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Neulasta®: Updates to precertification requirements, sites of service, and coverage options

October 31, 2016

Effective January 1, 2017, AmeriHealth is changing how we manage the drugs Neulasta® (pegfilgrastim) and Neulasta® Onpro®*. Currently, these drugs are covered under the medical benefit and do not require precertification approval. For dates of service on or after January 1, 2017, the following changes will occur:

  • All requests for these drugs under the medical benefit will require precertification approval from AmeriHealth.
  • As part of the precertification process, AmeriHealth will also review the setting where our commercial members receive these drugs.
  • Some members, including those whose pharmacy benefits are managed by FutureScripts®, our pharmacy benefits manager, will also be able to obtain these drugs under their pharmacy benefit.
During the next few weeks, AmeriHealth will send letters to notify affected providers and members about these changes.

Precertification requirements

AmeriHealth requires precertification approval for many specialty drugs covered under the medical benefit. This ensures that our members are receiving medications in accordance with the medical necessity criteria outlined in our medical policies.

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. This applies to members who are new to treatment with Neulasta®, as well as to those who have previously received the drug.

According to its U.S. Food and Drug Administration-approved label, Neulasta® must be given 24 hours after chemotherapy.

Due to the time-sensitive nature of Neulasta®, it is important to request precertification approval in advance of the member's scheduled treatment date. This allows ample time for AmeriHealth to review provider requests.

Most Cost-Effective Setting requirements

During precertification review, each member?s medical needs and clinical history are evaluated to determine if the drug requested by the provider is appropriate. As part of this precertification process, AmeriHealth reviews the provider's request for treatment setting for certain drugs covered under the medical benefit. Our Most Cost-Effective Setting Program ensures that members receive treatment in a setting that is both safe and cost-effective. As communicated in the October 2016 edition of Partners in Health UpdateSM, starting January 1, 2017, Neulasta® will be added to the Most Cost-Effective Setting Program for all commercial members.

Covered settings for Neulasta® include:

  • a physician's office;
  • the member?s home, where the injection is administered by an in-network home infusion provider;
  • an ambulatory (freestanding) infusion suite that is not owned by a hospital or health system in our network.
A hospital outpatient facility is the most costly setting in which to receive Neulasta®; therefore, it will primarily be approved only for members who are receiving an initial dose of Neulasta® or if there is a clinical rationale that requires the member to receive Neulasta® in the hospital outpatient facility. If the hospital outpatient facility is thought to be clinically necessary, the provider must submit documentation to AmeriHealth that addresses these circumstances.

Coverage for Neulasta® under the pharmacy benefit for commercial members

Covering Neulasta® and Neulasta® Onpro ®* under the medical or pharmacy benefit gives our commercial members more coverage options and greater convenience. Depending on their benefit contract, the copayment, deductible, and/or coinsurance may vary between medical and pharmacy benefits. We are encouraging members to compare both benefits to determine the coverage option that is more advantageous for them.

For members who choose to obtain Neulasta® under the pharmacy benefit through FutureScripts, providers will need to write new prescriptions. Providers will also need to ask members if they are interested in learning how to self-administer Neulasta® in their home or if they will return to the office the day after chemotherapy to receive Neulasta®.

For members who do not have pharmacy benefits with FutureScripts but are interested in self-administering Neulasta®, providers should encourage them to contact their pharmacy benefits manager to determine if Neulasta® is available under their prescription drug plan. If it is, members should be directed to compare the terms of their medical and pharmacy benefit plans to identify the benefit that provides more cost savings and/or convenience.

For more information

Providers can also find additional information about this program 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®.

FutureScripts provides pharmacy benefits management services.


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