Updates to the list of specialty drugs that will require precertification

October 2, 2020

Effective January 1, 2021, the following specialty drugs, which are eligible for coverage under the medical benefit for AmeriHealth members, will require precertification:

  • Neupogen® (filgrastim) – Colony-stimulating factors
  • Tecartus™ (brexucabtagene autoleucel) – Chimeric Antigen Receptor Therapy (CAR-T)
  • Xiaflex® (collagenase clostridium histolyticum) – Miscellaneous therapeutic agents
  • Zepzelca™ (lurbinectedin) – Antineoplastic agents

In addition, the following drugs are pending approval from the U.S. Food and Drug Administration (FDA) and will require precertification for AmeriHealth members as of the date they receive FDA approval in 2021, or as of January 1, 2021, for any drug approved by the FDA in 2020:

  • ciltacabtagene autoleucel – CAR-T  
  • dostarlimab – Anti-PD-1/PD-L1
  • evinacumab – Miscellaneous therapeutic agents
  • idecabtagene vicleucel – CAR-T
  • inclisiran – Miscellaneous therapeutic agents
  • lumasiran – Miscellaneous therapeutic agents
  • pegunigalsidase alfa – Enzyme replacement agents
  • ranibizumab biosimilar – Ophthalmic agents

The antineoplastic agent belantamab mafodotin-blmf has been on the precertification list since January 2020; however, it recently received FDA approval and is now branded as Blenrep™. The precertification list will be updated to reflect this new brand name and will include any drug approved by the FDA in 2020.

The following drugs will no longer require precertification approval from AmeriHealth as of January 1, 2021:

  • ​Fasenra® (benralizumab) – Respiratory agents*
  • Halaven® (eribulin mesylate) – Antineoplastic agents
  • Jevtana® (cabazitaxel) – Antineoplastic agents
  • Nucala® (mepolizumab) – Respiratory agents*
  • Sylvant® (siltuximab) – Miscellaneous therapeutic agents

*This drug is now available as a self-administered injection. It will no longer be eligible for coverage under the medical benefit as of January 1, 2021.

Lastly, the drugs Exondys-51® (eteplirsen), Viltepso™ (viltolarsen), and Vyondys-53® (golodirsen) will no longer require precertification approval as of January 1, 2021. These drugs will not be covered because AmeriHealth considers them to be experimental/investigational.

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In the absence of a published medical policy on any of these newly added 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 for AmeriHealth New Jersey and AmeriHealth Pennsylvania.