Quick Reference Guide - EmblemHealth

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INJECTABLE DRUG UTILIZATION MANAGEMENTPROGRAM GUIDEDrugs Requiring Prior Approval by ICOREFor services rendered on or after June 1, 2012, ICORE will conduct utilization management for the drugsidentified below when administered in a practitioner’s office (POS 11), in an outpatient hospital setting(POS 22) or in an ambulatory surgery center (POS 24). Prior approval from ICORE is not required formedications administered at home, during emergency room visits, observation unit visits or inpatient stays.Specialty Injectable Drugs Requiring Prior Approval StartingJune 1, 2012The codes shown on the table below require prior approval by ICORE. This list is subject to change asnew treatment information becomes available or as “J-Codes” are updated. The most current list will beavailable at www.emblemhealth.com/ICORE and distributed via the monthly eNewsFlash as changes areidentified.J-Code IVIG Drugs J-Code Brand NameJ1566 Carimune ® NF and Gammagard S/D J9264 Abraxane ®J1572 Flebogamma ® J9305 Alimta ®J1569 Gammagard J2469 Aloxi ®J1557 Gammaplex J0881 Aranesp ®J1561 Gamunex ® -C and Gammaked TM J9035 Avastin ® (for cancer only)J1568 Octagam ® J0585 Botox ®J1459 Privigen ® J0885 Epogen ® /Procrit ®J9055 Erbitux ®J9355 Herceptin ®J2820 Leukine ®J0587 Myobloc ®J-Code RA Drugs J2505 Neulasta ®J0129 Orencia ® J1440/J1441 Neupogen ®J1745 Remicade ® Q2043 Provenge ®J3488 Reclast ® J9310 Rituxan ®J2353Sandostatin ® LARJ1300 Soliris ®J9225 Vantas ®J9303 Vectibix ®J3487 Zometa ®2
INJECTABLE DRUG UTILIZATION MANAGEMENTPROGRAM GUIDEEmblemHealth Specialty Pharmacy ProgramIf a drug is on the Specialty Injectable Drug Prior Approval List List for for the the utilization management programprogram managed managed by ICORE, by ICORE, prior approval prior approval will be required will be from required ICORE. from ICORE. If you wish If you to use wish the to Specialty use theSpecialty Pharmacy Pharmacy Program to Program obtain to replacement obtain replacement medications medications from ICORE, from special ICORE, fax special forms fax available forms atavailable www.emblemhealth.com/ICORE at enable you to enable submit you a to request submit for a prior request approval for prior and approval drug replacementreplacement in one transaction. in one transaction. If you plan to If obtain you plan the to drug obtain from the another drug from contracted another vendor, contracted e.g., vendor,anddruge.g., BioScrip/Curascript, you must you must use ICORE’s use ICORE’s Web Web site at site www.icorehealthcare.com at or call or ICORE callICORE at 1-800-424-4084, at 1-800-424-4084, Monday Monday through Friday, through from Friday, 8 am from to 68 pm am EST, to 6 pm to request EST, to a request prior approval. a priorapproval. Once prior Once approval prior has approval been issued, has been an issued, order for an the order drugs for the may drugs be placed may be with placed the Specialty with the SpecialtyPharmacy Program.Practitioners will continue to obtain replacement drugs not part of the Injectable Drug UtilizationManagement Program by following the same procedures for the Specialty Pharmacy Program as theynow do.Please consult the Care Management chapter of the EmblemHealth Provider Manual for a listing ofmedications requiring prior approval through Express Scripts. The “Pharmacy Benefit Design,”“Nonpreferred Drugs” or “Medicaid and Family Health Plus” sections of the Pharmacy Serviceschapter provide guidance on prior approval requirements from EmblemHealth for medications not onthe EmblemHealth Injectable Drug Utilization Management Program list. The EmblemHealthProvider Manual can be found at www.emblemhealth.com.ICORE Web Site AccessWhen ordering a drug covered by the EmblemHealth Injectable Drug Utilization Management Program, youmay obtain prior approval by accessing ICORE’s Web site at www.icorehealthcare.com.Web Site AccessBeginning May 24, 2012, the Web administrator you assign for your practice can request a unique username and password to process prior approval requests for all practitioners who use the same TIN byaccessing ICORE’s provider self-service at www.icorehealthcare.com. Click on the “Provider andPhysicians” icon and then “New User Request ID.”• Please have the following information ready:- Provider/Facility Name- Tax ID- E-mail address• Please allow up to two business days for information regarding your user access.• The administrator will then be able to set up a user name for each individual ICORE Web site user inthe practice.• The ICORE Web site cannot be used for retrospective or expedited approval requests. Those must beprocessed directly through the ICORE call center.Note: Providers who need to order replacement drugs from ICORE must use the appropriate fax orderform located at www.emblemhealth.com/ICORE. (See the EmblemHealth Specialty Pharmacy Programsection of this guide.) If the replacement drug will be ordered from another company, prior approval may berequested using ICORE’s Web site and the drug order placed using your current processes. The supplier willbe responsible for ensuring prior approval is on file with ICORE before sending out replacement drugs.3
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