Category: Pharmacy (Various Insurance Payers)

Find the latest Pharmacy/Formulary Updates (Various Insurance Payers)

Posted in Pharmacy (Various Insurance Payers), Training, Updates

NY/CA UHC CommunityHealthPlan: updated info for Xolair and Synagis auth, 04/01/2021

Posted on by KR2Medical Billing

Starting 04/01/2021- the providers will need to request an authorization for Xolair and Synagris if they plan on billing through patient medical benefit. (Community Health Plan)

This change applies to providers in CA and NY (community health plans).

These requirements will apply whether members are new to therapy or have already been receiving these medications.

UHC will honor existing authorizations for Xolair until the end date on the authorization or the date the member’s eligibility changes.

Providers don’t need to submit a new prior authorization request for members who already have an authorization for Xolair on April 1, 2021.

You can submit prior authorization requests in the following ways:

  • Online: Use the Prior Authorization and Notification tool on Link. Go to UHCprovider.com/paan.
  • Call: Use the Provider Services phone number on the member’s health care identification card.
Posted in MVP (NY/VT) Insurance Payer, Pharmacy (Various Insurance Payers), Training, Updates

NY Managed Medicaid Plans Reimbursement Update: Pharmacies 05/01/2021

Posted on by KR2Medical Billing

Starting 05/01/2021– The prescriptions will no longer be covered and paid under the Managed Medicaid Plans (ei. MVP). Instead the prescriptions will be covered under NY Medicaid Fee for Service Fee Schedule.

Where can I find the list of covered medications?

  1. Medicaid Fee for Service has a list of covered medications. OTC (over the counter medications and most other medications are on that list. The list can be found on emdNY website.
  2. Medicaid Fee for Services also has a preferred medication list. This list can be found by clicking here.

Do I have to participate in NY Medicaid Fee for Service?

As a pharmacy (provider) you will need to participate in NY Medicaid Fee for Service, in order to fulfill the Managed Medicaid Patient RXs.

What else do I need, in order to process claims?

A Managed Medicaid Member has to show you their NY Medicaid Card or your Health Plan Card. As a Participating Pharmacy Provider you will need the CIN number in order to file your claims.

For General Information and Updates please click here.

Posted in BCBS Empire NY, NY Providers, Pharmacy (Various Insurance Payers), Training, Updates

BCBS (NY): HIV medication combinations may require Prior Auth, 05/01/2021

Posted on by KR2Medical Billing

Effective 05/01/21 and for the DOS thereafter, BCBS (Empire) NY, will implement a new prior authorization for HIV medications/drugs. This would help to ensure that the patients are not receiving therapeutic duplications when taking certain combinations.

In order for the Member to continue to receive the treatment that involves drug combinations, the provider must submit an authorization for EACH Drug and provide a MEDICAL NECESSITY rationale as to why that drug combination is clinically needed.

Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.

Examples of HIV drug combinations that would trigger duplicated drug combinations:

Providers and members expected to be impacted by this policy will receive advanced notice by mail.

Source: BCBS (NY) Providers Communications: March 2021