Medical Injectables Program Provider Questions and Answers
Horizon Blue Cross Blue Shield of New Jersey collaborates with Magellan Rx Management to manage our Medical Injectables Program (MIP). Magellan Rx Management, a specialty pharmaceutical management company, conducts medical necessity and appropriateness reviews (MNARs) for specific injectable medications in accordance with Horizon BCBSNJ's medical policy criteria and guidelines when provided: at a freestanding or hospital-based dialysis center; in an outpatient facility; in a patient's home; or in a physician's office.
Select a category below or scroll down to review the questions and answers.
Medical Necessity and Appropriateness Review (MNAR)
In-network specialty pharmacy/home infusion providers
Injectable Medication Codes Subject to MrxM Claim Review/Editing
This information was last revised on May 1, 2023
Magellan Rx Management is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in conducting medical necessity and appropriateness reviews (MNARs) for specific injectable medications. Magellan Rx Management is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.
General Program Information
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The MIP is a medical management program administered by Magellan Rx Management for certain injectable medications. Magellan Rx Management will perform medical necessity and appropriateness review (MNAR)in accordance with Horizon BCBSNJ medical policies criteria and guidelines in an effort to improve quality of care and patient safety.
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An MNAR is a process in which a participating or nonparticipating provider requests a review of the administration of an injectable medication to ensure it is medically necessary and appropriate. Doctors and other health care professionals are encouraged to contact Magellan Rx Management to obtain an MNAR prior to rendering services.
If you do not obtain a pre-service MNAR determination, your claims may be delayed or denied pending our receipt of the information needed to establish medical necessity.
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There are specific injectable medications included in this program. You may access the most current list on the Medical Injectables Program main page.
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Beginning August 1, 2023, MRxM will require the submission of pertinent medical record information to complete their MNAR for the injectable medications listed below.
- Aldurazyme
- Amondys 45
- Amvuttra
- Berinert
- Blenrep
- Blincyto
- Brineura
- Cinryze
- Elaprase
- Enjaymo
- Evkeeza
- Exondys 51
- Fyarro
- Gamifant
- Givlaari
- Kalbitor
- Krystexxa
- Lumizyme
- Mepsevii
- Naglazyme
- Nexviazyme
- Onpattro
- Oxlumo
- Poteligeo
- Proleukin
- Ruconest
- Soliris
- Spinraza
- Tepezza
- Tivdak
- Trodelvy
- Ultomiris
- Uplizna
- Viltepso
- VimizIm
- Vyondys 53
- Vyvgart
- Xenpozyme
Our list of injectable medications and HCPCS codes included as part of our MIP has been updated to include a medical record requirement indicator for these medications. Please note that this list is subject to change.
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The list of medications requiring MNAR is updated when medications are added or removed from the scope of this program. Prior to calling Magellan Rx Management for an MNAR, we encourage you to review the list on the Medical Injectables Program page.
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No. Depending on the place of service, you may not need a MNAR performed by Magellan Rx Management. Magellan Rx Management will not perform MNARs on injectable medications administered during an inpatient stay, in an observation room or in an Emergency Room.
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Magellan Rx Management and CareCentrix have shared responsibilities for certain medical injectable drugs included in the Horizon BCBSNJ Medical Injectables Program when provided in a patient's home.
If your patient will have medical injectable drugs administered in his or her home in New Jersey, please call Horizon Care@Home at 1-855-243-3321 to locate a participating provider and to initiate a pre-service determination.
If a medical injectable drug is to be provided in a patient's home located outside of New Jersey, please continue to contact Magellan Rx Management to initiate a medical necessity and appropriateness review.
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The MIP applies to all members enrolled in fully insured and level-funded plans/products listed below, as well as to members enrolled in these plans/products through self-insured Administrative Services Only (ASO) employer groups that have elected to participate in the MIP.
- BlueCard® Home
- Braven Health
- Direct Access
- EPO
- HMO
- Indemnity/Traditional
- Medicare Advantage
- OMNIA Health Plans
- POS
- PPO
- SHBP/SEHBP
- UNITE HERE HEALTH
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Members enrolled in the Federal Employee Program® (FEP®), Horizon NJ Health (Medicaid) and some Horizon Labor Advantage (HLA) plans are excluded from the MIP.
Medical Necessity and Appropriateness Review (MNAR)
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You should obtain an MNAR upon determining the patient's treatment plan for injectable medications. Obtaining an MNAR prior to services being rendered will help to expedite claims processing.
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No. Horizon BCBSNJ does not require MNARs for members whose Horizon BCBSNJ coverage is secondary to another commercial carrier.
