Type of Care

Code(s)​​

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Acute rehabilitation admissions

NA

Y

Y

Y

AmeriHealth

Elective surgical and nonsurgical inpatient admissions

NA

Y

Y

Y

AmeriHealth

Inpatient hospice admissions

NA

Y

Y

Y

AmeriHealth

Long term acute care (LATC) facility admissions

NA

Y

Y

Y

AmeriHealth

Skilled nursing facility admissions

NA

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Home Services

Home-care services

NA

Y

Y

Y

Commercial - AmeriHealth
Medicare Advantage - Tango

Home infusion services

NA

Y

Y

Y

Commercial - AmeriHealth
Medicare Advantage - Tango

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Cardiology

Arterial Ultrasound

93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93978, 93979

Y

Y

Y

Carelon

Diagnostic Coronary Angiography

93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7552, C7553, C7557, C7562, C7568, C7569, C7570

Y

Y

Y

Carelon

Percutaneous Coronary Intervention

92920, 92924, 92928, 92930, 92933, 92937, 92943, 92945, C9600, C9602, C9604, C9607

Y

Y

Y

Carelon

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Otolaryngology

Cochlear Implant Surgery and Associated Supplies/Bone-Anchored (Osseointegrated) Hearing Aids, Implantable Bone Conduction Hearing Aids

69714, 69715, 69717, 69718, 69930, L8614, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Bariatric Services

Obesity Surgery

43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Musculoskeletal Services

Bone Grafts

20930, 20931, 20932, 20933, 20934, 20936, 20937, 20938

Y

Y

Y

Carelon

Bone Growth Stimulator

E0748

Y

Y

Y

Carelon

Cervical Spine Surgery - Anterior Decompression with Fusion

22551, 22552, 22554, 22585, 22830, 63081, 63082

Y

Y

Y

Carelon

Cervical Spine Surgery - Anterior Decompression without Fusion

63075, 63076

Y

Y

Y

Carelon

Cervical Spine Surgery - Posterior Decompression with Fusion

22600, 22614, 22632, 22634, 22830, 22864

Y

Y

Y

Carelon

Cervical Spine Surgery - Posterior Decompression without Fusion

63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051, 63052, 63053

Y

Y

Y

Carelon

Cervical Total Disc Replacement (Arthroplasty)

22856, 22858, 22861, 22864, 0095T, 0098T

Y

Y

Y

Carelon

Hip Arthroscopy

27120, 27122, 29860, 29861, 29862, 29863, 29914, 29915, 29916

Y

Y

Y

Carelon

Hip Replacement

27125, 27130, 27132, 27134, 27137, 27138, S2118

Y

Y

Y

Carelon

Knee Arthroscopy

29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Y

Y

Y

Carelon

Knee Open

27331, 27332, 27333, 27334, 27335, 27345, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429

Y

Y

Y

Carelon

Knee Replacement

27437, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27486, 27487, 27488, J7330, S2112

Y

Y

Y

Carelon

Lumbar Decompression (Laminotomy/Laminectomy/Discectomy/

Foraminotomy)

63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, S2350, S2351

Y

Y

Y

Carelon

Lumbar Disc Replacement (Arthroplasty)

22857, 22860, 22862, 22865, 0164T, 0165T

Y

Y

Y

Carelon

Lumbar Fusion

22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22830

Y

Y

Y

Carelon

Sacroiliac Joint Fusion

27279, 27280, C1737

Y

Y

Y

Carelon

Shoulder - Arthroscopic and Open Procedures

23105, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828

Y

Y

Y

Carelon

Shoulder Replacement

23470, 23472, 23473, 23474

Y

Y

Y

Carelon

Spinal Deformity (Scoliosis/Kyphosis)

22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22610, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308

Y

Y

Y

Carelon

Spinal Instrumentation

22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859

Y

Y

Y

Carelon

Vertebroplasty, Kyphoplasty

22510, 22511, 22512, 22513, 22514, 22515, C7504, C7505, C7507, C7508

Y

Y

Y

Carelon

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Interventional Pain Management

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks - Cervical or Thoracic Epidural Steroid Injection

62320, 62321, 64479, 64480

Y

Y

Y

Carelon

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks - Lumbar or Sacral Epidural Steroid Injection

