Medical Drug Management

Components of our MDM program include:

• Requiring a National Drug Code (NDC) on medications that require prior authorization
• Editing outpatient and professional claims to ensure a medication has been approved and the dose administered matches the approval
• Application of maximum daily dose edits on a number of targeted medications
• Site of care management. Site of care management requires a number of targeted medications (e.g., immune globulins, Remicade, Soliris) to be administered in a non-hospital facility based location (i.e., home, provider’s office or ambulatory infusion site) unless certain medical necessity criteria are met.

As a result of the MDM program, we realized for our clients a medical specialty drug savings of more than $10 million during the first year of the program. Approximately 34 percent of the specialty drug spend under the medical benefit are oncology drugs. This savings is attributed to specialty drugs that were administered in a doctor’s office. Effective February 2015, we applied this program to specialty drugs administered at a hospital outpatient facility and stand-alone outpatient infusion center, which is where the remaining specialty drugs are being delivered on an outpatient basis.

Medical Mutual will continue to enhance our specialty drug management program to ensure we are managing our client’s health dollars to address market trends, new specialty drugs, and customer utilization

Medication Sourcing Program

Select specialty medications will be subject to medication sourcing requirements, when billed under the medical benefit, beginning January 1, 2025. Select medications will require medication sourcing from a contracted in-network specialty pharmacy when infused at a hospital outpatient department. This requirement applies to Commercial SuperMed HMO, SuperMed PPO, MedFlex Cle-Care and Affordable Care Act (ACA) members. This does not apply to Medicare Advantage members or for professional claims when billed on a CMS-1500 claim.

These in-network specialty pharmacies will bill Medical Mutual directly for the medication under the member’s medical benefit. Hospital outpatient departments will continue to receive reimbursement for the administration of medications supplied by a specialty pharmacy. Hospital outpatient departments may not bill members for drugs that are supplied by a specialty pharmacy.

All specialty medications identified for the medication sourcing program require prior authorization. Prior authorizations that are valid as of January 1, 2025, will be honored through the approved number of doses/validity period indicated on the determination letter. All new prior authorization requests, including renewals of a previously approved medication, on or after January 1, 2025, will be subject to the new sourcing requirements.

Hospital outpatient departments may continue to buy and bill specialty medications NOT subject to the medication sourcing requirement. Buy and bill refers to providers acquiring a drug through their own sources and billing it directly to Medical Mutual.

If you have questions about how the new medication sourcing requirement may affect you, please reach out to your network Provider Contracting Manager at (800) 625-2583.

View the list of medications subject to prior authorization, site of care, and medication sourcing or considered investigational here.

Site of Care Management Program

Select specialty medications that are already subject to prior authorization requirements will be subject to site of care management beginning March 1, 2016. Previously, it was announced the program would take effect on January 15, 2016. Coverage for impacted medications is restricted to administration by home infusion, at a provider’s office or at an ambulatory infusion center.

Infusions administered in a hospital setting are not eligible for reimbursement unless the provider receives prior approval from Medical Mutual that the medical necessity criteria have been met.

New requests and renewals of a previously approved medication will be subject to site of care management. Please note the site of care criteria will not apply to members under the age of 18. The standard prior authorization will apply, but the site of care questions will not.

View the list of medications subject to prior authorization, site of care, and medication sourcing or considered investigational here.

View the list of medications subject to Site of Care with the number of authorized doses allowed in a hospital, outpatient facility here.

Medicare Part B Step Therapy Program

Medical Mutual requires review of some medical benefit drugs (primarily injectables and biologics) under step therapy requirements. These step therapy requirements will be in addition to already-existing, non-step therapy related policies and review requirements for Medicare Advantage members.

Please note that step therapy requirements do not apply to members who are already receiving active treatment with a non-preferred drug. Step therapy implementation will be administered in accordance with all guidance from the Centers for Medicare & Medicaid Services (CMS).

Furthermore, Medicare Advantage members subject to step therapy requirements have the right to ask for an exception or to appeal a request that was denied due to step therapy requirements.

View the list of medications subject to step therapy or view the list of medications requiring prior approval (including those subject to site of care management) or considered investigational.

Medical Drug Prior Approval Update

View the list of medications subject to prior authorization, site of care, and medication sourcing or considered investigational here. To view a complete list of our Corporate Medical Policies, visit our Corporate Medical Policies page.

When these medications are provided under a member’s prescription drug benefit, please contact the pharmacy benefit manager at the number on the member’s identification card for prior approval requirements.

Additional Resources

Prime Therapeutics

Medical Mutual is pleased to partner with Prime Therapeutics, to manage prior approval requests for medications covered under the medical benefit.

Use Prime Therapeutics secure provider portal to:

• Submit non-urgent requests for prior approval
• Check on the status of submitted requests
• Submit a renewal on a previously approved request

The following reference tools are available:

• FAQ
• Prime Therapeutics Website Guide
• Drug Management Overview
• Drug Management Overview - Webinar Recording

As an alternative to using Prime Therapeutics, Providers may also submit the Prior Approval Form, which is linked below, to request prior approval for medical drugs. This is a global form, and it replaces the previous process that required use of forms that were specific to each drug.

Prior Approval & Investigational Services 

Prior Approval Form

NDC on Professional Claims

Locate the NDC submission field on the CMS-1500.

NDC on Institutional Claims

Locate the NDC submission field on the UB-04.