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 Q2050,
Lipodox Q2049)

Eloxatin J9263
(oxaliplatin)

Emend IV J1453
(fosaprepitant)

Erwinaze J9019
(asparaginase)

Firmagon J9155
(degarelix)

Gemzar J9201
(gemcitabine)

Granix J1447
(tbo-filgrastim)

Injectafer J1439
(injection, ferric carboxymaltose)

Oncaspar J9266
(pegaspargase)

Xeomin J0588
(incobotulinumtoxinA)

Zarxio Q5101
(filgrastim-sndz)

Zoladex J9202
(goserelin acetate)

 

View the Independent Health Clinical Guidelines policies.