EmblemHealth updates its Formulary on a regular basis. Find our most recent updates here.

UPDATE: Accredo’s Convenient Care Program Now Starting April 1, 2020

Effective April 1, 2020, maintenance doses of certain infused medications will only be covered when given in an EmblemHealth member’s home (Place of Service 12), an ambulatory infusion suite (AIS, Place of Service 12), or a doctor’s office (in a non-hospital setting, Place of Service 11).

 

The specialty drugs on the list below will no longer be covered in an outpatient hospital setting (Doctor’s Office-Off Campus, Place of Service 19 & On-Campus Outpatient Hospital, Place of Service 22), unless EmblemHealth approves an exception* for your patient. Members using an outpatient hospital setting for treatment without preauthorization will be responsible for the full cost of their drugs and treatment.  This only affects members age 21 and older with EmblemHealth commercial plans.

 

EmblemHealth is partnering with Accredo Specialty Pharmacy to provide in-home infusion treatments for our members through Accredo’s Convenient Care Program. To facilitate the transition of a member from an outpatient hospital setting to home or to a doctor’s office, an Accredo pharmacist will reach out to prescribers for a new prescription(s). Once the prescription is in place, an Accredo representative will call the member to schedule the delivery of the medicine(s) and treatment(s). After April 1, 2020, members may request a one-time-only refill of their specialty medicine(s) at their current provider if needed.

 

EmblemHealth has already partnered with Coram and Option Care home infusion vendors, who have ambulatory infusion suites throughout the country to serve your patients. For more information on ambulatory infusion suites, please call your nearest Coram or Option Care location.  

 

Starting April 1, 2020
 

BIVIGAM
 

HIZENTRA
 

CARIMUNE NF
 

HYQVIA
 

CUVITRU
 

INFLECTRA
 

FLEBOGAMMA 5&10%
 

OCTAGAM
 

GAMMAGARD LIQUID
 

PANZYGA
 

GAMMAGARD S-D
 

PRIVIGEN
 

GAMMAKED
 

REMICADE
 

GAMMAPLEX
 

RENFLEXIS
 

GAMUNEX-C
 


 

 

EmblemHealth recognizes that home infusion may not be suitable for all members, so providers must submit clinical rationale and documentation for review for exceptions.

* For administration in a Doctor’s Office-Off Campus (Place of Service 19) or an On-Campus Outpatient Hospital (Place of Service 22), ONE of the following criteria must be met:

  • Pediatric patients (under 21 years of age)
  • Documented history of a severe reaction, which is defined as anaphylactic reaction, to this medication or any constituent of it
  • Known cardiac condition (e.g. symptomatic cardiac arrhythmia) or pulmonary condition (e.g. significant respiratory disease, serious obstructive airway disease, %FVC ≤ 40%) that may increase the risk of an adverse reaction
  • Documented intolerance to this medication requiring constant telemetry monitoring of vitals
  • Unstable renal function which decreases the ability to respond to fluids
  • Difficult or unstable vascular access
  • Unsafe home environment
  • Acute mental status changes or cognitive conditions that impact the safety of infusion therapy
  • No access to emergency services

If you have questions or wish to submit an exception, please call us at 888-447-0295 (TTY: 711) . Our hours are 8 a.m. to 6 p.m. We would be happy to provide you with a list of approved home infusion vendors and ambulatory infusion suites.

You can also call Accredo at 844-581-4862 (TTY: 711). Their hours of operation are Monday to Friday, 8 a.m. to 5 p.m.

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