Providers > Specialty Carve-Out > FAQ

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  • What is LDI’s Specialty Injectable Carve Out Program?
  • LDI’s Specialty Injectable Carve Out Program is an innovative approach designed to manage specialty injectable medications for LDI’s clients (“LDI Client”).  LDI applies an established method of calculating reimbursement for specialty injectables to provide fair reimbursement to a health plan’s participating providers. In order to effectively use this feature of the specialty program, an LDI Client carves out specialty injectables from its medical benefits and amends its plan design so that the maximum allowable for injectables is based on LDI repricing.

  • What are specialty injectables?
  • Specialty injectables are defined as those drug therapies and ancillary items that are: (i) indicated for the treatment of chronic and/or life threatening disease states; (ii) require administration by injection, infusion or inhalation; (iii) require surveillance, counseling or monitoring in conjunction with their use; (iv) require special handling in their distribution; (v) are commonly administered by physicians and not patients; (vi) have limited availability or distribution; (vii) are considered an Orphan Drug, as that term is used on the industry (generally, any drug developed to treat a rare disease); (viii) are considered reimbursable under a major medical provision of a benefit plan; or (ix) require the use of non-standard billing and reimbursement practices.  A summary list of the Specialty Pharmaceuticals current as of the effective date of this Agreement is attached to this Q&A document.

  • How does the process work?
  • LDI has identified a list of specialty HCPCS codes that it will reprice. The LDI Client’s health plan extracts claims that contain those HCPCS codes from their claim set and forwards those claims to the LDI Client.  The LDI Client sends the claims to LDI and LDI converts the HCPCS codes to a quantity and manufacturer-specific NDC product and applies the 2004 Medicare allowable.  LDI returns the claims to the LDI Client, who then remits payment to the health plan’s participating provider at the repriced amount.

  • What must a Provider do differently when it provides specialty injectables to an LDI Client patient?
  • If you wish you can continue to purchase medications or LDI can supply medications directly to your office. Before providing services to a patient covered by an LDI Client health plan, the provider must call LDI to confirm eligibility and benefits, just as the provider would do for other medical services.  The LDI contact information should be on the patient’s identification card.

  • What is the turn-around time for this process?
  • Claims can be returned to the LDI Client approximately 1-2 days after receipt of the claims, resulting in no delay in payment to the health plan participating provider.