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Specialty Pharmacy

Arkansas Blue Cross and Blue Shield is committed to ensuring that Federal Employee Program (FEP) members receive high-quality health care that is consistent with evidence-based, nationally recognized clinical criteria and guidelines. Accordingly, we are implementing a change in the way we manage prior authorization for FEP members. This new program will be administered by Magellan Rx Management. On February 21, 2022, providers began contacting Magellan Rx to obtain prior authorizations for the in-scope drug for FEP members for dates of service on or after March 1, 2022. Providers directly contracted with Arkansas Blue Cross and Blue Shield may create an online account for Prior Approvals at Magellan Rx Provider Portal. For urgent or expedited requests call Magellan Rx at 800-443-5709.

Resources:

Specialty Drug Program Frequently Asked Questions

Magellan Rx Management is the pharmacy division of Magellan Health.

The program will apply to members enrolled in the following plans:

  • Federal Employee Program Standard
  • Federal Employee Program Basic
  • Federal Employee Program Blue Focus

The effective date of this program is March 1, 2022.

The list of medications included in the Medical Pharmacy Program is updated at least annually.

Prior authorizations are required for medications administered at the following places of service:

  • Physician office (CMS Place of Service code 11)
  • Patient’s homes (CMS Place of Service code 12)
  • Outpatient facilities (CMS Places of Service codes 19 & 22)

Providers may call Magellan Rx for authorization requests at 800-443-5709. 

If the provider is contracted directly with Arkansas Blue Cross and Blue Shield, non-urgent authorizations also may be done through the secure Magellan Rx secure provider portal at www.mrxgateway.com.

To expedite prior authorizations, the provider should have the following information:

  • Member name, date of birth and ID number
  • Health plan name (Arkansas Blue Cross and Blue Shield)
  • Member height and weight
  • Ordering provider name, tax ID number, address, and office telephone and fax numbers
  • Rendering provider name, tax ID number, address, and office telephone and fax numbers (if different from ordering provider)
  • Requested medication name or Healthcare Common Procedure Coding System (HCPCS) code
  • Anticipated start date of treatment
  • Dosing information and frequency
  • Diagnosis (ICD-10 code)
  • Any additional clinical information pertinent to the request

If requested by Magellan Rx, the provider should be prepared to upload the following documents to the Magellan provider portal or to fax the following documents to Magellan Rx’s Health Insurance Portability and Accountability Act (HIPAA)-compliant fax:

  • Clinical notes
  • Pathology reports
  • Relevant lab test results

Note: It is the responsibility of the ordering provider to obtain prior authorization before services are provided. If the ordering provider and the rendering provider are different, the rendering provider is responsible for ensuring that the appropriate approval is on file, prior to rendering services.

Providers directly contracted with Arkansas Blue Cross and Blue Shield may request access to the Magellan Rx provider portal. To do so, visit Magellan Rx’s provider portal at www.mrxgateway.comand complete the following steps:

  • Click on New Provider Access Request at the bottom of the page.
  • Complete the form and allow two business days for response.

Please have the following information ready:

  • Requestor’s name, email address, and phone number
  • Practice administrator name and email address (if different from requestor)
  • Health plan name (Arkansas Blue Cross and Blue Shield)
  • Practice name
  • Practice service address
  • Practice National Provider Identifier (NPI)
  • Practice tax ID number

You can email a secure message to MRxPR@magellanhealth.com. If it is an urgent request, you can call Magellan Rx at 800-443-5709.

No. Magellan Rx provider portal users linked to the practice tax ID number will be able to conduct transactions for every network clinician linked to the practice tax ID number.

Magellan Rx has been engaged only to oversee utilization management. Claims should be submitted to Arkansas Blue Cross and Blue Shield.

Yes. The claim for the rendering provider will be denied. Rendering providers need to make sure a prior authorization is on file with Magellan Rx before administering the medications to members. When prior authorization is required but was not obtained, providers can follow instructions on the Explanation of Benefits (EOB) to submit a claim appeal, as applicable.

For more information, providers can call Magellan Rx Management at 800-443-5709.

Prior Authorization Requests

Providers and their staff will have the opportunity to obtain prior authorizations to help streamline medication administration and service.

  • If a prior authorization request does not initially have enough evidence to be approved, it is pended to be clinically reviewed by Magellan Rx clinical pharmacists.
  • If the initial clinical reviewer finds the request meets clinical criteria, the initial clinical reviewer can approve the prior authorization request.
  • If the initial clinical reviewer cannot find enough evidence to approve the request, he/she will schedule a peer-to-peer conversation between the provider and Magellan Rx peer clinical reviewer, who is a board-certified physician. The Magellan Rx peer clinical reviewer will render the final determination based on the information received.

Note: Magellan Rx initial clinical reviewers are clinical pharmacists.

Yes. In most cases, approvals can be made based on the initial information provided by the requestor. If there is a question or concern regarding the information provided, the case will be sent to a pharmacist who will reach out to the requesting provider. If the pharmacist cannot reach an agreement regarding the appropriate course of treatment with respect to the requested medication, the case will be escalated to a Magellan Rx physician. A Magellan Rx physician will discuss the case with the provider, and they will make a mutual decision, in accordance with plan guidelines, on an appropriate course of action.

The ordering provider, rendering provider (if different from ordering) and member receive copies of the final determination notices.

Magellan Rx approvals link providers by their tax ID number. When approvals are entered into Arkansas Blue Cross and Blue Shield cross claims system, they will be attached to all network providers who share that tax ID number.

Providers who are directly contracted with Arkansas Blue Cross and Blue Shield must be signed into their account page on the Magellan Rx provider portal at www.mrxgateway.com.

  • After entering your patient’s information and selecting yourself or your group’s name as the requesting provider, answer yes to the question “Will an alternative servicing provider be utilized for this request?”
  • Search for and select the outpatient facility site where the member will receive the treatment.
  • Continue entering the prior authorization request.

If the request is made by phone, the requestor should provide this information to the Magellan Rx Management team.

All rendering providers are required to check the Magellan Rx provider portal to confirm a prior authorization has been issued prior to administering a medication that is part of this program.

To view a prior authorization, providers directly contracted with Arkansas Blue Cross and Blue Shield must be signed into their Magellan Rx provider portal account at www.mrxgateway.com:

  • Select View Prior Authorizations and enter either the patient’s first and last name, the member identification number, or the authorization number. Providers also have the option of viewing all prior authorizations associated with their tax ID number.
  • The provider should confirm the following information on the prior authorization:
    • Member name, date of birth, and ID number
    • Ordering and rendering provider information
    • Authorization validity period
    • The medication(s) and number of units approved

If a provider has any questions, he/she should contact Magellan Rx directly at 800-443-5709.

After an approval is generated, a change in dose and/or frequency may be requested via phone by Magellan Rx at 800-443-5709.

The approval duration or validity period of a prior authorization is dependent on the medication and is not negotiable.  

There is one prior authorization number per medication. However, Magellan Rx can process multiple requests via a single portal session or telephonic request.

Magellan Rx Management is an independent company that operates separately from Arkansas Blue Cross and Blue Shield and administers medical specialty drug program services for the benefit of Arkansas Blue Cross Federal Employee Program members. Arkansas Blue Cross and Blue Shield is an independent licensee of the Blue Cross Blue Shield Association.