Injectables / Infusion / Specialty Drugs support

Infused and Injectable Medication Program

Moda Health partners with Prime Therapeutics Management to assist you in medical pharmacy management through the provider administered infused and 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 for our members, we offer several programs centered around provider administered medications.

Injectable Medications Covered Under the Medical Benefit

Prime Therapeutics Management or Moda Health will review your prior authorization requests for select specialty injectable/infused medications that are given in an outpatient facility, a patient’s home, or a physician’s office.

Texas Fully Insured Individuals:
- Prior authorization is not required; however, post-service claims edits will apply. Moda Health applies post-service, pre-payment claims edits to diagnosis criteria and criteria for maximum billing units for the medications found here. Please note that only diagnosis code criteria and maximum billing units will apply and claims may be denied when used for unsupported indications or at a dose/frequency inconsistent with how the medication is intended to be used.
- Site of Care requirements (described below) do not apply.
Texas Equal Funding Groups:
All prior authorization requests for equal funding groups will go through Prime Therapeutics Management directly. Post service claim edits program (PSCE) and Site of Care program requirements (described below) will apply.
- Injectable Medication Prior Authorization List
- Injectable Medication Coverage Policies
Texas Fully Insured Groups:
All prior authorization requests for fully insured groups will go through Moda Health directly. Post service claim edits program (PSCE) and Site of Care program requirements (described below) do not apply.
- Injectable Medication Prior Authorization List
- Injectable Medication Coverage Policies

Infused and Injectable Medication Utilization Management Programs

Post Service Claim Edits Program (PSCE)

In partnership with Prime Therapeutics Management, Moda Health has 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 do this by reviewing claims post-service, but pre-payment for appropriate frequency, correct units, and eligible diagnosis codes.

This program only applies to Texas Equal Funding Groups at this time.

Site of Care Specialty Infusion Program

Through the current prior authorization program administered by Prime Therapeutics Management, infusion requests for a hospital outpatient setting for the medications listed under “Injectable Medication Criteria Policies” 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.

This program only applies to Texas Equal Funding Groups. Texas Individual and Texas Large Group members are not subject to this program.

Injectable Medication Criteria Policies

Most infused or injectable medications are reviewed by Prime Therapeutics Management, but some 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.

Working together to improve patient care

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.