As of January 1, 2021, AmeriHealth Pennsylvania updated 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 was expanded to include 202 drugs, with the following additions:
- evinacumab* – Miscellaneous therapeutic agents
- Fensolvi® (leuprolide acetate) – Endocrine/metabolic agents
- inclisiran* – Miscellaneous therapeutic agents
- lumasiran* (recently approved as Oxlumo™) – Miscellaneous therapeutic agents
- Nyvepria™ (pegfilgrastim-apgf) – Neutropenia
- pegunigalsidase alfa* – Enzyme replacement factors
- sutimlimab* – Miscellaneous therapeutic agents
For drugs that are pending approval from the U.S. Food and Drug Administration (FDA), their official brand names may be different than the names listed above. All names were valid at the time of article publication.
In addition, the following changes were made to the list:
- eptacog beta was changed to Sevenfact®, to reflect its current brand name
- inebilizumab was changed to Uplizna™, to reflect its current brand name
- Lucentis® (ranibizumab) now carries a biosimilar indicator, as a biosimilar to Lucentis is in the FDA pipeline; once approved, this biosimilar will also be subject to cost-share
- Valrox was changed to Roctavian™ (valoctocogene roxaparvovec), to reflect its current brand name
The above-mentioned changes are available on our website.
*Pending approval from the FDA.