Commercial

​Services that require precertification for AmeriHealth New Jersey Members (Effective 01/01/2021)


​Services that require precertification for AmeriHealth New Jersey members


As of January 1, 2021, 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 AIM Specialty Health®. To access the complete list of AIM 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


  • Bronchial thermoplasty

    31660, 31661

  • 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 

  • Uvulopalatopharyngoplasty (UPPP)

    42145

Musculoskeletal Procedures


Precertification is performed by AIM Specialty Health®. 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 AIM Specialty Health®. 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, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4100, Q4107, Q4130, 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 reassignment surgery

    11960, 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

    C1849, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, 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, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4227, Q4228, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4244, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4254, Q4255

  • Hair transplant

    15775, 15776
     
  • Injectable dermal fillers

    11950, 11951, 11952, 11954, Q2026, Q2028

  • 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, including inpatient hospital-to-hospital transfers


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 website, click here.


Radiology


Precertification is performed by AIM Specialty Health®. To access the complete list of AIM Specialty Health 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 AIM Specialty Health®. For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services. 
     
  • Bone-anchored (osseointegrated) hearing aids

    L8690, L8691, L8692, L8693, L8694
     
  • Continuous positive airway pressure (CPAP) devices, bi-level (Bi-PAP) devices, and all supplies

    Precertification is performed by AIM Specialty Health®. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & 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, E2373, 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

    E2368, E2369, E2370, E2374, E2375, E2376 

  • 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


Proton beam therapy


Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here.


Sleep studies (facility based)


Precertification is performed by AIM Specialty Health®. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click here.


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


Precertification review for these services is provided by Magellan Healthcare, Inc.

  • 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
    Precertification review for this service is provided by Magellan Healthcare, Inc.

Genetic and genomic tests requiring precertification


Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here.

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.

Antineoplastic agents


  • Abraxane® - J9264
  • Adcetris® - J9042
  • Alimta® - J9305
  • Avastin® - C9257 and J9035 (Note: Opthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Azedra - A9590
  • Azedra Dosimetric - A9590
  • Blenrep - J3590 and C9069
  • Blincyto™ - J9039
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro – J9144
  • Elzonris™ - J9269
  • Enhertu® - J9358
  • Erbitux® - J9055
  • Erwinaze® - J9019
  • Herceptin® - J9355 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Herceptin® Hylecta - J9356
  • Herzuma - Q5113
  • Instiladrin (pending FDA approval) - J3490 and C9399
  • Kadcyla® - J9354
  • Kanjinti™ - Q5117
  • Kyprolis® - J9047
  • Lumoxiti™ - J9313
  • Margenza™ - J3490, J3590, and C9399
  • Mvasi™ - Q5107 (Note: Opthalmologic use of Mvasi does not require precertification.)
  • Ogivri - Q5114
  • Ontruzant - Q5112
  • Padcev- J9177
  • Pemfexy - J9304
  • Perjeta® - J9306
  • Phesgo – J9316
  • Polivy - J9309
  • Poteligeo® - J9204
  • Provenge® - Q2043
  • Riabni™ - J3490, J3590, and C9399
  • Rituxan® - J9312 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Rituxan Hycela™ - J9311
  • Ruxience™ - Q5119
  • Sarclisa® - J9227
  • Taclantis™ (pending FDA approval) - J3490 and C9399
  • Tecartus™ (pending FDA approval) J3590 and C9073
  • Trazimera™ - Q5116
  • Trodelvy™ - J9317
  • Truxima™ - Q5115
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca – J9223
  • Zevalin®* - A9543
  • Zirabev™ - Q5118
  • ​Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T

* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here.


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
  • Dostarlimab (pending FDA approval) J3490, J3590, and C9399
  • Imfinzi™ - J9173
  • Keytruda™ - J9271
  • Libtayo® - J9119
  • Opdivo® - J9299
  • Tecentriq™ - J9022

Bone-modifying agents


  • Evenity™ - J3111
  • Prolia® - J0897
  • Xgeva® - J0897

Botulinum toxin agents


  • Botox® - J0585

Chemotherapy-induced nausea and vomiting (CINV) agents


  • Sustol® - J1627

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. 

  • Ciltacabtagene Autoleucel (pending FDA approval) J3490, J3590, and C9399
  • Idecabtagene Vicleucel (pending FDA approval) J3490, J3590, and C9399
  • Kymriah™ - Q2042
  • lisocabtagene maraleucel (pending FDA approval) - J3490, J3590, and C9399
  • Yescarta™ - Q2041

Colony stimulating factors


  • Fulphila™ - Q5108
  • Lapelga (pending FDA approval) - J3490, J3590, and C9399
  • Neulasta® - J2505 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Neulasta Onpro™ - J2505
  • Neupogen® - J1442
  • Nivestym™ - Q5110
  • Nyvepria™ – Q5122
  • Rolontis® (pending FDA approval) - J3490 and C9399
  • Udenyca™ - Q5111
  • Ziextenzo® - Q5120

Duchenne muscular dystrophy 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.