62323, 64483, 64484

Y

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Cervical or Thoracic Facet Injection

64490, 64491, 64492

Y

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Cervical Radiofrequency Ablation

64633, 64634

Y

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Lumbar or Sacral Facet Injection

64493, 64494, 64495

Y

Y

Y

Carelon

Paravertebral Facet Injection/Nerve Block/Neurolysis - Lumbar Radiofrequency Ablation

64635, 64636

Y

Y

Y

Carelon

Regional Sympathetic Nerve Blocks

64510, 64520

Y

Y

Y

Carelon

Sacroiliac Joint injections

27096, G0260

Y

Y

Y

Carelon

Spinal Cord and Nerve Root Stimulators - Implantation of Spinal Cord Stimulators

63650, 63655, 63663, 63664, 63685, 63688

Y

Y

Y

Carelon

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Reconstructive Procedures and Potentially Cosmetic Procedures

Blepharoplasty/
Ptosis Repair

15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909

Y

Y

Y

AmeriHealth

Bone Graft, Genioplasty and Mentoplasty

21120, 21121, 21122, 21123

Y

Y

Y

AmeriHealth

Breast Augmentation/

Mammoplasty

19325

Y

Y

Y

AmeriHealth

Breast Mastopexy

19316

Y

Y

Y

AmeriHealth

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, Q4107, Q4116, Q4130, Q4142, Q4143, S2066, S2067, S2068

Y

Y

Y

AmeriHealth

Breast Reduction

15877, 19318

Y

Y

Y

AmeriHealth

Canthopexy/

Canthoplasty

21280, 21282, 67950

Y

Y

Y

AmeriHealth

Cervicoplasty

17999

Y

Y

Y

AmeriHealth

Chemical Peels

15788, 15789, 15792, 15793

Y

Y

Y

AmeriHealth

Dermabrasion

15780, 15781, 15782, 15783

Y

Y

Y

AmeriHealth

Excision of Excessive Skin and/or Subcutaneous Tissue

15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839

Y

Y

Y

AmeriHealth

Gender Affirming Interventions

11920, 11921, 11922, 11960, 15877, 17380, 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

Y

Y

Y

AmeriHealth

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, A2026, A2027, A2028, A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039, A4100, Q4101, Q4102, Q4103, Q4104, Q4105, 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, Q4183, Q4184, Q4185, Q4186, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4227, Q4229, Q4230, Q4232, 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, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4344, Q4345, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4368, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397, Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433

Y

Y

Y

AmeriHealth

Hair Transplant

15775, 15776

Y

Y

Y

AmeriHealth

Insertion of Breast Implants

19340, 19342, 19396

Y

Y

Y

AmeriHealth

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

Y

Y

Y

AmeriHealth

Lipectomy, Liposuction, or Any Other Excess Fat-Removal Procedure

15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879

Y

Y

Y

AmeriHealth

Otoplasty

13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399

Y

Y

Y

AmeriHealth

Removal of Breast Implants

19328, 19330, 19370, 19371

Y

Y

Y

AmeriHealth

Rhinoplasty

30400, 30410, 30420, 30430, 30435, 30450

Y

Y

Y

AmeriHealth

Rhytidectomy

15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876

Y

Y

Y

AmeriHealth

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

Y

Y

Y

AmeriHealth

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

Y

Y

Y

AmeriHealth

Surgery for Varicose Veins, Including Perforators and Sclerotherapy

36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, S2202

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Day Rehabilitation

Day Rehabilitation Programs

0931, 0932

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Elective (Nonemergency) Ground, Air, and Sea Ambulance Transportation

Elective (Nonemergency) Ground, Air, and Sea Ambulance Transportation

A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Outpatient Private-Duty Nursing

Outpatient Private-Duty Nursing

S9123, S9124

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Outpatient Radiation Therapy

Brachytherapy

77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, 0395T, C2616, G0458

Y

Y

Y

eviCore

Cardiac Focal Ablation

0747T

Y

Y

Y

eviCore

Hyperthermia Treatment

77600, 77605, 77610, 77615, 77620

Y

Y

Y

eviCore

Image-Guided Radiation (IGRT)

77387

Y

Y

Y

eviCore

Intraoperative Radiation Therapy (IORT)

