Effective July 1, 2022, the list of specialty drugs that are eligible for coverage under the medical benefit for Independence Administrators members and Independence Blue Cross commercial and Medicare Advantage HMO and PPO members has changed.
The following drugs have recently been approved by the U.S. Food and Drug Administration (FDA) and require precertification:
- Alymsys™ (bevacizumab-maly) – Antineoplastic agents* NEW
- Infliximab (unbranded) – Immunological agents
- Kimmtrak® (tebentafusp-tebn) – Antineoplastic agents
- Opdualag™ (nivolumab and relatlimab-rmbw) – Antineoplastic agents
- Pluvicto™ (lutetium Lu 177 vipivotide tetraxetan)** – Antineoplastic agents
- Skyrizi® IV (risankizumab-rzaa) – Immunological agents
- Releuko™ (filgrastim-ayow) – Neutropenia
- Tezspire™ (tezepelumab-ekko) – Respiratory agents
The following drugs are pending FDA approval and will require precertification as of the date they receive FDA approval:
- Elivaldogene autotemcel – Gene replacement therapy
- Eylea® (aflibercept) biosimilar – Ophthalmic agents
- Spesolimab – Immunological agents
- Teclistamab – Antineoplastic agents
- Tislelizumab – Anti-PD-1/PD-L1 human monoclonal antibodies
- Toripalimab – Anti-PD-1/PD-L1 human monoclonal antibodies
The drug names listed above may change after the drug receives FDA approval. All names were valid at the time of article publication.
The following drugs were added to the precertification list during a prior update cycle. They have since been approved by the FDA, and the precertification list has been updated to reflect their new brand names:
- ciltacabtagene autoleucel has been updated to Carvykti™ – Chimeric antigen receptor T-cell (CAR-T) therapy NEW
- efgartigimod has been updated to Vyvgart™ – Miscellaneous therapeutic agents
- faricimab has been updated to Vabysmo® – Ophthalmic agents
- inclisiran has been updated to Leqvio® – Miscellaneous therapeutic agents
- sutimlimab has been updated to Enjaymo™ – Miscellaneous therapeutic agents
Removals
The following drugs have been removed from the precertification list, since they are no longer available in the U.S. market:
- Bebulin® (factor IX complex, intravenous) – Hemophilia/Coagulation factor
- Carimune® NF (nanofiltered immune globulin, intravenous [human]) – Intravenous immunoglobulin (IVIG)
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 the FDA-approved indications and Independence-recognized compendia.
These changes are reflected in an updated precertification requirement list, which has been posted to the Independence Blue Cross and Independence Administrators websites.
*Precertification for this drug only applies to antineoplastic indications; ophthalmological indications do not require precertification.
**Precertification review will be provided by eviCore healthcare (eviCore), an independent company.