Answers to Frequently Asked Questions Provider-Administered Injectable Drug Program
What is the Provider-Administered Injectable Drug Program?
The provider-administered injectable drug program is a reimbursement and utilization management program for services administered in the physician office setting. The drugs covered by the program are most often administered by physicians specializing in hematology/oncology, rheumatology, and urology. This program has been developed by and will be managed with the assistance of ICORE Healthcare, LLC (ICORE).
Why is HealthAmerica implementing this Provider-Administered Injectable Drug Program?
HealthAmerica strives to meet the needs of the changing health care environment. The purpose of this program is to manage specific drugs requiring administration by health care professionals, while ensuring quality care and affordability for our members.
Questions Related to Prior Authorization What is the implementation date of the prior authorization component of this program?
This program will begin on December 1, 2009.
What is the prior authorization component of the Provider-Administered Injectable Drug Program?
This component is a utilization management program that will require physicians to obtain a prior authorization for specific drugs that are administered in the physician office setting. ICORE will perform a prior authorization for the drugs identified below on behalf of HealthAmerica.
What drugs will require a prior authorization review by ICORE?
• Aloxi • Aranesp • Avastin • Epogen/Procrit • Herceptin • Neupogen • Neulasta • Leukine
How does this program interface with HealthAmerica’s current requirements for prior authorization of injectable drugs?
For drugs other than those listed above, prior authorization requirements and processes will not change. Call HealthAmerica at 800-755-1135 for all telephone requests for prior authorization. Your call will be routed to ICORE if you are requesting prior authorization for one of the drugs listed above. Effective 12/1/09 will prior authorization be required for Aloxi (J2469)?
Prior authorization will be required for Aloxi effective 12/1/09 for use with highly emetogenic chemotherapy as defined by the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) guidelines. Aloxi can be used with moderately emetogenic chemotherapy if the member failed on another 5HT3 (Kytril, Anzemet and Zofran). Chemotherapy regimens defined as highly emetogenic per ASCO and NCCN guidelines include: • Cisplatin • Mechlorethamine • Streptozocin • Cyclophosphamide • Carmustine • Dacarbazine • Dactinomycin
Who should obtain the prior authorization?
The ordering physician should obtain the prior authorization.
How do I contact ICORE to obtain a prior authorization?
Access ICORE’s secure website at www.icorehealthcare.com and click on the physiciantab; or for initial calls for prior authorization contact HealthAmerica at 800-755-1135, and your call will be routed to ICORE. For information related to existing ICORE authorizations or for reauthorizations, contact ICORE directly at (800) 424-1719, or utilize ICORE’s website at www.icorehealthcare.com and click on the physiciantab.
How do I access the ICORE website to authorize a drug?
You will receive specific information and instructions which will include your user name and password about one month prior to implementation of the program.
Does a prior authorization guarantee payment of a service?
No, a prior authorization does not guarantee payment for services. Payment is contingent upon member eligibility and benefits.
What will occur if a prior authorization is not obtained?
If prior authorization is not obtained for the applicable drugs, payment for those services will be denied. Members cannot be held responsible for denied charges.
What is the transition of care process? Members receiving a drug that was previously authorized by HealthAmerica will need to be authorized by ICORE to continue treatment after December 1, 2009. Authorizations issued by HealthAmerica before December 1, 2009, will be effective until the authorization end date. To continue treatment after the authorized end date, you must obtain an authorization from ICORE. (Claims for dates of services after the authorized end date will be denied if you have not obtained a continued authorization from ICORE.)
Members who will start treatment after December 1, 2009. For members who are not currently in treatment but will be receiving one of the drugs listed above after December 1, 2009, authorizations must be completed by ICORE before treatment begins.
Members being treated with Aloxi (J2469) and will continue treatment after December 1, 2009. Aloxi did not require prior authorization before December 1, 2009. As of December 1, 2009, ICORE will require prior authorization for this drug. For members already taking Aloxi before December 1, 2009, you will have 10 business days to obtain your first prior authorization with ICORE. Claims for dates of service between December 1, 2009, and December 14, 2009, (10 business days) will not be denied because of prior authorization. However, claims for dates of service on or after December 15, 2009 will be denied if you have not completed a prior authorization. What location of service does this prior authorization review process include?
The provider-administered injectable drug program applies to services rendered in the physician office setting.
What does the prior authorization number look like?
ICORE’s prior authorization number consists of up to 15 alphanumeric characters (e.g., 09123456789I). If the physician’s prior authorization request is not approved at the time of initial contact, the ordering physician may receive an ICORE tracking number, which is not the same as a prior authorization number. Physicians can use the tracking number to track the status of their request on ICORE’s website. How long does the prior authorization approval remain in effect?
This is determined by the plan of treatment and the drug being used. The following is the duration of the authorization by drug:
• Aranesp - 8 weeks for initial authorization, 12 weeks for re-authorization; for Myelodysplastic syndromes (MDS )
validity is 180 days for both authorization and re-authorization
• Epogen/Procrit - 8 weeks for initial authorization, 12 weeks for re -authorization; for Myelodysplastic syndromes
(MDS ) validity is 180 days for both authorization and re-authorization
Is a prior authorization necessary if HealthAmerica is not the member’s primary insurance?
Yes, HealthAmerica does require a prior authorization when responsible for claim.
Whom do I contact regarding denials and appeals?
For prior authorization appeals related to a denial received from ICORE, please follow the instructions on the denial letter.
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