through Express Scripts. The process will remain the same. If authorization is granted, these prescriptions will be automatically transferred to Prime Therapeutics on Jan. 1, 2026.
• If you start a new medication in 2026 that requires prior authorization, your doctor will request prior authorization from Prime Therapeutics. The process will be similar to the process for requesting prior authorization through Express Scripts. 

What if I have been notified that I need to change medications?

We estimate that less than 2% of members will have to switch to an alternate medication as a result of this switch in the pharmacy benefit manager. If you are one of those rare cases, follow the instructions from EmblemHealth and Prime Therapeutics to work with your doctor to find a replacement medication that works for you. A call with your doctor should be enough to send a new electronic prescription to your pharmacy. 

To ease the transition, Prime Therapeutics will allow a one-time refill of current medications in 2026. 

If you have more questions, you can: 

• Call EmblemHealth at the number on the back of your medical ID card.
• Visit emblemhealth.com/city and then select your plan for more details.
• Email the UFT Welfare Fund at rxhelp [at] uftwf [dot] org (rxhelp[at]uftwf[dot]org) if you have a specific question that remains unanswered. 

Please continue to check your postal mail for information from EmblemHealth and Prime Therapeutics.