77424, 77425

Y

Y

Y

eviCore

Neuro SRS

61796, 61797, 61798, 61799, 61800

Y

Y

Y

eviCore

Neutron Beam Radiation Therapy

77423

Y

Y

Y

eviCore

Proton Beam Radiation Therapy

77520, 77522, 77523, 77525

Y

Y

Y

eviCore

Radiation Treatment Delivery

77402, 77407, 77412, 77437, 77438, 77439, A9609

Y

Y

Y

eviCore

Radiation Treatment Planning

G0562

Y

Y

Y

eviCore

Radiation Treatment Planning

G0563

Y

Y

Y

eviCore

Stereotactic Radiation Therapy

77371, 77372, 77373, G0339, G0340

Y

Y

Y

eviCore

Therapeutic Radiopharmaceuticals

79005, 79101, A9513, A9606, A9607, A9699, S2095

Y

Y

Y

eviCore

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Radiology

3-D Rendering - Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Grouping

76376, 76377

Y

Y

Y

Carelon

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET) / Computed Tomography (CT) - Computed Tomography (CT) Heart for Calcium Scoring

75571

Y

Y

Y

Carelon

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET) / Computed Tomography (CT) - Coronary Computed Tomography (CT) and Computed Tomography Angiography (CTA) Scoring

75572, 75573, 75574, 75580

Y

Y

Y

Carelon

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET) / Computed Tomography (CT) - Tumor Imaging

78811, 78812, 78813, 78814, 78815, 78816

Y

Y

Y

Carelon

Computed Tomography (CT) - Abdomen

74150, 74160, 74170

Y

Y

Y

Carelon

Computed Tomography (CT) - Abdomen and Pelvis

74176, 74177, 74178

Y

Y

Y

Carelon

Computed Tomography (CT) - Cervical Spine

72125, 72126, 72127

Y

Y

Y

Carelon

Computed Tomography (CT) - Chest

71250, 71260, 71270

Y

Y

Y

Carelon

Computed Tomography (CT) - Head

70450, 70460, 70470, 70471, 70473

Y

Y

Y

Carelon

Computed Tomography (CT) - Lower Extremity

73700, 73701, 73702

Y

Y

Y

Carelon

Computed Tomography (CT) - Lumbar Spine

72131, 72132, 72133

Y

Y

Y

Carelon

Computed Tomography (CT) - Lung

71271

Y

Y

Y

Carelon

Computed Tomography (CT) - Neck

70490, 70491, 70492

Y

Y

Y

Carelon

Computed Tomography (CT) - Orbit

70480, 70481, 70482

Y

Y

Y

Carelon

Computed Tomography (CT) - Pelvis

72192, 72193, 72194

Y

Y

Y

Carelon

Computed Tomography (CT) - Sinus

70486, 70487, 70488

Y

Y

Y

Carelon

Computed Tomography (CT) - Thoracic Spine

72128, 72129, 72130

Y

Y

Y

Carelon

Computed Tomography (CT) - Upper Extremity

73700, 73701, 73702

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Abdomen

74175

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Abdomen and Pelvis

74174

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Abdominal Arteries

75635

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Chest

71275

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Head

70496

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Lower Extremity

73706

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Lung

71271

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Neck

70498

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Pelvis

72191

Y

Y

Y

Carelon

Computed Tomography Angiography (CTA) - Upper Extremity

73206

Y

Y

Y

Carelon

Diagnostic Computed Tomography (CT) Colonoscopy

74261, 74262

Y

Y

Y

Carelon

Fluorine-18 fluorodeoxyglucose (f-18 FDG)

S8085

Y

Y

Y

Carelon

Follow Up Study Computed Tomography (CT)

