DMBA Medical Pharmacy Prior Authorization Program PRESENTED BY

DMBA Medical Pharmacy Prior Authorization Program PRESENTED BY LISA CORBETT SENIOR PROVIDER RELATIONS MANAGER, MAGELLAN RX MANAGEMENT

Agenda 1 Program Overview 2 Review Process 3 Magellan Rx Website 4 Resources

Program Overview

Effective January 1, 2019, DMBA will be implementing a change in how certain drugs that fall under the medical benefit are managed. This new program will be administered by Magellan Rx Management (Magellan Rx). Magellan Rx will be responsible for reviewing and approving these drugs. Beginning December 17, 2018, providers may begin contacting Magellan Rx to obtain prior authorizations for members who will receive treatment/drugs within the scope of this program on or after January 1, 2019. 4

Places of Service Prior authorization is required by Magellan Rx when the drugs are administered by practitioners in the following places of service (POS): ü Physician Office (POS 11) ü Patient Homes (POS 12) ü Outpatient Facilities (POS 19, 22) 5

Impacted Members The program will apply to members enrolled in the following plans: • • • 6 Deseret Choice Hawaii Deseret Premier Deseret Protect Deseret Select Deseret Value

Transition of Care Process Date of Service Authorizations issued by DMBA for dates of service before January 1, 2019 for the medications identified as part of this program will be effective until the authorization end date. Validity Date To continue treatment after the original authorization validity date, you must obtain an authorization from Magellan Rx prior to the expiration date. End Date Claims for dates of services after the authorized end date will be denied if the provider has not obtained a successive authorization from Magellan Rx. 7

DMBA Drugs Requiring Preauthorization through Magellan Rx* HCPC NAME J 9264 Abraxane HCPC NAME J 9308 Cyramza HCPC NAME J 0638 Ilaris HCPC NAME J 2505 Neulasta HCPC NAME J 1602 Simponi_Aria J 3262 Actemra IV J 9145 Darzalex J 9173 Imfinzi J 2796 Nplate J 1300 Soliris J 0800 Acthar_HP J 1743 Elaprase J 9325 Imlygic J 2182 Nucala J 3358 Stelara IV J 9042 Adcetris J 3060 Elelyso Q 5103 Inflectra J 2350 Ocrevus J 1627 Sustol J 1931 Aldurazyme J 9176 Empliciti J 1599 Intravenous Immune Globulin J 1568 Octagam J 2860 Sylvant J 9305 Alimta J 3380 Entyvio J 9315 Istodax J 9266 Oncaspar J 9262 Synribo J 2469 Aloxi J 9055 Erbitux J 9043 Jevtana J 9205 Onivyde J 9022 Tecentriq J 0256 Aralast NP J 9019 Erwinaze J 9354 Kadcyla J 9299 Opdivo J 9330 Torisel J 0881 Aranesp J 0180 Fabrazyme J 1290 Kalbitor J 0129 Orencia IV J 9033 Treanda J 9302 Arzerra J 1572 Flebogamma J 2840 Kanuma J 9306 Perjeta J 2323 Tysabri J 9035 Avastin J 9307 Folotyn J 9271 Keytruda J 1459 Privigen J 9303 Vectibix J 9023 Bavencio J 0641 Fusilev J 2507 Krystexxa J 0885 Procrit/Epogen J 9041 Velcade J 9032 Beleodaq J 1569 Gammagard Liquid J 9047 Kyprolis J 0256 Prolastin-C J 1322 Vimizim J 9034 Bendeka J 1566 Gammagard S/D Q 2042 Kymriah J 0897 Prolia J 3385 Vpriv J 0490 Benlysta IV J 1561 Gammaked J 0202 Lemtrada Q 2043 Provenge J 0897 Xgeva J 1556 Bivigam J 1557 Gammaplex J 0221 Lumizyme J 1745 Remicade J 2357 Xolair J 9039 Blincyto J 1561 Gamunex-C J 9371 Marqibo Q 5104 Renflexis J 9228 Yervoy J 1566 Carimune NF J 9301 Gazyva J 0888 Mircera Q 5106 Retacrit Q 2041 Yescarta J 1786 Cerezyme J 0257 Glassia J 2562 Mozobil J 9312 Rituxan J 9352 Yondelis J 0717 Cimzia J 9179 Halaven J 9203 Mylotarg J 9311 Rituxan Hycela J 9400 Zaltrap J 2786 Cinqair J 9355 Herceptin J 1458 Naglazyme J 2353 Sandostatin_LAR J 0256 Zemaira *Other drugs may require preauthorization through DMBA. List subject to change. Visit ih. Magellan. Rx. com for current list. HCPC Codes highlighted in YELLOW are effective 1/1/19.

Unclassified Codes When billing unclassified drug codes (for example, J 3490, J 3590, J 7199, J 7599, etc. ) the National Drug Code (NDC) is also required by DMBA to identify the specific drug administered to the participant. DMBA uses NDC information to determine whether the drug meets the eligibility requirements of the participant’s medical plan. DMBA will deny charges for unclassified drug codes that are billed without the NDC, and the claim will need to be resubmitted with the NDC to be considered for payment. To avoid claim denials, please make certain unclassified drugs codes are properly billed with the appropriate NDC. 9

Review Process

Provider Responsibilities Responsible for obtaining the prior authorization before services are provided. Responsible for ensuring that the authorization was obtained prior to services being rendered. 11

Information Needed • Ordering Provider Name • Tax ID • Address • Office Telephone Number (Same information is needed for Rendering Provider if different from Ordering Provider) • • • Member Name Date of Birth ID Number Height Weight Diagnosis Code • Place of Service Code • Requested Drug Name or HCPCS Code • Dosage • Frequency • Anticipated Start Date of Treatment • Clinical notes • Pathology Reports • Relevant Test Results If additional information is requested by Magellan Rx, the practitioner should be prepared to upload documents on the provider portal or to fax documents to Magellan Rx HIPAA compliant fax at 888 -656 -6671. 12

Timeframes 15 72 Days Hours Completed within 15 calendar days from receipt of all necessary information. Completed within 72 hours from receipt of all necessary information. The review and determination process may take longer if member or provider eligibility verification is required and/or if the request requires additional clinical review. 13

Magellan Rx Website

Obtaining an Online Account Providers directly contracted with DMBA can create an online account. 1. Visit our self-service provider portal at ih. Magellan. Rx. com 2. Click on New Access Request-Provider under Quick Links 3. Click on Contact Us to register 15

Resources

Prior Authorization Resources For routine requests and clinical guideline information, visit ih. magellanrx. com For urgent or expedited requests call Magellan Rx at 800 -424 -8269. Magellan Rx Management has staff available 24 hours per day for urgent requests by phone (including after hours, weekends and holidays). If you have claim, benefits, and/or eligibility questions, please call DMBA Member Services: -777 -3622 [Monday through Friday from 8 a. m. to 5 p. m. MST] 17 800

Thank you for attending today! Lisa J. Corbett Senior Provider Relations Manager Magellan Rx Management ljcorbett@magellanhealth. com 978 -412 -2332 The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan Rx Management Health Plan Client members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.