Effective July 1, 2021, the list of specialty drugs that are eligible for coverage under the medical benefit for AmeriHealth commercial and Medicare Advantage HMO and PPO members will change.
The following drugs have been approved by the U.S. Food and Drug Administration (FDA) and will now require precertification:
- Cosela® (trilaciclib) – Miscellaneous therapeutic agents
- Pepaxto® (melphalan flufenamide) – Antineoplastic agents
- Riabni™ (rituximab-arrx) – Antineoplastic agents
The following drugs are pending FDA approval and will require precertification for AmeriHealth members as of the date they receive FDA approval:
- amivantamab – Antineoplastic agents
- anifrolumab – Immunological agents
- avalglucosidase alfa – Enzyme replacement agents
- efgartigimod – Miscellaneous therapeutic agents
- Lonca (loncastuximab tesirine) – Antineoplastic agents
- narsoplimab – Miscellaneous therapeutic agents
- retifanlimab – Anti-PD-1/PD-L1 human monoclonal antibodies
- sutimlimab – Miscellaneous therapeutic agents
- teplizumab – Miscellaneous therapeutic agents
- Uptravi IV (selexipag) – Pulmonary arterial hypertension
The drug names listed above may change after the drug is approved by the FDA. All names were valid at the time of article publication.
The following drugs were added to the precertification list during our last update cycle. They are now approved by the FDA, and the precertification list will be updated to reflect their new brand names:
- evinacumab has been updated to Evkeeza™ – Miscellaneous therapeutic agents
- idecabtagene vicleucel has been updated to Abecma™ – Chimeric antigen receptor therapy (CAR-T therapy)
- lisocabtagene maraleucel has been updated to Breyanzi® – Chimeric antigen receptor therapy (CAR-T therapy)
- margetuximab has been updated to Margenza™ – Antineoplastic agents
The following drug has been removed from the precertification list because it is no longer available on the market:
- Macugen® (pegaptanib) – Ophthalmic agents
Medical policies for FDA-approved drugs can be found on our
Medical and Claim Payment Policy Portal. In the absence of a published medical policy, all precertification 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 the
AmeriHealth New Jersey and
AmeriHealth Pennsylvania websites.