Payor Contracting 101
Practicing physicians encounter a wide variety of options when negotiating the terms and conditions of payment for
services. This Payor Contracting Toolkit, provided by the American Medical Association, is designed to help physicians
evaluate contracts with payors, understand the dierences among payors, and develop a basic working knowledge of
the range of insurance products and payment models associated with the contracting process. The materials in this
toolkit are for education and informational purposes only and should not be considered legal advice. Physician practices
should consult their own health care counsel or other advisors to evaluate specic agreements or contracting
opportunities with payors.
What is a “Payor”?
Answering the fundamental question of who or what is the “payor” may be complex. At base, a “payor” is the entity that pays for services rendered
by a healthcare provider. The payor may be a commercial insurance company, government program, employer, or patient. Physicians may also
contract with third-party administrators or intermediary contracting entities, including other health care providers who have assumed nancial risk
from a payor. The identity of the payor may determine the degree to which terms are xed or negotiable, the applicable laws, negotiating strategy
and goals and objectives of the relationship. Common examples of “payors” include:
• ERISA Self-Funded Employee Benet Plan/Union Trust – An
employer-sponsored health benet plan where nancial
responsibility for overall cost of care lies with the employer instead
of with an insurer. ERISA plans are usually exempt from state
insurance laws (e.g., prompt pay laws).
• Third Party Administrator – An entity that contracts with ERISA
plans to administer the health plans, including claims adjudication
and payment, utilization management, physician contracting, and
other administrative functions necessary for plan operations.
• Fee-for-Service Government Programs – Medicare, Medicaid,
Workers’ Compensation, Veterans’ Administration, etc. The terms of
such plans are typically set by the government entity and there may
be little room for a physician or practice to negotiate
anything dierent.
• Health Maintenance Organization (HMO) – HMOs contract with a
network of health care providers that have agreed to the HMO’s
reduced payment structure or fee schedule. Subject to few
exceptions, care provided under an HMO is covered only if a member
sees physicians within the HMO’s network.
• Preferred Provider Organization (PPO) – A PPO is a type of health
plan that contracts with medical providers, such as hospitals and
doctors, to create a network of “preferred” providers. These preferred
providers agree to the PPO’s payment structure, or fee schedule, for
services. PPOs also oer coverage for services provided by non-
preferred (non-contracted) physicians.
• Exclusive Provider Organization (EPO) – EPOs are similar to PPOs,
however, EPOs typically require members to receive services only
from participating physicians.
• Point of Service (POS) – A POS plan is a hybrid PPO/HMO which
provides the exibility of a PPO while retaining cost controls. For
example, POS plans may oer coverage for services provided by
non-preferred (non-contracted) physicians, but only upon a referral
from a PCP.
• Leased Network/Contracting Networks – Physician networks are
typically organized and managed by entities other than insurers. The
network contracts with physicians to form a network that insurers pay
to access, including self-funded plans and their TPAs.
• Accountable Care Organization (ACO) Clinically Integrated
Network (CINs) – The voluntary networks of providers are typically
organized and managed by health care providers (e.g., health
systems) instead of insurers with the goal of delivering high-quality,
coordinated care. The ACO or CIN may contract with insurers on
behalf of the physicians and may require the physician to adhere to
ACO or CIN clinical guidelines for care.
• Health Care Sharing Ministries – A nonprot ministry that solicits
contributions for sharing of health care costs among members.
Health Care Sharing Ministries are not “insurers” but are recognized
under the Aordable Care Act as satisfying the requirement for
individual coverage.
Private Practice Toolkit
2Payor Contracting 101
How Are Physicians Paid?
Payors use a variety of reimbursement methodologies and
reimbursement structures. Several reimbursement methodologies
might be combined in a single arrangement with a payor, often as a
means of transitioning to “value-based” payment. Reimbursement
methodologies may include the following: the following:
• Fee-for-service reimbursement – xed reimbursement amounts
per item or service furnished, commonly negotiated in a physician
participation agreement with the plan. At base, the “plan” pays the
cost of medical care, while the “payor” is an entity responsible for
the processing of patient eligibility, services, claims, enrollment, or
payment.
• Direct to Employer – direct and unique arrangements between
physicians and ERISA self-funded plans for discrete categories of
care. (Note that AMA has guidance on direct-to-employer
contracting).n direct-to-employer contracting).
• Care coordination – payment for care coordination activities, often
with a focus on population health management.
