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As previously communicated, effective January 1, 2015, new precertification requirements will apply to our commercial HMO and PPO and Medicare Advantage HMO members for the medical benefit drugs listed.

The following medical benefit drugs will be added to the precertification requirement list effective January 1, 2015:

• Beleodaq^TM (belinostat);
• Entyvio^TM (vedolizumab);
• Keytruda^® (pembrolizumab);
• Monovisc^® (high molecular weight hyaluronan) ? added to AmeriHealth New Jersey only, already on Delaware and Pennsylvania list;
• nivolumab (anti-PD-1 human monoclonal antibodies)*;
• Ruconest^® (recombinant C1-esterase inhibitor);
• Sylvant^TM (siltuximab);
• Vimizim^TM (elosulfase alfa) ? added to AmeriHealth New Jersey only, already on Delaware and Pennsylvania list.

In addition, the following medical benefit drugs will no longer require precertification approval effective January 1, 2015:

• Aredia^® (pamidronate disodium);
• Arzerra^® (ofatumumab);
• Boniva^® injection (ibandronate sodium);
• Ceredase^® (alglucerase);
• Eloxatin^® (oxaliplatin);
• Nulojix^® (belatacept);
• Orthovisc^® (high molecular weight hyaluronan);
• Synvisc^® (hylan G-F 20);
• Synvisc-One^® (hylan G-F 20).

These changes will be reflected in an updated precertification requirement list, which will be available later this month on our
Pennsylvania and Delaware provider website or our New Jersey provider website.

*Pending approval from the U.S. Food and Drug Administration.

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