76380

Y

Y

Y

Carelon

Functional Magnetic Resonance Imaging (MRI) Brain

70554, 70555

Y

Y

Y

Carelon

Low-Field MRI

S8042

Y

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Abdomen

74185, C8900, C8901, C8902

Y

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Chest

71555, C8909, C8910, C8911

Y

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Head

70547, 70548, 70549, 0615

Y

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Pelvis

72198, C8918, C8920

Y

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Spinal Canal

72159, C8931, C8932, C8933

Y

Y

Y

Carelon

Magnetic Resonance Angiography (MRA) - Upper Extremity

73225, C8934, C8935, C8936

Y

Y

Y

Carelon

Magnetic Resonance Elastography

76391

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Abdomen

74181, 74182, 74183, S8037

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Bone Marrow

77084

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Brain

70551, 70552, 70553

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Breast

77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Cardiac

75557, 75559, 75561, 75563, 75565, C9762, C9763

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Cervical Spine

72141, 72142, 72156

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Chest

71550, 71551, 71552

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Fetal

74712, 74713

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Lower Extremity

73718, 73719, 73720, 73721, 73722, 73723

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Lumbar Spine

72148, 72149, 72158

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Orbit

70540, 70542, 70543

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Pelvis

72195, 72196, 72197

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Temporomandibular Joint (TMJ)

70336

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Thoracic Spine

72146, 72147, 72157

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Upper Extremity (Any Joint)

73221, 73222, 73223

Y

Y

Y

Carelon

Magnetic Resonance Imaging (MRI) - Upper Extremity (Non-Joint)

73218, 73219, 73220

Y

Y

Y

Carelon

Magnetic Resonance Technology (MRT)

0616

Y

Y

Y

Carelon

Magnetoencephalography (MEG) - Head

95965, 95966

Y

Y

Y

Carelon

Nuclear Cardiology - Cardiac Blood Pool Imaging

78472, 78473, 78481, 78483, 78494, 78496

Y

Y

Y

Carelon

Nuclear Cardiology - Infarct Imaging

78451, 78452, 78453, 78454, 78466, 78468, 78469, 0742T

Y

Y

Y

Carelon

Positron Emission Tomography (PET) - Brain Imaging

78608, 78609

Y

Y

Y

Carelon

Positron Emission Tomography (PET) - Myocardial Imaging

78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492

Y

Y

Y

Carelon

Positron Emission Tomography (PET) - Other Imaging Services

0404

Y

Y

Y

Carelon

Quantitative Computed Tomography (QCT) Bone Densitometry

77078

Y

Y

Y

Carelon

Resting Transthoracic Echocardiography (TTE)

93303, 93304, 93306, 93307, 93308

Y

Y

Y

Carelon

Resting Transthoracic Echocardiography (TTE) - Echocardiography Add-On Codes

93320, 93321, 93325

Y

Y

Y

Carelon

Screening Computed Tomography (CT) Colonoscopy

74263

Y

Y

Y

Carelon

Stress Echocardiography

93350, 93351

Y

Y

Y

Carelon

Stress Echocardiography - Echocardiography Add-On Codes

93320, 93321, 93325, 93352

Y

Y

Y

Carelon

Transesophageal Echocardiography (TEE)

93312, 93313, 93314, 93315, 93316, 93317

Y

Y

Y

Carelon

Transesophageal Echocardiography (TEE) - Echocardiography Add-On Codes

93319, 93320, 93321, 93325

Y

Y

Y

Carelon

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Prosthetics/Orthoses

Custom Ankle-Foot Orthoses

L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4361

Y

N

N

AmeriHealth

Custom Knee Braces

L1834, L1840, L1844, L1846, L1860

Y

N

N

AmeriHealth

Custom Knee-Ankle-Foot Orthoses

L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128

Y

N

N

AmeriHealth

Custom Limb Prosthetics Including Accessories/

Components

L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5657, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6028, L6029, L6030, L6031, L6032, L6033, L6034, L6035, L6036, L6037, L6038, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6700, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7400, L7401, L7402, L7403, L7404, L7405, L7406, L7499

Y

N

N

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Selected Durable Medical Equipment (DME)

For repair or replacement of all DME items, as well as orthoses and prosthetics that require precertification, see the specific DME, orthoses, and prosthetics categories, for repair or replacement codes that require precertification.

