Table of Contents
Search
How Do I...

Search Tips

Table of Contents Search

  • For more specific results, select both a chapter and section.
  • To move from section to section within a chapter, use the left navigation bar.

Keyword Search

  • For best results, select a recommended search term if one appears in the search box.
  • To narrow your search, use the Filter By and Additional Keywords features in the left navigation bar.
  • To find an exact phrase, use quotes (e.g., “prior approval”).
  • To find all search terms, use the word AND in capital letters between search terms.
  • To find at least one search term, use the word OR in capital letters between search terms.
×
  • Injectables and Specialty Pharmacy Program > EmblemHealth Injectable Drug Utilization Management Program

    EmblemHealth works with Magellan Rx Management to provide utilization management for certain injectable drugs (see the Specialty Injectable Drugs Prior Approval List below). Magellan Rx's staff can assist our practitioners in choosing the best drug for members needing treatment for cancer, rheumatoid arthritis and other serious conditions and diseases. These drugs are covered under the member's medical benefit.

    Prior Approval for Provider-Administered Injectable Drugs

    Prior approval is required when the drug will be administered by a practitioner in their office (POS 11), in an outpatient hospital clinic (POS 22) or in an ambulatory surgery center (POS 24). Prior approval from Magellan Rx is not required for medications administered at home or during emergency room visits, observation unit visits or inpatient stays.

    Urgent requests for prior approval will be completed within 24 hours of receipt. Non-urgent requests will be completed within two business days of receiving all necessary information. If the request requires additional clinical review or eligibility verification, the review and determination processes may take longer.

    Reimbursement Methodology for Injectables and In-Office Medications

    EmblemHealth periodically reviews and adjusts reimbursement levels to reflect changes in market prices for acquiring and administering drugs. The following reimbursement methodology for our Injectables and Other In-Office Medication Fee Schedule becomes effective February 15, 2017.

    • Maximum Allowable Cost (MAC): Utilized for select therapeutic categories where a clinically equivalent, lower-cost alternative is available. Pricing is at the maximum allowable cost giving increased reimbursement over current Average Sale Price (ASP) rates, with margins comparable to higher cost agents within the same therapeutic class.
    • High-Cost Maximum Allowable Cost (High-Cost MAC): Utilized for select-branded, single-source drugs with no lower-cost alternative that provides fair and typical margin.
    • Average Sales Price (ASP) plus 15%: Utilized for multisource or generic drugs with an ASP available.
    • Average Sales Price (ASP) plus 10%: Utilized for branded or single-source drugs with an ASP available.
    • Average Sales Price (ASP) plus 8%: Utilized for preferred hyaluronic acid product.
    • Average Sales Price (ASP) plus 6%: Utilized for branded or single-source drugs not included in the ASP plus 10% category.
    • Average Wholesale Price (AWP) minus 15%: Utilized for drugs without an available ASP except for vaccines, implants and contraceptives.
    • Average Wholesale Price (AWP) minus 10%: Utilized for all vaccines.
    • Average Wholesale Price (AWP): Utilized for all implants and contraceptives.

    Injectables and Other In-Office Medication Fee Schedule

    Injectables and Other In-Office Medication Fee Schedule

    HCPCS for injectables and other in-office medications priced at MAC are listed in the table below.

    Code

    Code Description

    90283

    Immune Globulin (IgIV), human, for intravenous use (Code Price is per 500 mg) (Use 90283 for CPT billing requirements ONLY - see also J1459, J1557, J1561, J1566, J1568, J1569, J1572 and J1599 for non-CPT billing)

    J0640

    Injection, leucovorin calcium, per 50 mg

    J0641

    Injection, levoleucovorin calcium, 0.5 mg

    J1442

    Injection, filgrastim (G-CSF), 1 microgram

    J1447

    Injection, tbo-filgrastim, 1 microgram

    J1459

    Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g liquid), 500 mg

    J1556

    Injection, immune globulin (Bivigam), 500 mg (For billing prior to 1/1/14 see C9130 or J1599)

