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​​​​​​​​​​Services that require precertification for AmeriHealth Pennsylvania Members (Effective 01/01/2024)

Services that require precertification 


As of January 1, 2024, this list applies to all AmeriHealth Pennsylvania HMO and POS products, including Flex 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. 

You can find additional information regarding preapproval/precertification, member cost-sharing and prescription drug coverage on the AmeriHealth Preapproval/Precertification Requirements and Member Cost-Sharing page. 

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 procedure​​​s


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 in​​vestigational including: 


  • New emerging technology/procedures, as well as existing technology and procedures applied for new uses and treatments

Proce​​​dures
  • 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 manageme​​nt 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 poten​​tially 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 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

    A2001, A2002, A2004, A2007, A2008, A2009, A2010,​ A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021, A2022, A2023, A2024, A2025, 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, Q4210, 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, Q4244, 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, Q4277, 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
    ​

     
  • 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) gr​​​ound, air, and sea ambulance transportation, including inpatient hospital-to-hospital transfers


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


Outpatient private-duty nu​rsing


S9123, S9124 


Day rehabilitation progr​​ams


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​​​ including: 


  • Custom ankle-foot orthoses

    L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631​
     
  • Custom knee-ankle-foot orthoses

    L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128
     
  • Custom knee braces

    L1834, L1840, L1844, L1846, L1860
     
  • ​Custom limb prost​hetics including accessories/components
L5010, L5020, L5050, L​​5060, 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, 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, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, 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, L6050, L6055, L6100, L6110, L6120, L6130, 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, 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, L7260, L7400, L7401, L7402, L7403, L7404, L7405, L7499
 

Selected durable medi​​​​cal 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 gen​erating devices
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336
 

Medica​​​​l 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 ther​​apy


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 tra​nsplants


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/substa​​nce 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 diso​​​rders 


  • 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 syndrom​es 


  • 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 dis​​eases 


  • Long QT syndrome gene testing 
  • ​Aortic dilation or a​neurysm syndrome testing (includes Marfan syndrome) 


Other full gene an​​alysis testing 


  • Cystic fibrosis full gene sequencing and deletion/duplication analysis 
  • ​PMP22 full gene sequencing and deletio​n/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy) 


Tests for many genetic disorders simultane​​ously 


  • 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 diso​rders panels 

Specialty onc​​​​ology 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 tes​​ts 


  • 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 methylati​on 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) 


Geno​​​me-wide tests 


  • Microarray studies 
  • Whole exome testing 
  • Whole genome testing 
  • ​Mitochondrial genome or nuclear testing 


ANY genetic test for more than one gene or c​​​ondition (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 pr​ecertification


All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change. 


Amyotrophic Lateral Sclerosis agents

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

Antineoplastic ag​​ents 


  • Abraxane® - J9264
  • Adstiladrin® - J9029​
  • Adcetris® - J9042
  • Alymsys® - Q5126 (Note: Ophthalmologic use of Alymsys does not require precertification.)​
  • 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
  • Blincyto™ - J9039
  • Columvi™ - J9286​
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro™ – J9144
  • Elahe​re™ - J9063
  • ​Elrexfio™ - C9165, J3490, and J3590​
  • 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​
  • Kadcyla® - J9354
  • Kimmtrak® - J9274
  • Kyprolis® - J9047
  • Lunsumio™ - J9350​
  • Margenza™ - J9353
  • Monjuvi® - J9349​​
  • Ogivri™ - Q5114
  • Ontruzant® - Q5112
  • Opdualag™ - J9298
  • Paclitaxel - J9259
  • Padcev™- J9177
  • Pemfexy™ - J9258
  • 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™ - C9163, J3490, and J3590​
  • Tecvayli™ - J9380 
  • ​Tivdak™ - J9273
  • Trodelvy™ - J9317
  • Vegzelma® - Q5129 (Note: Ophthalmologic use of Vegzelma does not require precertification.)​
  • 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
  • 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​
  • Tislelizumab (pending FDA approval) - J3490 and C9399
  • Toripalimab (pending FDA approval) - J3490 and C9399​
  • Zynyz™ - J9345​
    • ​

Bone-modifying a​​gents 


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


Botulinum toxin agent​​s 


  • ​Botox® - J0585 ​

Chimeric antigen receptor (CAR-T) thera​​pies


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/m​​etabolic agents ​

  • Acthar® Gel - J0801 and J0802​
  • lanerotide - J1932
  • 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 agen​​​ts


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
  • Apadamtase Alfa (pending FDA approval) – J3490, J3590, and C9399​
  • 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
  • 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 fac​​tors


