The Independence Dosage and Frequency Program will be expanded to include
three additional drugs, on the effective dates listed below.
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])
- 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])
- 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])
- Inflectra® (infliximab-dyyb)
- Ixifi™ (infliximab-qbtx)
- Kanuma® (sebelipase alfa) – NEW FOR DECEMBER 3, 2018
- Mvasi™ (bevacizumab-awwb)*
- Octagam® (immune globulin intravenous [human])
- Ogivri™(trastuzumab-dkst)
- Onpattro™ (patisiran) – NEW FOR DECEMBER 3, 2018
- 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) – NEW FOR DECEMBER 3, 2018
- Stelara® (ustekinumab)
- Xolair® (omalizumab)
- Yervoy® (ipilimumab)
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.
Members who are currently receiving any drug on this program, are subject to
Dosage and Frequency review at every renewal of precertification.
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
Medical policies for the following three drugs are currently in development
or have been posted as a Notification of a future policy version. In lieu of
updated policies, Independence will follow the dosage and frequency guidelines
listed in the prescribing information for each drug.
Commercial policies
- #08.01.28: Sebelipase alfa (Kanuma®)
– Notification
- #08.01.36: Nusinersen (Spinraza™)
- #08.01.50: Patisiran (Onpattro™)
Medicare Advantage
policies
- #MA08.078: Sebelipase alfa (Kanuma®)
– Notification
- #MA08.086: Nusinersen (Spinraza™)
- #MA08.100: Patisiran (Onpattro™)
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.