    J1557

    Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg (For billing prior to 1/1/12 use 90283, J1599 or C9270)

    J1561

    Injection, immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g. liquid), 500 mg

    J1566

    Injection, immune globulin, intravenous, lyophilized (e.g powder), not otherwise specified, 500 mg (Only Carimune NF, Panglobulin NF and Gammagard S/D should be billed using this code)

    J1568

    Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg

    J1569

    Injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g. liquid), 500 mg

    J1572

    Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g. liquid), 500 mg

    J1626

    Injection, granisetron hydrochloride, 100 mcg

    J2405

    Injection, ondansetron hydrochloride, per 1 mg

    J2430

    Injection, pamidronate disodium, per 30 mg

    J2469

    Injection, palonosetron HCl, 25 mcg

    J3489

    Injection, zoledronic acid, 1 mg

    J9171

    Injection, docetaxel, 1 mg

    J9217

    Leuprolide acetate (for depot suspension), 7.5 mg

    J9267

    Injection, paclitaxel, 1 mg

    Q5101

    Injection, filgrastim, (G-CSF), biosimilar, 1 microgram (Code became effective for Medicare billing 3/6/15)

    HCPCS for injectables and other in-office medications priced at High Cost MAC are listed in the table below.

    Code

    Code Description

    J0202

    Injection, alemtuzumab, 1 mg

    J1300

    Injection, eculizumab, 10 mg

    J2860

    Injection, siltuximab, 10 mg (Code re-used by CMS effective 1/1/16) (For billing prior to 1/1/16 use C9455 or J3590)

    J9032

    Injection, belinostat, 10 mg (For billing prior to 1/1/16 use C9442 or J9999)

    J9039

    Injection, blinatumomab, 1 microgram (For billing prior to 1/1/16 use C9449 or J9999)

    J9042

    Injection, brentuximab vedotin, 1 mg (For billing prior to 1/1/13 use C9287 or J9999)

    J9043

    Injection, cabazitaxel, 1 mg (For billing prior to 1/1/12 use J9999 or C9276)

    J9228

    Injection, ipilimumab, 1 mg (For billing prior to 1/1/12 use J9999 or C9284)

    J9264

    Injection, paclitaxel protein-bound particles, 1 mg

    J9271

    Injection, pembrolizumab, 1 mg (For billing prior to 1/1/16 use C9027 or J9999)

    J9299

    Injection, nivolumab, 1 mg (For billing prior to 1/1/16 use C9453 or J9999)

    J9306

    Injection, pertuzumab, 1 mg (For billing prior to 1/1/14 use C9292 or J9999)

    J9308

    Injection, ramucirumab, 5 mg (For billing prior to 1/1/16 use C9025 or J9999)

    J9315

    Injection, romidepsin, 1 mg (For billing prior to 1/1/11 use J9999 or C9265)

    J9354

    Injection, ado-trastuzumab emtansine, 1 mg (For billing prior to 1/1/14 use C9131 or J9999)

    Q2043

    Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Code Price is per 250 mL)

    HCPCS for injectables and other in-office medications priced at ASP plus 10% are listed in the table below.

    Code

    Code Description

    J0129

    Injection, abatacept, 10 mg (Code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug self administered)

    J0135

    Injection, adalimumab, 20 mg

    J0180

    Injection, agalsidase beta, 1 mg

    J0220

    Injection, alglucosidase alfa, 10 mg, not otherwise specified

    J0221

    Injection, alglucosidase alfa, (Lumizyme), 10 mg (For billing prior to 1/1/12 use J3590 or C9277)

    J0490

    Injection, belimumab, 10 mg

    J0587

    Injection, rimabotulinumtoxinB,100 units

    J0597

    Injection, C-1 esterase inhibitor (human), Berinert, 10 units (For billing prior to 1/1/11 use J3590 or C9269)