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A rendering and/or ordering participating provider can initiate an MNAR determination by:
- Visiting ih.magellanrx.com
- Calling Magellan Rx Management at 1-800-424-4508, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time (ET). Multiple requests can be handled with one call. Magellan Rx Management representatives are available after hours and on weekends for urgent requests.
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Please have the following information available when contacting Magellan Rx Management to initiate an MNAR:
- Ordering provider name, address, phone and fax numbers
- Rendering provider name, address, phone and fax numbers (if different from ordering provider)
- Horizon BCBSNJ member identification number, name, date of birth and gender
- Member height, weight and body surface area
- Anticipated start date of treatment (if known)
- Requested injectable medications
- Dosing information and frequency
- Diagnosis and disease state severity
- Past therapeutic failures
- Concomitant medications
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Additional information may be requested depending on the injectable medication, such as:
- Clinical notes
- Pathology reports
- Relevant lab test results
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An ordering provider is responsible for requesting and obtaining the MNAR and supplying all of the clinical information.
If an MNAR is not obtained prior to services being rendered, claims payment may be delayed pending completion of a MNAR determination.
Please refer to the Quick Reference Guide and follow the steps on verifying the status of an MNAR determination on ih.magellanrx.com.
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Yes. You may request a Peer-to-Peer consultation by calling Magellan Rx Management at 1-800-424-4508, Monday through Friday, between 8 am and 5 pm ET.
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As a rendering provider, you are responsible for ensuring an MNAR determination is on file for the patient. If you call Magellan Rx Management to initiate an MNAR, Magellan Rx Management will contact the ordering physician to obtain the necessary clinical information.
If an MNAR is not obtained prior to services being rendered, claims payment may be delayed pending completion of an MNAR determination.
Please refer to the Quick Reference Guide and follow the steps on verifying the status of an MNAR determination on ih.magellanrx.com.
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Yes. Facilities and ancillary providers may initiate an MNAR, but Magellan Rx Management will need to contact the ordering physician to obtain the clinical information necessary to make a determination.
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The ordering and rendering provider (if applicable) will receive a copy of the determination letter. The MNAR determination may also be viewed on ih.magellanrx.com, or you can call Magellan Rx Management at 1-800-424-4508 to confirm the determination.
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If Magellan Rx Management does not have all of the necessary information to make a determination, then the MNAR request will be postponed for clinical review. The provider will be given a tracking number and be notified that additional clinical information is required.
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No, clinical trials are not a part of this program. You should contact Horizon BCBSNJ's Complex Case Management department at 1-888-621-5894 for clinical trial information.
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Magellan Rx Management will conduct MNARs for injectable medicine Avastin when this drug is being used for cancer diagnoses. Magellan Rx Management will not conduct MNARS for Avastin when this drug is being used to treat ophthalmic macular conditions.
Review the following medical policies for more information. -
If a drug is being self-administered by the patient or the caregiver, the request of this medication should be submitted under the member's pharmacy benefit. Examples of some drugs that could be used as self-administration are:
- Colony stimulating factor (e.g., Zarxio, Granix, Neupogen, Neulasta)
- Erythropoietin agent (e.g., Epogen, Procrit, Arenasp)
- Autoimmune agents (e.g., Benlysta, Stelara, Actemra, Orencia, and Cimzia)
- Asthma (Fasenra, Nucala)
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MRxM will render MNAR determinations within the time frames note below.
Urgent requests will be completed within 24 hours of receiving the request.
Non-urgent requests for Medicare members will be completed as soon as possible based on the medical urgency of the case, but in no more than three business days of receiving all necessary information.
Non-urgent requests for other members will be completed within three to five business days of receiving all necessary information.
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MNAR approval periods may vary based on the injectable medication, but MNAR approval generally expires after six months.
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Yes. A letter of determination will be sent to the ordering provider, rendering provider and patient.
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Yes. A change to an existing, approved MNAR determination can be requested by calling Magellan Rx Management at 1-800-424-4508. The clinical staff will review the request and render a decision.
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The MIP allows one approval number per drug; however, Magellan Rx Management can process multiple requests during the same web session or phone call.
Claims
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Submit MIP claims to Horizon BCBSNJ as you do normally.
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If a claim is submitted without obtaining a pre-service MNAR, the processing of that claim will be delayed until medical necessity and appropriate review can be performed and medical necessity is established.
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You should call Horizon BCBSNJ's Physician Services at 1-800-624-1110. Facilities should call Horizon BCBSNJ's Facility Centralized Service Center at 1-888-666-2535.