  • Casemirsen (pending FDA approval) - J3490, J3590, and C9399
  • Viltolarsen (pending FDA approval)- J3490, J3590, and C9399

Endocrine/metabolic agents


  • Cosyntropin depot (pending FDA approval) - J3490, J3590, and C9399
  • H.P. Acthar® - J0800
  • Lutathera®* - A9513 and A9699
  • Makena® - J1726 and J1729
  • Sandostatin® LAR - J2353
  • Somatuline® depot - J1930

Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). To access the eviCore website, click here.


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
  • Brineura™ - J0567
  • Cerezyme® - J1786
  • Elaprase® - J1743
  • Elelyso® - J3060
  • Fabrazyme® - J0180
  • Kanuma® - J2840
  • Lumizyme® - J0221
  • Mepsevii™ - J3397
  • Naglazyme® - J1458
  • Pegunigalsidase Alfa (pending FDA approval) J3490, J3590, and C9399
  • Replagal® (pending FDA approval) - J3490  
  • Revcovi™ - J3590 and C9399
  • Vimizim™ - J1322
  • VPRIV® - J3385

Gene 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.

  • Luxturna™ - J3398
  • Valrox (pending FDA approval)- J3490 and C9399
  • Zolgensma® - J3399
  • Zynteglo (pending FDA approval) - J3490, 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
  • Autoplex T - J7198
  • Bebulin VH - J7194
  • Bebulin - J7194
  • Benefix - J7195
  • Bioclate - J7192
  • Coagadex - J7175
  • Corifact - J7180
  • Eloctate - J7205
  • Esperoct- J7204
  • Feiba NF - J7198
  • Feiba VH - J7198
  • Fibryga - J7177
  • Fibryna - J7178
  • Helixate FS - J7192
  • Hemlibra - J7170
  • Hemofil-M - J7190
  • Humate-P - J7187
  • Hyate-C - J7191
  • Idelvion - J7202
  • Ixinity - J7199
  • Jivi® - J7199 and J7208
  • Koate-DV I- J7190
  • Kogenate FS - J7192
  • Kovaltry - J7207 and J7211
  • Monarc - J7190
  • Monoclate-P - J7190
  • Mononine - J7193
  • Novoeight - J7182
  • Novoseven RT - J7189
  • Novoseven - J7189
  • Nuwiq - J7209
  • Obizur - J7188
  • Profilnine SD - J7194
  • Proplex T - J7194
  • Rebinyn - J7203
  • Recombinate - J7192
  • Refacto - 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® - J7333

Immunological agents


  • Actemra® - J3262
  • Avsola™ - Q5121
  • Benlysta® - J0490
  • Entyvio™ - J3380
  • Ilumya™ - J3245
  • Inflectra™ - Q5103
  • Ixifi™ - Q5109
  • Orencia® - J0129
  • Remicade® - J1745 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Renflexis™ - Q5104
  • Simponi® Aria - J1602
  • Stelara® - J3357 and J3358        

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)
    • Asceniv - J1599 and C9072
    • Bivigam - J1556
    • Carimune - J1566
    • Flebogamma - J1572
    • Flebogamma-Dif - J1572
    • Gammagard - J1569
    • Gammagard Liquid - J1569
    • Gammagard S/D - J1566
    • Gammaked - J1561
    • Gammaplex - J1557
    • Gamunex-C - J1561
    • Octagam - J1568
    • Panzyga - J1599
    • Privigen - J1459
  • Subcutaneous Immune Globulin (SCIG)
    • Cutaquig - J7799
    • 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.