    J0598

    Injection, C1 esterase inhibitor (human), Cinryze, 10 units

    J0717

    Injection, certolizumab pegol, 1 mg (Code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)

    J0775

    Injection, collagenase, clostridium histolyticum, 0.01 mg (For billing prior to 1/1/11 use J3590 or C9266)

    J0875

    Injection, dalbavancin, 5 mg (For billing prior to 1/1/16 use C9443 or J3490)

    J1290

    Injection, ecallantide, 1 mg (For billing prior to 1/1/11 use J3590 or C9263)

    J1438

    Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician; not for use when drug is self-administered)

    J1602

    Injection, golimumab, 1 mg, for intravenous use (For billing prior to 1/1/14 use C9399 or J3590)

    J1745

    Injection, infliximab, 10 mg

    J1786

    Injection, imiglucerase, 10 units

    J1950

    Injection, leuprolide acetate (for depot suspension), per 3.75 mg

    J2278

    Injection, ziconotide, 1 microgram

    J2323

    Injection, natalizumab, 1 mg

    J2353

    Injection, octreotide, depot form for intramuscular injection, 1 mg

    J2357

    Injection, omalizumab, 5 mg

    J2407

    Injection, oritavancin, 10 mg (For billing prior to 1/1/16 use C9444 or J3490)

    J2507

    Injection, pegloticase, 1 mg (For billing prior to 1/1/12 use J3590 or C9281)

    J2562

    Injection, plerixafor, 1 mg (For billing prior to 1/1/10 use J3490 or C9252)

    J2783

    Injection, rasburicase, 0.5 mg

    J2791

    Injection, Rho(D) immune globulin (human), (Rhophylac), intramuscular or intravenous, 100 IU (see also 90384 and 90386 for CPT billing requirements)

    J2792

    Injection, rho D immune globulin, intravenous, human, solvent detergent, 100 IU (see also 90384 and 90386 for CPT billing requirements)

    J2796

    Injection, romiplostim, 10 micrograms (For billing prior to 1/1/10 use J3590 or C9245)

    J3060

    Injection, taliglucerase alfa, 10 units

    J3090

    Injection, tedizolid phosphate, 1 mg (For billing prior to 1/1/16 use C9446 or J3490)

    J3240

    Injection,thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial (Code Price is per 1 vial)

    J3262

    Injection, tocilizumab, 1 mg (For billing prior to 1/1/11 use J3590 or C9264)

    J3357

    Injection, ustekinumab, 1 mg (For billing prior to 1/1/11 use J3590 or C9261)

    J3380

    Injection, vedolizumab, 1 mg (For billing prior to 1/1/16 use C9026 or J3590)

    J3385

    Injection, velaglucerase alfa, 100 units (For billing prior to 1/1/11 use J3490 or C9271)

    J3396

    Injection, verteporfin, 0.1 mg

    J7183

    Injection, von Willebrand factor complex (human), Wilate, 1 IU VWF:RCO

    J7185

    Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha), per IU

    J7186

    Injection, antihemophilic factor VIII/Von Willebrand factor complex (human), per factor VIII I.U.

    J7187

    Injection, Von Willebrand factor complex (Humate-P), per IU, VWF:RCO

    J7189

    Factor VIIa (antihemophilic factor, recombinant), per 1 microgram

    J7190

    Factor VIII (antihemophilic factor [human]) per IU

    J7192

    Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified

    J7193

    Factor IX (antihemophilic factor, purified, non-recombinant) per IU

    J7194

    Factor IX, complex, per IU

    J7195

    Injection factor IX (antihemophilic factor, recombinant) per IU, not otherwise specified

    J7205

    Injection, factor VIII, Fc fusion protein (recombinant), per IU

    J7313

    Injection, fluocinolone acetonide intravitreal implant, 0.01 mg (For billing prior to 1/1/16 use C9450 or J3490)

