Maximum Dosage and Frequency – Commercial Medical Benefit Drug Policyopen_in_new

This policy sets product‑specific maximum per‑administration doses, HCPCS/NDC billing quantity limits, and maximum dosing frequencies for many injectable/infused drugs — uses within those maxima for FDA‑approved or guideline/evidence‑supported indications are covered, while dosing beyond the listed maxima or for unsupported indications is considered unproven/not medically necessary (exceptions may be allowed for patients >95th percentile weight/BSA — 140 kg or 2.71 m^2 — or per a member’s Certificate of Coverage). Coverage/payment is contingent on meeting the per‑product HCPCS/NDC and frequency limits and requires documentation of the diagnosis, dates/doses/routes billed, patient weight/BSA with dose calculations when applicable, and review against the member‑specific benefit plan and any federal/state mandates.

"Giant cell arteritis (Actemra / tocilizumab) P."