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.
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