Injectable medication program
As you are aware Moda has partnered with Prime Therapeutics Management LLC 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 Prime Therapeutics Management LLC 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 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?
Prime Therapeutics Management LLC will review your prior authorization requests for the following specialty injectable medications that are performed in:
- an outpatient facility
- a patient’s home
- a physician’s office
Injectable Medication Prior Authorization List
What injectable medications are covered under the pharmacy benefit?
Beginning April 1, 2019, Moda, Ardon Health, and other participating specialty pharmacies will be expanding their management of specialty medications to include infused medications. This program expansion aims to provide consistent, quality service, improved reporting, and 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 | Tezspire | J2356 |
| Respiratory/Dermatology | Nucala | J2182 |
| Multiple Sclerosis | Ocrevus | J2350 |
| Multiple Sclerosis | Ocrevus Zunovo | J3590 |
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.
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 currently applicable to Oregon commercial fully insured members, including group and individual members, and will also apply to OEBB members on October 1, 2019, and PEBB members on January 1, 2020. This does not currently apply to Moda Medicare Advantage, select ASO, or OHP/EOCCO members. A complete list of groups for which these medications are covered under the medical benefit can be found below. For all other groups, coverage will be under the pharmacy benefit only. This list of medications included in this program will be reviewed annually.
For more information, please see the resources below.
How to submit a request to Prime Therapeutics Management LLC
- Visit the self-service provider portal at Medical Rx Prior Authorization | Prime Therapeutics Management LLC
- Or Call 800-424-8114
Additional Resources
- Infused Medications Covered Under the Pharmacy Benefit for Select Groups
- Group Exclusion List
- FAQ: Coverage Changes for Infused Specialty Medications
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.
Questions?
If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service
Questions?
If you can't find an answer, please feel free to contact our Customer Service
Employer web tools
Benefit Tracker
Check benefits, eligibility, incentive and utilization
Rate finder is now in the Producer Dashboard
Log in with your current username and password to create quotes for groups up to 50.
Producer DashboardLog in
Hello.
We have exciting news to share. ODS is changing its name to Moda Health.
Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.
Together, we can be more, be better.
Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:
Hello.
Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:
Changing your location to Oregon
You can return to your previous location in the site header.