Moda Health has partnered with Prime Therapeutics Management to assist you in medical pharmacy management through the provider administered injectable medication program. Moda Health is committed to providing our members with access to high-quality healthcare. With this commitment in mind and to ensure quality care and affordability to our members, we will implement updates to our processes regarding the review and approval of certain injectable medications.
Prime Therapeutics Management - Moda Health Plan Delegates administrative functions to Prime Therapeutics Management. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Articles (LCAs) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Additional indications may be covered at the discretion of the health plan.
Prime Therapeutics Management will review your prior authorization requests for the following specialty injectable medications that are performed in an outpatient facility, a patient’s home, or a physician’s office. You can see a full list of which Injectable Medications require a prior authorization, and their respective policies here:
In a partnership with Prime Therapeutics Management, Moda Health implemented a claim check program for injectable and/or infusion medications. The claim check program monitors and promotes appropriate use, safety, and cost effectiveness of medications prescribed to our members. We will do this by reviewing claims for appropriate frequency, correct units, and eligible diagnosis codes.
This program will be limited to the following injectable and/or infusion medications, ordered or administered by providers. Moda Health applies post-service, pre-payment claims edits to diagnosis criteria and criteria for maximum units for the following medications. Prior authorization criteria do not apply for these medications. However, if the services billed do not meet the guidelines, the claims will be subject to review and potentially disallowed. Please review the criteria below for specific covered diagnosis codes and dosing limits for each medication.
Our partnership with Prime Therapeutics Management will expand to include a Site of Care program that directs members to the most cost-effective, yet clinically appropriate, location to receive their infusion(s) of the select specialty medications (see medication list, below).
Through the current prior authorization program administered by Prime Therapeutics Management, infusion requests for a hospital outpatient setting for the listed medications will be redirected to a preferred site of service, which will be either preferred home infusion providers or a professional office setting. Infusions for these medications will not be covered when administered in a hospital outpatient infusion center.
The medications included in the Site of Care program already require prior authorization through Prime Therapeutics Management. The Site of Care program requirements will be administered as part of the existing prior authorization program. As a reminder, Moda will deny services as provider responsibility when prior authorization is not obtained for any medications that require prior authorization.
Some injectable medications are reviewed by Moda Health. Please see the bottom of the Injectable Medication Prior Authorization List to find out which medications should be submitted directly to Moda Health.
Making sure our members receive the best possible care at the most affordable price is why we come to work each day. But we can’t do this alone. We appreciate your support in assuring Moda Health members receive high quality, affordable care and deliver results consistent with nationally recognized clinical criteria and guidelines.
To learn more about our injectable medication program, please take a look at our FAQs about our Injectable Drug Program or call our Customer Service team toll-free at 877-605-3229.
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