HomeAdministrativeBilling & ReimbursementHealth and WellnessMedicalNaviNet OpenPharmacyProductsQuality Management

Medical

Updates to the list of specialty drugs that will require precertification for AmeriHealth Pennsylvania members 

October 2, 2019    

Effective January 1, 2020, the following specialty drugs, which are eligible for coverage under the medical benefit for AmeriHealth Pennsylvania members, will require precertification:

  • Eylea® (aflibercept) – Ophthalmic agents
  • KanjintiTM (trastuzumab-anns) – Antineoplastic agents
  • Lucentis® (ranibizumab) – Ophthalmic agents
  • Macugen (pegaptanib) – Ophthalmic agents
  • PolivyTM (polatuzumab vedotin-piiq) – Antineoplastic agents
  • Revatio® (sildenafil) – Pulmonary arterial hypertension
  • RuxienceTM (rituximab-pvvr) – Antineoplastic agents
  • SynojoyntTM (sodium hyaluronate) – Hyaluronate acid products
  • TriluronTM (sodium hyaluronate) – Hyaluronate acid products
  • Tyvaso® (treprostinil) – Pulmonary arterial hypertension
  • Ventavis® (iloprost) – Pulmonary arterial hypertension
  • Zirabev (bevacizumab-bvzr) – Antineoplastic agents

In addition, the following drugs are currently pending approval from the U.S. Food and Drug Administration (FDA) and will require precertification for AmeriHealth Pennsylvania members once they receive FDA approval in 2020, or as of January 1, 2020, for any drug approved in 2019:

  • abicipar – Ophthalmic agents
  • brolucizumab – Ophthalmic agents
  • casimersen – Duchenne muscular dystrophy
  • cosyntropin depot – Endocrine/metabolic agents
  • crizanlizumab – Miscellaneous therapeutic agents
  • eptinezumab – Miscellaneous therapeutic agents
  • givosiran – Miscellaneous therapeutic agents
  • golodirsen – Duchenne muscular dystrophy
  • isatuximab – Antineoplastic agents
  • Lapelga (pegfilgrastim) – Colony-stimulating factor
  • lisocabtagene maraleucel – Chimeric antigen receptor therapy
  • margetuximab – Antineoplastic agents
  • Reblozyl (luspatercept-ammt) – Miscellaneous therapeutic agents
  • RVT-802 – Miscellaneous therapeutic agents
  • viltolarsen – Duchenne muscular dystrophy
  • Zynteglo (betibeglogene darolentivec) – Gene therapy

Lastly, the following drugs will no longer require precertification approval from AmeriHealth as of January 1, 2020:

  • Beleodaq® (belinostat) – Antineoplastic agents
  • FolotynTM (pralatrexate) – Antineoplastic agents
  • Imlygic® (talimogene laherparepvec) – Antineoplastic agents
  • Istodax® (romidepsin) – Antineoplastic agents
  • Monovisc® (high molecular weight hyaluronan) – Hyaluronate acid products

Learn more

In the absence of a published medical policy on any of these newly approved drugs, all requests will be subject to review in accordance with the FDA-approved indications and AmeriHealth-recognized compendia.

These changes will be reflected in an updated precertification requirement list, which will be posted to our website before these changes go into effect. The availability of the updated precertification list will be announced in a future Partners in Health UpdateSM article.





© 2019 AmeriHealthSite Map    Anti-Fraud    Privacy Policy    Legal    Disclaimer