EmblemHealth Injectable Drug Utilization Management Program

Accredo provides utilization management (UM) for a list of specific injectable drugs on behalf of EmblemHealth’s Injectable Drug Utilization Management Program.

The drugs on the list, which include, but are not limited, to chemotherapy and rheumatoid arthritis medications, are ordered or administered by practitioners either in their office (POS 11), an outpatient hospital (POS 22) or ambulatory surgery center (POS 24) setting. The drugs on the list are covered as part of our members’ medical insurance benefit* and will require prior approval from Accredo. This program is not intended to and does not change our members’ benefits* or your claims submission procedures.

Program details may be found in the Quick Reference Guide and the Frequently Asked Questions.The guide lists the drugs and the J-codes that require prior approval and summarizes how to request prior approvals from Accredo. We have also included a step-by-step guide with screen shots to assist you.

What Is Accredo?

Accredo, a specialty pharmacy provider, is part of Express Scripts.

Prior Approval Requirement
The ordering provider will need to request prior approval by calling Accredo at 855-216-2166, Monday to Friday, 8 a.m. to 11 p.m.; Saturdays, 8 a.m. to 5 p.m.

Questions?

Please see our Frequently Asked Questions. If you still have questions and would like to contact us, please sign into our secure website to use our Message Center. 

*Commercial plans underwritten by Group Health Incorporated (EmblemHealth EPO/PPO, GHI EPO/PPO) and HIP members assigned to a Montefiore (CMO) or HealthCare Partners (HCP) primary care physician, are excluded from this program.

IMPORTANT SERVICE LOCATION ALERT

EmblemHealth’s Injectable Drug Utilization Management Program, managed by Accredo, applies only to service locations in New York State. Service locations outside New York State are exempt from the requirements of this program.

Use the EmblemHealth Specialty Pharmacy Program?

Prior approvals are still required for the listed drugs. Special fax forms for the HIP Drug Replacement Program enable providers to submit a request for prior approval and drug replacement in one transaction. Providers may continue to use the Specialty Pharmacy Program to obtain drugs not on the list for this new program or to obtain drugs from a vendor other than Accredo.