Services that require precertification for AmeriHealth New Jersey members
As of July 1, 2024, this list applies to all AmeriHealth New Jersey HMO, POS, EPO, and PPO products.
This applies to services performed on an elective, nonemergency basis
Because a service or item is subject to precertification, it does not guarantee coverage. The terms and conditions of your benefit plan must be reviewed to determine if any of these services or items are excluded.
Precertification is not a determination of eligibility or a guarantee of payment. Coverage and payment are contingent upon, among other things, the patient being eligible, i.e., actively enrolled in the health benefits plan when the precertification is issued and when approved services are provided. Coverage and payment are also subject to limitations, exclusions, and other specific terms of the health benefits plan that apply to the coverage request. In addition to the precertification requirements listed above, you should contact AmeriHealth New Jersey and provide prenotification for certain categories of treatment so you will know prior to receiving treatment whether it is a covered service. The categories of treatment (in any setting) that require prenotification include:
- Any surgical procedure that may be considered potentially cosmetic;
- Any procedure, treatment, drug, or device that represents “new or emerging technology," including infusion therapy drugs newly approved by the FDA;
- Services that might be considered experimental/investigational.
Note: If a non-emergent service is unavailable from a provider within the network, precertification for a plan exception for out-of-network coverage may be requested for those members who do not have an out-of-network benefit. Please refer to the AmeriHealth New Jersey Provider Manual for Participating Professional Providers (Provider Manual) for additional information on out-of-network requests.
The list of services requiring precertification is subject to change. For questions about precertification, please call Customer Service at
1-888-YOUR-AH1 (1-888-968-7241).
You can also go to
amerihealthnj.com/html/providers/policies.html to learn more about precertification requirements for all products.
All home-care services (including infusion therapy in the home)
Inpatient services
- Acute rehabilitation admissions
- Elective surgical and nonsurgical inpatient admissions
- Inpatient hospice admissions
- Long term acute care (LTAC) facility admissions
- Skilled nursing facility admissions
Cardiology procedures
Precertification is performed by Carelon Medical Benefits Management, an independent company. To access the complete list of Carelon Clinical Appropriateness Guidelines for Cardiology and Arterial Ultrasound, click here.
- Arterial ultrasound
- Diagnostic coronary angiography
- Percutaneous coronary intervention
Any procedure, device, or service that may potentially be considered experimental or investigational including:
- New emerging technology/procedures, as well as existing technology and procedures applied for new uses and treatments
Procedures
- Cochlear implant surgery and associated supplies/bone-anchored (osseointegrated) hearing aids, implantable bone conduction hearing aids
69714, 69715, 69717, 69718, 69930, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693
- Obesity surgery
43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999
Musculoskeletal Procedures
Precertification is performed by Carelon Medical Benefits Management, an independent company.
For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.
- Bone graft substitutes and bone morphogenetic proteins for spine surgery
- Cervical decompression with or without fusion
- Cervical disc arthroplasty
- Hip arthroplasty
- Hip arthroscopy and open procedures
- Knee arthroplasty
- Knee arthroscopy and open procedures
- Lumbar disc arthroplasty
- Lumbar discectomy, foraminotomy, and laminotomy
- Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)
- Lumbar laminectomy
- Meniscal allograft transplantation of the knee
- Shoulder arthroplasty
- Shoulder arthroscopy and open procedures
- Treatment of osteochondral defects
- Vertebroplasty/Kyphoplasty
Interventional pain management services
Precertification is performed by Carelon Medical Benefits Management, an independent company. For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.
- Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
- Paravertebral Facet Injection/Nerve Block/Neurolysis
- Regional Sympathetic Nerve Block
- Sacroiliac joint injections
- Implanted spinal cord stimulators
Reconstructive procedures and potentially cosmetic procedures
- Blepharoplasty/ptosis repair
15820, 15821, 15822, 15823,
67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
- Bone graft, genioplasty and mentoplasty
21120, 21121, 21122, 21123
- Breast Reconstruction
11920, 11921, 11922, 11970, 11971, 15271, 15272, 15769, 15771, 15772, 15773, 15774, 15777, 19300, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4100, Q4107, Q4116, Q4130, Q4142, Q4143, S2066, S2067, S2068
- Breast Reduction
15877, 19318
- Breast Augmentation/Mammoplasty
19325
- Breast Mastopexy
19316
- Insertion of Breast Implants
19340, 19342, 19396
- Removal of Breast Implants
19328, 19330, 19370, 19371
- Canthopexy/Canthoplasty
21280, 21282, 67950
- Cervicoplasty
15819
- Chemical peels
15788, 15789, 15792, 15793
- Dermabrasion
15780, 15781, 15782, 15783
- Excision of excessive skin and/or subcutaneous tissue
15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839
- Gender Affirming interventions
11920, 11921, 11922, 11960, 15877, 19303, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
- Genetically and bio-engineered skin substitutes for wound care
A2001, A2002, A2004, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021, A2022, A2023, A2024, A2025, A2506, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4199, Q4205, Q4206, Q4208, Q4209, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4227, Q4228, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279,Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4314, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333
- Hair transplant
15775, 15776
- Keloid removal
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
- Lipectomy, liposuction, or any other excess fat-removal procedure
15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879
- Otoplasty
13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399
- Rhinoplasty
30400, 30410, 30420, 30430, 30435, 30450
- Rhytidectomy
15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876
- Scar revision
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
- Skin closures
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770
- Surgery for varicose veins, including perforators and sclerotherapy
36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799
Elective (nonemergency) ground, air, and sea ambulance transportation
A0140, A0426, A0428, A0430, A0431,
A0434, S9960, S9961
Outpatient private-duty nursing
S9123, S9124
Day rehabilitation programs
0931, 0932
Outpatient radiation therapy
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore Lab Management Program Clinical Guidelines for AmeriHealth, click Laboratory Management | eviCore healthcare.
Radiology
Precertification is performed by Carelon Medical Benefits Management, an independent company. To access the complete list of Carelon Diagnostic Imaging Utilization Management Clinical Guidelines, click
here.
- CT
- CTA
- Echocardiography services
- Testing transthoracic echocardiography (TTE)
- Stress echocardiography (SE)
- Transesophageal echocardiography (TE)
- MRA
- MRI
- Nuclear cardiology
- PET scans
Prosthetics/orthoses
Follow New Jersey orthotics and prosthetics mandate, as applicable. Items addressed by the mandate do not require precertification.
Selected durable medical equipment (DME)
- Bone growth stimulators
E0747, E0760
- Bone growth stimulator, electrical, noninvasive, spinal
Precertification is performed by Carelon Medical Benefits Management, an independent company.
For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.
- Bone-anchored (osseointegrated) hearing aids
69716, 69719, 69726, 69727, L8690, L8691, L8692, L8693, L8694
- Continuous positive airway pressure (CPAP) devices, bi-level (Bi-PAP) devices, and all supplies
Precertification is performed by Carelon Medical Benefits Management, an independent company. To access the complete list of Carelon Sleep Disorder Management Diagnostic and Treatment Guidelines, click here.
- Dynamic adjustable and static progressive stretching devices (excludes CPMs)
E1800, E1802, E1805, E1810, E1812, E1825, E1830
- Electric, power, and motorized wheelchairs including custom accessories
E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294 E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613 E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630 K0010, K0011, K0012, K0013, K0014, K0056, K0108, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823 K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862 K0863, K0864, K0890, K0891, K0898
- Insulin pumps
E0784, E0787, S1034
- Manual wheelchairs with the exception of those that are rented
E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039 E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110
E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222
E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270
E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608
E2609, E2613,
E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628
E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108
- Negative pressure wound therapy
A6550, A9272, E2402, K0743, K0744, K0745, K0746
- Neuromuscular stimulators
E0744, E0745, E0764, E0770
- Power operated vehicles (POV)
E1230, K0800, K0801, K0802, K0812
- Pressure reducing support surfaces including:
- Air fluidized bed
E0194
- Non powered advanced pressure reducing mattress
E0371, E0373
- Powered air flotation bed (low air loss therapy)
E0193, E0372
- Powered pressure reducing mattress
E0277
- Push rim activated power assist devices
E0986
- Repair or replacement of all DME items, as well as orthoses and prosthetics that require precertification - See specific DME, orthoses, and prosthetics categories for Repair or Replacement codes that require precertification.
- Speech generating devices
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336
Medical foods
B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435
Hyperbaric oxygen therapy
0413, G0277
In-Lab / Facility sleep studies
Precertification is performed by Carelon Medical Benefits Management, an independent company. To access the complete list of Carelon Sleep Disorder Management Diagnostic and Treatment Guidelines, click here.
