Effective January 1, 2017, AmeriHealth is changing how we manage the
drugs Neulasta® (pegfilgrastim) and
Neulasta® Onpro®*. Currently, these drugs are
covered under the medical benefit and do not require precertification
approval. For dates of service on or after January 1, 2017, the following
changes will occur:
- All requests for these drugs under the medical benefit will require
precertification approval from AmeriHealth.
- As part of the precertification process, AmeriHealth will also review the
setting where our commercial members
receive these drugs.
- Some members, including those whose pharmacy benefits are managed by
FutureScripts®, our pharmacy benefits manager, will also be able
to obtain these drugs under their pharmacy benefit.
During the next few weeks, AmeriHealth will send letters to notify affected
providers and members about these
changes.
Precertification requirements
AmeriHealth requires precertification approval for many specialty drugs
covered under the medical benefit. This
ensures that our members are receiving medications in accordance with the
medical necessity criteria outlined in our
medical policies.
For dates of service on or after January 1, 2017, all requests for
Neulasta® under the medical benefit will require
precertification approval from AmeriHealth for commercial members. This applies
to members who are new to
treatment with Neulasta®, as well as to those who have
previously received the drug.
According to its U.S. Food and Drug Administration-approved label,
Neulasta® must be given 24 hours after
chemotherapy.
Due to the time-sensitive nature of Neulasta®, it is
important to request precertification approval in advance of the
member's scheduled treatment date. This allows ample time for AmeriHealth to
review provider requests.
Most Cost-Effective Setting requirements
During precertification review, each member?s medical
needs and clinical history are evaluated to determine
if the drug requested by the provider is appropriate.
As part of this precertification process, AmeriHealth
reviews the provider's request for treatment setting
for certain drugs covered under the medical benefit.
Our Most Cost-Effective Setting Program ensures
that members receive treatment in a setting that is
both safe and cost-effective. As communicated in the
October 2016 edition of Partners in Health UpdateSM,
starting January 1, 2017, Neulasta® will be added
to the Most Cost-Effective Setting Program for all
commercial members.
Covered settings for Neulasta® include:
- a physician's office;
- the member?s home, where the injection is
administered by an in-network home infusion
provider;
- an ambulatory (freestanding) infusion suite that is
not owned by a hospital or health system in our
network.
A hospital outpatient facility is the most costly setting
in which to receive Neulasta
®; therefore, it will primarily
be approved only for members who are receiving an
initial dose of Neulasta
® or if there is a clinical rationale
that requires the member to receive Neulasta
® in the
hospital outpatient facility. If the hospital outpatient
facility is thought to be clinically necessary, the provider must submit
documentation to AmeriHealth that addresses
these circumstances.
Coverage for Neulasta® under
the
pharmacy benefit for commercial
members
Covering Neulasta® and Neulasta® Onpro
®* under the
medical or pharmacy benefit gives our commercial
members more coverage options and greater
convenience. Depending on their benefit contract,
the copayment, deductible, and/or coinsurance may
vary between medical and pharmacy benefits. We
are encouraging members to compare both benefits
to determine the coverage option that is more
advantageous for them.
For members who choose to obtain Neulasta® under
the pharmacy benefit through FutureScripts, providers
will need to write new prescriptions. Providers will
also need to ask members if they are interested in
learning how to self-administer Neulasta® in their
home or if they will return to the office the day after
chemotherapy to receive Neulasta®.
For members who do not have pharmacy benefits with
FutureScripts but are interested in self-administering
Neulasta®, providers should encourage them to
contact their pharmacy benefits manager to determine
if Neulasta® is available under their prescription drug
plan. If it is, members should be directed to compare
the terms of their medical and pharmacy benefit plans
to identify the benefit that provides more cost savings
and/or convenience.
For more information
Providers can also find additional information about this program in Medical
Policy #08.01.32: Pegfilgrastim
(Neulasta®), which is currently posted as a Notification and
will become effective on January 1, 2017.
To access medical policies, visit our Medical Policy
Portal. Select Accept and Go to Medical Policy Online, then select
Commercial under Active Notifications.
If you have questions about any of these changes, contact your Provider
Partnership Associate or Network
Coordinator.
*All mentions of Neulasta® are inclusive
of Neulasta® Onpro®.
FutureScripts provides pharmacy benefits management services.