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Injectable medication program

As you are aware Moda 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 in regard to the review and approval of certain injectable medications.

The MagellanRx program applies to all fully insured Commercial membership. Select ASO, Medicare Advantage, PERS Medicare and non-Medicare membership will be added at this time as well. An additional 6 new HCPCs are being added to the prior authorization list of medications.

All in-network individual, ASO, small, and large group plans, Moda will deny services if required prior authorization is not obtained prior to rendering the service. If a prior authorization is not obtained for in-network services, Moda will deny charges as provider responsibility.

What injectable medications are covered under the medical benefit?

MagellanRx will review your prior authorization requests for the following specialty injectable medications that are performed in:

Effective March 1, 2019
J0638 Ilaris

What injectable medications are covered under the pharmacy benefit?

Beginning Apr. 1, 2019, Moda and Ardon Health Specialty Pharmacy will be expanding their management of specialty medications to include infused medications. This program expansion aims to provide consistent, quality service, improved reporting, and an enhanced member experience with lower member out-of-pocket costs.

For all applicable Oregon Moda Health commercial fully insured members, including group and individual members, select infused specialty medications will only be covered under the pharmacy benefit and claims submitted under the medical benefit will be denied as provider liability. Claims for the administration of the medication should continue to be billed to the member’s medical benefit.

Effective April 1, 2019
Type Brand name Procedure code
Respiratory/Dermatology Cinqair J2786
Respiratory/Dermatology Fasenra J0517
Respiratory/Dermatology Xolair J2357
Respiratory/Dermatology Nucala J2182
Multiple Sclerosis Ocrevus J2350
Neurology Spinraza J2326

These prescriptions should be sent to Ardon Health or participating pharmacies for processing and fulfilment rather than being obtained through the “buy and bill” process. Please note: Ardon Health does not have access to Spinraza at this time and it should be sourced from participating pharmacies.

Prior authorization for the infused specialty medications listed above may be completed by submitting the request through the CoverMyMeds ePA tool found at covermymeds.com, or by contacting Ardon Health or participating pharmacies directly.

This benefit change is only applicable to Oregon commercial fully insured members, including group and individual members, and does not currently apply to Moda Medicare Advantage, ASO, or OHP/EOCCO members. A complete list of groups for which these medications are covered under the medical benefit can be found below. This list will be updated annually; however, new drugs may be added to the list at the time of FDA approval.

Resources

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 FAQ (last updated 2/2017) or call our Customer Service team toll-free at 800-258-2037.

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