Pharmacy Services and Specialty Pharmacy

04/13/2021

This program contains information regarding our pharmacy network, formularies, benefit designs, preauthorization requirements, and specialty pharmacy. 

 

You will also find information about our Home Delivery and Smart90SM programs, which offer our members cost savings and convenience. 

Pharmacy contact numbers are listed in the Directory chapter of the Provider Manual.

We provide information about our pharmaceutical management procedures and formularies at least annually and whenever we make changes. These updates may include the following:

  • Pharmacy benefit designs
  • Formulary changes
  • Preauthorization criteria
  • Procedures for generic substitution, therapeutic interchange, step therapy, or other management methods impacting the practitioner's prescribing decisions
  • Any other requirements, restrictions, limitations, or incentives that apply to the use of certain pharmaceuticals

If you require printed copies or have any questions regarding our pharmaceutical management procedures, call Clinical Pharmacy Services at 877-362-5670.

Claims Submission

For instructions on submitting claims, see the Directory and Claims chapters of the Provider Manual. Claims submitted without obtaining a required preauthorization number will be denied, and the member cannot be billed. Claims must also include National Drug Code numbers and Taxonomy Codes.

 

Billing for Drug Waste

The portion of the drug 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.

 

Reimbursement Methodology for Injectables and In-Office Medications

EmblemHealth periodically reviews and adjusts reimbursement levels to reflect changes in market prices for acquiring and administering drugs. For the reimbursement methodology, see our Injectables and Other In-Office Medication Fee Schedule.

 

Reimbursement Methodology for Radiopharmaceuticals

With respect to the radiopharmaceutical codes below, defined by Healthcare Common Procedure Coding System (HCPCS), EmblemHealth pays health care professionals the Average Sales Price (ASP) plus 15%. If ASP is not available, the reimbursement rate is Average Wholesale Pricing (AWP) minus 15%.

  • A9500-A9700
  • A4641-A4647
  • Q9949-Q9969

EmblemHealth Formularies

The EmblemHealth formularies cover many brand-name and generic pharmaceuticals for members who have prescription drug coverage, as defined by their benefit plan. Experimental or investigational drugs (i.e., non-FDA approved) are excluded from coverage. See formulary pages in Clinical Corner:

EmblemHealth Pharmacy and Therapeutics (P&T) Committee

The EmblemHealth Pharmacy and Therapeutics (P&T) Committee reviews and finalizes recommendations from the specialty subcommittees when selecting medications for inclusion in our formularies. Together, these committees review safety, efficacy, and cost to identify the pharmaceuticals that provide optimal results for our members. Members of the P&T and specialty committees include participating doctors (primary care and specialists), pharmacists, and administrators. The committees meet regularly to keep the drug formularies current.

 

Additions to the Formulary

Following the introduction of any new drug in the U.S. market, the P&T Committee typically allows for an up to six-month period of study before any final decision is made on inclusion of the drug to the formulary. During this time, the P&T Committee carefully observes the use and experience of the newly marketed drug in the general population. They examine its efficacy, safety, and drug interactions, and evaluate member needs to determine whether there are any advantages of the new drugs over the existing formulary drugs. A final recommendation is made after this study period.

 

Practitioners can request the inclusion of a drug in the Commercial Formulary. Such requests must be submitted with pertinent clinical data and/or literature justifying the addition of the drug to the formulary. The appropriate specialty subcommittee(s) review the request and send their recommendation to the P&T Committee for a final decision. To submit a request, complete the Addition to Formulary Request Form and fax to 877-300-9695 or mail to:

EmblemHealth
Pharmacy Benefit Services
Attn: Formulary Management Team
55 Water Street

New York, NY 10041

We offer several pharmacy benefit designs. Each design determines drug coverage and members’ copay amounts. Each pharmacy benefit plan is subject to regulations, state and federal laws, clinical guidelines, a prior approval process, and quantity limitations, unless otherwise specified. Covered pharmacy services must be listed on the MedicaidCommercial, or Medicare formularies, unless the member's benefit includes nonformulary/nonpreferred drugs (the drug formularies may describe drugs as either "formulary" or "preferred," or "nonformulary" or "nonpreferred").

 

Generic Versus Brand 

Our prescription benefit designs are formatted into three categories of prescription medications. Due to the number of drugs on the market, the continuous introduction of new drugs, new applications of existing drugs, and new information regarding safety, the designs are continually revised.