• Quality incentives – payment is based in part on achieving pre-set
quality of care metrics across an assigned population of members.
• Bundled payments – xed prospective or retrospective
reimbursement for a dened bundle of services that can be
furnished by dierent physicians (e.g., hip/knee replacement).
• Shared savings – potential upside-only reimbursement, in addition
to fee-for-service reimbursement, when aggregate population
health care costs are less than a predened baseline amount. The
“savings” are shared between the payor and the physician.
• Shared risk – potential upside or downside reimbursement, in
addition to fee-for-service reimbursement, depending on whether
aggregate population health care costs are more or less than a
predened baseline amount. The “savings” or “losses” are shared
between the payor and the physician (or among physicians).
• Full or partial capitated payments – A per-member, per-month
reimbursement to provide all (or a dened subset of) covered
services without reference to volume, utilization, or costs. There is
typically no separate fee-for-service payment from the payor, except
for specied carved-out services.
Deciding to Contract with a Payor/Join a Network
There are many factors to weigh when deciding to contract with
payors, including your existing payor mix, patient population, and
which plans, and employers oer insurance/cover beneciaries in your
market. In many markets, health insurers are heavily concentrated,
and there may be a predominant payor with which you will need to
contract to serve most patients in the region.
Physicians should consider the following when deciding whether to
enter a payor contract:
• Benets of in-network status, such as securing clear reimbursement
terms and rates, having access to payor’s members, and avoiding the
challenges associated with out-of-network status.
• Ramications of out-of-network status, such as payment of usual
and customary charges (not billed charges), limits on out-of-
network benets, collecting from patients, and evolving laws on
surprise billing.
• Payor’s market share (i.e., number of members aliated with a
particular payor in the market)
• Physician organization’s value proposition, including what sets the
physician apart from other, similar physicians.
• Operational considerations, such as whether the physician
organization’s processes align with payor requirements (and the
operational or cultural costs of achieving such alignment).
o Examples of this include utilization management processes
(manual vs electronic, methods/tools for quality
measurement and reporting to a payor, required
arrangements with third parties (e.g., benet managers,
clearinghouses, etc.).
• Payor’s past performance.
• Payor requirements for data sharing (access and evaluation of
associated privacy/security concerns).
• Volume of services with utilization management requirements (such
as prior authorization).
• Payor physician proling and measurement programs that track
quality and cost for each physician. (i.e., what methodology/metrics
does the payer use? How will this be publicly reported – especially to
patients? What is the dispute process? How can this aect payment
– e.g., does a “preferred” ranking put the physician in a dierent tier
with more favorable patient cost share to attract more patients?)
The information described above is intended to help practices
understand the overall strategic considerations involved in their
payor negotiating strategy. A practice’s ability to negotiate a
favorable contract will be determined in large part by the context
of the negotiation, including the factors described above. While the
decision to join a payor (and to negotiate with a payor) may be
complex, practices can optimize their opportunities by developing
a clear understanding of each party’s goals and constraints in the
negotiation. Practices may also benet from working with
experienced health care counsel to assist in designing a negotiating
strategy that is feasible given this overall context.
3Payor Contracting 101
Payor Contract Review Checklist
This Checklist provides an overview of key terms and considerations when reviewing a payor contract as well as questions
for physicians to ask when reviewing, understanding, and negotiating agreements.
Parties, Plans & Products Does the contract clearly identify
the parties to the contract? Does the contract specify plans and
reimbursement methodologies covered under the contract? If
the payor adds a plan to the contract, can the physician review
and/or opt-out of on a plan-by-plan basis?
Physician Services Does the contract clearly describe
physician’s services covered by the contract, along with any
limitations or exclusions? Does the contract address medical
necessity and coverage rules for physician’s services? Does the
payor have specic prior authorization policies (and
transparency of policies) for services or prescriptions? What is
the payor’s PA process (manual vs. electronic) and are other
third parties involved (benet managers)?
Key Denitions Are the key terms used in the contract clearly
dened? Some examples of key terms include adverse change,
aliates, billed charges, clean claim, covered services, eective
date, emergency care, enrollee/member/beneciary, medical
necessity, and payor.
Credentialing Requirements Does the contract clearly
indicate which party is responsible for credentialing? Are
credentialing and corrective action procedures clearly
described? Can physicians provide services and receive
payment while their credentialing application is pending? Are
payors required to notify the physician before actions
disciplining or disqualifying a physician? Additional
credentialing considerations include condentiality of peer
review documents, peer review organization state license
requirements, and feasibility of meeting credentialing
requirements (e.g., site visits, turn-around times,
reporting, etc.).
