Connecticut, New Jersey, New York – Specialty Pharmacy Requirements for Certain Specialty Medications

April 2018 ~

UnitedHealthcare (UHC) affiliate, Oxford Health, will soon require its commercial plan members, participating hospitals in New York, New Jersey and Connecticut to purchase certain medications from a specialty pharmacy.

Effective October 1, Oxford Health members in the identified states will be restricted to purchasing certain multiple sclerosis and anti-inflammatory specialty medications from the specialty pharmacy, BriovaRx. BriovaRx will bill Oxford Health Plans directly for these medications. Hospitals will only need to bill Oxford Health the appropriate code for administration of the medication and should not bill UHC for the medication itself.

The multiple sclerosis and anti-inflammatory specialty medications impacted by this change are:

This list of specialty medications is subject to change with 90 days written notice.

This protocol applies to the listed drugs when dispensed in the outpatient hospital setting of participating hospitals for Oxford Health Plan members.

UHC anticipates that all hospitals will be able to procure the specialty medications to be administered in an outpatient hospital setting from BriovaRx. Oxford Health may issue a denial of payment for failure to follow the protocol. Hospitals may not bill members for these medications.

As stated in the notice from UHC, payment policy will prohibit payment to hospitals for these medications unless the hospital has contracted their Separately Reimbursable Drugs at 165% of CMS or less. This protocol does not apply when Medicare or another health benefit plan is the primary payer and Oxford Health Plans is the secondary payer.

For more information, refer to UHC Oxford’s April 2018 Clinical Policy Drug Coverage Guidelines.



Source(s): UnitedHealthcare Network Bulletin April 2018;