Medical Mutual - Health Plans for Life

Medical Drug Management

With hundreds of medications in the U.S. Food and Drug Administration (FDA) pipeline that could significantly impact future healthcare quality and costs, Medical Mutual has launched a Medical Drug Management (MDM) initiative called Mutual Rx.

The first phase of the Mutual Rx initiative, Specialty Pharmacy, will require National Drug Code (NDC) data (including code, quantity and unit of measure) when billing for select medications on professional claims.

Please refer often to the list of HCPCS codes requiring NDC identifiers on claims.

Medical Drug Management Reimbursement Policy

Effective October 1, 2015, Medical Mutual will reject payment for units of drugs that exceed the manufacturer’s FDA-approved labeling maximum recommended dose when submitted under the member’s medical benefit. The patient may not be billed for the balance of the denied units.

Any drug with manufacturer’s FDA-approved labeling guidelines pertaining to dosing for the medical condition for which it has been prescribed may be subject to the Medical Drug Management Reimbursement Policy. Medications that require prior approval are processed based on the dose approved at the time of the request.

Please refer to the Medical Drug Management Reimbursement Policy for more information.

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 November 2018. This list is subject to change.

Medical Drug Prior Approval Update

Effective July 30, 2015, the following prescription medications require prior approval when requested under the member’s medical benefit through Medical Mutual:*

  • Adcetris (brentuximab vedotin)
  • Blinctyo (blinatumomab)
  • Cyramza (ramucirumab)
  • Zaltrap (ziv-aflibercept)

Effective August 30, 2015, the following prescription medications require prior approval when requested under the member’s medical benefit through Medical Mutual:*

  • Sandostatin (octreotide acetate)
  • Sandostatin LAR (octreotide acetate injection)

Effective October 30, 2015, the following prescription medications will require prior approval when requested under the member’s medical benefit through Medical Mutual:*

  • Dacogen (decitabine)
  • Ixempra (ixabepilone)
  • NPlate (romiplostim)
  • Ozurdex (dexamethasone intravitreal implant)
  • Retisert (fluocinolone acetonide intravitreal implant)
  • Vidaza (azacitidine)

The above lists are subject to change. 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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