Proton beam therapy
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore Lab Management Program Clinical Guidelines for AmeriHealth, click Laboratory Management | eviCore healthcare.
All transplant procedures, with the exception of corneal transplants
0584T, 0585T, 0586T, 15775, 15776, 27415, 27416, 29866, 29867, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150
Mental health/serious mental illness/substance abuse
- Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
- Repetitive transcranial magnetic stimulation (RTMS)
- Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
Autism spectrum disorders
- Applied behavioral analysis
Genetic and genomic tests requiring precertification
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore Lab Management Program Clinical Guidelines for AmeriHealth, click Laboratory Management | eviCore healthcare.
The following list is a guide to the types of genetic and genomic tests that require precertification. Due to the volume of tests, it is not possible to list each test separately. To determine if a test requires precertification, please see the complete procedure code list for details.
Please note: precertification of genetic and genomic tests applies to commercial members only.
Hereditary cancer syndromes
- BRCA gene testing (breast and ovarian cancer syndrome)
- Lynch syndrome gene testing
- Familial adenomatous polyposis gene testing
- PTEN gene testing (Cowden syndrome)
- General cancer type panels (such as colon, breast, or neuroendocrine cancers)
Hereditary heart diseases
- Long QT syndrome gene testing
- Aortic dilation or aneurysm syndrome testing (includes Marfan syndrome)
Other full gene analysis testing
- Cystic fibrosis full gene sequencing and deletion/duplication analysis
- PMP22 full gene sequencing and deletion/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy)
Tests for many genetic disorders simultaneously
- Expanded carrier screening panels (such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening)
- Hearing loss panels
- Intellectual disability panels
- Noonan spectrum disorders panels
Specialty oncology tests
- Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™)
- Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others)
- Tissue of origin testing (for cancer of unknown primary)
- PCA3 testing for prostate cancer
Pharmacogenomic tests
- Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19)
- Specialized drug response gene panels (such as Assurex GeneSight®, GeneTrait, Genecept®, Millennium PGTSM)
- Warfarin response testing
- MGMT methylation analysis for glioblastoma
Other specialty tests
- Coronary artery disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6)
- Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR)
Genome-wide tests
- Microarray studies
- Whole exome testing
- Whole genome testing
- Mitochondrial genome or nuclear testing
ANY genetic test for more than one gene or condition (often includes words like “panel" or “comprehensive" in the name)
ANY genetic test that will be billed with a non-specific procedure code
- Billed with CPT® codes
81400-81408
- Billed with an unlisted code:
81479, 81599, 84999
Specialty drugs requiring precertification
All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change.
Amyotrophic Lateral Sclerosis agents
- NurOwn® - J3490, J3590, and C9399
Antineoplastic agents
- Abraxane® -
J9258, J9259, and J9264
- Adstiladrin® -
J9029
- Adcetris® -
J9042
-
Alymsys®
- Q5126 (Note: Ophthalmologic use of Alymsys does not require precertification.)
- Avastin® - C9257, J9035, and Q5129 (Note: Ophthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
- Azedra®* -
A9590
- Blincyto™ -
J9039
- Columvi™ - J9286
- Cyramza® -
J9308
- Darzalex™ -
J9145
- Darzalex Faspro™ –
J9144
-
Elahere™ -
J9063
- Elrexfio™ - J1323
- Enhertu® -
J9358
- Epkinly™ - J9321
- Erbitux® -
J9055
- Erwinaze® -
J9019
- Herceptin® -
J9355
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Herceptin® Hylecta -
J9356
- Herzuma® -
Q5113
- Imjudo® -
J9347
- Instiladrin
(pending FDA approval) -
J3490 and C9399
- Kadcyla® -
J9354
-
Kimmtrak® - J9274
- Kyprolis® -
J9047
- Loqtorzi™ - J3263
- Lunsumio™ -
J9350
- Margenza™ -
J9353
-
Monjuvi® -
J9349
- Ogivri™ -
Q5114
- Ontruzant®-
Q5112
-
Opdualag™ - J9298
- Padcev™-
J9177
- Pemfexy™ - J9304
- Perjeta® -
J9306
- Phesgo™–
J9316
-
Pluvicto™* -
J3490 and C9399
- Polivy™ -
J9309
- Poteligeo® -
J9204
- Provenge® -
Q2043
- Riabni™ -
Q5123
- Rituxan® -
J9312
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Rituxan Hycela™ -
J9311
-
Rybrevant™ –
J9061
- Rylaze™ -
J9021
- Sarclisa® -
J9227
- Taclantis (pending FDA approval) -
J3490 and C9399
- Talvey™ - J3055
-
Tecvayli™ -
J9380
- Tivdak™ -
J9273
- Trodelvy™ -
J9317
- Xofigo®* -
A9606
- Yervoy™ -
J9228
- Zepzelca™ –
J9223
- Zevalin®* -
A9543
- Zolbetuximab (pending FDA approval) - J3490, J3590, and C9399
- Zynlonta™
J9359
* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore Lab Management Program Clinical Guidelines for AmeriHealth, click Laboratory Management | eviCore healthcare.
