EBCBS_Predetermination

**Attention NYSSMOH Members**

EBCBS in their April Newsletter has listed certain drugs that are now available for predetermination. It should be noted…that without a predetermination claims for these drugs will be pended for charts notes.Practices are encouraged to review their aging reports for unpaid claims for listed drugs and to complete the predeterminations (post and pre) forms to ensure timely payment.

Predetermination now available for certain specialty pharmacy drugs effective
April 5, 2010

Code/ Drug /Applicable policy

Code     Drug     Applicable policy
J0129     Orencia     Drug.00040
J1440 and J1441     Neupogen     CG-Drug-16
J1745     Remicade     Drug.00002
J2355     Neumega     CG-Drug-01
J2469     Aloxi     CG-Drug-01
J2505     Neulasta     CG-Drug-16
J3490     Cimzia     Drug.00002
J9010     Campath     CG-Drug-01
J9015     Proleukin     CG-Drug-01
J9025     Vidaza     CG-Drug-01
J9035     Avastin     Drug.00038
J9041     Velcade     CG-Drug-01
J9055     Erbitux     Drug.00036
J9263     Eloxatin     CG-Drug-01
J9264     Abraxane     CG-Drug-01
J9293     Novantrone     CG-Drug-01
J9303     Vectibix     Drug.00035
J9305     Alimta     CG-Drug-01
J9310     Rituxan     Drug.00041
J9355     Herceptin     Drug.00039
J9395     Faslodex     CG-Drug-01

This predetermination will allow you to know in advance if use of these drugs will meet Empire coverage requirements, including but not limited to member eligibility, benefit plan language, medical policies and clinical guidelines. As always, you can administer these drugs without obtaining a predetermination and have the claim reviewed post service for medical necessity and benefit coverage.
You can file a predetermination form online. Forms are available on empireblue.com> download commonly used forms > specialty pharmacy forms
You can fax us the form:
Simply download the form from empireblue.com > provider home > answers @ empire > download commonly used forms >specialty pharmacy forms. Then fax it to the number listed on the form.
You can call us:
Contact Empire Medical Management at 800-982-8089
You can e-mail us:
Send an e-mail to NYSecurePre-Cert@Wellpoint.com

Any questions please contact Empire Blue directly.

Regards

Abraham Mittelman, MD
President, NYSSMOH