In collaboration with the health plan's operations department, PerformRx has established a process that will allow payment without prior authorization for erythropoetin claims that do not exceed a cumulative unit total of 50,000. Claims with a cumulative total exceeding 50,000 units per month will require submission of a request for coverage determination.
Coverage determination requests are submitted to PerformRx. Dialysis centers and/or physicians must submit the coverage determination request form in addition to all required supporting documentation including lab values, physicians' orders, etc. to the PerformRx Specialty Drug Program to establish medical necessity for erythropoietin cumulative monthly doses greater than 50,000 units.
Favorable coverage determinations will be issued for up to three months per request. Dosage increases will require submission of a new coverage determination request.
The coverage determination request form can be obtained by accessing the plan website or by calling the PerformRx Specialty Drug Program.