  • Lemtrada® - J0202
  • Ocrevus™ - J2350
  • Tysabri® - J2323

Ophthalmic agents


  • Abicipar (pending FDA approval) - J3490, J3590, and C9399
  • Beovu® - J0179
  • Eylea® - J0178
  • Lucentis® - J2778
  • Macugen® - J2503
  • Ranibizumab Biosimilar (pending FDA approval) J3490, J3590, and C9399
  • Tepezza® - J3241

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
  • Trevyent (pending FDA approval) - 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

Miscellaneous therapeutic agents


  • Adakveo® - J0791
  • Ampligen® (pending FDA approval) - J3490
  • Crysvita - J0584
  • Evianacumab (pending FDA approval) J3490, J3590, and C9399
  • Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
  • Gamifant® - J9210
  • Givlaari - J0223
  • Ilaris - J0638
  • Inclisiran (pending FDA approval) J3490, J3590, and C9399
  • Inebilizumab (pending FDA approval)- J3490 and C9399
  • Krystexxa - J2507
  • Onpattro® - J0222
  • Oxlumo™ – J3490, J3590, and C9399
  • Radicava - J1301
  • Reblozyl® - J0896
  • Remune (pending FDA approval) - J3490
  • Rethymic™ (RVT-802) (pending FDA approval) - J3490, J3590, and C9399
  • Soliris® - J1300 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Spinraza - J2326
  • Trogarzo - J1746
  • Ultomiris™ - J1303
  • Uplizna – J1823
  • Vyepti™ - J3032
  • Xiaflex® – J0775​​


Revisions 



​January 1, 2021 


The following revisions were incorporated into the January 1, 2021 update. 

Additions, drugs added 


Antineoplastic agents


  • Margenza™ - J3490, J3590, and C9399
  • Riabni™ - J3490, J3590, and C9399
  • Tecartus™ (pending FDA approval) – J3590 and C9073
  • ​Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 0540T

Anti PD-1/PD-L1 human monoclonal antibodies


  • ​Dostarlimab (pending FDA approval) – J3490, J3590, and C9399 

Chimeric antigen r​​​eceptor (CAR-T) therapies


  • Ciltacabtagene Autoleucel (pending FDA approval) – J3490, J3590, and C9399
  • ​Idecabtagene Vicleucel (pending FDA approval) – J3490, J3590, and C9399

Colony stimulating facto​​rs


  • Neupogen® - J1442
  • ​Nyvepria™ – Q5122 

Enzyme replacement a​​​gents


  • ​Pegunigalsidase Alfa (pending FDA approval) – J3490, J3590, and C9399 

Ophthalmic a​​​​gents


  • ​Ranibizumab Biosimilar (pending FDA approval) – J3490, J3590, and C​9399 

Miscellaneous therapeutic​​​ agents


  • Evianacumab (pending FDA approval) – J3490, J3590, and C9399
  • Inclisiran (pending FDA approval) – J3490, J3590, and C9399
  • Oxlumo™ – J3490, J3590, and C9399
  • ​Xiaflex®​ – J0775 

​​​Additions, codes added 

Antineoplastic agen​​ts


  • Blenrep – C9069
  • Darzalex Faspro – J9144
  • Phesgo – J9316
  • Trodelvy™ - J9317
  • ​Zepzelca™ - J9223 

Hemophilia/Coagulati​​​​on factors


  • ​Sevenfact – J7212 

Intravenous Immun​​e Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)


  • ​Asceniv – C9072 

Miscellaneous ther​​apeutic agents


  • ​Uplizna – J1823 

Additions, language added 

Antineoplastic agents


  • Instiladrin – (pending FDA approval)
  • ​Taclantis™ – (pending FDA approval) 

Colony stimulating​​ factors


  • ​Rolontis® – (pending FDA approval) 

Duchenne muscular d​​ystrophy 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. 

Gene therapy


  • ​Valrox – (pending FDA approval) 

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. 
  • ​Trevyent – (pending FDA approval) 

Miscellaneous therapeutic ag​​ents


  • ​Inebilizumab – (pending FDA approval)

Deletions​​
, drugs removed 

Antineoplastic agents


  • Halaven® – J9719
  • Jevtana® – J9043
  • ​Margetuximab (pending FDA approval) - J3490, J3590, and C9399

Duchenne muscular dystrophy a​​​gents


  • Exondys-51™ – J1428
  • ​Vyondys 53 – J1429 

Respiratory agents


  • Fasenra™ – J0517
  • ​Nucala® – J2182

Miscellaneous therapeutic agents


  • Ravulizumab – J3490
  • ​Sylvant™ – J2860
 
Deletions​​​, codes removed 

Reconstructive procedures and potentially cosmetic procedures


  • Breast Reconstruction – 19366
  • Breast Augmentation/Mammoplasty – 19324 

Antineoplastic agents


  • Blenrep – C9399
  • Darzalex Faspro – C9062
  • Phesgo – J3590 and C9399
  • Trodelvy™ – J3590 and C9066
  • ​Zepzelca™ – J3490 and C9399

Hemophilia/Coagulation factors


  • ​Sevenfact – J7189

Miscellaneous therapeutic agents


  • ​​​Upli​zna – J3490 and C9399

Deletions, language removed


Ophthalmic 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.​


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