Payment Provisions
Late Payments or Non-Payment What are the remedies
or penalties for late payments (e.g., late fees, interest, etc.)?
Can a physician easily identify nonpayment/underpayment?
How can a physician directly enforce payment?
Payment methodology Does the contract specify within
how many days the payor must pay the physician? Does
the contract incorporate any state prompt-pay laws? What
billing forms must be used? What constitutes a clean
claim? Does the contract require physicians to accept
electronic payments (vs. paper checks)? Does the contract
require the provider to accept virtual credit cards for
payment, or to contract with any third-party EFT payment
processors? Are there fees associated with receiving
payments through VCC or EFT?
Submission of claims Does the timeframe for submission
of claims coincide with physician’s billing cycles? Does the
payor require electronic submission of claims? If so, are
practices required to submit via a particular
clearinghouse? What method does the payor require for
submission of associated clinical data for claims (fax,
portal, email, US mail, etc.)? Aside from payment, for what
other purposes does the payor use claims data?
Enrollee Payments Is the physician allowed to bill
enrollees for coinsurance, co-payments, and appropriate
deductibles at the time of service? Is the physician
allowed to bill enrollees usual and customary charges for
non-covered services?
Overpayment/Oset How are overpayments to physician
treated (e.g., will overpayments be oset from future
payments; will the physician receive advanced notice of
such osets)?
Appeal Does physician have sucient time to evaluate
and appeal a denied claim? If overpayments may be oset,
will osets begin only after an appeal concludes?
Rates How are rates determined (e.g., fee schedule,
percentage of Medicare, other calculation)? If rates are
based on Medicare, are they based on the then-current
Medicare fee schedule? Does the contract allow the payor
to adjust rates, and can physician dispute the change or
terminate the contract? Do rates increase annually (e.g.,
percentage over prior rates, linked to Consumer Price
Index)? Are physicians required to oer payor the lowest
rates it oers any other payor?
Coordination of Benets Does the contract identify which
party is responsible for coordination of benets? Does the
contract address whether recovery from all potential
sources may exceed the contract price?
Financial Data and Audits Is the physician required to
provide nancial data to payor? Is the payor’s right to
nancial data limited to specic, relevant information?
Does the obligation to share nancial data apply to both
parties (particularly for capitated arrangements)? Are the
notice and audit timeframes addressed in the contract,
and are they reasonable?
Policies, Procedures, Guidelines Does the contract clearly
identify all policies or procedures with which the
physician must comply? Has the physician reviewed
policies, procedures, or guidelines that are incorporated
into the contract before signing the contract? If not, has
4Payor Contracting 101
the physician requested policies, procedures, and
guidelines from the payor and reviewed these documents
prior contracting? Does the contract require notice of
changes to documents that are incorporated into the
contract? Can a physician terminate the contract if the
terms of updated documents are not acceptable?
Utilization and Quality Review
Utilization/Quality Review Structures Are utilization
review (UR) and quality review structures reasonable and
clearly dened? Are each party’s roles and responsibilities
clearly dened? Is the UR administrator who is responsible
for UR determinations identied? Does physician have a
right to independent external review? Does the contract
require prior written notice for amendments to UR terms?
Does the practice have the ability to terminate the contract
if amended terms are not acceptable? If so, how
burdensome is the process (e.g., simple notice vs.
mandatory arbitration)?
Prior Authorization/Concurrent/Retrospective Review
Does the contract clearly identify (or point to specic,
easily accessed electronic lists) services, drugs, or supplies
that are subject to prior authorization? Are procedures
clear, workable, and timely (i.e. specic prior authorization
processing times; urgent prior authorization process and
associated processing time)? Does the payor oer
electronic prior authorization processing via standard
electronic transactions integrated within practice
management systems/electronic health records (vs. payor
portals)? Does payment continue even if an enrollee loses
eligibility during a course of treatment? Are there
limitations on payor’s ability to deny payment, particularly
if its prior authorization or concurrent review process
approved the care? What are the qualications of the
medical personnel reviewing prior authorizations (Are
they guaranteed to be in the same medical specialty or
subspecialty?)? The AMA has prior authorization
resources available.
Appeals and Dispute Resolution Does the contract
address physician’s appeal rights? Does the contract
address the process for grievance or dispute resolution
regarding claims or denials based on UR?
