Medical Mutual - Health Plans for Life

Medical Drug Management

Medical Mutual recognized years ago that a comprehensive approach to managing specialty drugs, including high cost oncology drugs, covered under the medical and pharmacy benefits was critical to all of our customers. This was due to the fact that many new specialty drugs were being introduced to the marketplace and many of these specialty drugs are being administered to patients at their doctor’s office, a hospital outpatient facility, or stand-alone outpatient infusion center. These are not the types of drugs that could be obtained at a drug store.

As a result, Medical Mutual invested millions of dollars a couple of years ago to build and enhance upon the existing medical management approach that many health plans utilize and created a Medical Drug Management (MDM) program.

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.

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 ages 21 and under. The standard prior authorization will apply, but the site of care questions will not. This age is based on the definition of a pediatric patient from the Academy of Pediatrics.

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

*As of May 2018. This list is subject to change.

Medical Drug Prior Approval Update

For more information on prescription medications requiring prior approval or that are considered investigational, and to view a complete list of our Corporate Medical Policies, visit Tools & Resources, Care Management, Corporate Medical Policies.

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

  • Provider Manual

    Information regarding submitting NDC identifiers is available in the Claims Submission section of the Provider Manual.

  • Corporate Medical Policies

    Guidelines for determining coverage for specific procedures, therapies, devices and services.

  • Prior Approval and Investigational Services

    A list of services that are considered investigational or require prior approval before a procedure.

  • ExpressPAth
    Medical Mutual is pleased to offer ExpressPAth, a web-based tool that providers can use to manage prior approval requests for medications covered under the medical benefit. Use it to:
    • Submit requests for prior approval
    • Check on the status of submitted requests
    • Submit a renewal on a previously approved request
  • 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.

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