Anti PD-1/PD-L1 human monoclonal antibodies
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Bavencio® -
J9023
- Camrelizumab (pending FDA approval) - J3490, J3590, and C9399
- Cosentyx® IV – J3247
- Cosibelimab (pending FDA approval) - J3490, J3590, and C9399
- Imfinzi™ -
J9173
- Jemperli™ - J9272
- Keytruda™ -
J9271
- Libtayo®
- J9119
- Opdivo® -
J9299
- Penpulimab
(pending FDA approval) -
J3490, J3590, and C9399
- Tecentriq™ -
J9022
- Tevimbra® - J3490 and C9399
- Zynyz™ - J9345
Bone-modifying agents
- Evenity™ -
J3111
- Prolia® -
J0897
- Xgeva® -
J0897
Botulinum toxin agents
Chimeric antigen receptor (CAR-T) therapies
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Abecma® -
Q2055
- Breyanzi® - Q2054
-
Carvykti™ - Q2056
- Kymriah™ -
Q2042
- Tecartus™ -
Q2053
- Yescarta™ -
Q2041
-
Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T
Endocrine/metabolic agents
- Achtar H.P.® - J0801 and J0802
- Lanreotide – J1932
- Lutathera®* -
A9513 and A9699
- Lutathera®* - A9513 and A9699
- Sandostatin® LAR -
J2353
- Somatuline® depot -
J1930
- Xenpozyme™ -
J0218
* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore Lab Management Program Clinical Guidelines for AmeriHealth, click Laboratory Management | eviCore healthcare.
Enzyme replacement agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Aldurazyme® -
J1931
- Adzynma - J7171
- Brineura™ -
J0567
- Cerezyme® -
J1786
- Cinaxadamtase Alfa (pending FDA approval) – J3490, J3590, and C9399
- Cipaglucosidase Alfa (pending FDA approval) - J3490, J3590, and C9399
- Elaprase® -
J1743
- Elelyso® -
J3060
- Elfabrio® - J2508
- Fabrazyme® -
J0180
- Kanuma® -
J2840
- Lamzede® - J0217
- Lumizyme® -
J0221
- Mepsevii™
- J3397
- Naglazyme® -
J1458
- Nexviazyme™ -
J0219
- Pombiliti™ - J1203
-
Replagal®
(pending FDA approval) -
J3490
-
Revcovi™
- J3590 and C9399
-
Vimizim™ -
J1322
- Vpriv® - J3385
-
Xenpozyme® - J3590 and C9399
Gene Replacement / Gene Editing Therapies
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Casgevy™ - J3490, J3590, and C9399
- Elevidys® - J1413
- Fidanacogene Elaparvoec (pending FDA approval) - J3490, J3590, and C9399
- Hemgenix® -
J1411
- Luxturna™
- J3398
- Lyfgenia™ - J3490, J3590, and C9399
- Roctavian® - J1412
-
Skysona® -
J3590 and C9399
- Vvjuvek™ - J3401
- Zolgensma®
- J3399
-
Zynteglo® -
J3590 and C9399
Hemophilia/Coagulation factors
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Advate® -
J7192
- Adynovate -
J7207
- Afstyla®-
J7210
- Alphanate® -
J7186
- Alphanine SD® -
J7193
- Alprolix® -
J7201
- Altuviiio™ - J7214
- Bebulin VH® -
J7194
- Benefix® -
J7195
- Coagadex® -
J7175
- Corifact® -
J7180
- Eloctate® -
J7205
- Esperoct®-
J7204
- Feiba NF® -
J7198
- Feiba VH® -
J7198
- Fibryga® -
J7177
- Helixate FS® -
J7192
- Hemlibra® -
J7170
- Hemofil-M® -
J7190
- Humate-P® -
J7187
- Idelvion® -
J7202
- Ixinity® -
J7213
- Jivi® -
J7199 and J7208
- Koate-DVI®-
J7190
- Kogenate FS® -
J7192
- Kovaltry® -
J7207 and J7211
- Monoclate-P® -
J7190
- Mononine® -
J7193
- Novoeight® -
J7182
- Novoseven RT® -
J7189
- Novoseven® -
J7189
- Nuwiq® -
J7209
- Obizur® -
J7188
- Profilnine SD® -
J7194
- Rebinyn® -
J7203
- Recombinate® -
J7192
- RiaSTAP® -
J7178
- Rixubis® -
J7195 and J7200
- Sevenfact® –
J7212
- Tretten® -
