Provider should verify specific Part B drug benefits; step therapy initiated for macular degeneration and anemia injections
Security Health Plans Medicare Advantage plans, including Ally Rx D-SNP and Secure Saver MSA, provide coverage for Part B drugs administered in an office or outpatient setting. Benefits may differ based on the member’s eligibility. Please verify member specific eligibility and benefits using the online Provider Portal. The following are examples of information that can be found using the Provider Portal:
- Member eligibility and termination dates
- Group numbers
- Type of policy (HMO, POS, indemnity, etc.)
- COB information
- Out-of-pocket amounts (deductible, coinsurance, copayments)
- Prior authorization submission and status
You can check if you are a contracted provider on our Provider Directory. Most of Security Health Plan’s Medicare Advantage plans allow for members to use a non-contracted provider, but this use may incur a higher out-of-pocket cost to the member.
Providers are required to buy the Part B drugs and bill Security Health Plan on a medical claim.
Security Health Plan’s Medicare Advantage plans renew on a calendar year basis. These plans:
- Are not COBRA plans
- Are fully funded
- Cannot exclude for pre-existing conditions
Security Health Plan’s Medicare Advantage plans do not have lifetime maximums or annual benefit caps on Part B drugs administered in the office or in an outpatient setting.
Coverage of Part B drugs and office visits varies based on the member’s policy. Please log in to the Security Health Plan Provider Portal to view member specific information such as deductible, coinsurance, copayments and out-of-pocket limits. You can also view how much has been applied to deductible and out-of-pocket costs using the Provider Portal.
- If a primary or specialty care office visit is billed, members may have an office visit copay, depending on plan benefits.
- Administration fees for Part B drugs do not apply any member cost-share when billed by a contracted provider.
Prior authorization required for some Part B drugs
Per Security Health Plan policy, we do not require a doctor’s referral for Part B drugs. However, prior authorization may be required.
Please check the Security Health Plan authorization page, to see if the Part B drug you are administering requires prior authorization.
Step therapy initiated for certain Part B injections
Effective for dates of service on or after May 1, 2019, Security Health Plan will implement step therapy requirements for ‘NEW’ starts of the following injectable drugs used to treat macular degeneration and anemia:
- aflibercept (Eylea®), ranibizumab (Lucentis®) and pegaptanib (Macugen®) - with bevacizumab as the preferred drug
- epoetin alfa (Epogen®, Procrit®) - with epoetin alfa-epbx (Retacrit®) as the preferred drug
Implementation for ‘new’ starts means that no members currently receiving eligible step therapy drugs under part B will have to change their drug. Step therapy prior authorization will be managed through Security Health Plan’s specialty pharmacy medication partner, Magellan. Call 1-800-424-8243; website spcustomer.magellanprovider.com.