Bone Growth Stimulators - Low-Intensity Ultrasound Noninvasive Bone Growth Stimulation

E0760

Y

Y

Y

AmeriHealth

Bone Growth Stimulators - Other Than Spinal Noninvasive Electrical Bone Growth Stimulation

E0747

Y

Y

Y

AmeriHealth

Bone Growth Stimulators - Spinal Noninvasive Electrical Bone Growth Stimulation

E0748

Y

Y

Y

AmeriHealth

Bone-Anchored (Osseointegrated) Hearing Aids

69716, 69719, 69726, 69727, 69728, 69729, 69730, L8690, L8691, L8692, L8693, L8694

Y

Y

Y

AmeriHealth

Continuous Positive Airway Pressure (CPAP) Devices, Bi-Level (Bi-PAP) Devices, and All Supplies

A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0470, E0471, E0561, E0562, E0601

Y

Y

Y

Carelon

Dynamic Adjustable and Static Progressive Stretching Devices (excludes CPMs)

E1800, E1802, E1805, E1810, E1812, E1825, E1830

Y

Y

Y

AmeriHealth

Electric, Power, and Motorized Wheelchairs Including Custom Accessories

E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294, E2298, 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

Y

Y

Y

AmeriHealth

Electric, Power, and Motorized Wheelchairs Including Custom Accessories

K0830, K0831

Y

Y

Y

AmeriHealth

Insulin Pumps

E0784, E0787, S1034

Y

Y

Y

AmeriHealth

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, 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

Y

Y

Y

AmeriHealth

Negative Pressure Wound Therapy

A6550, A9272, E2402, K0743, K0744, K0745, K0746

Y

Y

Y

AmeriHealth

Neuromuscular Stimulators

E0744, E0745, E0764, E0770

Y

Y

Y

AmeriHealth

Power Operated Vehicles (POV)

E1230, K0800, K0801, K0802, K0812

Y

Y

Y

AmeriHealth

Pressure Reducing Support Surfaces - Air Fluidized Bed

E0194

Y

Y

Y

AmeriHealth

Pressure Reducing Support Surfaces - Non-Powered Advanced Pressure Reducing Mattress

E0371, E0373

Y

Y

Y

AmeriHealth

Pressure Reducing Support Surfaces - Powered Air Flotation Bed (Low Air Loss Therapy)

E0193, E0372

Y

Y

Y

AmeriHealth

Pressure Reducing Support Surfaces - Powered Pressure Reducing Mattress

E0277

Y

Y

Y

AmeriHealth

Push Rim Activated Power Assist Devices

E0986

Y

Y

Y

AmeriHealth

Speech Generating Devices

E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Medical Foods

Medical Foods

B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Hyperbaric Oxygen Therapy

Hyperbaric Oxygen Therapy

G0277, 0413

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

In-Lab / Facility Sleep Studies

In-Lab / Facility Sleep Studies

95782, 95783, 95805, 95807, 95808, 95810, 95811

Y

Y

Y

Carelon

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

All Transplant Procedures, with the Exception of Corneal Transplants

All Transplant Procedures, with the Exception of Corneal Transplants

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, 0584T, 0585T, 0586T, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Mental Health/Serious Mental Illness/Substance Abuse

Repetitive transcranial magnetic stimulation (rTMS)

90867, 90868, 90869, 0889T, 0890T, 0891T, 0892T

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Applied Behavioral Analysis

Applied Behavioral Analysis

97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T

Y

Y

Y

AmeriHealth

Type of Care

Code(s)

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Genetic and Genomic Tests

Any genetic test that is billed with a non-specific procedure code that requires precertification. This includes genetic tests billed with CPT® codes 81400 through 81408 as well as unlisted CPT® codes 81479, 81599, and 84999.

Genetic and Genomic Tests

81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81195, 81200, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81221, 81222, 81223, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81238, 81248, 81249, 81252, 81253, 81257, 81258, 81259, 81269, 81277, 81283, 81286, 81289, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81308, 81313, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 81326, 81327, 81328, 81335, 81336, 81337, 81346, 81349, 81350, 81351, 81353, 81354, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81479, 81493, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81524, 81525, 81529, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 81558, 81595, 81599, 84999, 87183, 87494, 87627, 0001U, 0004M, 0005U, 0006M, 0007M, 0011M, 0012M, 0013M, 0016M, 0016U, 0017M, 0017U, 0018U, 0019U, 0020M, 0022U, 0026U, 0029U, 0030U, 0031U, 0032U, 0034U, 0036U, 0037U, 0045U, 0047U, 0048U, 0050U, 0055U, 0060U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0133U, 0134U, 0136U, 0137U, 0138U, 0153U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0179U, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0329U, 0331U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0355U, 0356U, 0362U, 0363U, 0363U, 0364U, 0368U, 0379U, 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0418U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0444U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0488U, 0489U, 0493U, 0494U, 0495U, 0496U, 0497U, 0498U, 0499U, 0501U, 0506U, 0507U, 0510U, 0516U, 0523U, 0529U, 0530U, 0532U, 0533U, 0534U, 0536U, 0537U, 0538U, 0539U, 0540U, 0543U, 0549U, 0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U, 0572U, 0600U, 0602U, 0605U, 0607U, 0608U, 0611U, 0612U, 0613U, G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3850, S3852, S3854, S3861, S3865, S3866, S3870

