​​​​​​​​​​​​​​​​Services that require precertification for AmeriHealth New Jersey Members (Effective 07/01/2024)​

​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 PGT^SM) 
• 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

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

• Botox® - J0585

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​
  

Intravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)

• 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

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

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 

AmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.