Certain medical benefit injectable drugs require prior approval from Magellan Rx (see EmblemHealth Injectable Drug Utilization Management Program in this chapter). For drugs that require prior approval, HIP practitioners who use the drug replacement program should order directly from Magellan Rx using the fax forms provided in Order Forms for HIP Drug Replacement Program in this chapter. For medical benefit injectable drugs that do not require prior approval from Magellan Rx, please place orders with EmblemHealth's Specialty Pharmacy department by completing and submitting the Specialty Program Request Form.
Practitioners must write each prescription to reflect the specific needs of the patient. When ordering patient-specific injectable drugs, practitioners must complete both a prescription order form and the New York State prescription form and submit them to EmblemHealth. When refills are needed and the order has not changed, the practitioner need only complete the order form for prescribed refills. If the dosage or frequency of the order has changed, the physician must submit a separate New York State prescription form.
To request any of the forms mentioned above, call our Specialty Pharmacy department at 1-888-447-0295. To submit the forms, send them to us either by fax at 1-877-243-4812 or by e-mail at email@example.com.
Once EmblemHealth receives the order, our Specialty Pharmacy department reviews it for appropriate dosing and indications based on FDA and EmblemHealth medical guidelines. We also verify patient eligibility and coverage, including the following:
- If eligibility is confirmed and the dosing and treatment indications meet the medical guidelines, orders will be processed and delivered within two (2) business days.
- If patient eligibility cannot be verified or the service is not covered, we will notify the prescribing practitioner within 24 hours.
- If eligibility is confirmed but the patient does not meet the medical guidelines, the following process will occur within 72 hours:
- A representative from the EmblemHealth Specialty Pharmacy department will contact the physician.
- If the request still does not meet the medical guidelines, the member will receive a letter of denial detailing our appeal policies.
All injectables categorized as a medical benefit are shipped to the prescribing practitioner. Under special circumstances, EmblemHealth may approve the delivery of medical benefit injectables directly to a member's home. To do so, the practitioner must complete an agreement waiver and return it to EmblemHealth's Specialty Pharmacy department. To order a waiver form, call 1-888-447-0295. Submit completed forms by fax to 1-877-243-4812 or by e-mail to firstname.lastname@example.org.
Note: Certain controlled substances, such as testosterone, may not be covered as a medical benefit through our Specialty Pharmacy program. Practitioners may, however, request reimbursement for the cost of these controlled substances if they are administered in the practitioner's office.
Glossary terms found on this page:
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
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 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 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.