Effective January 1, 2019, Independence will make the following
changes to more effectively manage two specialty drugs that treat
cryopyrin-associated periodic syndromes (CAPS):
- Arcalyst? (rilonacept) will be transitioned from the
medical benefit to the pharmacy benefit. This drug is considered a
self-administered drug by its manufacturer. As such, Independence provides
coverage for self-administered drugs under the pharmacy benefit through
FutureScripts?, our independent pharmacy benefits manager.
Independence members who do not have FutureScripts should contact their
pharmacy benefits manager to see how Arcalyst is covered through their
prescription drug plan.
- Ilaris? (canakinumab) will require precertification for
all members enrolled in Independence Commercial and Medicare Advantage plans.
In addition, Ilaris will be added to the Dosage and Frequency Program for all
members, as well as the Most Cost-Effective Setting Program for members
enrolled in commercial plans. All requests for Ilaris will require review for
medical necessity, dosage and frequency, and, when appropriate, setting during
the precertification process.
Note: Members enrolled in commercial plans who already obtained
precertification approval to receive Ilaris in a hospital outpatient facility
may continue treatment in this setting until their current precertification
approval expires. At the next precertification review, Independence will
evaluate the requested setting and make a coverage determination.
About the Dosage and Frequency Program
Since January 1, 2011, Independence has reviewed the requested dosage and
frequency of administration for select drugs as part of the precertification
process. Coverage of the drugs included in this program 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 policies for each drug will be required to submit documentation (i.e.,
published peer-reviewed literature) to Independence 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 that exceed the amount approved through the
precertification process. For more information on the dosage and frequency
guidelines, please refer to the specific policies for each drug included in the
program.
About the Most Cost-Effective Setting
Program
During precertification review, each member?s medical needs and clinical
history are evaluated to determine if the drug requested by the provider is
appropriate. Since January 1, 2012, as part of our Most Cost-Effective Setting
Program, Independence has been reviewing the requested treatment setting for
certain drugs covered under the member?s medical benefit to ensure that they
are administered in settings that are both safe and cost-effective.
Covered settings for drugs in this program include:
- a physician?s office;
- the member?s home, where the infusion is administered by an in-network home
infusion provider;
- an ambulatory (freestanding) infusion suite that is not owned by a hospital
or health system in our network.
A hospital outpatient facility setting will primarily be considered for
members who are receiving an initial dose of Ilaris, or if there is a clinical
rationale that requires the member to receive treatment in that setting. The
provider must submit documentation to Independence to support the request for
coverage in the hospital outpatient facility. This information will be reviewed
and a coverage determination on setting will be made.
Medical policy information
Independence?s commercial Medical Policy #08.00.78: Self-Administered Drugs
is currently being updated to include Arcalyst. To access this policy, visit
our Medical Policy
Portal. Select Accept and Go to Medical Policy Online, then select
Commercial, and type the policy name or number in the Search field.
We are in the process of creating new medical policies for Ilaris. In the
interim, requests for Ilaris received on or after January 1, 2019, will be
evaluated in accordance with the manufacturer?s prescribing information and the
U.S. Food and Drug Administration labeling.
If you have any questions about these changes, please call the Independence
Clinical Services department at 1-800-ASK-BLUE.
FutureScripts is an independent company that provides
pharmacy benefits management services.