As a reminder,
as of January 1, 2021, the following specialty drugs, which are eligible for coverage under the medical benefit for AmeriHealth members, require precertification:
- Neupogen® (filgrastim) – Colony-stimulating factors
- Nivestym® (filgrastim-aafi) – Colony-stimulating factors
- Oxlumo™ (lumasiran) – Miscellaneous therapeutic agents
- 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 have been added to the precertification list but are pending approval from the U.S. Food and Drug Administration (FDA). These drugs will require precertification for AmeriHealth members as of the date they receive FDA approval
- ciltacabtagene autoleucel – CAR-T
- dostarlimab – Anti-PD-1/PD-L1
- evinacumab – Miscellaneous therapeutic agents
- idecabtagene vicleucel – CAR-T
- inclisiran – 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 has been updated to reflect this new brand name.
The following drugs 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) no longer require precertification approval as of January 1, 2021. These drugs are not 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 are reflected in the precertification requirement list, which has been posted to our website for AmeriHealth New Jersey and AmeriHealth Pennsylvania.