Y

Y

Y

eviCore

Drug Name

Code

PA Commercial

NJ Commercial

NJ Medicare
Advantage

Precertification Performed by

Specialty Drugs

For specialty drugs, all listed brands and their generic equivalents or biosimilars require precertification.

Alzheimer’s Disease Agents

Leqembi®

J0174

N

N

Y

AmeriHealth

Kisunla™

J0175

N

N

Y

AmeriHealth

Amyotrophic Lateral Sclerosis Agents

Qalsody®

J1304

Y

Y

Y

AmeriHealth

NurOwn®

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Antineoplastic Agents

Azedra®

A9590

Y

Y

Y

eviCore

Pluvicto™

A9607

Y

Y

Y

eviCore

Avastin®

C9257

Y

Y

Y

AmeriHealth

Rytelo™

J0870

Y

Y

Y

AmeriHealth

Elrexfio™

J1323

Y

Y

Y

AmeriHealth

Vyloy®

J1326

Y

Y

Y

AmeriHealth

Talvey™

J3055

Y

Y

Y

AmeriHealth

Taclantis

J3490, J3590

Y

Y

Y

AmeriHealth

Avzivi®

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Patritumab deruxtecan

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Blenrep

J3590, C9399

Y

Y

Y

AmeriHealth

Datroway®

J9011

Y

Y

Y

AmeriHealth

Rylaze™

J9021

Y

Y

Y

AmeriHealth

Anktiva®

J9028

Y

Y

Y

AmeriHealth

Adstiladrin®

J9029

Y

Y

Y

AmeriHealth

Avastin®

J9035

Y

Y

Y

AmeriHealth

Blincyto™

J9039

Y

Y

Y

AmeriHealth

Adcetris®

J9042

Y

Y

Y

AmeriHealth

Kyprolis®

J9047

Y

Y

Y

AmeriHealth

Erbitux®

J9055

Y

Y

Y

AmeriHealth

Rybrevant™

J9061

Y

Y

Y

AmeriHealth

Elahere™

J9063

Y

Y

Y

AmeriHealth

Darzalex Faspro™

J9144

Y

Y

Y

AmeriHealth

Darzalex™

J9145

Y

Y

Y

AmeriHealth

Padcev™

J9177

Y

Y

Y

AmeriHealth

Poteligeo®

J9204

Y

Y

Y

AmeriHealth

Zepzelca™

J9223

Y

Y

Y

AmeriHealth

Sarclisa®

J9227

Y

Y

Y

AmeriHealth

Yervoy™

J9228

Y

Y

Y

AmeriHealth

Abraxane®

J9264

Y

Y

Y

AmeriHealth

Tivdak™

J9273

Y

Y

Y

AmeriHealth

Kimmtrak®

J9274

Y

Y

Y

AmeriHealth

Ziihera®

J9276

Y

Y

Y

AmeriHealth

Columvi™

J9286

Y

Y

Y

AmeriHealth

Opdualag™

J9298

Y

Y

Y

AmeriHealth

Pemfexy™

J9304

Y

Y

Y

AmeriHealth

Perjeta®

J9306

Y

Y

Y

AmeriHealth

Cyramza®

J9308

Y

Y

Y

AmeriHealth

Polivy™

J9309

Y

Y

Y

AmeriHealth

Rituxan Hycela™

J9311

Y

Y

Y

AmeriHealth

Rituxan®

J9312

Y

Y

Y

AmeriHealth

Phesgo™

J9316

Y

Y

Y

AmeriHealth

Trodelvy®

J9317

Y

Y

Y

AmeriHealth

Epkinly™

J9321

Y

Y

Y

AmeriHealth

Emrelis™

J9326

Y

Y

Y

AmeriHealth

Imjudo®

J9347

Y

Y

Y

AmeriHealth

Monjuvi®

J9349

Y

Y

Y

AmeriHealth

Lunsumio™

J9350

Y

Y

Y

AmeriHealth

Margenza™

