We are advocating that members who receive infusion therapy drugs like
alglucerase (Ceredase?), imiglucerase (Cerezyme?), velaglucerase alfa (VPRIV?),
eculizumab (Soliris?), and intravenous immunoglobulin (IVIG) obtain these drugs
in the setting that is most appropriate, based on factors such as, but not
limited to:
the setting that has been determined to be both cost-effective and safe for the
member;
the level of care required by the patient based on his or her medical history
and current health status;
recommendations from the drug manufacturer;
current standards in medical practice.
Typically, only those patients who are starting a new treatment regimen for the
drugs listed, or those who have a history of treatment-related adverse effects
that require monitoring, require a higher level of care at an outpatient
facility or hospital. Aside from these exceptions, most patients can safely
receive these drugs in either a provider's office or in their home through a
home infusion provider.
Administering drugs in the office or at home
The following options are available for administering these drugs in a
provider's office or in the member's home:
Buy and bill. Providers can buy the drug and bill the health plan for
reimbursement once the drug has been given to the member.
Home infusion therapy. Many patients prefer the convenience of receiving
these infusion therapy drugs in their home through an IBC-participating home
infusion provider. Providers should discuss this option with their patients,
when appropriate.
Requesting administration in an outpatient facility or hospital
Providers who request coverage for administration of these drugs in an
outpatient facility or hospital may be asked during precertification to provide
details about the patient's medical history to support the request. A team of
IBC medical directors and nurses will review the submitted documentation and
determine whether coverage in one of these settings is approved.
Impacts to coverage
IBC will continue to cover these infusion therapy drugs and all services
associated with the administration of these drugs when both of the following
requirements are met:
The member meets the medical necessity criteria outlined in the applicable
medical policy.
The drug is given in the setting that has been determined by IBC as most
appropriate for the member.
Please call Customer Service at 1-800-ASK-BLUE if you have any
questions about setting options for these infusion therapy drugs. Customer
Service can also assist you with home infusion options.
]