Welcome to Summit Health
Summit Health has partnered with MagellanRx to assist you in medical pharmacy management through the provider administered injectable medication program. Summit Health is committed to providing our members with access to high-quality healthcare. With this commitment in mind and to ensure quality care and affordability to our members, we will implement updates to our processes regarding the review and approval of certain injectable medications.
MagellanRx - Summit Health Plan Delegates administrative functions to MagellanRx. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Articles (LCAs) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.
Medicare Part B Step Therapy Requirements
Select medications covered under Medicare Part B are subject to step therapy requirements. See a full list of medications that require step therapy through the preferred agent.
Contact MagellanRx:
Routine requests – ih.magellanrx.com
For urgent or expedited requests, call 800-424-8114
MagellanRx has staff available 24 hours a day for urgent requests by phone (including after hours, weekends and holidays). If you have claim, benefits, and/or eligibility questions, please call Summit Health Customer Service at 844-827-2355.
MagellanRx will review your prior authorization requests for the following specialty injectable medications that are administered in:
See a full list of which injectable medications require a Prior Authorization under a Medical benefit.
Making sure our members receive the best possible care at the most affordable price is why we come to work each day. But we can’t do this alone. We appreciate your support in assuring Summit Health members receive high quality, affordable care and deliver results consistent with nationally recognized clinical criteria and guidelines.
To learn more about our injectable medication program, call our Customer Service team toll-free at 844-827-2355.
In a partnership with MagellanRX, Summit Health implemented a claim check program for injectable and/or infusion medications.
The claim check program monitors and promotes appropriate use, safety, and cost effectiveness of medications prescribed to our members. We will do this by reviewing claims for appropriate frequency, correct units, and eligible diagnosis codes.
This program will be limited to the injectable and/or infusion medications listed below, when ordered or administered by providers. Summit Health applies post-service, pre-payment claims edits to diagnosis criteria and criteria for maximum units for the following medications. Prior authorization criteria do not apply for these medications.
As we gain better insight into utilization patterns, we will expand this initiative to cover and include more specialty and injectable drugs in the future. Updates will be posted to this page as the program is expanded.
This program will be limited to claims reviewed and to medications injected and/or infused in a professional office, home or outpatient setting.
Claims submitted will be reviewed against clinical guidelines. If the services billed do not meet the guidelines, the claims will be subject to review and potentially disallowed.
We appreciate your partnership to improve the quality, value, and coordination of care for our members and your patients. As your partner in this evolving journey, we are committed to providing service excellence in process improvement.
Last updated March 30, 2022
H2765_4006
Last updated Oct. 1, 2023
H2765_4006
Call 844-827-2355 (TTY users, please call 711).
Our customer service team is available from 7 a.m.– 8 p.m. (Pacific Time), seven days a week October 1 – March 31 (closed on Thanksgiving and Christmas), and weekdays April 1 – September 30. Your call will be handled by our automated phone systems outside business hour.