J9353

Y

Y

Y

AmeriHealth

Kadcyla®

J9354

Y

Y

Y

AmeriHealth

Herceptin®

J9355

Y

Y

Y

AmeriHealth

Herceptin® Hylecta

J9356

Y

Y

Y

AmeriHealth

Enhertu®

J9358

Y

Y

Y

AmeriHealth

Zynlonta™

J9359

Y

Y

Y

AmeriHealth

Tecvayli™

J9380

Y

Y

Y

AmeriHealth

Bizengri®

J9382

Y

Y

Y

AmeriHealth

Provenge®

Q2043

Y

Y

Y

AmeriHealth

Herzuma®

Q5113

Y

Y

Y

AmeriHealth

Trazimera®

Q5116

Y

Y

Y

AmeriHealth

Alymsys®

Q5126

Y

Y

Y

AmeriHealth

Hercessi™

Q5146

Y

Y

Y

AmeriHealth

Jobevne

Q5160

Y

Y

Y

AmeriHealth

Anti PD-1/PD-L1 Human Monoclonal Antibodies

Loqtorzi™

J3263

Y

Y

Y

AmeriHealth

Camrelizumab

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Keytruda Qlex®

J3590, C9399

Y

Y

Y

AmeriHealth

Tecentriq™

J9022

Y

Y

Y

AmeriHealth

Bavencio®

J9023

Y

Y

Y

AmeriHealth

Tecentriq Hybreza™

J9024

Y

Y

Y

AmeriHealth

Libtayo®

J9119

Y

Y

Y

AmeriHealth

Imfinzi™

J9173

Y

Y

Y

AmeriHealth

Keytruda™

J9271

Y

Y

Y

AmeriHealth

Jemperli™

J9272

Y

Y

Y

AmeriHealth

Unloxcyt™

J9275

Y

Y

Y

AmeriHealth

Opdivo Qvantig™

J9289

Y

Y

Y

AmeriHealth

Opdivo®

J9299

Y

Y

Y

AmeriHealth

Tevimbra®

J9329

Y

Y

Y

AmeriHealth

Zynyz™

J9345

Y

Y

Y

AmeriHealth

Bone-Modifying Agents

Enoby®

C9399

Y

Y

Y

AmeriHealth

Prolia®

J0897

Y

Y

Y

AmeriHealth

Xgeva®

J0897

Y

Y

Y

AmeriHealth

Evenity™

J3111

Y

Y

Y

AmeriHealth

Enoby®

J3590

Y

Y

Y

AmeriHealth

Xtrenbo®

J3590,
C9399

Y

Y

Y

AmeriHealth

Aukelso®

J3590, C9399

Y

Y

Y

AmeriHealth

Bildyos®

J3590, C9399

Y

Y

Y

AmeriHealth

Bilprevda®

J3590, C9399

Y

Y

Y

AmeriHealth

Bosaya®

J3590, C9399

Y

Y

Y

AmeriHealth

Osenvelt®

Q5157

Y

Y

Y

AmeriHealth

Bomyntra®

Q5158

Y

Y

Y

AmeriHealth

Conexxance®

Q5158

Y

Y

Y

AmeriHealth

Ospomyv™

Q5159

Y

Y

Y

AmeriHealth

Botulinum Toxin Agents

Botox®

J0585

Y

Y

Y

AmeriHealth

Chimeric Antigen Receptor (CAR-T) Therapies

Yescarta™

Q2041

Y

Y

Y

AmeriHealth

Kymriah™

Q2042

Y

Y

Y

AmeriHealth

Tecartus™

Q2053

Y

Y

Y

AmeriHealth

Breyanzi®

Q2054

Y

Y

Y

AmeriHealth

Abecma®

Q2055

Y

Y

Y

AmeriHealth

Carvykti™

Q2056

Y

Y

Y

AmeriHealth

Aucatzyl®

Q2058

Y

Y

Y

AmeriHealth

Duchenne Muscular Dystrophy

Amondys 45

J1426

Y

Y

Y

AmeriHealth

Exondys 51

J1428

Y

Y

Y

AmeriHealth

Vyondys 53

J1429

Y

Y

Y

AmeriHealth

Endocrine/Metabolic Agents

Lutathera®

A9513

Y

Y

Y

eviCore

Xenpozyme®

J0218

Y

Y

Y

AmeriHealth

