Certain specialty pharmacy medications, such as injectables, are complex to administer and often entail frequent dosage adjustments, severe side effects and special storage or handling instructions. They may have a narrow therapeutic range and require periodic lab or diagnostic testing.
The FDA has approved some injectables for several indications. They are covered as either a pharmacy or medical benefit. How injectables are covered depends on the diagnosis, specific formulations and administration setting and method.
EmblemHealth works with Magellan Rx Management Specialty Pharmacy Services, an industry leader, to provide these types of specialty pharmacy medications through our Specialty Pharmacy Program.* Magellan Rx offers:
- Experience providing specialty pharmacy services to members.
- Educational materials to support at-home administration.
- Free syringes and needles to members for self-administered specialty drugs.
- Comprehensive coordination of care, including refill reminders.
- Dedicated pharmacists and nurses available to patients and physicians 24 hours a day, seven days a week. They provide comprehensive support to help maximize formulary compliance and improve patient outcomes.
- State-of-the-art online tools for prior approvals (see EmblemHealth Injectable Drug Utilization Management Program in this chapter).
*Additional vendors may be used for limited distribution of specialty drugs not available from Magellan Rx.
Glossary terms found on this page:
A test or procedure ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services.
A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Also called a drug formulary.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.