 

Tier 1 - Preferred Generic Drugs

Generic drugs (Tier 1) are chemically identical to brand drugs but are priced at a fraction of the cost and offer an excellent value to the member. To gain FDA approval, generic drugs must:

  • Contain the same active ingredients as the branded drug (inactive ingredients may vary).
  • Be identical to the brand drug in strength, dosage form, safety, and route of administration.
  • Be of the same quality, performance characteristics, and use indications.
  • Be manufactured under the same strict standards of the FDA's good manufacturing practice regulations required for branded products.

When writing for generic drugs, remember to leave the “DAW” field blank to ensure the generic version of the drugs are dispensed.

 

Tier 2 - Preferred Brand Drugs

Our preferred brand drugs are on Tier 2 and offer our members brand drugs at a lower copay or cost-share than nonpreferred drugs. These preferred drugs are typically multi-source brand drugs produced by various manufacturers. 

 

Tier 3 - Nonpreferred Brand and Generic Drugs

Drugs placed in Tier 3 generally have a similar, more cost-effective option available in either the preferred generic drug category (Tier 1) or the preferred brand drug category (Tier 2).

 

Most new FDA-approved drugs are initially placed in Tier 3 and excluded from coverage for up to six (6) months until the P&T Committee reviews them for safety, efficacy, and clinical comparisons.

 

Copay Designs 

The Copay Designs Table outlines the more common benefit structures with regards to copayment.

 

Copay Designs

Benefit Levels

Benefit Structure

Single Tier Copay (with or without a deductible)

  • The same copay for covered generic, preferred brand, and nonpreferred brand or generic drugs

Two-Tier Copay (with or without a deductible)

  • A lower copay for covered generic drugs
  • A higher copay for covered preferred brand and nonpreferred brand or generic drugs

Three-Tier Copay (with or without a deductible)

  • A lower copay for covered generic drugs
  • A middle copay for covered preferred brand drugs
  • A higher copay for covered nonpreferred brand or generic drugs

Percentage Coinsurance (with or without a deductible)

  • Coinsurance is based on a defined or set percentage of the actual cost for covered generic, preferred brand, and nonpreferred brand or generic drugs

 

Members must pay a copay and/or deductible for each supply of medication received at a participating retail or mail order pharmacy, as required by their benefit plan.

 

Note: Medicaid members cannot be denied health care services based on their inability to pay the copay at the time of service. However, providers may bill these members or take other action to collect the owed copay amount.

Under this program, EmblemHealth promotes the use of less expensive, equally effective prescription drugs when medically appropriate. Medicaid members must use pharmacies that accept their EmblemHealth ID card. Pharmacies must comply with all applicable Medicaid program requirements. See our Medicaid Pharmacy Program Guide, which provides information on:

  • Medicaid State Border Logic
  • Preauthorization Requirements
  • Excluded Medications
  • Vaccines for Children Program
  • Regulations Regarding Known Sex Offenders – See also: Prior Approval for Procedures, Supplies and Drugs for Erectile Dysfunction Treatment in the Utilization and Care Management chapter of the Provider Manual.
  • ·       Medicaid Behavioral Health Pharmacy: 
    • Emergency Pharmacy 
    • Injectable Anti-Psychotic Agent Access
    • Treatment of Substance Use Disorder
    • Smoking Cessation Products
    • Injectable Medication Procedures 

We offer Medicare Advantage plans with Part D benefits under the EmblemHealth Medicare HMO and EmblemHealth Medicare PPO programs. We also offer a stand-alone Medicare Part D prescription drug plan (PDP), EmblemHealth Medicare PDP, to Medicare members in New York State who do not have prescription drug coverage through another Medicare Advantage prescription drug plan. See our Medicare Pharmacy Program Guide, which provides information on the following:

Participating Retail Pharmacies 

EmblemHealth offers its members more than 60,000 independent and chain pharmacies nationwide through Express Scripts, Inc. (ESI). To find a network pharmacy, go to emblemhealth.com/find-a-doctor

 

Home Delivery Pharmacy Program  

EmblemHealth also partners with ESI to provide convenient and cost-effective home delivery pharmacy services. 

Providers may e-prescribe directly to Express Scripts home delivery pharmacy or call 888-327-9791for instructions on how to fax a prescription to ESI. This line is available seven days a week, from 8 a.m. to 8:30 p.m. Users of TTY can call 800-899-2114, 24 hours a day, seven days a week. 

