Home Administrative Billing & Reimbursement Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Four drugs added to the Dosage and Frequency Program

April 13, 2017

Effective May 5, 2017, vedolizumab (Entyvio®), octreotide acetate (Sandostatin® LAR Depot), ustekinumab (Stelara®), and omalizumab (Xolair®) will be added to the AmeriHealth Dosage and Frequency Program. Medical policies for each of these drugs already include the dosage and frequency requirements.

Since January 1, 2011, AmeriHealth has reviewed the requested dosage and frequency of administration for select drugs as part of the precertification process. With the addition of these four drugs to the Dosage and Frequency Program, the following is the comprehensive list of drugs that will be reviewed for dosage and frequency:

  • bevacizumab (Avastin®)*
  • cetuximab (Erbitux®)
  • immune globulin, intravenous/subcutaneous (IVIG/SCIG)
  • infliximab (Remicade®)
  • infliximab-dyyb (Inflectra®)
  • ipilimumab (Yervoy®)
  • octreotide acetate (Sandostatin® LAR Depot)
  • omalizumab (Xolair®)
  • rituximab (Rituxan®)
  • trastuzumab (Herceptin®)
  • ustekinumab (Stelara®)
  • vedolizumab (Entyvio®)

Coverage of these drugs is contingent upon review by AmeriHealth for appropriate dosage and frequency. Providers who request coverage above the dosage and frequency requirements listed in the medical policy for each drug will be required to submit documentation to AmeriHealth (i.e., published peer-reviewed literature) to support the request.

AmeriHealth reserves the right to conduct a post-payment review and audit of claims submitted for any drug that is part of the Dosage and Frequency Program and may recover payments made in excess of the amount approved through the precertification process. For more information on the dosage and frequency guidelines, please refer to the following medical policies for each drug included in the program:

  • 08.00.55: Omalizumab (Xolair®)
  • 08.00.82: Ustekinumab (Stelara®)
  • 08.01.10: Octreotide acetate (Sandostatin® LAR Depot)
  • 08.01.18: Vedolizumab (Entyvio®)

To access these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial and type the name or policy number in the Search field. To access policies from AmeriHealth NaviNet® Plan Central, select Medical Policy Portal under Provider Tools in the right-hand column.

If you have any questions about the precertification process for any drugs in the Dosage and Frequency Program, please call the AmeriHealth Clinical Services Department.

*Bevacizumab (Avastin®) only requires precertification approval for dosage and frequency for oncologic indications. Coverage requests for intravitreal injection of bevacizumab (Avastin®) to treat the ophthalmologic conditions listed in this drug?s medical policy do not require precertification.

NaviNet is a registered trademark of NaviNet, Inc.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of AmeriHealth, AmeriHealth HMO, Inc., AmeriHealth Insurance Company of New Jersey.
© 2023 AmeriHealth Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer