Date Issued: 12/27/2016
In 2017, EmblemHealth will begin to review specialty pharmaceutical drugs submitted via both professional and facility claims. Our review categories and parameters are established using guidelines from the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and professional literature. Reviews will ensure a relationship between established parameters and medical appropriateness or necessity (e.g., diagnosis, member age or maximum billable units).
Reviews will identify the following pharmaceutical agent code(s):
- Those submitted on claims without the corresponding covered/inclusive diagnosis code, or when submitted with a noncovered/exclusive diagnosis code.
- Any quantity or unit exceeding the expected daily maximum dose for the drug alone, or for the drug when paired with a covered diagnosis.