As part of our continuing
efforts to improve the quality and affordability of health care, we are making
important changes to the precertification process for our members who receive
the following infusion therapy drugs:
- alglucerase (Ceredase?)
- imiglucerase (Cerezyme?)
- velaglucerase alfa
(VPRIV?)
- eculizumab
(Soliris?)
Effective January 1,
2012, all precertification requests for these drugs will be reviewed to
determine if members are receiving them in the setting that is cost-effective,
safe, and clinically appropriate for their medical needs. This decision is
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 member based on his or her medical history and current health status;
- recommendations from the drug
manufacturer;
- current standards in
medical practice.
Typically, administration of the
infusion therapy drugs listed above should only occur in an outpatient facility
or hospital when patients are receiving an initial dose of one of these drugs,
or for those who have a history of treatment-related adverse effects that
require monitoring. 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 members prefer the convenience of receiving infusion therapy drugs in
their home through a home infusion provider. Providers should discuss this
option with their IBC 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 will be
asked during precertification to provide details about the member?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 these
settings is approved.
Impacts to coverage
IBC will continue to cover
these drugs and all services associated with their administration 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 approved by IBC as part of the precertification
review process.
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.