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.

Asparlas
(calaspargase pegol-mknl)

Doxorubicin liposomal
Doxil
Lipodox

Eloxatin
(oxaliplatin)

Emend IV
(fosaprepitant)

Erwinaze
(asparaginase)

Firmagon
(degarelix)

Gemzar
(gemcitabine)

Infugem
(gemcitabine)

Injectafer
(injection, ferric carboxymaltose)

Oncaspar
(pegaspargase)

Rylaze
(asparaginase Erwinia chrysanthemi (recombinant)‐rywn)

Zarxio
(filgrastim-sndz)

Zoladex
(goserelin acetate) ***Effective 5/14/22 - Prior authorization required through Independent Health for Medisource and Child Health Plus. Subject only to post service claim edits for all other lines of business.***

 

View the Independent Health Clinical Guidelines policies.