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Neulasta®: Updates to precertification and setting requirements and coverage options now in effect

January 11, 2017

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As of January 1, 2017, Independence changed how we manage Neulasta® (pegfilgrastim) and Neulasta® Onpro®*. These changes include the following:

  • All requests for coverage for Neulasta® under the medical benefit require precertification approval from Independence prior to our members receiving the drug.
  • As part of our Most Cost-Effective Setting Program, Independence will also review the setting where members enrolled in commercial plans receive Neulasta®.
  • Members enrolled in commercial plans whose pharmacy benefits are managed by FutureScripts®, our independent pharmacy benefits manager, are also able to obtain Neulasta® under their pharmacy benefit. Note: For Medicare Advantage members, Neulasta® is currently covered under the Part D benefit.

Precertification approval

Independence requires precertification approval for many specialty drugs to ensure that the medical necessity criteria listed in our medical policies are satisfied. For dates of service on or after January 1, 2017, all requests for Neulasta® under the medical benefit require precertification approval from Independence for commercial and Medicare Advantage members.

According to its U.S. Food and Drug Administration-approved label, Neulasta® is given 24 hours after chemotherapy. Due to the time-sensitive nature of the drug, it is important for you to request precertification approval in advance of the member?s scheduled treatment date. This allows Independence sufficient time to review the request.

Setting approval

During precertification review, each member?s medical needs and clinical history are evaluated to determine if the drug for which coverage is requested satisfies the coverage criteria. As part of this precertification process, Independence reviews the provider?s request for treatment setting for certain drugs covered under the medical benefit to ensure that our members receive treatment in a setting that is both cost-effective and safe. As of January 1, 2017, Neulasta® was added to the Most Cost-Effective Setting Program for all commercial plans. Cost-effective settings for Neulasta® include:

  • a physician?s office, where you can either (1) buy the drug and request reimbursement from Independence or (2) order the drug via the Independence Direct Ship Drug Program and incur no cost for acquiring the drug;
  • the member?s home, where the injection is administered by an in-network home infusion provider;
  • an ambulatory (freestanding) infusion suite, not owned by a hospital or health system in our network.

A hospital outpatient facility is the most costly setting in which to administer Neulasta®; and coverage in such a setting will be considered for those members who are receiving their initial dose of Neulasta® or for members whose condition requires the intensive monitoring and access to emergent care uniquely available on a hospital campus. Independence will require submission of relevant medical records identifying the specific reason the hospital outpatient setting is requested for ongoing administration of Neulasta®. This information will be reviewed and a coverage determination on setting will be made.

Coverage for Neulasta® under the pharmacy benefit for commercial members

Offering coverage for Neulasta® under either the medical or pharmacy benefit gives our commercial members more options and greater convenience. The terms, conditions, and cost-sharing provisions (including copayment, deductible, and coinsurance) in their benefit contracts may vary between medical and pharmacy benefits, so members should compare both benefits to determine the coverage option that is more advantageous for them.

If members choose to obtain Neulasta® under the pharmacy benefit through FutureScripts, they will need a prescription. At your professional discretion, Neulasta® may be prescribed for self-administration or may be physician-administered. In the event your office administers a dose of Neulasta®, this service is eligible for reimbursement with submission of a claim.

For members who do not have pharmacy benefits with FutureScripts but who have pharmacy benefit coverage with another vendor and are interested in self-administering Neulasta®, you should encourage them to contact their pharmacy benefits manager to determine if Neulasta® is available for coverage under their prescription drug plan.

For more information

Providers can find additional information about Neulasta® in the following Independence medical policies:

  • Commercial: #08.01.32: Pegfilgrastim (Neulasta®)
  • Medicare Advantage: #MA08.082: Pegfilgrastim (Neulasta®)

To access medical policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial or Medicare Advantage under Active Notifications.

If you have questions about any of these changes, contact your Network Coordinator.

*All mentions of Neulasta® are inclusive of Neulasta® Onpro®.

FutureScripts is an independent company that provides pharmacy benefits management services.

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