As part of our continuing efforts to improve the quality and affordability of health care, we are making important changes to the precertification process for our members who receive the following infusion therapy drugs:

• alglucerase (Ceredase?)
• imiglucerase (Cerezyme?)
• velaglucerase alfa (VPRIV?)
• eculizumab (Soliris?)

Effective January 1, 2012, all precertification requests for these drugs will be reviewed to determine if members are receiving them in the setting that is cost-effective, safe, and clinically appropriate for their medical needs. This decision is based on factors such as, but not limited to:

• the setting that has been determined to be both cost-effective and safe for the member;
• the level of care required by the member based on his or her medical history and current health status;
• recommendations from the drug manufacturer;
• current standards in medical practice.

Typically, administration of the infusion therapy drugs listed above should only occur in an outpatient facility or hospital when patients are receiving an initial dose of one of these drugs, or for those who have a history of treatment-related adverse effects that require monitoring. Aside from these exceptions, most patients can safely receive these drugs in either a provider?s office or in their home through a home infusion provider.

Administering drugs in the office or at home

The following options are available for administering these drugs in a provider?s office or in the member?s home:

• Buy and bill. Providers can buy the drug and bill the health plan for reimbursement once the drug has been given to the member.
• Home infusion therapy. Many members prefer the convenience of receiving infusion therapy drugs in their home through a home infusion provider. Providers should discuss this option with their AmeriHealth patients, when appropriate.

Requesting administration in an outpatient facility or hospital

Providers who request coverage for administration of these drugs in an outpatient facility or hospital will be asked during precertification to provide details about the member?s medical history to support the request. A team of AmeriHealth medical directors and nurses will review the submitted documentation and determine whether coverage in these settings is approved.

Impacts to coverage

AmeriHealth will continue to cover these drugs and all services associated with their administration when both of the following requirements are met:

• The member meets the medical necessity criteria outlined in the applicable medical policy.
• The drug is given in the setting that has been approved by AmeriHealth as part of the precertification review process.

Please call Customer Service at 1-800-275-2583 if you have any questions about setting options for these infusion therapy drugs. Customer Service can also assist you with home infusion options.