[
As of January 1, 2017, AmeriHealth changed how we manage
Neulasta® (pegfilgrastim) and Neulasta®
Onpro®*. These changes include the following:
- All requests for coverage for Neulasta® under the medical
benefit require precertification approval from AmeriHealth prior to our members
receiving the drug.
- As part of our Most Cost-Effective Setting Program, AmeriHealth
will also review the setting where members enrolled in commercial plans receive
Neulasta®.
- Members enrolled in commercial plans whose pharmacy benefits are managed by
FutureScripts®, our pharmacy benefits manager, are also able to
obtain Neulasta® under their pharmacy benefit.
Precertification approval
AmeriHealth requires precertification approval for many specialty drugs to
ensure that the medical necessity criteria listed in our medical policies are
satisfied. For dates of service on or after January 1, 2017, all requests for
Neulasta® under the medical benefit require precertification
approval from AmeriHealth for commercial members.
According to its U.S. Food and Drug Administration-approved label,
Neulasta® is given 24 hours after chemotherapy. Due to the
time-sensitive nature of the drug, it is important for you to request
precertification approval in advance of the member?s scheduled treatment date.
This allows AmeriHealth sufficient time to review the request.
Setting approval
During precertification review, each member?s medical needs and clinical
history are evaluated to determine if the drug for which coverage is requested
satisfies the coverage criteria. As part of this precertification process,
AmeriHealth reviews the provider?s request for treatment setting for certain
drugs covered under the medical benefit to ensure that our members receive
treatment in a setting that is both cost-effective and safe. As of January 1,
2017, Neulasta® was added to the Most Cost-Effective Setting
Program for all commercial plans. Cost-effective settings for
Neulasta® include:
- a physician?s office, where you can either (1) buy the drug and request
reimbursement from AmeriHealth or (2) order the drug via the AmeriHealth Direct
Ship Drug Program and incur no cost for acquiring the drug;
- the member?s home, where the injection is administered by an in-network
home infusion provider;
- an ambulatory (freestanding) infusion suite, not owned by a hospital or
health system in our network.
A hospital outpatient facility is the most costly setting in which to
administer Neulasta®; and coverage in such a setting will be
considered for those members who are receiving their initial dose of
Neulasta® or for members whose condition requires the intensive
monitoring and access to emergent care uniquely available on a hospital campus.
AmeriHealth will require submission of relevant medical records identifying the
specific reason the hospital outpatient setting is requested for ongoing
administration of Neulasta®. This information will be reviewed
and a coverage determination on setting will be made.
Coverage for Neulasta® under the pharmacy benefit
Offering coverage for Neulasta® under either the medical or
pharmacy benefit gives our commercial members more options and greater
convenience. The terms, conditions, and cost-sharing provisions (including
copayment, deductible, and coinsurance) in their benefit contracts may vary
between medical and pharmacy benefits, so members should compare both benefits
to determine the coverage option that is more advantageous for them.
If members choose to obtain Neulasta® under the pharmacy
benefit through FutureScripts, they will need a prescription. At your
professional discretion, Neulasta® may be prescribed for
self-administration or may be physician-administered. In the event your office
administers a dose of Neulasta®, this service is eligible for
reimbursement with submission of a claim.
For members who do not have pharmacy benefits with FutureScripts but who
have pharmacy benefit coverage with another vendor and are interested in
self-administering Neulasta®, you should encourage them to
contact their pharmacy benefits manager to determine if Neulasta®
is available for coverage under their prescription drug plan.
For more information
Providers can find additional information about Neulasta® in
Medical Policy #08.01.32: Pegfilgrastim (Neulasta®). To access
this policy, visit our Medical Policy Portal and select Accept and Go to
Medical Policy Online. Then select Commercial and type the policy
name or number in the Search field.
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®.
]