J7181
- Vonvendi® -
J7179 and J7199
- Wilate® -
J7183
- Xyntha® -
J7185
Hyaluronate acid products
- Cingal
(pending FDA approval) -
J3490
- Durolane®
- J7318
- Euflexxa™ -
J7323
- Gel-One® -
J7326
- Gelsyn-3™ -
J7328
- GenVisc 850® -
J7320
- Hyalgan® -
J7321
- Hymovis® -
J7322
- Supartz® -
J7321
- Synojoynt™ -
J7331
- Triluron™ -
J7332
- TriVisc™ -
J7329
- VISCO-3®
-
J7321
Immunological agents
- Actemra®-
J3262 (See note below.)
- Benlysta® IV -
J0490
- Entyvio™ -
J3380 (See note below.)
- Ilumya™ -
J3245
- Omvoh™ - J2267
- Orencia® IV-
J0129
- Saphnelo™ -
J0491
- Simponi® Aria -
J1602
-
Skyrizi® IV - J2327
- Spevigo® -
J1747
- Stelara®- J3357 and J3358
- Tofidence™ - Q5133
- Wezlana – Q5137, Q5138
HCPCS codes J3362 and J3380 will only require precertification when not reported with the JB modifier.
Intravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Intravenous Immune Globulin (IVIG)
- Alyglo™ - J1599
- Asceniv® -
J1554
- Bivigam® -
J1556
- Flebogamma® -
J1572
- Flebogamma®-Dif -
J1572
- Gammagard®Liquid -
J1569
- Gammagard S/D® -
J1566
- Gammaked® -
J1561
- Gammaplex® -
J1557
- Gamunex-C® -
J1561
- Octagam® -
J1568
- Panzyga® -
J1576
- Privigen® -
J1459
- Subcutaneous Immune Globulin (SCIG)
- Cutaquig® -
J1551
- Cuvitru® -
J1555
- Hizentra® -
J1559
- Hyqvia® -
J1575
- Xembify®
-
J1558
Multiple sclerosis agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Briumvi™ -
J2329
- Lemtrada® -
J0202
- Ocrevus™ -
J2350
- Tyruko® - Q5134
- Tysabri® -
J2323
Myasthemia Gravis Agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Rystiggo® - J9333
- Vyvgart™ - J9332
- Vyygart® Hytrulo - J9334
Neutropenia
- Efbemalenograstim Alfa (pending FDA approval) -
J3490, J3590, and C9399
- Fulphila™ -
Q5108
-
Fylnetra® - Q5130
- Lapelga
(pending FDA approval) -
J3490, J3590, and C9399
- Neupogen® -
J1442
-
Releuko™ - Q5125
-
Rolvedon™ -
J1449
- Ryzneuta® - J9361
-
Stimufend®
-
Q5127
- Udenyca™ -
Q5111
- Ziextenzo® -
Q5120
Ophthalmic agents
- Beovu® -
J0179
- Byooviz™ -
Q5124
-
Cimerli™ -
Q5128
- Eylea® - J1078 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
- Eylea® HD – J1077 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
- Lucentis® -
J2778 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
- Susvimo™-
J2779
- Tepezza®
-
J3241
-
Vabysmo® -
J2777
Pulmonary arterial hypertension
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Flolan® -
J1325
- Remodulin® -
J3285
- Revatio® -
J3490 and C9399
- Tyvaso® -
J7686
- Veletri® -
J1325
- Ventavis® -
Q4074
Respiratory agents
- Cinqair® -
J2786
- Synagis® -
90378
- Xolair®
-
J2357
Respiratory enzymes (Alpha-1 antitrypsin)
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Aralast -
J0256
- Glassia™ -
J0257
- Prolastin® -
J0256
- Zemaira® -
J0256
Tumor Infiltrating Lymphocyte (TIL) Therapy
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
- Amtagyi™ – J3490, J3590, and C9399
Miscellaneous therapeutic agents
- Adakveo® -
J0791
- Ampligen®
(pending FDA approval) -
J3490
-
Amvuttra™ -
J0225
-
Cosela® -
J1448
- Crysvita®- J0584
-
Enjaymo™ - J1302
-
Evkeeza™ -
J1305
- Exenatide sustained-release ITCA 650
(pending FDA approval) - J3490
- Gamifant® -
J9210
- Givlaari®-
J0223
- Ilaris®
- J0638
- Krystexxa®
- J2507
- Lantidra® - J3490, J3590, and C9399
