NaviNet® Chemotherapy/Infusion and Home Infusion Authorizations Guide September 2011

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield – independent licensees of the Blue Cross and Blue Shield Association. Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

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NaviNet Chemotherapy/Infusion and Home Infusion Authorizations

Effective January 1, 2011, the following requirements apply when submitting an authorization request for infusion drugs under the medical benefit:  Providers must report additional data, such as member height and weight, with the request as well as the actual dosage of the requested drug.  Eight drugs will be reviewed based on our Dosing and Frequency Requirements: bevacizumab (Avastin®)*, cetuximab (Erbitux®), infliximab (Remicade®), intravenous immune globulin (IVIG), onabotulinumtoxinA (Botox®), oxaliplatin (Eloxatin®), rituximab (Rituxan®), and trastuzumab (Herceptin®). As a result of these changes, the Chemotherapy/Infusion and Home Infusion Authorization transactions have changed.

The medical policies for the eight affected drugs include the Dosing and Frequency Requirements, as well as a clinical question set for each drug except for onabotulinumtoxinA (Botox®). The clinical question set for this drug is not currently available in its medical policy. To view the medical policies through the NaviNet® web portal, select Reference Materials and Reports from the Plan Transactions menu and then Medical Policy. Then type the drug name into the Search box on the Medical Policy homepage. Note: The list of drugs affected by the Dosing and Frequency Requirements is subject to change.

*Requests for intravitreal injection of bevacizumab (Avastin®) to treat the ophthalmologic conditions listed in this drug’s medical policy do not require precertification or preapproval. However, individual product requirements must be verified.

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NaviNet Chemotherapy/Infusion and Home Infusion Authorizations

Chemotherapy/Infusion transaction The Chemotherapy/Infusion transaction still allows you to create new submission requests, add new drugs to existing requests, and/or extend the treatment plan of an existing authorization. After selecting the appropriate setting from the provided drop-down menu, you can access the list of infusion therapy drugs that require preauthorization in an outpatient or professional office setting by clicking on the List of Drugs link. Note: The list of drugs may be updated as determined by medical policy.

Respond to the remaining three questions displayed at the bottom of the screen, and select Submit once complete. The next screen will vary based on the member’s coverage, the setting where the services are being provided, and the answers to the three questions on the previous screen. There are two possible outcomes:  If authorization is not required, the next screen will state: “Authorization is not required based upon the information provided.”  If authorization is required, the next screen will be the request form, which is shown on the next page. You will be asked to indicate at least one primary diagnosis and the member’s current height and weight (entered in a numeric format and with the appropriate quantifier [inches/centimeters or pounds/kilograms] selected). You can also enter pertinent clinical information as needed.

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NaviNet Chemotherapy/Infusion and Home Infusion Authorizations

Then, complete the following sections of the form related to the infusion code. Select Yes for “Loading Dose” if the initial (or loading) dose is greater than subsequent scheduled doses. The system will then allow you to input the same infusion code twice — once for the loading dose and a second time for subsequent doses. Complete the remaining fields, including the route of administration, dosage, dosage quantifier (gram, milligram, microgram, or international unit), drug name, drug start date, drug end date, the number of treatment days, and the frequency.

The same data entry process should be repeated for a prescribed second or third infusion code, if needed. Once all data entry is complete, select the Submit button.

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NaviNet Chemotherapy/Infusion and Home Infusion Authorizations

The drug you are requesting may require additional clinical information for approval. If so, a clinical question screen will display. A copy of the clinical question set is available in the medical policy for each of the seven drugs. The response screen will indicate whether your request was approved or pended for review. If the request is pended, our clinical precertification team will review, request additional information if necessary, and provide a determination within two business days after all information necessary to complete the review is received. You can view their determination through the Authorization Status Inquiry transaction. Home infusion The Home Infusion Authorization transaction continues to allow ancillary providers to create new submission requests, add new drugs to existing requests, and/or extend the treatment plan of an existing authorization. You should continue to identify the ordering physician, indicate whether the member is receiving hospice services, and note the appropriate diagnoses. In addition, you will need to enter the member’s current height and weight (entered in a numeric format and with the appropriate quantifier [inches/centimeters or pounds/kilograms] selected).

Respond to the remaining questions as presented above. See the clinical question sets for Remicade® and IVIG in the medical policies for these drugs. If your office has additional questions or requires training for NaviNet, please call the eBusiness Help Desk at 215-241-2305.

NaviNet® is a registered trademark of NaviNet, Inc. An affiliate of IBC holds a minority ownership interest in NaviNet, Inc., an independent company. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.