 

Medley Pharmacy is another home delivery pharmacy services option for members in New York City, Long Island, and New Jersey. Providers may fax prescriptions to Medley at 718-782-7951.

 

Smart90TM Program

Patients can get a 3-month supply of long-term maintenance medications from select pharmacies or through home delivery from the Express Scripts Pharmacy. Getting a single 3-month supply saves patients money compared to purchasing three (3) 1-month supplies. Patients make fewer trips to the pharmacy and are less likely to miss a dose since they do not have to refill as often.  

EmblemHealth engages in several initiatives to manage the use of opioid drugs. EmblemHealth formularies include opioid analgesics and access to non-opioid analgesics as treatment alternatives, including nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, and anticonvulsants.

 

Opioid Case Management 

EmblemHealth identifies members for outreach who are on multiple opioids or are receiving high doses of opioids for a long period of time. As part of the Case Management process, EmblemHealth Clinical Pharmacists call each member and their prescriber to discuss the member’s use of opioids.

 

Fraud, Waste, and Abuse Program

To help improve coordination of care and promote the safe use of controlled substances, a member may be locked in to a single provider and a single pharmacy if evidence of fraud or opioid misuse is substantiated.

 

The program uses techniques to identify drug-seeking behavior, use of opioids in tandem with drug treatment medications, stockpiling, dangerous combinations of medications, frequent emergency department prescriptions, using multiple pharmacies, and excessive dosing based on morphine equivalent dose.

 

Advanced Opioid Management Solution

EmblemHealth participates in the Advanced Opioid Management® solution focused on opioid education throughout a continuum of patient care.

Practitioners must obtain preauthorization when:

  • Prescribing an FDA-approved nonpreferred (Tier 3) drug for a member whose benefit does not cover nonpreferred drugs.
  • Requesting a non-FDA-approved drug or an approved drug for a non-FDA-approved usage for members.

The easiest way to determine whether a drug requires preauthorization and to whom the preauthorization request needs to be made is to use the Preauthorization Check Tool

 

Express Scripts (ESI) performs utilization management services for most drugs, including specialty pharmacy, pediatric chemotherapy, and supportive agents. The services include preauthorization, quantity limits, and step therapy for all members who are not managed by Montefiore CMO or HealthCare Partners. All preauthorizations issued by ESI are added to member benefit records.

 

ESI does not manage adult chemotherapy and supportive agents. New Century Health conducts utilization management review for these services.

Some specialty pharmacy medications are complex to administer and often involve frequent dosage adjustments, severe side effects, and special storage or handling instructions. They may have a narrow therapeutic range and require periodic lab or diagnostic testing. 

 

Specialty pharmacy medications may be covered as either a pharmacy or medical benefit depending on the diagnosis, specific formulations, and administration setting and method.

 

Pharmacy Benefits (for patient pick-up at a retail pharmacy)

  1. Send prescriptions for specialty medications to a retail pharmacy participating in our Specialty Pharmacy Network
  2. Once filled, your patient can pick up the specialty medication from the retail pharmacy for proper storage until office administration.

Medical Benefits (for medication shipped to patient or provider office)

  1. A prescriber can either:
    • Buy and Bill – purchase, and bill EmblemHealth for, an inventory of specialty medications directly from the manufacturer or willing licensed pharmacy and store them in the office for administration to patients.
    • Use a Specialty Pharmacy Provider – submit prescriptions for specialty medications to a participating specialty pharmacy provider who will ship the medication to the prescriber's office for administration to the patient, or to the patient for self-administration. When necessary, a pharmacist contacts the prescribing physician's office to confirm the member's treatment plan. 

Accredo is our preferred provider for specialty pharmacy medications. Accredo offers:

  • Experience providing specialty pharmacy services to members.
  • Educational materials to support at-home administration.
  • Free syringes and needles to members for self-administered specialty drugs.
  • Comprehensive coordination of care, including refill reminders.
  • Dedicated pharmacists and nurses available to patients and physicians 24 hours a day, seven days a week. They provide comprehensive support to help maximize formulary compliance and improve patient outcomes.

For Direct Delivery to a Member 

Accredo’s Patient Care Advocate calls the member to coordinate delivery. During this call, a specialty clinician is available to counsel the patient. 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 any needed counseling and training on self-administration.

 

Accredo’s specialty pharmacy makes every effort to dispense product within 24 hours of receipt of a complete referral.