Certain medical benefit injectable drugs require prior approval from EmblemHealth. Drugs requiring prior approval must be reviewed by 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 EmblemHealth Specialty Pharmacy Program 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 via our provider portal.
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:
Specialty pharmacy services begin when a prescription is sent to Accredo by a patient (via phone or mail) or a physician (via phone or secure fax). The intake team conducts an administrative review of the prescription to verify the patient’s name, telephone number, address, physician’s name, and drug coverage. Pharmacy staff complete reviews for mailed or faxed prescriptions and handle verbal prescriptions that are called in by physicians.
To determine clinical appropriateness, our expert team of specialty clinicians performs a series of clinical reviews and protocols based on the programs [Client] has in place, such as Prior Authorization and Step Therapy; drug interactions with prescription and nonprescription medications, as well as those administered outside of the prescription adjudication system (for example, at the doctor’s office); and other waste management edits. When necessary, a pharmacist contacts the prescribing physician’s office to confirm the member’s treatment plan.
Next, our patient care advocates place an outbound call to the member to verify the shipping address and to determine when the member will be available to accept delivery of the prescription. During this call, a specialty clinician is available to counsel the patient. Once the representative confirms delivery arrangements and billing information, the prescription is processed to ensure the most efficient method of dispensing and shipping is utilized. Pharmacy router technology directs the dispensing of the prescription to take place at the pharmacy closest to the member, depending on inventory, capacity, and hours of operation.
Accredo dispenses and packages the prescription order with member literature on the proper administration, product usage, and appropriate ancillary supplies required for self-administration. For those therapies requiring nursing and administration supplies (such as pumps and tubing), a specialized nurse contacts the patient or caregiver to coordinate an appointment time for initiation of therapy and any necessary training. In some cases, unless the member requests not to be contacted, a nurse or pharmacist places a follow-up call to the member for counseling and training on self-administration, if needed.
Coordinating Medication Delivery
A patient care advocate schedules delivery of the specialty medication based on the member’s unique requirements. For example, if the member is new to therapy and requires instruction on proper injection technique from a nurse, we coordinate delivery at a date and time convenient to both the member and home care nurse, if applicable. As an alternative, we can also arrange to deliver the medicine to the member’s physician’s office for administration and instruction.
Our specialty pharmacy makes every effort to dispense product within 24 hours of receipt of a complete referral. However, physicians, patients, or caregivers may request shipment dates beyond 24 hours. We have found that flexibility around the shipment time enhances the member experience. In these instances, we coordinate deliveries based on a need-by date, enabling the member to receive packages on the date and time the member or the member’s caregiver is available to receive the order.
All injectables categorized as a medical benefit are shipped to the prescribing practitioner or call 1-888-447-0295. Submit completed forms by fax to 1-877-243-4812 or submit via our physician portal.
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:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
The process by which a claim is paid or denied based on eligibility and contract determination.
Services that have been approved for payment based on a review of EmblemHealth's policies.
Occurs when a clinical professional reviews information about a patient's health.
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 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 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 recommendation by a physician that an enrollee receive care from a specialty physician or facility.