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If Magellan Rx Management does not receive requested information necessary to make a determination on a post-service MNAR request, claims will be denied with the message “clinical information not supplied.”
Magellan Rx Management will make multiple attempts to obtain clinical information from the ordering provider to conduct a post-service MNAR determination.
If requested information is not received from the ordering provider:
- BlueCard® claims will be denied on the 11th day after the date of the initial request.
- Non-BlueCard claims will be denied on the 26th day after the date of the initial request.
Appeals
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Information on how to appeal an adverse decision will be provided within the determination letter issued by Magellan Rx Management. Generally, a provider may dispute an adverse decision that was based on medical necessity by following the instructions below.
For non-Medicare members, call Magellan Rx Management at 1-800-424-4508.
For Medicare members, fax appeals to 1-888‐656‐6805 or mail appeals to:
Magellan Rx Management
Attn: Appeals Department
PO Box 1459
Maryland Heights, MO 63043 -
For an appeal involving a medical judgment or MNAR, call Magellan Rx Management at 1-800-424-4508.
For claims appeals not involving medical judgment of an MNAR, call Horizon BCBSNJ's Physician Services at 1-800-624-1110.
Hemophilia Drugs
As part of the Medical Injectables Program (MIP), Magellan Rx Management (MRxM) conducts medical necessity and appropriateness review (MNAR) for hemophilia drugs. This program aims to ensure that patients are receiving the most appropriate dose of product based on each individual's unique clinical situation. MRxM's process in regard to hemophilia drugs includes an added component to be completed by the rendering provider prior to dispensing product to ensure appropriate assay management, inventory management and patient engagement is being provided.
Please review the questions and answers below for more information about the hemophilia services as part of the MIP.
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The process to request an MNAR for hemophilia drugs is no different than the process to request an MNAR for other injectable medications as part of the MIP. The determination is based on the clinical criteria found in our Medical Policy Manual. To obtain an MNAR, visit MRxM's secure websiteMRxM's secure website opens a dialog window.
For New Jersey participating specialty pharmacies, please call Horizon Care@Home at 1-855-243-3321.
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Length of MNAR approvals may vary depending on reason for use. Based on the Horizon BCBSNJ medical policy guidelines, the typical approval duration for hemophilia drug products is 6 to 12 months.
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There are 2 additional pieces of information that MRxM needs as part of their review of hemophilia drugs as part of the MIP:
- Hemophilia Case
Review
Form
The Hemophilia Case Review Form is a case management tool that helps us ensure that hemophilia drugs are being dispensed appropriately according to the MNAR and Horizon BCBSNJ's medical policies. - Dose Recommendation Letter
Based on the review of the Hemophilia Case Review Form, MRxM sends a Dose Recommendation Letter to the rendering provider. This letter provides MRxM's recommendation for dosing a single dispensing event. The Dose Recommendation Letter is not an approval letter and it does not replace the MNAR.
- Hemophilia Case
Review
Form
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Throughout the duration of the approved MNAR, rendering providers are required to complete and submit the Hemophilia Case Review Form prior to each time hemophilia drug products are dispensed, which is usually on a monthly basis.
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Some of the information that should be included in the Hemophilia Case Review Form are:
- Current doses patient has on hand
- Bleeding history since last dispense
- Please also include relevant progress notes and/or bleeding diaries.
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Once completed, the Hemophilia Case Review Form can be faxed to MRxM at 1-888-656-0841.
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The Hemophilia Case Review Form can be accessed on our Medical Injectables Program page.
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Hemophilia Case Review Forms that are not submitted prior to dispensing a drug, can still be submitted by the rendering provider after the drug has been dispensed. MRxM will contact rendering providers to collect dispensing information if forms are not received.
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Hemophilia Case Review Forms may be submitted up to a week prior to a dispensing date and preferably no less than at least 48 hours before a drug is dispensed.
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MRxM will review submitted forms and send out a Dose Recommendation Letter typically within 8 business hours of receipt. If information is missing from the Hemophilia Case Review Form, MRxM will contact the rendering provider to obtain it.
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MRxM's Dose Recommendation Letter provides a recommendation for dosing for a single dispensing event based on:
- Horizon BCBSNJ clinical guidelines and policy criteria
- The required dose
- The rendering provider's inventory
- The patient doses on hand
- Vial sizes available to be ordered
- Patient bleed history
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The Dose Recommendation Letter is not an approval letter and it does not replace the MNAR.
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Yes, the Dose Recommendation Letter provides the rendering provider with a recommendation for dosing for a single dispensing event based on Horizon BCBSNJ clinical guidelines and policy criteria. The Dose Recommendation Letter helps to ensure that hemophilia drugs are dispensed in alignment with an existing approved MNAR.