    J7316

    Injection, ocriplasmin, 0.125 mg (For billing prior to 1/1/14 use C9298 or J3590) (Code re-used by CMS 1/1/14)

    J8655

    Netupitant 300 mg and palonosetron 0.5 mg (Code Price is per 1 capsule)

    J9019

    Injection, asparaginase (Erwinaze), 1,000 IU (For billing prior to 1/1/13 use C9289 or J9999)

    J9027

    Injection, clofarabine, 1 mg

    J9033

    Injection, bendamustine HCl, 1 mg

    J9035

    Injection, bevacizumab, 10 mg

    J9041

    Injection, bortezomib, 0.1 mg

    J9047

    Injection, carfilzomib, 1 mg (For billing prior to 1/1/14 use C9295 or J9999)

    J9055

    Injection, cetuximab, 10 mg

    J9179

    Injection, eribulin mesylate, 0.1 mg (For billing prior to 1/1/12 use J9999 or C9280)

    J9207

    Injection, ixabepilone, 1 mg

    J9266

    Injection, pegaspargase, per single dose vial

    J9302

    Injection, ofatumumab, 10 mg (For billing prior to 1/1/11 use J9999 or C9260)

    J9303

    Injection, panitumumab, 10 mg

    J9305

    Injection, pemetrexed, 10 mg

    J9307

    Injection, pralatrexate, 1 mg (For billing prior to 1/1/11 use J9999 or C9259)

    J9310

    Injection, rituximab, 100 mg

    J9330

    Injection, temsirolimus, 1 mg

    J9355

    Injection, trastuzumab, 10 mg

    J9357

    Injection, valrubicin, intravesical, 200 mg

    J9395

    Injection, fulvestrant, 25 mg

    J9400

    Injection, ziv-aflibercept, 1 mg (For billing prior to 1/1/14 use C9296 or J9999)

    Q2049

    Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg

    HCPCS for injectables and other in-office medications priced at ASP plus 8% are listed in the table below.

    Code

    Code Description

    J7326

    Hyaluronan or derivative, Gel-One, for intra-articular injection, Per dose

    HCPCS for injectables and other in-office medications priced at ASP+6% are listed in the table below.

    Code

    Code Description

    J0178

    Injection, aflibercept, 1 mg

    J0585

    Injection, onabotulinumtoxinA, 1 unit

    J0897

    Injection, denosumab, 1 mg (For billing prior to 1/1/12 use J3590 or C9272)

    J2503

    Injection, pegaptanib sodium, 0.3 mg

    J2505

    Injection, pegfilgrastim, 6 mg

    J2778

    Injection, ranibizumab, 0.1 mg

    J7321

    Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose (Hyalgan dose is 20 mg/2 mL and Supartz dose is 25 mg/2.5 mL) (Note: Total dose regimen = 3 - 5 injections)

    J7323

    Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (20 mg/2 mL) (Note: Total dose regimen = 3 injections)

    J7324

    Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (30 mg/2 mL) (Note: Total dose regimen = 3 - 4 injections)

    J7325

    Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg (For billing prior to 1/1/10 see J7322 for Synvisc and J3490 for Synvisc-One)

    J7327

    Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose (For billing prior to 1/1/15 use C9399 or J3490) (Dose 88 mg/4 mL) (Note: Total dose regimen = 1 dose)

    J7328

    Hyaluronan or derivative, Gel-Syn, for intra-articular injection, 0.1 mg

    Q9980

    Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1 mg

    HCPCS for injectables and other in-office medications priced at AWP are listed in the table below.

