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  • 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.

    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
    • 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

    Rules That Applied To Retired Networks & Benefit Plans

    Provider Network Member Assigned to a Advantage Care Physicians* EmblemHealth/
    HIP Is Managing Entity*
    HealthCare Partners Is Managing Entity* Montefiore CMO Is Managing Entity*

    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 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.

          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.

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

            A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

            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.

            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.

            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 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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