Term and Termination How long is the initial term?
Does the contract automatically renew? This can be
problematic if payors are changing contract terms
(especially rates) and changes are not transparent to the
physician. Can the contract be terminated by either party
without cause upon written notice (e.g., 30 to 90 days’
prior written notice)? Can the contract be terminated
immediately in certain circumstances (e.g., loss of license,
insolvency, exclusion from federal health care programs;
non-payment)? Do parties have an opportunity to cure a
material breach after receiving notice of the breach? If so,
how long is the cure period? Can the physician terminate
on written notice for non-payment? If so, can the
physician terminate the whole arrangement due to
breach by a single plan? Or, can the physician terminate
his or her participation in a single plan without
terminating the whole arrangement? Can the physician
terminate the agreement without penalties in response to
a unilateral amendment or material policy change (note
that some state laws require payors to oer this option)?
Eect of Termination Can the physician terminate the
physician’s participation in an individual plan(s) without
terminating the entire contract? Which terms survive
termination? Is the physician’s obligation to continue to
provide services time-limited, and is the payor obligated
to pay the contact price during that time? Is a physician
prohibited from rejoining the network after termination?
What are the post-termination rates for the payor and
plans that were covered by the contract?
Amendment Are all changes or amendments required to
be in writing and signed by both parties or can a party
propose amendments unilaterally? If the latter, can the
other party object and dispute the amendment or
terminate the agreement? Is the physician bound by any
“click-through” provisions online?
Assignment/Change of Control Does the agreement
terminate upon the change of control of either party?
When is notice required for a change of control (e.g., new
EIN/NPI, change in controlling interest)? Does the contract
prohibit assignment, delegation, or subcontracting by
either party without prior written notice and/or consent?
Are there any exceptions?
Indemnication Do the indemnication terms apply to
both parties? Do the protections include agents and
employees? Do the indemnication terms jeopardize
physician’s liability insurance coverage? Do these terms
survive the termination of the contract?
Non-Solicitation Does the agreement restrict the
physician from contacting or otherwise soliciting his or
her patients after it is terminated? Does it limit physicians’
communications with ongoing patients related to
utilization of other providers within a network?
Dispute Resolution How are costs allocated? How are the
mediator(s) or arbitrator(s) selected? Where will mediation
or arbitration occur? Is arbitration binding or non-
binding? What types of disputes must be resolved
through arbitration?
Operational Considerations Can the payor outsource
functions that may aect the speed or reliability of
payment or communications? Does the payor require use
of third parties for any functionalities (i.e. prior
authorization for certain service types with a benet
manager, or contracting with a third-party company for
electronic payments)? If a third party is involved, what is
the turnaround time for requested information? Are there
5Payor Contracting 101
additional fees associated with these third parties (i.e.
processing fees for electronic funds transfers, portal fees
for electronic remittance advice). Does the payor require
use of their proprietary portal for compliance or
reporting? How does the payor use patient and physician
data? Consider taking the following steps before agreeing
to a payor contract: (1) review claims data for the payor
(e.g., gross revenue and any recurring problems); (2) if
applicable, ask dierent departments for their impressions
of the payor (e.g., quality, nance, clinical sta); (3)
consider the payor’s market share and market focus; and
(4) benchmark the payor against other payors.
6Payor Contracting 101
Payor Contract – Sample Contract
Language
The payor contract is the basic agreement setting out the obligations of the payor and the physician (or practice).
Therefore, it is important to identify terms that are particularly benecial to physicians or payors. The provisions described
here are frequently negotiated and, as reected below, may be written in a way that favors one party more than the other.
Please note that the examples included here are intended as educational content only and may not be appropriate to use
in a specic payor agreement without further review or modication. This sample language should not be construed as
legal advice; the AMA does not guarantee the enforceability or appropriateness of this language when applied to any
particular agreement. Physicians should seek guidance from experienced health care counsel in connection with any use
of this sample language.
Eligibility
Favorable to physician:
Payor shall be responsible for identifying and verifying eligibility of
Members. Payor shall provide each Member with an identication
card. It is the Payor’s responsibility to update and maintain eligibility
les and systems to ensure that eligibility verication is timely and
accurate. Physician may rely on eligibility verications obtained
from a Payor or its designee and Payor shall reimburse Physician in
accordance with this Agreement even if a Member is later
determined to be ineligible on the date of service.
