All commercial plan members (except ASO members) must use Magellan Rx for self-administered specialty drugs, including:
- Calcium regulators
- Growth hormones
- Hepatitis C agents
- HIV fusion inhibitors
- Infertility agents
- Injectable contraceptives (e.g., progestin)
- Multiple sclerosis agents
- Plaque psoriasis agents
- Rheumatoid arthritis agents
Members cannot use retail or home delivery pharmacies for these items.
Some specialty drugs require submission of a Certificate of Medical Necessity (CMN) or a physician's prior approval (PPA). To order a CMN or PPA, practitioners should contact the EmblemHealth Specialty Pharmacy department at 1-888-447-0295.
Magellan Rx Specialty Pharmacy Services fills prescriptions and delivers them directly to the member's home. To ensure member privacy, all prescriptions are delivered by courier service and packaged in nondescript materials. A signature is required at the time of delivery, unless other arrangements have been made. Members are instructed to check that their order is accurate and, if necessary, refrigerate the medication.
All prescriptions, including transfers of existing prescriptions, must be submitted to Magellan Rx by phone at 1-866-554-2673 or by fax at 1-866-364-2673. For more information, contact the EmblemHealth Specialty Pharmacy department at 1-888-447-0295.
For a list of medications requiring prior approval through Express Scripts, see the Care Management chapter. For prior approval processes for medications not on the EmblemHealth Injectable Drug Utilization Management Program list that follows, see the Pharmacy Benefit Designs, Nonpreferred Drugs or Medicaid Pharmacy Program sections of the Pharmacy Services chapter.
Note: Certain chemotherapy and rheumatoid arthritis drugs now require prior approval from Magellan Rx. These drugs are listed on the Specialty Injectable Drugs Prior Approval List. You must set up an Magellan Rx account to request prior approval for these drugs. Please see Setting Up Your Magellan Rx Account in this chapter.
Glossary terms found on this page:
Treatment of malignant disease by chemical or biological antineoplastic agents.
The inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.
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.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
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 written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.
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 medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
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.