    Code

    Code Description

    J7297

    Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration

    J7298

    Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration

    J7300

    Intrauterine copper contraceptive

    J7301

    Levonorgestrel-releasing intrauterine contraceptive system,13.5 mg

    J7307

    Etonogestrel (contraceptive) implant system, including implant and supplies (Code Price is per 1 implant system)

    J7311

    Fluocinolone acetonide, intravitreal implant

    J7312

    Injection, dexamethasone, intravitreal implant, 0.1 mg (For billing prior to 1/1/11 use J3490 or C9256)

    J7330

    Autologous cultured chondrocytes, implant

    J9225

    Histrelin implant (Vantas), 50 mg

    J9226

    Histrelin implant (Supprelin LA), 50 mg

    S1090

    Mometasone furoate sinus implant, 370 micrograms - see also C2625 or J3490

    Member Coverage

    The following table identifies which members are covered by or excluded from the EmblemHealth Injectable Drug Utilization Management Program.

    Provider Network Member Assigned to a Physician Group Practice* EmblemHealth/
    HIP Is Managing Entity**
    HealthCare Partners Is Managing Entity** Montefiore CMO Is Managing Entity**

    HIP-underwritten commercial plans

    • NY Metro Network
    • Premium Network
    • Prime Network
    • NY Metro Network
    • Vytra Network
      (Vytra HMO Plans)

    Yes

    Yes

    Excluded from program

    Excluded from program

    State Sponsored Programs

    • Enhanced Care Prime Network

    Yes

    Yes

    Excluded from program

    Excluded from program

    Medicare

    • Medicare Choice PPO Network
    • Medicare Essential Network
    • VIP Prime Network

    Yes

    Yes

    Excluded from program

    Excluded from program

    FEHB plans

    Yes

    Yes

    Excluded from program

    Excluded from program

    Vytra Network (Vytra ASO Plans)

    Yes

    Yes

    Excluded from program

    Excluded from program

    GHI-underwritten commercial plans

    • CBP, National, Tristate Networks
    • Network Access Network

    Excluded from program

    Excluded from program

    n/a

    n/a

    * AdvantageCare Physicians: Manhattan's Physician Group, Preferred Health Partners, Queens-Long Island Medical Group, Staten Island Physician Practice
    ** Managing entity assignment is on the back of the member's ID card. It can also be found on the Member Details page of the Eligibility/Benefits lookup feature. You can access this feature on our secure provider website: www.emblemhealth.com/Providers.

    Who Requests Prior Approval

    It is the responsibility of the referring practitioner (i.e., a PCP or specialist ordering the injectable drug) to obtain the prior approval before services are rendered. If the referring and rendering practitioners are different, the rendering practitioner is responsible for ensuring that a prior approval is on file before services are rendered.

    Prior Approval Processes

    To request a Magellan Rx prior approval or reapproval for both urgent and non-urgent requests, either:

    • Visit Magellan Rx's secure website: ih.magellanrx.com. Select the "Providers and Physicians" icon
    • Call Magellan Rx at 1-800-424-4084, Monday through Friday, from 8 a.m. to 6 p.m., EST. Multiple requests can be processed on one call.

    To request prior approval for a member to obtain drugs in an outpatient setting or from another provider, sign in to Magellan Rx's secure website: ih.magellanrx.com. Then:

    1. Select the "Providers and Physicians" icon.
    2. Enter your patient's information and select your or your group's name as the requesting provider.
    3. Answer "Yes" to the question "Will an alternative servicing provider be utilized for this request?"
    4. Search for and select the hospital site or ambulatory surgery center where the member will receive the injectable drug.
    5. Continue entering the prior approval request.

    To view an existing prior approval, sign in to Magellan Rx's secure website: ih.magellanrx.com. Then:

    1. Select the "Providers and Physicians" icon.
    2. Select "View Authorizations." You can search for a specific member or view all of the prior approvals issued to your TIN.
    3. Verify the following information on the prior approval:
      • Member name and ID number
      • Service provider
      • Facility location
      • Service dates
      • Service dates have not expired
      • Approved drug(s) and number of units

    Order Forms for HIP Drug Replacement Program

    To request replacement drugs from Magellan Rx's for HIP members, print and complete a prior approval request form for the drug (see links directly below). Then fax to Magellan Rx at 1-888-656-6671. The two forms below also appear at the end of this chapter.

