Effective April 1, 2020, maintenance doses of certain infused medications will only be covered when given in your patient’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 ConnectiCare 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 age 21 and older with ConnectiCare commercial plans.
ConnectiCare is partnering with Accredo Specialty Pharmacy to provide home infusion treatments in members’ homes through Accredo’s Convenient Care Program. To help transition members from an outpatient hospital setting to home, or a doctor’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 Apr. 1, 2020, if needed.
ConnectiCare has partnered with Coram and Option Care home infusion vendors, who have ambulatory infusion suites throughout the country to serve your patients who are ConnectiCare members. For more information on ambulatory infusion suites, please call your local Coram or Option Care.
|Drugs not covered in outpatient setting starting Apr. 1, 2020|
Change in preauthorization process
The drugs listed above currently require preauthorization requests be submitted to our partner, Magellan Rx Management (Magellan Rx). Starting March 1, 2020, ConnectiCare will review preauthorization requests for these drugs. You can continue submitting preauthorization requests for these drugs to Magellan Rx until Feb. 29, 2020.
Through this preauthorization program, we will direct commercial members to an alternative site of service, when appropriate. ConnectiCare recognizes that home infusion (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) may not be suitable for all members. Providers must submit clinical rationale and documentation for review for exceptions as part of their preauthorization requests.
*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 that 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
Here’s what you need to know about existing preauthorization approvals for the drugs above:
- Your patients’ current authorizations will be valid through the date noted in the approval letter. Any renewals after March 1, 2020 must be submitted and approved by ConnectiCare’s Pharmacy Department.
- You can request authorizations and exceptions by:
- Fax: 1-800-249-1367
- Phone: 1-800-828-3407 (our hours are 8 a.m. to 6 p.m., Monday to Friday)
If you have questions, please call us at 1-800-828-3407. 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. Their hours of operation are 8 a.m. to 5 p.m., Monday through Friday.