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Injectables / Infusion / Specialty Drugs support


Injectable Medication Program

Moda Health has partnered with MagellanRx to assist you in medical pharmacy management through the provider administered injectable medication program. Moda Health is committed to providing our members with access to high-quality healthcare. With this commitment in mind and to ensure quality care and affordability to our members, we will implement updates to our processes regarding the review and approval of certain injectable medications.

Injectable Medications Covered Under the Medical Benefit

MagellanRx will review your prior authorization requests for the following specialty injectable medications that are performed in an outpatient facility, a patient’s home, or a physician’s office.

See a full list of which injectable medications require a Prior Authorization under the medical benefit and their coverage policies at the follow locations:

Post Service Claim Edits Program (PSCE)

In a partnership with MagellanRX, Moda Health implemented a claim check program for injectable and/or infusion medications.

The claim check program monitors and promotes appropriate use, safety, and cost effectiveness of medications prescribed to our members. We will do this by reviewing claims for appropriate frequency, correct units, and eligible diagnosis codes.

This program applies to all injectable and/or infusion medications currently requiring prior authorization that are, ordered or administered by providers. However, the medications within the list below do not require prior authorization. Moda Health applies post-service; pre-payment claims edits to diagnosis criteria and criteria for maximum units for the following medications. Please review the criteria for specific covered diagnosis codes and dosing limits for each medication. You can find the full list of medications that do not require prior authorization, but are still included in the PSCE program and their coverage policies at the following location:

Site of Care Specialty Infusion Program

Our partnership with Magellan Rx will expand to include a Site of Care program that directs members to the most cost-effective, yet clinically appropriate, location to receive their infusion(s) of the select specialty medications (see medication list, below).

Through the current prior authorization program administered by Magellan Rx, infusion requests for a hospital outpatient setting for the listed medications will be redirected to a preferred site of service, which will be either preferred home infusion providers or a professional office setting. Infusions for these medications will not be covered when administered in a hospital outpatient infusion center.

The medications included in the Site of Care program already require prior authorization through Magellan Rx. The Site of Care program requirements will be administered as part of the existing prior authorization program. As a reminder, Moda will deny services as provider responsibility when prior authorization is not obtained for any medications that require prior authorization.

This program only applies to Texas Equal Funding Groups. Texas Individual and Texas Large Group members are not subject to this program. 

Working together to improve patient care

Making sure our members receive the best possible care at the most affordable price is why we come to work each day. But we can’t do this alone. We appreciate your support in assuring Moda Health members receive high quality, affordable care and deliver results consistent with nationally recognized clinical criteria and guidelines.

To learn more about our injectable medication program, please take a look at our FAQs about our Injectable Drug Program or call our Customer Service team toll-free at 877-605-3229.

Questions?

Medical Customer Service is at 844-931-1779.

We're available 6:00 a.m. to 6:00 p.m. Monday through Friday, 9:00 a.m. to Noon Saturday, Sunday, and Holidays (Central Time).

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