The AmeriHealth Dosage and Frequency Program has been expanded to include four additional drugs, on the effective dates listed below. As of January 1, 2019, Ilaris® (canakinumab) was added to the program as part of the 2019 changes to coverage for cryopyrin-associated periodic syndromes (CAPS), as previously communicated in a Partners in Health UpdateSM article. The effective dates for the other three drugs coincide with the date each drug received approval from the U.S. Food and Drug Administration (FDA).
The following is the comprehensive list of drugs that will be reviewed for dosage and frequency:
- Avastin® (bevacizumab)*†
- Bivigam® (immune globulin intravenous [human])
- Blincyto® (blinatumomab)
- Carimune® NF (immune globulin intravenous [human])
- Cutaquig® (immune globulin subcutaneous [human]) – AS OF DECEMBER 12, 2018
- Cuvitru™ (immune globulin subcutaneous [human])
- Entyvio® (vedolizumab)
- Erbitux® (cetuximab)
- Flebogamma® (immune globulin intravenous [human])
- Flebogamma® DIF (immune globulin intravenous [human])
- Gamastan® S/D (immune globulin [human])
- Gamifant® (emapalumab-lzsg) – AS OF NOVEMBER 20, 2018
- Gammagard® Liquid (immune globulin infusion [human])
- Gammagard® S/D (immune globulin intravenous [human])
- Gammaked™ (immune globulin [human])
- Gammaplex® (immune globulin intravenous [human])
- Gamunex®-C (immune globulin injection [human])
- Herceptin® (trastuzumab)†
- Hizentra® (immune globulin subcutaneous [human])
- HyQvia® (immune globulin infusion [human])
- Ilaris® (canakinumab) – AS OF JANUARY 1, 2019
- Inflectra® (infliximab-dyyb)
- Ixifi™ (infliximab-qbtx)
- Kanuma® (sebelipase alfa)
- Mvasi™ (bevacizumab-awwb)*
- Octagam® (immune globulin intravenous [human])
- Ogivri™(trastuzumab-dkst)
- Onpattro™ (patisiran)
- Panzyga® (immunoglobulin intravenous)
- Privigen® (immune globulin intravenous)
- Remicade® (infliximab)†
- Renflexis® (infliximab-abda)
- Rituxan® (rituximab)†
- Rituxan Hycela™ (rituximab/hyaluronidase human for subcutaneous injection)
- Sandostatin® LAR Depot (octreotide acetate)
- Spinraza® (nusinersen)
- Stelara® (ustekinumab)
- Ultomiris™ (ravulizumab-cwvz) – AS OF DECEMBER 21, 2018
- Xolair® (omalizumab)
- Yervoy® (ipilimumab)
About the Dosage and Frequency Program
Since January 1, 2011, AmeriHealth 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 AmeriHealth 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 AmeriHealth to support the request. Members who are currently receiving any drug on this program are subject to Dosage and Frequency review at every renewal of precertification.
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 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.
If you have any questions about the precertification process for drugs included in the Dosage and Frequency Program, please call the AmeriHealth Clinical Services department at 1-888-YOUR-AH1 for AmeriHealth New Jersey and 1-800-275-2583 for AmeriHealth Pennsylvania.
Updated policies
Medical policies for the four newly added drugs are currently in development. In lieu of published policies, AmeriHealth will follow the dosage and frequency guidelines listed in the prescribing information for each drug, as approved by the FDA.
To access medical policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online and then type the policy name or number in the Search field.
*Bevacizumab (Avastin®, Mvasi™) only requires precertification approval for dosage and frequency for oncologic indications. Coverage requests for intravitreal injection of bevacizumab (Avastin®, Mvasi™) to treat the ophthalmologic conditions listed in this drug’s policies do not require precertification.
†Dosage and frequency requirements apply to all FDA-approved biosimilars to this originator product.