Prior Authorization (PA) for Physician Administered Drugs and Training Schedule with ICORE for Physician Administered Drugs

 

 I.        Prior Authorization (PA) for Physician Administered Drugs

South Carolina Department of Health and Human Services (SCDHHS) is implementing a new provider-administered injectable drug program in conjunction with ICORE Healthcare, LLC (ICORE), a specialty pharmaceutical management company.  The program affects certain drugs requiring administration by health care professionals and will ensure quality care and affordability for our members.

For all Physician Administered drugs that require a PA performed on or after September 9, 2013, referring providers will be required to request PA for all beneficiaries participating in Fee-For-Service (FFS) or Medical Homes Networks (MHNs).  ICORE will begin accepting PA requests on September 3, 2013, for dates of service beginning September 9, 2013. Claims submitted for services rendered without an approved authorization will be denied.  ICORE will conduct medical necessity reviews forthe injectable medications listed below. 

 

HCPCS Code

Drug Name

J2505

Neulasta

J9355

Herceptin

J9035

Avastin

J1745

Remicade

J9263

Eloxatin

J9305

Alimta

J9055

Erbitux

J9310

Rituxan

J2323

Tysabri

J2469

Aloxi

J9264

Abraxane

J0881

Aranesp

J1441

Neupogen

J0885

Procrit

J0129

Orencia

J1440

Neupogen

J9303

Vectibix

J9228

Yervoy

J9179

Halavan

J2507

Krystexxa

C9131

Kadcyla

C9292

Perjeta

Q2043

Provenge

 

The following eligibility categories participating in either FFS or MHN programs will be excluded from obtaining a PA for Physician Administered drugs:

  • Beneficiaries with current Medicare coverage (dual Medicare and Medicaid coverage)
  • Beneficiaries with third party HMO coverage
  • Beneficiaries that are incarcerated
  • Beneficiaries enrolled in the Hospice program
  • Beneficiaries enrolled in the PACE program
  • Beneficiaries with limited benefits

 

Physician Administered drugs administered in conjunction with an inpatient stay or emergency room visit will not be subject to PA requirements.  For information regarding emergency services please refer to the appropriate Medicaid manual.

The Hospitals and Physicians, Laboratories, and Other Medical Professionals provider manuals will be updated September 1, 2013, to reflect this policy change.  These manuals can be found on the SCDHHS website at www.scdhhs.gov.  The procedure list will also be available in the above titled manuals, see “Procedure Codes Requiring Prior Authorization” in Section 4.  The list of procedures requiring PA is subject to change as new drugs come to market.  Section 4 of the manuals will be updated monthly, if new drugs are released.

 

II.         Training Schedule with ICORE for Physician Administered Drugs

SCDHHS and ICORE will be providing webinar trainings for providers on the PA process.  The following dates and times are being offered.

·         Tuesday August 27th: 10:00 a.m. or 2:00 p.m.

·         Wednesday August 28th: 10:00 a.m. or 2:00 p.m.

 

To register for one of the webinars please choose a date and time from the list above and send the following information via email to injectablesolutions@icorehealthcare.com .

 

·         Webinar Date and Time

·         Group Name

·         Address

·         Email and phone contact information

·         Number of participants (please indicate if attendees are clinical and/or administrative.

 

Once completed, you will receive an e-mail confirmation with instructions on accessing the webinar.

This bulletin affects those members currently either enrolled with the fee-for-service Medicaid program or those that may be enrolled in an MHN. For members that may be enrolled in a Managed Care Organization (MCO) please  contact the appropriate managed care organization (MCO) for information regarding the MCO’s policy or prior authorization of physician administered drugs.  

Please refer any questions or concerns regarding this bulletin to the SCDHHS Provider Service Center at (888) 289-0709.  Thank you for your continued support of the South Carolina Medicaid program.

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