Reminder: Accredo’s Convenient Care Program Starts March 1, 2020

EmblemHealth is partnering with Accredo Specialty Pharmacy to provide home infusion treatments in the member’s home through Accredo’s Convenient Care Program. Effective March 1, 2020, maintenance doses of certain infused medications will only be covered when given in your patient’s home, an ambulatory infusion suite or a prescriber’s office (in a non-hospital setting). The specialty drugs on the list below will no longer be covered in an outpatient hospital setting, unless EmblemHealth approves an exception* for your patient. Members using an outpatient hospital setting for their treatments, without prior authorization, will be responsible for the full cost of their drugs and treatment. This only affects members with EmblemHealth commercial plans age 18 and older.

To facilitate the transition of members from an outpatient hospital setting to home or a provider’s office, an Accredo pharmacist will reach out to prescribers for 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 treatments. Members may request a one-time-only refill of their specialty medicine(s) at their current provider after March 1, 2020 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 local Coram or Option Care.

Drugs not covered in outpatient setting
starting March 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.

*The following are considerations for services in an outpatient hospital setting:

  • Pediatric patients (under 18 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.