Favorable to payor:
Physician will verify a Member’s eligibility before providing a
Covered Service unless the situation involves the provision of an
Emergency Service in which case Physician will conrm eligibility in
a manner that is consistent with Law on redeterminations of
eligibility. Physician will not be reimbursed for any services furnished
to a patient who was not an eligible Member on the date of service.
Overpayments and Recoupments
Favorable to physician:
Notwithstanding any other provision of this Agreement, Payor shall
issue requests for overpayments to Physician within three hundred
sixty-ve (365) days from the date of the initial Claim payment or it
shall be waived by Payor except in instances of fraud or
misrepresentation by Physician. In no event shall Payor oset
overpayments against amounts due to Physician without
Physician’s written consent.
Favorable to payor:
In the event of an overpayment, Payor will issue an overpayment
letter requesting repayment of the funds. If the Physician does not
timely dispute or repay the overpayment within sixty (60) days, Payor
may collect the amount by osetting or recouping from any amounts
due to the Physician. Physician will promptly notify Payor and
applicable governmental agencies of any overpayments identied by
Physician. Notwithstanding any other provision of this Agreement, the
oset and recoupment rights for an overpayment may be exercised to
the time period permitted by Law.
Contract Amendments
Favorable to physician:
Any amendment to this Agreement shall require the mutual written
agreement of both Parties.
Favorable to payor:
Payor may amend this Agreement upon forty-ve (45) days prior
written notice to Physician. The proposed amendment shall take
eect unless Physician noties Payor of its termination of the
Agreement within forty-ve (45) days of receipt of the notice
of amendment.
Physician Manual / Payor Policy Changes
Favorable to physician:
Physician shall comply with the Physician Manual and all applicable
policies of Payor in eect as of the Eective Date of the Agreement
and as provided to Physician. Payor shall notify Physician at least
ninety (90) days in advance of implementing any new policies or
making material changes to the Physician Manual. A “material
change” shall include, but not be limited to, (i) any changes to or
negative impact to reimbursement to Physician; and (ii) any
increased operational or administrative burden to Physician. In the
event Physician objects to a material change, the change will not
take eect as to Physician without the mutual written agreement of
the Parties.
Favorable to payor:
Physician shall comply with the Physician Manual and all applicable
policies of Payor, any of which may be amended by Payor from time
to time at the Payor’s sole discretion.
Special Considerations for Value-Based Agreements
Agreements with a value-based component create unique legal
considerations. For example, an agreement involving value-based
payment may require the physician to contract through a preferred
network or submit certain additional data. It may also involve data
sharing and payment terms associated with non-fee-for-service
models like shared savings. Also, it is important to understand the risk
arrangement being discussed as this will impact payment. (upside
only? downside risk?) The AMA has made guidance applicable to
value-based physician contracts available here.
7Payor Contracting 101
Examples of Signicant Payor Unilateral
Policy Changes
In addition to the formal contractual language described above, physicians should be aware of certain important policy
changes made by payors in recent years. Policy changes are signicant because, in many cases, payors may unilaterally
make these changes by amending a manual or written procedure documents. Depending on the terms of the payor
agreement, a physician may receive limited notice of these changes, and may not be able to eectively contest or reject
the change. In some cases, a physician’s only recourse is to terminate the agreement entirely due to such changes.
However, other agreements may specify that changes to policies, procedures, or manuals may not take eect without the
consent of the physician practice.
In some recent cases, unilateral policy changes have been associated with emerging payor practices that impact physician
clinical decision-making in important ways. Some examples to be on the lookout for include:
1) Language Permitting Down coding
Certain payor agreements, policies, or manuals now contain language
permitting the payor to override a service billed by a physician, and
instead unilaterally pay the physician for a dierent service
reimbursed at a lower rate. This may be true even if the physician has
fully documented the medical necessity of the service, if the payor is
using technology or a vendor to determine what the physician
“should have” billed.
Examples of recent contractual language allowing this practice are
as follows:
Example 1: In an eort to reduce the administrative burden of
requesting and submitting medical records for review, [Payor] will
begin using [Proprietary Tool] which determines appropriate E/M
professional coding levels based on data such as patient’s age and
conditions for the Medical Decision-Making key component. [Payor]
will presume the provider meets the requirements of the E/M code
level they have submitted related to the History and Exam key
components for the initial adjudication of the claim.
