Tag: #specialtydrug

Posted in #Medicare, #Medicareadvantage, #reimbursement, EmblemHealth NY, NY Providers, Payer Updates, Pharmacy (Various Insurance Payers), Training

Emblem Health new Specialty Meds/Pharmacy Policy

Posted on by KR2Medical Billing

Effective 7/14/25 there is a new specialty pharmacy policy will apply to all of Emblem Health lines of busines: commercial, Medicare, medicaid.

Image via emblemhealth

This policy applies to all outpatient providers in the following place of service: outpatient hospital, physician office,home of the member and ambulatory infusion.

Takeaways:

1. According to this policy the providers need to contact the respective specialty pharmacy to request prior auth and are only allowed to bill for specialty medications administration NOT the medication itself.

2. The Specialty Pharmacy will be allowed to bill Emblem health under the member’s medical benefit and receive reimbursement.

Image via EmblemHealth

3. For any Medicaid EmblemHealth plan- the medicatin codes must be on Medicaid Fee Schedule. If the code is not listed it will not be reimbursed.

Exclusion: this policy does not apply to home infusion providers.

For a full list of specialty medications please visit Emblem Health for more information and a PDF version of the policy

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Posted in Cinga Insurance

Cigna- Drug Formulary Changes effective January 2022

Posted on by KR2Medical Billing

In this blog post we will explore the changes that affect Specialty medications for both medical and pharmacy benefits.

What does this mean for providers?

Please check to see which changes apply to your patients. Please contact Cigna or check on their website CignaforHCP.com for more specialty drug changes and any other suitable alternatives.

What does this mean for patients?

Patients that get their medication from a pharmacy may see higher out of pocket costs. Please contact your healthcare provider to see if there are any other suitable alternatives.  

Medical Benefit Specialty Medications:

  1. Immuno globulins: Cigna preferred drugs are Flebogamma, Gamunex-C, Gammaked, Gammaplex, Hizentra, Octagam, and Privigen. Any other Immuno globulins that are on the non-preferred list will require a step therapy. Cinga is letting the current authorizations for non-preferred immune globulins be active until the authorization expiration date. After which the provider will need to reevaluate the patient for any preferred drugs.
  2. Iron Replacement: Cigna will require a prior authorization for following iron replacement drugs-Feraheme, Injectafer, and Monoferric. These drug will also have step therapy that will go through Verofer. This requirement does NOT apply for patients with dialysis-dependent chronic kidney disease. IF the patient has a pharmacy benefit (Advantage and Performance Formularies) will require a prior authorization WITH a step therapy.
  3. Neutropenia: Udenyca will no longer will be on the preferred list. Patients that currently take Udenyca are allowed to keep taking it until their current authorization will expire. (Patients that do have a three-tier pharmacy benefit MAY see their cost share change, if they fill the Rx under their pharmacy benefit).  Cigna will make Ziextenzo a preferred medication and will be added to the list with Neulasta, Neulasta Onpro, and Nyvepria.
  4. Pulmonary Hypertension: Remodulin-will require a step therapy through treprostinil (generic equivalent)
  5. Transplant Therapy: Nulojix will require precertification and may require a site of care review.

Pharmacy Benefit Specialty Medications:

  1. HIV medications: Cigna will REMOVE the following medications from the formulary-Kaletra, Atripia, Emritva, Intelence, and Symfi/Symfi Lo.
  2. Multiple Sclerosis: For patients that start the treatment and providers that initiate a new prior authorization-all single-source brands (oral, injectable, and infusion medications, will have a step therapy requirement.
  3. Oncology: Cigna will put Tasigna on a non-preferred list. For any new treatment and initiated prior authorizations there will be a step therapy requirement.

For a full list of Medication/drug formulary changes for the year 2022, please click here.

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