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Reminder: Upcoming changes to precertification requirements for 2017

December 1, 2016

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Effective January 1, 2017, new precertification requirements will apply to our commercial HMO and PPO members for the following services and drugs eligible for coverage under the medical benefit.

Services

As of January 1, 2017, insulin pumps will require precertification approval from AmeriHealth.

As of January 1, 2017, applied behavioral analysis for treatment of autism spectrum disorders will require precertification approval from AmeriHealth New Jersey. Please note that this precertification review is provided by Magellan Healthcare, Inc.

Drugs

As of January 1, 2017, the drugs listed below will require precertification approval from AmeriHealth:

  • Cinqair® (reslizumab)
  • Cubicin® (daptomycin)
  • DarzalexTM (daratumumab)
  • Erwinaze® (L-asparaginase)
  • Exondys 51TM (eteplirsen)
  • Faslodex® (fulvestrant)
  • Hymovis® (high molecular weight viscoelastic hyaluronan)
  • InflectraTM (infliximab)*
  • Neulasta® (pegfilgrastim)*
  • Neulasta® (pegfilgrastim) Onpro®*
  • Sandostatin® LAR (octreotide acetate)
  • TecentriqTM (atezolizumab)

In addition, the following drugs are currently pending approval from the U.S. Food and Drug Administration (FDA). Once they receive FDA approval, they will also require precertification approval from AmeriHealth:

  • Cingal® (sodium hyaluronate/triamcinolone hexacetonide)
  • OcrevusTM (ocrelizumab)
  • Remune® (HIV-1 immunogen)

These changes will be reflected in an updated precertification requirement list, which will be posted on our AmeriHealth New Jersey website or AmeriHealth Pennsylvania website later this month, prior to these changes going into effect.

*Precertification requirements apply to all biosimilars of infliximab and pegfilgrastim approved by the FDA.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most AmeriHealth members.


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