All commercial plan members requiring oral specialty and self-administered specialty injectables must obtain medications from Accredo. Accredo is the preferred specialty pharmacy for Medicaid and Medicare members requiring oral or self-administered specialty injectables. The list of self-administered specialty drugs includes:
- Calcium regulators
- Growth hormones
- Hepatitis C agents
- HIV fusion inhibitors
- Infertility agents
- Injectable contraceptives (e.g., progestin)
- Multiple sclerosis agents
- Plaque psoriasis agents
- Rheumatoid arthritis agents
Some specialty drugs require submission of a Certificate of Medical Necessity (CMN) or a physician's prior approval (PPA). To order a CMN or PPA, practitioners should contact the EmblemHealth Specialty Pharmacy department at 1-888-447-0295.
Accredo Specialty Pharmacy Services fills prescriptions and delivers them directly to the member's home. To ensure member privacy, all prescriptions are delivered by courier service and packaged in nondescript materials. A signature is required at the time of delivery, unless other arrangements have been made. Members are instructed to check that their order is accurate and, if necessary, refrigerate the medication.
All prescriptions, including transfers of existing prescriptions, must be submitted to Accredo by phone at 1-888-615-3144or by fax at 1-800-391-9709. For more information, contact the EmblemHealth Specialty Pharmacy department at 1-888-447-0295.
For prior approval processes for medications not on the EmblemHealth Injectable Drug Utilization Management Program list that follows, see the Pharmacy Benefit Designs, Nonpreferred Drugs or Medicaid Pharmacy Program sections of the Pharmacy Services chapter.
Glossary terms found on this page:
The inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.