ICORE Healthcare: Injectable Drug Utilization Management Program Overview for EmblemHealth Providers. May 1, 2012

Transcription

1 ICORE Healthcare: Injectable Drug Utilization Management Program Overview for EmblemHealth Providers May 1, 2012

2 Agenda Topics for Today 1. Program Summary Specialty Injectable Drugs in scope EmblemHealth members in scope Transition of Care Process 2. Prior Authorization Obtaining a user ID for ICORE s website ICORE Prior Approval Process Web and Phone Providers utilizing the Specialty Pharmacy Drug Replacement Program Fax 3. Web Tool Demo ICORE Healthcare A Magellan Health Company 2

3 Program Summary

4 Program Summary Effective June 1, 2012, providers will need to contact ICORE for prior approval for 30 drugs either by phone (800) or through ICORE s HIPAA-compliant web portal at The prior approval will be necessary when administration of drug will be in a Physician Office (place of service 11); Outpatient Hospital (place of service 22) or Ambulatory Surgical Center (place of service 24) Emblem retains primary responsibility for customer service, with support from ICORE as needed related to prior approvals and for claims processing ICORE Healthcare A Magellan Health Company 4

5 Program Summary Specialty Injectable Drugs In Scope J-Code J1566 J-Code IVIG Drugs RA Drugs J0129 Orencia J1745 Remicade J3488 Reclast Carimune NF and Gammagard S/D J1572 Flebogamma J1569 J1557 J1561 Gammagard Gammaplex Gamunex -C and Gammaked TM J1568 Octagam J1459 Privigen 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 J1440/J144 Neupogen Q2043 Provenge J9310 Rituxan J2353 Sandostatin LAR J1300 Soliris J9225 Vantas J9303 Vectibix J3487 Zometa ICORE Healthcare A Magellan Health Company 5

6 Members Impacted by Program Members Covered by Program Members Excluded from the Program GHI HMO/POS Commercial plans underwritten by HIP (HIP HMO/POS/EPO/PPO, CompreHealth EPO/HMO and Vytra HMO) HIP state- sponsored programs (Medicaid, Family Health Plus and Child Health Plus) EmblemHealth Medicare HMO (underwritten by HIP) EmblemHealth Medicare PPO (underwritten by GHI) GHI and HIP FEHB plans Vytra ASO account members. HIP members who have elected to obtain care from one of our physician group practices (shown on member ID card): Manhattan s Physician Group Preferred Health Partners, (Brooklyn) Queens Long Island Medical Group Staten Island Physician Practice Commercial plans underwritten by Group Health Incorporated (EmblemHealth EPO/PPO and GHI EPO/PPO) NY Bridge Plan (underwritten by Group Health Incorporated) and HIP Members assigned to a Montefiore or Health Care Partners PCP are excluded from this program. Montefiore (CMO) or Health Care Partners (HCP) will have the Managing Entity assignment shown on the back of their member ID cards and on the Member Details page of the Eligibility/Benefits lookup feature on ICORE Healthcare A Magellan Health Company 6

7 Transition of Care Process Members who will start treatment on or after June 1, 2012 Authorizations must be completed by ICORE before treatment begins. Members currently being treated with drugs in scope that DID NOT require a prior authorization before June 1, 2012 Continuation of treatment will require a prior authorization from ICORE. Magellan Health Services, Inc. 7 ICORE Healthcare A Magellan Health Company 7

8 Prior Authorization Process

9 Access to ICORE s Website Starting May 24, 2012, providers are able to request a user ID and password using ICORE s Website: Providers who have not yet done so must consider who in their practice will be your primary administrator and who will need to have access to ICORE s web site. If a provider administers any of the drugs in scope, but will not be initiating the prior approval, it still may be necessary for them to refer to the authorization number so a web access will be needed. ICORE Healthcare A Magellan Health Company 9

10 How to Submit a Request - Providers 3 Easy Options: Visit ICORE s Web site at Call ICORE at M-F 8am-6pm Fax requests (Specialty Pharmacy process) Click on the Providers and Physicians icon. ICORE Healthcare A Magellan Health Company 10

11 Timeframes for Requests Standard requests: Non urgent requests will be completed within 3 days from receipt of the request. In most cases, ICORE can review and determine prior authorization during the initial phone call if all information needed to process a request is provided. The review and determination process may take longer if member or provider eligibility verification is required and/or if the request requires additional clinical review. Urgent requests: Medication needed on same day must be obtained by contacting the ICORE Call Center. All other urgent requests will be completed within 24 hours from receipt of request. In most cases, ICORE can review and determine prior authorization during the initial phone call if all information needed to process a request is provided. The review and determination process may take longer if member or provider eligibility verification is required and/or if the request requires additional clinical review. Magellan Health Services, Inc. 11 ICORE Healthcare A Magellan Health Company 11

12 ICORE s Prior Authorization Process for Providers To expedite the authorization process please have the following information ready: Member name and ID Requested drug Start date of treatment Member weight and body surface Dosing and frequency Diagnosis Past therapeutic failures Note: If requested, be prepared to fax the following documents to (888) : Clinical notes Pathology reports Relevant lab test results ICORE Healthcare A Magellan Health Company 12

13 Specialty Pharmacy Provider Process If the drug is on the Specialty Injectable Drug Prior Approval List for the utilization program managed by ICORE, prior approval will be required from ICORE. If the provider is looking to use the Specialty Pharmacy Program to obtain replacement medications from ICORE, special fax forms have been developed to enable providers to submit a request for prior approval and drug replacement in one transaction. If the provider intends to obtain the drug from another contracted vendor, e.g. Bioscrip/Curascript, they should use ICORE s web site or call ICORE to request a prior approval. Once prior approval has been issued, an order for the drugs may be placed with the Specialty Pharmacy Program. ICORE Healthcare A Magellan Health Company 13

14 ICORE Specialty Pharmacy Program ICORE Healthcare A Magellan Health Company 14

15 ICORE Specialty Pharmacy Program (non-chemo) ICORE Healthcare A Magellan Health Company 15

16 ICORE Specialty Pharmacy Program (chemo) ICORE Healthcare A Magellan Health Company 16

17 Web Tool Demo

18 Web Tool Demonstration Web Tool DEMO ICORE Healthcare A Magellan Health Company 18

19 Program Details for Injectable Drug Utilization Management Program To request a Prior Authorization by phone To request a Prior Authorization by Fax (option for Buy & Bill Providers only) To request via the Web General inquiries for Providers EmblemHealth (Eligibility/Benefits/Claims) option 1 ICORE Healthcare A Magellan Health Company 19

20 Questions? ICORE Healthcare A Magellan Health Company 20