Example 2: [Payor or aliate of Payor] will review emergency
services claims to determine appropriate use of emergency room
and whether an emergency medical condition existed. At a
minimum, both the facility and the physician will receive
reimbursement for screening services:
1) For physician services billed on a CMS-1500 claim: If a prudent
layperson review determines that the service was not an
emergency, [Payor] is required to reimburse, at a minimum, for
Current Procedural Terminology (CPT) code 99281, the
Emergency Department Visit Level 1 screening fee.
2) For facility charges billed on a UB-04: If a prudent layperson
review determines the service was not an emergency, [Payor]
must reimburse for revenue code 451, EMTALA Emergency
Medical Screening Services.
2) Language permitting or requiring bundling of
distinct services
Some payors are adopting software solutions or using third-party
vendors to group together physician services into bundled services.
Often this is based on the payor’s determination that reimbursement
for distinct services is already reected in payment for a single
comprehensive code. In some cases, this means the payor may avoid
separate payment for services performed and properly documented
by a physician, based on software edits grouping the service into a
bundled code. Physicians should understand how payors will apply
these “bundling” policies and their rights to appeal or contest the
decision to bundle services this way.
Example: Eective [Date], we will begin using [Software], a new
clinical code editing software for medical and behavioral products.
[Software] will facilitate accurate claim processing for medical and
behavioral claims submitted on a CMS-1500 claim form. [Software]
code auditing is based on assumptions regarding the most
common clinical scenarios for services performed by a health care
professional for the same patient. [Software] logic is based upon a
thorough review by physicians of current clinical practices,
specialty society guidance, and industry standard coding. Services
considered incidental or mutually exclusive to the primary service
rendered, or as part of a global allowance, are not eligible for
separate reimbursement. Patients covered under [Payor]-
administered plans should not be balanced billed for clinically
edited non-paid services. A procedure that is performed at the
same time as a more complex primary procedure, requiring little
additional physician resources and/or is clinically integral to the
performance of the primary procedure, is considered incidental to
the related primary procedure(s) on the same date of service and
will not be separately reimbursed.
8Payor Contracting 101Payor Contracting 101
3) Language on payment options
Some payors are adopting electronic payment requirements through
third parties that may impose additional costs on the physician.
Physicians should understand all reimbursement options from the
payor and any costs associated with each reimbursement option.
Example: [Third party vendor] oers the following payment options:
(1) Electronic Funds Transfer (EFT) – EFT is a fast and reliable method
to receive payments and is the preferred method for [Payor]. In order
to register for [Payor] payments and choose EFT as your payment
preference, visit [Third party vendor] registration page. (2) Virtual
Card Payment – Standard credit card processing and transaction
fees apply. Fees are based on your credit card processor’s fees and
your current banking rates. [Third party vendor] does not charge
any additional fee for processing. For each payment transaction, a
credit card number unique to that payment transaction is sent
either by secure fax, or by mail. Processing these payments is similar
to accepting and entering patient payments via credit card into your
payment system. (3) Paper Check – If your oce would prefer to
receive check payments, please call [Third party support] at
[customer support number].
4) Language for required use of specialty pharmacies
An increased number of payors are contracted with a third-party
specialty pharmacy to lower up-front medication acquisition costs to
physicians, integrate coordination of coverage between physician,
patient, and payor, assure compliance with guidelines and standards,
and others. Physicians should understand options for specialty
pharmacies for each payor, required use of specialty pharmacies. It is
important to note that some payors may have dierent requirements
for each plan. Physicians should check specic plan requirements
prior to medication administration.
Example: [Payor] contracts with select specialty pharmacies to
obtain specialty medications for physician administration to our
members. Specialty medication coverage is based on the member’s
benet. Prior Authorization or Predetermination approval may still
apply to specic specialty medications. In accordance with their
benets, some members may be required to use a specic preferred
specialty pharmacy, or be subject to a split ll program, for benets
to apply. For more information about medical criteria, please refer
to the Medical Policies. Note: Depending upon administration
(physician-administered or self-administered), the member’s plan
will determine which benet (medical coverage or pharmacy
coverage) will cover the medication. Please call the number on the
member’s ID card to verify coverage, or for further assistance or
clarication on your patient’s benets.
Disclaimer: The information and guidance provided in this document are believed to be current and accurate at the time of posting. This information is not intended to be and
should not be construed to be or relied upon as, legal, nancial or consulting advice. Consider consulting with an attorney and/or other advisor to obtain guidance relating to your
specic situation. References and links to third parties do not constitute an endorsement, sponsorship or warranty by the AMA, and the AMA hereby disclaims all express and implied
warranties of any kind.
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