IBC 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 January 2012, IBC considers the most appropriate setting for commercial
members to receive certain injectable and infusion therapy drugs as part of the
precertification review process.
Effective July 1, 2013, two additional drugs will require precertification
based on setting. The following is the updated list of drugs that require
precertification approval for setting:
Aralast (alpha-1 proteinase inhibitor [human])
Berinert[
®] (C1 esterase inhibitor [human]) New for July 2013
Ceredase[
®] (alglucerase)
Cerezyme[
®] (imiglucerase)
Cinryze[
®] (C1 esterase inhibitor [human]) New for July 2013
Elelyso[
]TM[] (taliglucerase alfa)
Fabrazyme[
®] (agalsidase beta)
Glassia (alpha-1 proteinase inhibitor [human])
Intravenous immunoglobulin (IVIG)
Kalbitor[
®] (ecallantide)
Lucentis[
®] (ranibizumab)
Lumizyme[
®] (alglucosidase alfa)
Macugen[
®] (pegaptanib)
Myozyme[
®] (alglucosidase alfa)
Prolastin[
®] (alpha-1 proteinase inhibitor [human])
Prolia[
®] (denosumab)
Soliris[
®] (eculizumab)
Stelara[
®] (ustekinmab)
Synribo[
]TM[] (omacetaxine mepesuccinate)
VPRIV[
®] (velaglucerase alfa)
Xolair[
®] (omalizumab)
Zemaira[
®] (alpha-1 proteinase inhibitor [human])
These drugs continue to be covered by IBC for members who meet the clinical
criteria outlined in our medical policy for each drug, but only when the drugs
are administered in the most appropriate setting approved by IBC during the
precertification review process.
During this process, each member?s unique medical needs and clinical history
will be considered to determine which setting is most appropriate. IBC will
also review black box warnings included in the prescribing information for a
drug at the time that precertification is requested. If there are
circumstances that require a member to receive a drug in an outpatient
facility, the provider must submit documentation to IBC that specifically
addresses these circumstances when submitting a request for coverage.
To review the medical policies for the drugs listed, visit our [
]Medical Policy website[] and type the
name of the drug in the Search box.