Home Administrative Billing & Reimbursement BlueCard® 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 Independence Dosage and Frequency Program. Medical policies for each of these drugs already include the dosage and frequency requirements.

Since January 1, 2011, Independence 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 Independence 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 Independence (i.e., published peer-reviewed literature) to support the request.

Independence 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 specific medical policies for each drug included in the program.

Commercial policies

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

Medicare Advantage policies

MA08.025: Omalizumab (Xolair®)
MA08.042: Ustekinumab (Stelara®)
MA08.065: Octreotide acetate (Sandostatin® LAR Depot)
MA08.001: Vedolizumab (Entyvio®)

To access these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial or Medicare Advantage, depending on which version of the policy you would like to view, and then type the name or policy number in the Search field. To access policies from Independence 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 Independence 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., an independent company.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.