Reminder: Updates to Most Cost-Effective Setting Program for injectable and infusion therapy drugs

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Reminder: Updates to Most Cost-Effective Setting Program for injectable and infusion therapy drugs

December 18, 2017

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Independence wants to ensure that our members receive injectable/infusion therapy drugs in a setting that is both safe and cost-effective for their clinical condition. Since 2012, Independence has been reviewing the most appropriate setting for commercial members to receive certain injectable and infusion therapy drugs as part of the precertification review process.

Effective January 1, 2018, the drugs Nucala^®, Ocrevus^™, Radicava^™, and Somatuline^® Depot will be added to the list of drugs that require review for setting as part of the precertification process for commercial members.

Members who have approvals extending into 2018 for Nucala and Ocrevus can continue to receive treatment in their current setting until their precertification approval expires. However, during the next precertification request, Independence will review the requested setting and make a determination. Members who are currently receiving Radicava and Somatuline Depot will be subject to precertification review as of January 1, 2018. This will ensure that members meet the coverage criteria for the drug and that they are receiving treatment in a cost-effective setting.

What does this mean for your patients?

These drugs are covered by Independence for members who meet the clinical criteria outlined in our medical policy for each drug and receive the drug in the setting approved by Independence during precertification review.

During precertification review, each member?s medical needs and clinical history are evaluated to determine if the drug and setting requested by the provider are appropriate. Typically, the first administration of the drugs included in this program will be approved in the hospital outpatient facility. This allows the member to be monitored for any treatment-related adverse effects. If the member does not experience any adverse effects during treatment, subsequent drug administration will be approved in a more cost-effective setting, such as the member?s home, the provider?s office, or an ambulatory (freestanding) infusion suite. If there are circumstances that require a member to continue receiving the drug in the hospital outpatient facility, the provider must submit documentation to Independence that specifically addresses these circumstances when submitting a request for coverage.

Medical policy information

To review the medical policies for the drugs listed, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commericial, and type the name of the drug in the Search box.