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  • EmblemHealth Specialty Pharmacy Program > EmblemHealth Injectable Drug Utilization Management Program

    EmblemHealth provides utilization management for certain medical injectable drugs(see the Specialty Injectable Drugs Prior Approval List below).

    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 EmblemHealth Injectables and Specialty Pharmacy Program is not required for medications administered at home or during emergency room visits, observation unit visits, or inpatient stays.

    Urgent medical requests for prior approval will be completed within 72 hours of receipt. Non-urgent requests will be completed within 14 calendar days of receiving all necessary information. If the request requires additional clinical review or eligibility verification, the review and determination processes may take longer.

    The list below identifies medical groups and members that are excluded from the EmblemHealth Specialty Pharmacy Program.

    • HealthCare Partners
    • Montefiore
    • City of New York Commercial

    Note: Effective January 1, 2016, utilization management for GHI PPO City of New York employees and non-Medicare-eligible retirees with GHI PPO benefits will be managed by Empire BCBS for inpatient and outpatient services.

    Call 800-521-9574

    Fax 800-241-5308

    To see what needs authorization, use their look-up tool: https://www.empireblue.com/wps/portal/ehpprovider.

    See a list of all services requiring pre-certification from Empire BCBS.

    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 Advantage Care Physicians* EmblemHealth/
    HIP Is Managing Entity*
    HealthCare Partners Is Managing Entity* Montefiore CMO Is Managing Entity*

    HIP-underwritten commercial plans

    • NY Metro Network (Retired August 1, 2018)
    • Premium Network
    • Prime Network (including GHI HMO and Vytra HMO)

    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

    GHI-underwritten commercial plans

    • CBP, National, Tristate Networks
    • Network Access Network

    Excluded from program

    Excluded from program

    n/a

    n/a

    Vytra Networks (Vytra HMO & ASO Plans)

    Yes

    Yes

    Excluded from program

    Excluded from program

    * 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 prior approval, you can contact EmblemHealth's Specialty Pharmacy department by calling 1-888-447-0295 or submit completed forms by fax to 1-877-243-4812.

    Visit our Provider Portal then select the "Prescriber” and submit the request online.

    Call EmblemHealth’s Specialty Pharmacy department 1-888-447-0295, Monday through Friday, 8 a.m. to 6 p.m.

    To request prior approval for a member to obtain drugs in an outpatient setting or from another provider, then:

    1. Select the "Prescribers" icon.
    2. Click “Next “Enter the member’s information
    3. Enter the drug and dosing information
    4. Enter the prescriber information
    5. Enter the diagnosis
    6. Answer the questionnaire
    7. Attach any/all supporting document for the request
    8. Submit
    9. Continue entering the prior approval request

    Specialty Injectable Drugs Prior Approval List



    Additional Codes that Require Prior Approval Effective January 12, 2018
    Drug Brand Name Drug Generic Name Procedure Code
    Actemra Tocilizumab J3262
    Acthar_hp Corticotropin J0800
    Aldurazyme Laronidase J1931
    Benlysta Belimumab J0490
    Berinert C1 esterase inhibitor (human) J0597
    Cerezyme Imiglucerase J1786
    Cimzia Certolizumab pegol J0717
    Cinryze C1 esterase inhibitor (human) J0598
    Elaprase Idursulfase J1743
    Elelyso Taliglucerase alfa J3060
    Entyvio Vedolizumab J3380
    Eylea Aflibercept J0178
    Fabrazyme Agalsidase beta J0180
    Fusilev Levoleucovorin calcium J0641
    Halaven Eribulin J9179
    Hizentra Subcutaneous immune globulin J1559
    Hyqvia Subcutaneous immune globulin J1575
    Inflectra Infliximab-dyyb Q5102
    Jevtana Cabazitaxel J9043
    Kadcyla Ado-trastuzumab emtansine J9354
    Keytruda Pembrolizumab J9271
    Lemtrada Alemtuzumab J0202
    Lucentis Ranibizumab J2778
    Lumizyme Alglucosidase alfa J0221
    Naglazyme Galsulfase J1458
    Nplate Romiplostim J2796
    Opdivo Nivolumab J9299
    Perjeta Pertuzumab J9306
    Prolia Denosumab J0897
    Simponi aria Golimumab J1602
    Stelara Ustekinumab J3357
    Tysabri Natalizumab J2323
    Vpriv Velaglucerase alfa J3385
    Xeomin Incobotulinumtoxina J0588
    Xgeva Denosumab J0897
    Yervoy Ipilimumab J9228

    Current as of July 29, 2015

    Code IVIG Drugs
    J1556 Bivigam
    J1566 Carimune NF and Gammagard S/D
    J1572 Flebogamma
    J1569 Gammagard
    J1557 Gammaplex
    J1561 Gamunex-C and Gammaked
    J1568 Octagam
    J1459 Privigen
    J-Code RA Drugs
    J0129 Orencia
    J1745 Remicade
    J-Code Brand Name
    J9264 Abraxane
    J9305 Alimta
    J2469 Aloxi
    J0881 Aranesp
    J9035 Avastin (for cancer only)
    J0585 Botox
    J0885 Epogen/Procrit
    J9055 Erbitux
    J9355 Herceptin
    J2820 Leukine
    J0587 Myobloc
    J2505 Neulasta
    J1442 Neupogen
    Q2043 Provenge
    J9310 Rituxan
    J2353 Sandostatin LAR
    J1300 Soliris
    J9225 Vantas
    J9303 Vectibix
    J3489 Zoledronic acid

    Claims Submission

    Submit all claims to Accredo. 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

    FThe 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 EmblemHealth’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.

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    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 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).

    A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

    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.

    When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called Coordination of Benefits.

    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.

    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.

    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.

    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 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.

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