ICORE Healthcare: Injectable DrugUtilization Management ProgramOverview for EmblemHealth Providers

May 1, 2012

Agenda Topics for Today

1. Program Summary

– Specialty Injectable Drugs in scope

– EmblemHealth members in scope

– Transition of Care Process

2. Prior Authorization

– Obtaining a user ID for ICORE’s website

– ICORE Prior Approval Process• Web and Phone

– Providers utilizing the Specialty Pharmacy Drug ReplacementProgram

• Fax

3. Web Tool Demo

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Program Summary

Program Summary

•Effective June 1, 2012, providers will need to contact ICORE for priorapproval for 30 drugs either by phone (800) 424-1814 or throughICORE’s HIPAA-compliant web portal at www.icorehealthcare.com.

• The prior approval will be necessary when administration of drug will bein a Physician Office (place of service 11); Outpatient Hospital (place ofservice 22) or Ambulatory Surgical Center (place of service 24)

•Emblem retains primary responsibility for customer service, with supportfrom ICORE as needed related to prior approvals and for claimsprocessing

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Program SummarySpecialty Injectable Drugs In Scope

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J-Code RA Drugs

J0129 Orencia®

J1745 Remicade®

J3488 Reclast®

J-Code IVIG Drugs

J1566 Carimune® NFand GammagardS/D

J1572 Flebogamma®

J1569 Gammagard

J1557 Gammaplex

J1561 Gamunex®-C andGammakedTM

J1568 Octagam®

J1459 Privigen®

J-Code Brand NameJ9264 Abraxane®

J9305 Alimta®

J2469 Aloxi®

J0881 Aranesp®

J9035Avastin® (forcancer only)

J0585 Botox®

J0885 Epogen®/Procrit®

J9055 Erbitux®

J9355 Herceptin®

J2820 Leukine®

J0587 Myobloc®

J2505 Neulasta®

J1440/J144 Neupogen®

Q2043 Provenge®

J9310 Rituxan®

J2353 Sandostatin® LAR

J1300 Soliris®

J9225 Vantas®

J9303 Vectibix®

J3487 Zometa®

Members Impacted by Program

Members Covered by Program

• GHI HMO/POS

• Commercial plans underwritten by HIP (HIPHMO/POS/EPO/PPO, CompreHealth EPO/HMOand Vytra HMO)

• HIP state- sponsored programs (Medicaid, FamilyHealth Plus and Child Health Plus)

• EmblemHealth Medicare HMO (underwritten byHIP) EmblemHealth Medicare PPO (underwrittenby GHI)

• GHI and HIP FEHB plans

• Vytra ASO account members.

• HIP members who have elected to obtain care fromone of our physician group practices (shown onmember ID card):

– Manhattan’s Physician Group

– Preferred Health Partners, (Brooklyn)

– Queens–Long Island Medical Group

– Staten Island Physician Practice

Members Excluded from the Program

• Commercial plans underwritten by GroupHealth Incorporated (EmblemHealth EPO/PPOand GHI EPO/PPO)

• NY Bridge Plan (underwritten by Group HealthIncorporated) and HIP Members assigned to aMontefiore or Health Care Partners PCP areexcluded from this program.

• Montefiore (CMO) or Health Care Partners(HCP) will have the Managing Entityassignment shown on the back of their memberID cards and on the Member Details page of theEligibility/Benefits lookup feature onwww.emblemhealth.com.

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Transition of Care Process

Members who will start treatment on or after June 1, 2012

• Authorizations must be completed by ICORE before treatment begins.

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Members currently being treated with drugs in scopethat DID NOT require a prior authorization beforeJune 1, 2012

• Continuation of treatment will require a priorauthorization from ICORE.

Prior Authorization Process

Access to ICORE’s Website

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Starting May 24, 2012, providers are able to request a user ID andpassword using ICORE’s Website: www.icorehealthcare.com

Providers who have not yet done so must consider who in their practicewill be your primary administrator and who will need to have access toICORE’s web site.

If a provider administers any of the drugs in scope, but will not beinitiating the prior approval, it still may be necessary for them to refer tothe authorization number so a web access will be needed.

How to Submit a Request - Providers

3 Easy Options:

• Visit ICORE’s Web site at www.icorehealthcare.com

• Call ICORE at 1-800-424-4084 M-F 8am-6pm

• Fax requests (Specialty Pharmacy process)

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Click on the “Providersand Physicians” icon.

Timeframes for Requests

Standard requests:

•Non urgent requests will be completed within 3 days from receipt of the request.

•In most cases, ICORE can review and determine prior authorization during the initial phonecall if all information needed to process a request is provided.

•The review and determination process may take longer if member or provider eligibilityverification is required and/or if the request requires additional clinical review.

Urgent requests:

•Medication needed on same day must be obtained by contacting the ICORE Call Center.

•All other urgent requests will be completed within 24 hours from receipt of request.

•In most cases, ICORE can review and determine prior authorization during the initial phonecall if all information needed to process a request is provided.

•The review and determination process may take longer if member or provider eligibilityverification is required and/or if the request requires additional clinical review.

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ICORE’s Prior Authorization Processfor Providers

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To expedite the authorization process please have the following informationready:

•Member name and ID

•Requested drug

•Start date of treatment

•Member weight and body surface

•Dosing and frequency

•Diagnosis

•Past therapeutic failures

Note: If requested, be prepared to fax the following documents to (888) 656-6671:

•Clinical notes

•Pathology reports

•Relevant lab test results

Specialty Pharmacy Provider Process

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•If the drug is on the Specialty Injectable Drug Prior Approval List for theutilization program managed by ICORE, prior approval will be required fromICORE.

•If the provider is looking to use the Specialty Pharmacy Program to obtainreplacement medications from ICORE, special fax forms have been developedto enable providers to submit a request for prior approval and drugreplacement in one transaction.

•If the provider intends to obtain the drug from another contracted vendor, e.g.Bioscrip/Curascript, they should use ICORE’s web site or call ICORE torequest a prior approval. Once prior approval has been issued, an order forthe drugs may be placed with the Specialty Pharmacy Program.

ICORE Specialty Pharmacy Program

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ICORE Specialty Pharmacy Program(non-chemo)

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ICORE Specialty Pharmacy Program(chemo)

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Web Tool Demo

Web Tool Demonstration

www.icorehealthcare.com

Web Tool DEMO

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Program Detailsfor Injectable Drug Utilization Management Program

• To request a Prior Authorization by phone

– 1-800-424-4084

• To request a Prior Authorization by Fax (option for Buy & Bill Providers only)

– 1-888-656-6671

• To request via the Web

– www.icorehealthcare.com

• General inquiries for Providers

– EmblemHealth– (Eligibility/Benefits/Claims)

• www.emblemhealth.com

• 866-447-9717 option 1

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Questions?