    If you have any questions, contact Magellan Rx at 1-800-424-4084, Monday through Friday, from 8 a.m. to 6 p.m., EST.

    Information Magellan RX Needs to Process Prior Approval Requests

    To expedite the prior approval process, please have the following information ready:

    • Requesting provider name, address and office phone number
    • Service provider name, address and office phone number (if different from above)
    • Member name and ID number
    • Requested medical pharmacy drug(s)
    • Anticipated start date of treatment (if known)
    • Member height, weight and/or body surface area
    • Dosing information and frequency
    • Diagnosis (ICD codes)
    • Past therapeutic failures

      In case you're asked to provide them, please have the following documents ready. If they are requested, fax them to 1-888-656-6671:

      • Clinical notes
      • Pathology reports
      • Relevant lab test results

        The prior approval is valid for a specified number of units administered within a specified time frame. If the member needs additional units or receives the drug on a date outside the time frame, please contact Magellan Rx and request they adjust the prior approval. This will ensure the claim is not denied for being outside the time frame or for including more units than authorized in the prior approval.

        Specialty Injectable Drugs Prior Approval List

        The codes in the table below require prior approval by Magellan Rx as part of EmblemHealth's Injectable Drug Utilization Management Program. This list is subject to change as new treatment information becomes available.

        The prior approval determination must be made within three business days of receiving the necessary information. When prior approval is received for these drugs, it will be available behind sign-in on the Magellan Rx website: ih.magellanrx.com, but not on the EmblemHealth website. We will also notify the member and the provider of the determination by phone and in writing. For Medicare members, phone notification is provided only in the event of an urgent request.

        Current as of July 29, 2015

        J-Code

        IVIG Drugs

         

        J-Code

        Brand Name

        J1556 Bivigam  

        J9264 

        Abraxane

        J1566

        Carimune NF and Gammagard S/D

        J9305

        Alimta

        J1572

        Flebogamma

        J2469

        Aloxi

        J1569

        Gammagard

        J0881

        Aranesp

        J1557

        Gammaplex

        J9035

        Avastin (for cancer only)

        J1561

        Gamunex-C and Gammaked

        J0585

        Botox

        J1568

        Octagam

        J0885

        Epogen/Procrit

        J1459

        Privigen

        J9055

        Erbitux

        J-Code

        RA Drugs

        J9355

        Herceptin

        J0129

        Orencia

        J2820

        Leukine

        J1745

        Remicade

        J0587

        Myobloc

        J2505

        Neulasta

         

         

        J1442

        Neupogen

         

        Q2043

        Provenge

        J9310

        Rituxan

        J2353

        Sandostatin LAR

        J1300

        Soliris

        J9225

        Vantas

        J9303

        Vectibix

        J3489

        Zoledronic acid

        *Effective July 1, 2013, J3487 Zometa and J3488 Reclast were removed from the J-code list and replaced with J3489 Zoledronic acid, per a CMS J-code edit.

        Setting Up Your Magellan Rx Account

        You must register for an Magellan Rx account to request and check the status of prior approvals. To create your Magellan Rx account, either:

        • Visit Magellan Rx's website: ih.magellanrx.com. Then:
          1. Select "Providers" under the "Quick Links" menu.
          2. Click the "New User Request Access" link under the "Sign In" button.
          3. Select the "Contact Us" link.
          4. Complete the required fields (noted with a red asterisk) and any additional information requested in the text box.
          5. Click "Submit."
        • Call Magellan Rx at 1-800-424-4084, Monday through Friday, from 8 a.m. to 6 p.m., EST.

          Continuity of Care

          Magellan Rx prior approvals began June 1, 2012, and retroactive approvals do not apply. All drugs covered under EmblemHealth's Injectable Drug Utilization Management Program that were administered on or after June 1, 2012, must have a prior approval on file with Magellan Rx. This helps ensures claims are paid correctly.

