Effective May 5, 2017, vedolizumab
(Entyvio®), octreotide acetate (Sandostatin® LAR
Depot), ustekinumab (Stelara®), and omalizumab
(Xolair®) will be added to the AmeriHealth Dosage and Frequency
Program. Medical policies for each of these drugs already include the dosage
and frequency requirements.
Since January 1, 2011, AmeriHealth 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 AmeriHealth 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 AmeriHealth (i.e., published
peer-reviewed literature) to support the request.
AmeriHealth 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 following medical policies for each drug
included in the program:
- 08.00.55: Omalizumab (Xolair®)
- 08.00.82: Ustekinumab (Stelara®)
- 08.01.10: Octreotide acetate (Sandostatin® LAR Depot)
- 08.01.18: Vedolizumab (Entyvio®)
To access these policies, visit our Medical Policy Portal. Select Accept and Go to Medical
Policy Online, then select Commercial and type the name or policy
number in the Search field. To access policies from AmeriHealth
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 AmeriHealth 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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