Posted in In The Know Series, Insurance, Training

EmblemHealth Coverage Update-Certain Infusion medications-Effective 04/01/2020

Accredo Convenient Care Program to start on 04/01/2020

Things to consider:

-Accredo’s Convenient Care Program is responsible for in-home fusion treatment for EmblemHealth members

-This update applies ONLY to members that are 21 years and older AND have an EmblemHealth Commercial Plan Coverage

-Coverage is for infusion medications that can be provided for patients in their homes or AIS (Ambulatory Infusion Suites/POS 12 or physicians office /POS 11

After 04/01/2020-members do have an option to request ONE-TIME-ONLY refill of the specialty medicine at their CURRENT PROVIDER, if needed (check with customer service if Prior Auth would be required, if your Provider is in POS 19 or POS 22)

-Prior authorization is required in order to receive treatment in outpatient hospital setting. IF member is using Doctors Office of Campus POS19 or POS22 w/o an authorization, member will be responsible for the FULL AMOUNT OF the drug cost and treatment.

Transition Process:

1. An Accredo Representative will reach out to prescriber for a NEW prescription

2. Once a valid Prescription is received the Accredo Rep then will reach out to the member and schedule a delivery of medicine.

In Network Ambulatory Infusion Suites:

-Coram and Option Care infusion vendors have AIS throughout the country

Please contact your nearest Coram or Option Care location for more information

List of Specialty medications:

BIVIGAMHIZENTRA
CARIMUNE NFHYQVIA
CUVITRUINFLECTRA
FLEBOGAMMA 5&10%OCTAGAM
GAMMAGARD LIQUIDPANZYGA
GAMMAGARD S-DPRIVIGEN
GAMMAKEDREMICADE
GAMMAPLEXRENFLEXIS
GAMUNEX-C 

*Expeptions:

In order for the member to start or to continue the treatment in POS 19 or POS22 – the provider needs to submit clinical rationale and documentation for review.

AND

Member must to meet ONE of the following criteria:

-Pediatric Patient (under 21 years of age)

-Documented history of severe reaction, which is defined as anaphylactic reaction, to this medication or any constituent of it

-Known cardiac condition (e.g. symptomatic cardiac arrhythmias) or pulmonary condition (e.g. significant respiratory disease, serious obstructive airway disease, %FVC less or equal to 40%) that may increase a 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 of 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

Submitting an exception or request help to locate an approved home infusion vendor or AIS (ambulatory infusion suites):

-Contact EmblemHealth 888-447-0295

-Hours: 8am to 6pm

OR you can contact:

Accredo Phone#: 844-581-4862

Link to the full EmblemHealth Announcement: https://www.emblemhealth.com/providers/resources/toolkit/Reminder-Accredo-Convenient-Care-Program-Starts-April1-2020

Author:

My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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