SPRING 2012 
  In This Issue:

Medicare and Medicaid Updates

Introducing Care360

EmblemHealth Injectable Drug Utilization Management Program Begins

Claims Corner

Utilization Review Criteria Update

Medical Director Availability After an Adverse Determination

Member Rights and Responsibilities

Provider Advisory Webinars a Success

CAHPS Member Satisfaction Surveys Are in the Field!

Behind the Scenes

Colorectal Cancer Screening

Medication Adherence for Chronic Conditions

Medical Management of COPD

Dental Hygiene Is Important

How to Help Your Patient With ADHD

Your Role in Slowing the Obesity Epidemic

Health and Wellness Programs

What Is a Health Outcome Survey?

Clinical Corner

News&Notes Archive

EmblemHealth Injectable Drug Utilization
Management Program Begins

Beginning June 1, 2012, , ICORE Healthcare, LLC will provide utilization management (UM) services for certain injectable drugs. The drugs on this list will require prior approval from ICORE when ordered or administered by practitioners either in their offices (POS 11), an outpatient hospital (POS 22) or an ambulatory surgery center (POS 24) setting.

Instructional Webinars
ICORE will be offering Webinars to introduce practitioners to their Web site and will provide guidance on how to request prior approvals for the injectable drugs on the list. Below are the dates for the ICORE Webinars:

May 24, 2012 4:00 pm
May 30, 2012 4:00 pm
May 31, 2012 1:00 pm
June 1, 2012 1:00 pm
June 4, 2012 4:00 pm

Please register at least one week prior to the Webinar you wish to attend. ICORE will then e-mail a confirmation that includes a call-in number and Web link with instructions.

Specialty Pharmacy Program
Practitioners who currently obtain replacement drugs from ICORE under the EmblemHealth Specialty Pharmacy Program must use new fax forms to obtain prior approval and drug replacement of the program-related medications in one transaction. Practitioners will continue to obtain replacement drugs not part of the UM program by following the same procedures for the Specialty Pharmacy Program as they now do.

Which Members Are Affected?
The listed drugs are covered as part of our members' medical insurance benefit and will require prior approval from ICORE. This program is not intended to and does not change our members' benefits or your claims submission procedures. The program will apply to:

  • Commercial plans underwritten by HIP (HIP HMO/POS/EPO/PPO, CompreHealth EPO/HMO and Vytra HMO)
  • HIP state-sponsored programs (Medicaid, Family Health Plus and Child Health Plus)
  • EmblemHealth Medicare HMO (underwritten by HIP), EmblemHealth Medicare PPO (underwritten by GHI)
  • GHI and HIP FEHB plans
  • Vytra ASO account members

Also included are members who have elected to obtain care from one of our physician medical groups:

  • Manhattan's Physician Group
  • Preferred Health Partners (Brooklyn)
  • Queens–Long Island Medical Group
  • Staten Island Physician Practice

Exceptions: Commercial plans underwritten by Group Health Incorporated (EmblemHealth EPO/PPO, GHI EPO/PPO) and the NY Bridge Plan (also underwritten by GHI), and HIP members assigned to a Montefiore (CMO) or HealthCare Partners (HCP) PCP, are excluded from this program. The Managing Entities are indicated on the member ID cards and on the Member Details page of the Eligibility/Benefits lookup feature on www.emblemhealth.com.

We will post additional program details on our Web site as we get closer to the implementation date. If you have questions, please sign into our secure Web site to use our Message Center.


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