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Changes to approved drug dose, frequency, or regimen must be resubmitted for precertification

May 31, 2012

Since January 1, 2011, IBC has reviewed the dose and frequency of administration for eight drugs as part of the precertification process. By reviewing this information, IBC can confirm that requested coverage is being authorized for the dose and at a frequency generally accepted by the medical community as appropriate for the condition being treated. These eight drugs are: bevacizumab (Avastin®)* cetuximab (Erbitux®) immune globulin, intravenous (IVIG) infliximab (Remicade®) onabotulinumtoxinA (Botox®) oxaliplatin (Eloxatin®) rituximab (Rituxan®) trastuzumab (Herceptin®) As a reminder, if, during the course of therapy for which precertification is issued, the member?s dose, frequency, or regimen changes (based on factors such as changes in member weight or incomplete therapeutic response), an amended coverage request must be submitted to IBC for a new approval as part of the precertification process. IBC reserves the right to conduct post-payment review and audit of claims submitted for these eight drugs and may recover payments made in excess of the amount approved through the precertification process. Please refer to the medical policies for each of these eight drugs for more information on the Dosing and Frequency Guidelines associated with each one. To do so, visit our Medical Policy website, select Accept and Go to Medical Policy Online, and type the name of the drug into the Search box. You can also access medical policies through the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu and then Medical Policy. Please call 1-800-ASK-BLUE if you have any questions about the precertification process for these drugs.

*Requests for intravitreal injection of bevacizumab (Avastin®) to treat the ophthalmologic conditions listed in this drug?s medical policy do not require precertification. Only oncology requests for bevacizumab (Avastin®) require precertification approval for dose and frequency.

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