Now in effect! Updates to the list of specialty drugs that require precertification

July 29, 2020

This article was revised on July 29, 2020.

As a reminder, the following specialty drugs, which have been approved by the U.S. Food and Drug Administration (FDA) and are eligible for coverage under the medical benefit for AmeriHealth commercial HMO and PPO members, will require precertification as of August 1, 2020, for AmeriHealth New Jersey members and July 1, 2020, for AmeriHealth Pennsylvania members:

  • AvsolaTM (infliximab-axxq) – Immunological agents
  • Enhertu® (fam-trastuzumab deruxtecan-nxki) – Cancer
  • PadcevTM (enfortumab vedotin-ejfv) – Cancer
  • TepezzaTM (teprotumumab-trbw) – Ophthalmic agents
  • ZiextenzoTM (pegfilgrastim-bmez) – Colony-stimulating factors

In addition, the following drugs are currently pending FDA approval. These drugs will require precertification for AmeriHealth members once they receive FDA approval:

  • Inebilizumab – Miscellaneous therapeutic agents
  • Instiladrin® (nadofaragene firadenovec) – Cancer
  • Rolontis® (eflapegrastim) – Colony-stimulating factors
  • Taclantis (paclitaxel injection concentrated for suspension) – Cancer
  • Trevyent (treprostinil) – Pulmonary arterial hypertension
  • Valrox (valoctocogene roxaparvovec) – Gene therapy

Note: The final approved brand names may be different than the brand names listed above. All brand names were valid at the time of article publication.

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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 are reflected in an updated precertification requirement list, which has been posted to our AmeriHealth New Jersey and AmeriHealth Pennsylvania websites.