​To ensure optimal management of high-cost biologics prescribed for complex autoimmune conditions (e.g., psoriasis, ulcerative colitis) and for severe asthma or allergic conditions (e.g., eosinophilic asthma, atopic dermatitis), the following changes went into effect October 1, 2022, for the AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey Select Drug Program^® and Value Formulary:

1. Submission of medical records is required to confirm medical necessity. Attestations are no longer accepted.
2. Submission of medical record or paid claim history to support previous trial(s) with the pre-requisite(s) (when applicable). Attestations are no longer accepted.
3. Objective measure(s) of efficacy is added to the reauthorization criteria (when applicable).
4. Dosing and frequency does not exceed maximum FDA recommendation per indication requested.
• ​New update for Dupixent, Fasenra, Nucala, and Xolair as of October 1, 2022.

These changes impact new starts and members seeking reauthorization as of October 1, 2022. Members with an active authorization will not experience interruption to therapy.

The following drugs are impacted by this update: 

Please include pertinent chart notes when submitting prior authorization requests for these drugs. View instructions for submitting prior authorization here.

For additional information, please refer to the following drug coverage policies:

Dupilumab (Dupixent^®)

Immune Modulating Therapies

Interleukin-5 (IL-5) Antibody Agents

Omalizumab (Xolair^®)