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Effective January 1, 2017, AmeriHealth is changing how we manage
Neulasta® (pegfilgrastim) and Neulasta®
Onpro®*. Currently, these drugs are covered under our members?
medical benefit and do not require precertification
approval. Effective January 1, 2017, the following changes will take place:
- All requests for coverage for Neulasta® under the medical
benefit will 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, will also be able to obtain Neulasta® under
their pharmacy benefit.
AmeriHealth recently sent letters to notify affected providers about these
changes.
Precertification approval
AmeriHealth requires precertification approval for many specialty drugs to
ensure that the medical necessity criteria
listed in our medical policy are satisfied. For dates of service on or after
January 1, 2017, all requests for Neulasta®
under the medical benefit will 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 will also review 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. Effective January 1, 2017, Neulasta® will be
added to the Most Cost-Effective Setting Program.
Cost-effective settings for Neulasta® include:
- A physician?s office, where you can either buy the
drug and request reimbursement from AmeriHealth,
or 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 for commercial
members
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 copay, deductible, and coinsurance) in
their benefit contracts may vary between medical and
pharmacy benefits, so members may 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
require 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®),
which is currently posted as a Notification and will become effective on
January 1, 2017.
To access medical policies, visit our Medical
Policy Portal. Select Accept and Go
to Medical Policy Online, then select Commercial under Active
Notifications.
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®.