The Independence Dosage and Frequency Program will be expanded to include four additional drugs, on the effective dates listed below.

The following is the comprehensive list of drugs that will be reviewed for dosage and frequency:   

• bevacizumab (Avastin^?)*^†
• bevacizumab-awwb (Mvasi^™)*
• blinatumomab (Blincyto^®) – NEW FOR OCTOBER 8, 2018
• cetuximab (Erbitux^®)
• immune globulin, intravenous/subcutaneous (IVIG/SCIG)
• infliximab (Remicade^®)^†
• infliximab-abda (Renflexis^™)
• infliximab-dyyb (Inflectra^®)
• infliximab-qbtx (Ixifi^™) – NEW FOR OCTOBER 8, 2018
• ipilimumab (Yervoy^®)
• octreotide acetate (Sandostatin^® LAR Depot)
• omalizumab (Xolair^®)
• rituximab (Rituxan^®)^†
• rituximab/hyaluronidase human for subcutaneous injection (Rituxan Hycela^™)
• sebelipase alfa (Kanuma^®) – NEW FOR DECEMBER 3, 2018
• trastuzumab (Herceptin^®)^†
• trastuzumab-dkst (Ogivri^™) – NEW FOR OCTOBER 8, 2018
• ustekinumab (Stelara^®)
• vedolizumab (Entyvio^®)

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.

If you have any questions about the precertification process for drugs included in the Dosage and Frequency Program, please call the Independence Clinical Services department at 1-800-ASK-BLUE.

Updated policies

The following medical policies will be updated on the effective dates listed above to include information on the Dosage and Frequency Program:

• #08.00.33: Trastuzumab (Herceptin^®) and Related Biosimilars
• #08.00.34: Infliximab and Related Biosimilars
• #08.01.21: Blinatumomab (Blincyto^®)
• #08.01.28: Sebelipase alfa (Kanuma^®)
  
  

• #MA08.018: Trastuzumab (Herceptin^®) and Related Biosimilars
• #MA08.019: Infliximab and Related Biosimilars
• #MA08.058: Blinatumomab (Blincyto^®)
• #MA08.078: Sebelipase alfa (Kanuma^®)

To access these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial or Medicare Advantage, depending on which version of the policy you would like to view, 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 U.S. Food and Drug Administration-approved biosimilars to this originator product.