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Please call MRxM at 1-800-424-7892 Monday through Friday, from 8:30 a.m. to 5 p.m., ET, for information regarding recommended dosing.
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In urgent situations, it is best to dispense the hemophilia drug to the patient and submit an MNAR for retroactive review.
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Rendering providers should submit supporting clinical information to meet the assay management requirements along with the Hemophilia Case Review Form.
MRxM will review these situations on a case-by-case basis and will work with rendering providers to achieve a dispensed dose that is as close to +1% of the prescribed dose as possible.
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If a pre-service MNAR was obtained, hemophilia claims will process based on the determination of the MNAR. If a claim is submitted without obtaining a pre-service MNAR, the processing of that claim will be delayed until medical necessity and appropriateness review can be performed and medical necessity is established.
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For questions on hemophilia services, call MRxM at 1-800-424-7892.
In-network specialty pharmacy/home infusion providers
Medical injectable drugs require special handling, and can cause higher out-of-pocket costs for members. Horizon Blue Cross Blue Shield of New Jersey wants to make sure our members get quality care, while lowering their out-of-pocket costs for these specialty medications.
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Many patients are able to pay lower out-of-pocket costs when they use in-network specialty pharmacies and home infusion providers. Specialty pharmacies and infusion companies will ship an injectable medication to a doctor's office to be infused there or provide the drug to be administered by a nurse in the member's home.
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The following in-network specialty pharmacies offer quality products, reliable delivery and proven clinical expertise:
Accredo Health Group
Phone: 1-866-204-9480
Fax: 1-800-711-3526 or 1-866-225-5718
AllianceRX Walgreens Prime
Phone: 1-888-347-3416
Fax: 1-888-570-4700
BioPlus Specialty Pharmacy
Phone: 1-866-841-4714
Fax: 1-800-269-5493
Caremark
Phone: 1-800-237-2767
Fax: 1-800-323-2445
Dunn Meadow Pharmacy
Phone: 1-844-262-8200
Fax: 1-201-949-3455
Giannotto's Pharmacy
Phone: 1-855-442-6668
Fax: 1-973-482-9901
Qualitas Pharmacy Services
Phone: 1-800-242-0113
Fax: 1-844 488-2491 -
CareCentrix is Horizon BCBSNJ's home infusion services management vendor. Physicians and facility discharge planning staff can send referrals for home infusion services directly to CareCentrix by calling 1-855-243-3321 or by faxing 1-866-522-8555. CareCentrix will then arrange for the services to be provided at the in-network level of benefits.
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Yes, Magellan Rx Management, Horizon BCBSNJ's utilization management vendor for our Medical Injectables Program, conducts medical necessity and appropriateness reviews for specific injectable medications. A list of the injectable medications that require review by MRxM can be accessed on our Medical Injectables Program page.
If your patient is receiving home infusion services through a CareCentrix provider, CareCentrix will obtain authorization from MRxM.
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If an authorization needs to be updated to change the rendering provider from an out-of-network to an in-network provider, please call Magellan Rx Management at 1-800-424-4508.
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As part of our MIP, Horizon BCBSNJ requires participating practitioners to complete the Consent for Referral to an Out-of-Network Provider Form when using out-of-network specialty pharmacies and home infusion medical services.
Completion and submission of our Consent for Referral to an Out-of-Network Provider Form, signed by the patient/member, is required as per the guidelines of our Out-of-Network Referral Policy.
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No. The Consent for Referral to an Out-of-Network Provider Form should only be completed for members enrolled in plans that include out-of-network benefits.
This form, per the guidelines of our Out-of-Network Referral Policy, does not apply to, and should not be completed for members enrolled in plans that do not include out-of-network benefits (e.g., Horizon HMO, Horizon EPO, OMNIA℠ Health Plans, Horizon Medicare Blue Value [HMO]).
Injectable Medication Codes Subject to MrxM Claim Review/Editing
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Magellan Rx Management reviews claims that are submitted with certain HCPCS codes (representing injectable medications) to help ensure that the billing details for these medications are appropriate per Horizon BCBSNJ medical policy guidelines.
The list of codes included in this aspect of the MIP, may be reviewed in the Injectable Medication Codes Subject to MRxM Claim Review/Editing section of the MIP Code list.
Please note that the codes/injectable medications subject to this review DO NOT require Medical Necessity and Appropriateness Review (MNAR) as part of the our Medical Injectables Program.
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Yes, the guidelines that support this claims review process may be accessed, along with other policies, within our Medical Policy Manual and on our Reimbursement Policies & Guidelines webpage.