EmblemHealth Injectable Drug Utilization Management Program

Magellan Rx Healthcare, LLC provides utilization management (UM) for a list of specific injectable drugs on behalf of EmblemHealth’s Injectable Drug Utilization Management Program.

The drugs on the list, which include, but are not limited, to chemotherapy and rheumatoid arthritis medications, are ordered or administered by practitioners either in their office (POS 11), an outpatient hospital (POS 22) or ambulatory surgery center (POS 24) setting. The drugs on the list are covered as part of our members’ medical insurance benefit* and will require prior approval from Magellan Rx. This program is not intended to and does not change our members’ benefits* or your claims submission procedures.

Program details may be found in the Quick Reference Guide and the Frequently Asked Questions.The guide lists the drugs and the J-codes that require prior approval and summarizes how to request prior approvals from Magellan Rx. We have also included a step-by-step guide with screen shots to assist you.

What Is Magellan Rx?

Magellan Rx is a subsidiary of Magellan Health Services and is a leading injectable drug benefits management company with expertise in specialty pharmaceuticals. Magellan Rx's Medical Pharmacy Solutions program has full utilization management accreditation from URAC. URAC is the Washington, DC-based health care accrediting organization that establishes quality standards for the health care industry.

Prior Approval Requirement
The ordering provider will need to request prior approval by using the Magellan Rx easy and comprehensive website or by calling Magellan Rx at 1-800-424-4084, Monday through Friday, from 8 am to 6 pm.

Access to Magellan Rx’s Website

You or your designated administrator will be able to request a user ID and password using the Magellan Rx website. The Quick Reference Guide has instructions on how to set up an account. To facilitate this setup, please consider who in your practice will be your primary administrator and who will need to have access to Magellan Rx’s website.

Questions?

Please see our Frequently Asked Questions. If you still have questions and would like to contact us, please sign into our secure website to use our Message Center. 

*Commercial plans underwritten by Group Health Incorporated (EmblemHealth EPO/PPO, GHI EPO/PPO) and HIP members assigned to a Montefiore (CMO) or HealthCare Partners (HCP) primary care physican, are excluded from this program.

IMPORTANT SERVICE LOCATION ALERT

EmblemHealth’s Injectable Drug Utilization Management Program, managed by Magellan Rx, applies only to service locations in New York State. Service locations outside New York State are exempt from the requirements of this program.

Use the EmblemHealth Specialty Pharmacy Program?

Prior approvals are still required for the listed drugs. Special fax forms for the HIP Drug Replacement Program enable providers to submit a request for prior approval and drug replacement in one transaction. Providers may continue to use the Specialty Pharmacy Program to obtain drugs not on the list for this new program or to obtain drugs from a vendor other than Magellan Rx.