As of January 1, 2019, AmeriHealth has implemented the following changes to more effectively manage two specialty drugs that treat cryopyrin-associated periodic syndromes (CAPS):

• Arcalyst^®(rilonacept) has been transitioned from the medical benefit to the pharmacy benefit. This drug is considered a self-administered drug by its manufacturer. AmeriHealth provides coverage for self-administered drugs under the pharmacy benefit through FutureScripts^®, our pharmacy benefits manager. AmeriHealth members who do not have FutureScripts should contact their pharmacy benefits manager to understand how Arcalyst^® is covered through their prescription drug plan.

Note: Providers will no longer be able to order Arcalyst^®through the AmeriHealth Direct Ship Drug Program, as this program only provides delivery for select drugs covered under the medical benefit

• Ilaris^® (canakinumab) requires precertification for all members enrolled in AmeriHealth plans. In addition, Ilaris^® has been added to the Dosage and Frequency Program and the Most Cost-Effective Setting Program for all members. All requests for Ilaris^® require review for medical necessity, dosage and frequency, and, setting during the precertification process.

Note: Members who have already obtained precertification approval to receive Ilaris^® in a hospital outpatient facility may continue treatment in this setting until their current precertification approval expires. At the next precertification review, AmeriHealth will evaluate the requested setting and make a coverage determination.

About the Dosage and Frequency Program

Since January 1, 2011, AmeriHealth has reviewed the requested dosage and frequency of administration for select drugs as part of the precertification process. Coverage of the drugs included in this program is contingent upon review by AmeriHealth for appropriate dosage and frequency. Providers who request coverage above the dosage and frequency requirements listed in the medical policies for each drug will be required to submit documentation (i.e., published peer-reviewed literature) to AmeriHealth to support the request.

AmeriHealth reserves the right to conduct a post-payment review and audit of claims submitted for any drug that is part of the Dosage and Frequency Program and may recover payments that exceed the amount approved through the precertification process. For more information on the dosage and frequency guidelines, please refer to the specific policies for each drug included in the program.

About the Most Cost-Effective Setting Program

During precertification review, each member’s medical needs and clinical history are evaluated to determine if the drug requested by the provider is appropriate. Since January 1, 2012, as part of our Most Cost-Effective Setting Program, AmeriHealth has been reviewing the requested treatment setting for certain drugs covered under the member’s medical benefit to ensure that they are administered in settings that are both safe and cost-effective.

Covered settings for drugs in this program include:

• a physician’s office;
• the member’s home, where the infusion 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 will primarily be considered for members who are receiving an initial dose of Ilaris^®, or if there is a clinical rationale that requires the member to receive treatment in that setting. The provider must submit documentation to AmeriHealth to support the request for coverage in the hospital outpatient facility. This information will be reviewed and a coverage determination on setting will be made.

For more information on this program, including a comprehensive list of all drugs on the program, go to our dedicated webpages for AmeriHealth New Jersey and AmeriHealth Pennsylvania.

Medical policy information

The AmeriHealth Medical Policy #08.00.78aa: Self-Administered Drugs has been updated to include Arcalyst^®. To access this policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial Policies, and type the policy name or number in the Search field.

The AmeriHealth Medical Policy #08.01.51: Canakinumab (Ilaris^®) is in development and is expected to be available in the coming weeks.

Requests for Ilaris^® received between January 1, 2019, and the publication of this policy will be evaluated in accordance with the manufacturer’s prescribing information and the U.S. Food and Drug Administration labeling.

If you have any questions about these changes, please call the AmeriHealth Clinical Services department at 1-888-YOUR-AH1 for AmeriHealth New Jersey or 1-800-275-2583 for AmeriHealth Pennsylvania.