-
Leqvio® - J1306
-
Narsoplimab (pending FDA approval) -
C9399 and J3590
- Onpattro® -
J0222
-
Oxlumo™ -
J0224
- Reblozyl® -
J0896
- Remune
(pending FDA approval) -
J3490
- Rethymic™ -
J3590, and C9399
- Soliris® -
J1300
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
- Spinraza™ -
J2326
- Tzield-
J9381
- Ultomiris™ -
J1303
- Uplizna™
– J1823
- Veopoz™ - J9376
- Vyepti™ -
J3032
- Xiaflex® –
J0775
Revisions
July 1, 2024
The following revisions were incorporated into the July 1, 2024 update.
Revisions For the section “Reconstructive procedures and potentially cosmetic procedures", the title for the subsection “Gender reassignment surgery" changed to “Gender Affirming interventions".
Additions Gender Affirming interventions 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation 11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation 15877 Suction Assisted Lipectomy; Trunk Genetically and bio-engineered skin substitutes for wound care Q4311 Acesso, per square centimeter Q4312 Acesso ac, per square centimeter Q4314 Reeva ft, per square cenitmeter Q4317 Vitograft, per square centimeter Q4318 E-graft, per square centimeter Q4319 Sanograft, per square centimeter Q4320 Pellograft, per square centimeter Q4321 Renograft, per square centimeter Q4322 Caregraft, per square centimeter Q4325 Acapatch, per square centimeter Q4326 Woundplus, per square centimeter Q4327 Duoamnion, per square centimeter Q4328 Most, per square centimeter Q4329 Singlay, per square centimeter Q4330 Total, per square centimeter Q4331 Axolotl graft, per square centimeter Q4332 Axolotl dualgraft, per square centimeter Q4333 Ardeograft, per square centimeter Amyotrophic Lateral Sclerosis agents NurOwn® - J3490, J3590, and C9399 Antineoplastic agents Loqtorzi™ - J3263 Anti PD-1/PD-L1 human monoclonal antibodies Cosentyx® IV – J3247 Tevimbra® - J3490 and C9399
Enzyme replacement agents Adzynma - J7171 Gene Replacement / Gene Editing Therapies Lyfgenia™ - J3394 Zynteglo® - J3393 Immunological agents Omvoh™ - J2267 Wezlana – Q5137, Q5138 Intravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG) Intravenous Immune Globulin (IVIG) Alyglo™ - J1599 Neutropenia Ryzneuta® - J9361 Tumor Infiltrating Lymphocyte (TIL) Therapy Amtagyi™ – J3490, J3590, and C9399
____________________________________________________________________
Deletions
Genetically and bio-engineered skin substitutes for wound care Q4210 Axolotl graft or axolotl dualgraft, per square centimeter Q4277 Woundplus membrane or e-graft, per square centimeter Amyotrophic Lateral Sclerosis agents Debamestrocel (pending FDA approval) - J3490, J3590, and C9399 Anti PD-1/PD-L1 human monoclonal antibodies Tislelizumab (pending FDA approval) - J3490 and C9399 Toripalimab (pending FDA approval) - J3490 and C9399 Enzyme replacement agents Apadamtase Alfa (pending FDA approval) - J3490, J3590, and C9167 Gene Replacement / Gene Editing Therapies Lyfgenia™ - J3490, J3590, and C9399 Zynteglo® - J3590 and C9399 Immunological agents Omvoh™ - J3490, J3590, and C9168 Neutropenia Ryzneuta® - J3590 and C9399 Tumor Infiltrating Lymphocyte (TIL) Therapy Lifileucel (pending FDA approval) – J3490, J3590, and C9399
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