As a reminder, in 2016 new precertification requirements will apply to our commercial HMO and PPO and Medicare Advantage HMO members for the following service and drugs.

Service

Bronchial thermoplasty will require precertification approval from AmeriHealth in 2016 as follows:

• Effective January 1, 2016, precertification will be required for members enrolled in Medicare Advantage plans.
• Effective March 1, 2016, precertification will be required for members enrolled in commercial plans.

Drugs

As of January 1, 2016, the eight medical benefit drugs listed below will require precertification approval from AmeriHealth:

• Adagen^® (pegademase bovine)
• Blincyto^® (blinatumomab)
• Cyramza^® (ramucirumab)
• Imlygic^™ (talimogene laherparepvec)
• Kanuma^™ (sebelipase alfa)*
• Lemtrada^® (alemtuzumab)
• Nucala^® (mepolizumab)
• Zevalin^® (ibritumomab tiuxetan)^†

These changes will be reflected in updated precertification requirement lists, which will be posted later this month for AmeriHealth New Jersey and for AmeriHealth Pennsylvania.

In addition, Notifications for the medical policies for Adagen (pegademase bovine) and Cyramza (ramucirumab) will be available this month:

• Adagen (pegademase bovine):
• Commercial: #08.01.26: Pegademase bovine (Adagen^®)
• Cyramza (ramucirumab):
• Commercial: #08.01.25: Ramucirumab (Cyramza^®)
• Medicare Advantage: #MA08.075: Ramucirumab (Cyramza^®)

To view the Notifications for these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial or Medicare Advantage under Notifications.

In January 2016, new policies for Imlygic^™ (talimogene laherparepvec) and Nucala^® (mepolizumab) will be made available. Medical necessity criteria for these drugs will be based on the U.S. Food and Drug Administration (FDA)-approved indications.

*Pending approval from the FDA

^† Precertification review for this drug is currently provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore) for AmeriHealth Pennsylvania HMO members. Precertification for this drug will be reviewed by eviCore starting January 1, 2016, for all AmeriHealth New Jersey members.