​Effective January 1, 2023, AmeriHealth is making changes to the list of specialty drugs that require precertification under the medical benefit for members administered by AmeriHealth Administrators and enrolled in AmeriHealth HMO, Inc. or AmeriHealth Insurance Company of New Jersey Commercial plans.

Additions

The following drugs have been approved by the U.S. Food and Drug Administration (FDA) and will require precertification:

• Cimerli™ (ranibizumab-eqrn) – Ophthalmic Agents
• Fylnetra^® (pegfilgrastim-pbbk) – Neutropenia
• Skysona^® (elivaldogene autotemcel) – Gene Replacement/Gene Editing Therapies
• Stimufend^® (pegfilgrastim-fpgk) – Neutropenia
• Zynteglo^® (betibeglogene autotemcel) – Gene Replacement/Gene Editing Therapies

The following drugs are pending FDA approval and will require precertification as of the date they receive FDA approval:

• beremagene geperpavec – Gene Replacement/Gene Editing Therapies
• etranacogene dezaparvovec – Gene Replacement/Gene Editing Therapies
• mirvetuximab soravtansine – Antineoplastic Agents
• mosunetuzumab – Antineoplastic Agents
• tofersen – Amyotrophic Lateral Sclerosis Agents
• tremelimumab – Antineoplastic Agents

Changes

The following drugs were added to the precertification list during a prior update cycle, in advance of their FDA approval. They have since been approved by the FDA, and the precertification list will be updated to reflect the new brand names:

• olipudase alfa will be updated to Xenpozyme^® – Enzyme Replacement Agents
• Rolontis^® will be updated to Rolvedon™ – Neutropenia
• spesolimab will be updated to Spevigo^® – Immunological Agents
• vutrisiran will be updated to Amvuttra™ – Miscellaneous Therapeutic Agents

The drug ublituximab will be moved from the Antineoplastic Agents class to the Multiple Sclerosis Agents class, to align with its newly sought-after indication.

Lastly, the Gene Replacement Therapy category will be changed to Gene Replacement/Gene Editing Therapies, to reflect the emergence of new therapeutic technologies within the class.

Learn more

Medical policies for FDA-approved drugs can be found on our Medical and Claim Payment Policy Portal. In the absence of a published medical policy, all precertification requests will be subject to review in accordance with FDA labeling and AmeriHealth-recognized compendia.

These changes will be reflected in an updated precertification requirement list, which will be posted to the AmeriHealth Administrators, AmeriHealth New Jersey, and AmeriHealth Pennsylvania websites.