Acthar® Gel

J0801

Y

Y

Y

AmeriHealth

Cortrophin® Gel

J0802

Y

Y

Y

AmeriHealth

Somatuline® Depot

J1930

Y

Y

Y

AmeriHealth

Lanreotide

J1932

Y

Y

Y

AmeriHealth

Sandostatin® LAR

J2353

Y

Y

Y

AmeriHealth

Enzyme Replacement Agents

Fabrazyme®

J0180

Y

Y

Y

AmeriHealth

Lamzede®

J0217

Y

Y

Y

AmeriHealth

Nexviazyme™

J0219

Y

Y

Y

AmeriHealth

Lumizyme®

J0221

Y

Y

Y

AmeriHealth

Brineura™

J0567

Y

Y

Y

AmeriHealth

Pombiliti™

J1203

Y

Y

Y

AmeriHealth

Vimizim™

J1322

Y

Y

Y

AmeriHealth

Naglazyme®

J1458

Y

Y

Y

AmeriHealth

Elaprase®

J1743

Y

Y

Y

AmeriHealth

Cerezyme®

J1786

Y

Y

Y

AmeriHealth

Aldurazyme®

J1931

Y

Y

Y

AmeriHealth

Elfabrio®

J2508

Y

Y

Y

AmeriHealth

Kanuma®

J2840

Y

Y

Y

AmeriHealth

Elelyso®

J3060

Y

Y

Y

AmeriHealth

Vpriv®

J3385

Y

Y

Y

AmeriHealth

Mepsevii™

J3397

Y

Y

Y

AmeriHealth

Replagal®

J3490

Y

Y

Y

AmeriHealth

Tividenofusp alfa

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Revcovi™

J3590, C9399

Y

Y

Y

AmeriHealth

Adzynma

J7171

Y

Y

Y

AmeriHealth

Gene Replacement / Gene Editing Therapies

Hemgenix®

J1411

Y

Y

Y

AmeriHealth

Roctavian

J1412

Y

Y

Y

AmeriHealth

Elevidys®

J1413

Y

Y

Y

AmeriHealth

Skysona®

J3387

Y

Y

Y

AmeriHealth

Lenmeldy™

J3391

Y

Y

Y

AmeriHealth

Casgevy™

J3392

Y

Y

Y

AmeriHealth

Zynteglo®

J3393

Y

Y

Y

AmeriHealth

Lyfgenia™

J3394

Y

Y

Y

AmeriHealth

Luxturna™

J3398

Y

Y

Y

AmeriHealth

Zolgensma®

J3399

Y

Y

Y

AmeriHealth

Vvjuvek™

J3401

Y

Y

Y

AmeriHealth

Clemidsogene lanparvovec

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Eladocagene exuparvovec

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Etuvetidigene autotemcel

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Marnetegragene aututemcel

J3490, J3590, C9399

Y

Y

Y

AmeriHealth

Itvisma®

J3590, C9399

Y

Y

Y

AmeriHealth

Papzimeos®

J3590, C9399

Y

Y

Y

AmeriHealth

Zevaskyn®

J3389

Y

Y

Y

AmeriHealth

Hemophilia/Coagulation Factors

Hemlibra®

J7170

Y

Y

Y

AmeriHealth

Hympavzi™

J7172

Y

Y

Y

AmeriHealth

Alhemo®

J7173

Y

Y

Y

AmeriHealth

Qfitlia™

J7174

Y

Y

Y

AmeriHealth

Coagadex®

J7175

Y

Y

Y

AmeriHealth

Fibryga®

J7177

Y

Y

Y

AmeriHealth

RiaSTAP®

J7178

Y

Y

Y

AmeriHealth

Vonvendi®

J7179

Y

Y

Y

AmeriHealth

Corifact®

J7180

Y

Y

Y

AmeriHealth

Tretten®

J7181

Y

Y

Y

AmeriHealth

Novoeight®

J7182

Y

Y

Y

AmeriHealth

Wilate®