Effective January 1, 2023, AmeriHealth HMO, Inc. will update its list of specialty drugs that require member cost-sharing (i.e., 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 updated cost-share list will include 221 drugs, with the following additions:
- beremagene geperpavec* – Gene Replacement/Gene Editing Therapies
- Cimerli™ (ranibizumab-eqrn) – Ophthalmic Agents
- etranacogene dezaparvovec* – Gene Replacement/Gene Editing Therapies
- Fylnetra™ (pegfilgrastim-pbbk) – Neutropenia
- pegcetacoplan* – Ophthalmic Agents
- Stimufend® (pegfilgrastim-fpgk) – Neutropenia
- tofersen* – Amytrophic Lateral Sclerosis Agents
- ublituximab* – Multiple Sclerosis Agents
- Xenpozyme® (olipudase alfa) – Enzyme Replacement Agents
The following drugs were added to the cost-share list during a previous update cycle, prior to receiving FDA approval. These drugs have since received FDA approval, and their brand names have changed as follows:
- Elivaldogene autotemcel will be changed to Skysona® – Gene Replacement/Gene Editing Therapies
- Rolontis will be changed to Rolvedon™ – Neutropenia
- Spesolimab will be changed to Spevigo® – Immunological Agents
- Vutrisiran will be changed to Amvuttra™– Miscellaneous Therapeutic Agents
The following changes have also been made to this list:
- A new category will be added for Amyotrophic Lateral Sclerosis Agents.
- The Gene Replacement Therapy category will be changed to Gene Replacement/Gene Editing Therapies, to reflect the emergence of new technologies within the category.
- The immunological agents Actemra®, Benlysta®, Orencia®, and Stelara® will now include the (IV) designation to indicate that the intravenous formulation of these drugs is subject to cost-share under the medical benefit.
An updated medical benefit specialty drug cost-share list will be available on our website prior to January 1, 2023.
*Pending approval from the U.S. Food and Drug Administration (FDA). After these drugs receive FDA approval, their brand names may change from those listed above. All names were valid at the time of article publication.