Independent Health Medical Pharmacy Claims Edit Policies

For the following policies, Independent Health applies pre-payment claims edits using diagnosis and maximum unit critera. Medical Necessity criteria contained in these policies does not apply.

Doxorubicin liposomal
Doxil
Lipodox

Eloxatin 
(oxaliplatin)

Emend IV
(fosaprepitant)

Erwinaze 
(asparaginase)

Firmagon 
(degarelix)

Gemzar
(gemcitabine)

Granix
(tbo-filgrastim)

Injectafer 
(injection, ferric carboxymaltose)

Oncaspar 
(pegaspargase)

Xeomin
(incobotulinumtoxinA)

Zarxio 
(filgrastim-sndz)

Zoladex
(goserelin acetate)

 

View the Independent Health Clinical Guidelines policies.