Provider Manual

Chapter 11: EmblemHealth Specialty Pharmacy Program

 

Certain specialty pharmacy medications are complex to administer and often entail 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.
 

The FDA has approved some injectables for multiple indications. They may be  covered as either a pharmacy or medical benefit. How injectables are covered depends on the diagnosis, specific formulations, and administration setting and method.
 

EmblemHealth works with Accredo , an industry leader, to provide these types of 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.

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.

All commercial plan members requiring oral specialty and self-administered specialty injectables must obtain medications from Accredo. Accredo is the preferred specialty pharmacy for Medicaid and Medicare members requiring oral or self-administered specialty injectables.  The list of self-administered specialty drugs includes:

  • Calcium regulators
  • Growth hormones
  • Hepatitis C agents
  • HIV fusion inhibitors
  • Infertility agents
  • Injectable contraceptives (e.g., progestin)
  • Multiple sclerosis agents
  • Plaque psoriasis agents
  • Rheumatoid arthritis agents

Some specialty drugs require submission of a Certificate of Medical Necessity (CMN) or a physician's prior approval (PPA). To order a CMN or PPA, practitioners should contact the EmblemHealth Specialty Pharmacy department at 1-888-447-0295.

Accredo Specialty Pharmacy Services fills prescriptions and delivers them directly to the member's home. To ensure member privacy, all prescriptions are delivered by courier service and packaged in nondescript materials. A signature is required at the time of delivery, unless other arrangements have been made. Members are instructed to check that their order is accurate and, if necessary, refrigerate the medication.

All prescriptions, including transfers of existing prescriptions, must be submitted to Accredo by phone at 1-888-615-3144or by fax at 1-800-391-9709. For more information, contact the EmblemHealth Specialty Pharmacy department at 1-888-447-0295.

For prior approval processes for medications not on the EmblemHealth Injectable Drug Utilization Management Program list that follows, see the Pharmacy Benefit Designs, Nonpreferred Drugs or Medicaid Pharmacy Program sections of the Pharmacy Services chapter.

Claims Submission

For instructions on submitting claims, see the Directory and Claims chapters. Claims submitted without obtaining a required preauthorization number will be denied, and the member cannot be billed.

Billing for Drug Waste

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.

Reimbursement Methodology for Radiopharmaceuticals

With respect to the radiopharmaceutical codes below, defined by Health 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

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. Below is the reimbursement methodology for our Injectables and Other In-Office Medication Fee Schedule.

·Maximum Allowable Cost (MAC): Utilized for select therapeutic categories where a clinically equivalent, lower-cost alternative is available. Pricing is at the maximum allowable cost, giving increased reimbursement over current Average Sales Price (ASP) rates, with margins comparable to higher-cost agents within the same therapeutic class.

·High-Cost Maximum Allowable Cost (High-Cost MAC): Utilized for select-branded, single-source drugs with no lower-cost alternative that provides fair and typical margin.

  • Average Sales Price (ASP) plus 15%: Utilized for multisource or generic drugs with an ASP available.
  • Average Sales Price (ASP) plus 10%: Utilized for branded or single-source drugs with an ASP available.
  • Average Sales Price (ASP) plus 8%: Utilized for preferred hyaluronic acid product.
  • Average Sales Price (ASP) plus 6%: Utilized for branded or single-source drugs not included in the ASP plus 10% category.
  • Average Wholesale Price (AWP) minus 15%: Utilized for drugs without an available ASP except where otherwise stated. 
  • Average Wholesale Price (AWP) minus 10%: Utilized for all vaccines.
  • Average Wholesale Price (AWP): Utilized for all implants and contraceptives.

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 1-888-447-0295or 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.

Members in an Active Course of Treatment Before January 1, 2019
To ensure correct claims payment for members who, before January 1, 2019, received any of the specialty injectable drugs in the Code List table above (i.e., a valid referral was obtained or claims for these drugs were already submitted and paid), the administering provider must contact EmblemHealth Injectables and Specialty Pharmacy Program to obtain a prior approval number.

 

For ongoing treatment, a new prior approval must be submitted once the current prior approval expires.