          Members in an Active Course of Treatment Before June 1, 2012
          To ensure correct claims payment for members who, before June 1, 2012, received any of the specialty injectable drugs in the Code List table above (i.e., a valid referral was obtained or claims for these drugs were already submitted and paid), the administering provider must contact Magellan Rx to obtain a prior approval number. For these cases, Magellan Rx will not conduct a full medical necessity review.

          Prior approvals are valid for up to six months from the date they were approved. For ongoing treatment, a new prior approval must be submitted once the current prior approval expires.

          Members Who Began a Course of Treatment on or After June 1, 2012
          For members who are not yet in treatment but who, on or after June 1, 2012, will receive any of the specialty injectable drugs in the Code List table above, prior approval must be obtained from Magellan Rx before treatment can begin.

          Claims Submission

          We work with Magellan Rx on utilization management only. Please do not submit claims to Magellan Rx. You should continue to submit claims to the same address or, if submitting electronically, using the same Payor ID you use now. For instructions on submitting claims, see the Directory and Claims chapters.

          Claims submitted without obtaining a required prior approval number will be denied and the member may not be billed.

          Billing for Drug Waste

          For certain drugs, Magellan Rx's automated prior approval system calculates dosages based on the member's actual weight or body surface area without considering vial size. In some cases, a portion of the drug in the vial may therefore go unused. Please follow these guidelines when billing for drug waste:

          • If the remainder of a single-use vial or other single-use package must be discarded after administering a dose/quantity of the drug, the claim should be submitted with two lines.
          • The portion of the drug that was administered should be submitted on one line.
          • The JW modifier must be submitted on a separate claim line with the discarded amount.
          • The JW modifier should only be used on the claim line with the discarded amount.

            Denials and Appeals

            Pre-Service Adverse Determinations
            Before a final decision is made, you will have an opportunity to speak with a pharmacist and a physician, as well as to submit relevant medical records. If you still disagree with Magellan Rx's determination, you may exercise your reconsideration and appeal rights. These rights differ for our Commercial, Medicaid and Medicare plans and are outlined in separate dispute resolution chapters.

            Post-Service Adverse Determinations
            The practitioner or member may file a clinical appeal with EmblemHealth. Please follow the instructions for filing an appeal that accompanies the denial. These processes differ for our Commercial, Medicaid and Medicare plans and are outlined in separate dispute resolution chapters.

            My Subscriptions

            Enter your e-mail address to receive a link to your subscriptions.

            Submit
            ×

            Glossary terms found on this page:

            A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.

            Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

            Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

            An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

            Services that have been approved for payment based on a review of EmblemHealth's policies.

            Services that have been approved for payment based on a review of EmblemHealth's policies.

            Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

            Treatment of malignant disease by chemical or biological antineoplastic agents.

            An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

            Occurs when a clinical professional reviews information about a patient's health.

            The government agency responsible for administering the Medicare and Medicaid programs.

            A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

            Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

            A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

            A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

            The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.

            A drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug.

            An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

            An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

            • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
            • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
            • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
            • Maintains medical records for all patients
            • Has a requirement that every patient be under the care of a member of the medical staff
            • Provides 24-hour patient services
            • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

            A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

            A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

            The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



            Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

            An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

            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.

            A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

            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.

            The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

            A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

            A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

            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.

            A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

            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
            • Dentist
            • Chiropractor
            • Doctor of podiatric medicine
            • Physical therapist
            • Nurse midwife
            • Certified and registered psychologist
            • Certified and qualified social worker
            • Optometrist
            • Nurse anesthetist
            • Speech-language pathologist
            • Audiologist
            • 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 set of providers contracted with a health plan to provide services to the enrollees.

            A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.

            A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

            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.

            ×

          You are now leaving the Medicare section of the EmblemHealth website.

          Click to Continue ×

          Your member ID # is on the front of your ID card.