Specialty drugs that will require precertification

Effective July 1, 2020, the following specialty drugs, which have been approved by the U.S. Food and Drug Administration (FDA) and are eligible for coverage under the medical benefit for AmeriHealth New Jersey and AmeriHealth Pennsylvania members, will require precertification:

• Avsola^TM (infliximab-axxq) – Immunological agents
• Enhertu^® (fam-trastuzumab deruxtecan-nxki) – Cancer
• Padcev^TM (enfortumab vedotin-ejfv) – Cancer
• Sevenfact (coagulation factor VIIa [recombinant]-jncw) – Hemophilia/Coagulation factors
• Tepezza^TM (teprotumumab-trbw) – Ophthalmic agents
• Ziextenzo^® (pegfilgrastim-bmez) – Colony-stimulating factors

In addition, the following drugs are currently pending FDA approval and will require precertification for AmeriHealth members once they receive FDA approval:

• Inebilizumab – Miscellaneous therapeutic agents
• Instiladrin^® (nadofaragene firadenovec) – Cancer
• Rolontis^® (eflapegrastim) – Colony-stimulating factors
• Taclantis^® (paclitaxel injection concentrated for suspension) – Cancer      
• Trevyent (treprostinil) – Pulmonary arterial hypertension
• Valrox (valoctocogene roxaparvovec) – Gene therapy

In the absence of a published medical policy on any of these drugs, coverage requests will be subject to review in accordance with the FDA-approved indications and AmeriHealth-recognized compendia.

Specialty drugs that will require member cost-sharing

Effective July 1, 2020, AmeriHealth Pennsylvania will also update its list of specialty drugs that require member cost-sharing (e.g., copayment, deductible, and coinsurance). Cost-sharing applies to select medical benefit specialty drugs for members who are enrolled in Commercial FLEX products and other select plans. The member’s cost-sharing amount is based on the terms of the member’s benefit contract. In accordance with your Provider Agreement, it is the provider’s responsibility to verify a member’s individual benefits and cost-share requirements

The cost-share list will be expanded to include 195 drugs, including the following additions:

• Avsola^TM (infliximab-axxq)
• Inebilizumab*
• Rolontis^® (eflapegrastim)*
• Sevenfact (coagulation factor VIIa [recombinant]-jncw)
• Tepezza^TM (teprotumumab-trbw)
• Trevyent (treprostinil)*
• Valrox (valoctocogene roxaparvovec)*
• Xipere^TM (triamcinolone acetonide suprachoroidal injectable suspension)*
• Ziextenzo^TM (pegfilgrastim-bmez)

Note: The final FDA-approved brand names may be different than the brand names listed above. All brand names were valid at the time of article publication.

The above-mentioned changes will be available on our website for AmeriHealth New Jersey and AmeriHealth Pennsylvania.

*Pending approval from the FDA.