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
  • Hyate-C® - J7191
  • 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


Immunologica​​l agents 


  • Actemra® IV - J3262
  • Avsola™ - Q5121
  • Benlysta® IV - J0490
  • Entyvio™ - J3380
  • Ilumya™ - J3245
  • Inflectra™ - Q5103
  • Infliximab (unbranded) – J1745​
  • Ixifi™ - Q5109
  • Orencia® IV- J0129
  • Remicade® - J1745 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Renflexis™ - Q5104
  • Saphnelo™ - J0491
  • Simponi® Aria - J1602
  • Skyrizi® IV - J2327
  • Spevigo® - J1747
  • Stelara® - J3357 and J3358  

Intravenous Immune Globulin/Su​​bcutaneous 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® - 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
    • ​​Xe​​​mbify® - J1558 


Multiple​ scleros​is ​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® - J3490, J3590, and C9399​
  • ​Ty​sabri® - J2323 

Myasthemia Gravis Agents

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.​

  • Rystiggo® - J9333
  • Vyygart™ - J9332
  • Vyygart® Hytrulo - J9334


Neutropenia

  • Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Fulphila™ - Q5108
  • Fylnetra® - Q5130​
  • Lapelga (pending FDA approval) - J3490, J3590, and C9399
  • Neupogen® - J1442
  • Releuko™ - Q5125
  • Rolvedon™ - J1449​
  • Stimufend® - Q5127
  • Udenyca™ - Q5111
  • Ziextenzo® - Q5120


Ophthalmi​​​c agents 


  • Beovu® - J0179
  • Byooviz™ - Q5124
  • Cimerli™ - Q5128​
  • ​Eylea® HD - J0178, J3590, and C9161 (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™- C2779
  • Tepezza® - J3241
  • Vabysmo® - J2777

    • ​
    ​

Pulmonary arterial hyperten​​​sion


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 ag​​​ents 


  • Cinqair® - J2786
  • Synagis® - 90378
  • ​Xolair® - J2357 


Respiratory enzyme​​s (Alpha-1 antitrypsin)


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  
  • Aralast - J0256
  • Glassia™ - J0257
  • Prolastin® - J0256
  • ​Zemaira® - J0256 

Tumor Infiltrating Lymphocyte (TIL) Therapy

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

 

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


Miscellaneous therapeuti​​​c 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
  • Vyepti™ - J3032
  • Xiaflex® – J0775 

​Revisio​​​ns​
​

January 1, 2024


The following revisions were incorporated into the January 1, 2024 update.​

Additions​​

Reconstructive procedures and potentially cosmetic procedures

Breast Reconstruction

19300

Genetically and bio-engineered skin substitutes for wound care

Q4279
Q4287
Q4288
Q4289
Q4290
Q4291
Q4292
Q4293
Q4294
Q4295
Q4296
Q4297
Q4298
Q4299
Q4300
Q4301
Q4302
Q4303
Q4304

Prosthetics/orthoses
 
Custom limb prosthetics including accessories/components
 
L5615
L5926

Amyotrophic Lateral Sclerosis agents

Debamestrocel (pending FDA approval) - J3490, J3590, and C9399
 
Antineoplastic agents
 
Columvi™ - J9286
Elrexfio™ - C9165, J3490, and J3590
Epkinly™ - J9321
Pemfexy™ - J9258
Talvey™ - C9163, J3490, and J3590
Zolbetuximab (pending FDA approval) - J3490, J3590, and C9399

Anti PD-1/PD-L1 human monoclonal antibodies

Camrelizumab (pending FDA approval) - J3490, J3590, and C9399
Cosibelimab (pending FDA approval) - J3490, J3590, and C9399
Zynyz™ - J9345

Enzyme replacement agents

Apadamtase Alfa (pending FDA approval) – J3490, J3590, and C9399
Cinaxadamtase Alfa (pending FDA approval) – J3490, J3590, and C9399
Elfabrio® - J2508
Lamzede® - J0217

Gene Replacement / Gene Editing Therapies

Casgevy™ - J3490, J3590, and C9399
Elevidys® - J1413
Fidanacogene Elaparvoec (pending FDA approval) - J3490, J3590, and C9399
Lyfgenia™- J3490, J3590, and C9399
Roctavian® - J1412
Vvjuvek™ - J3401

Multiple sclerosis agents

Tyruko® - J3490, J3590, and C9399
 
Myasthemia Gravis Agents

Rystiggo® - J9333
Vyvgart™ - J9332
Vyygart® Hytrulo - J9334
 
(The Specialty Drugs requiring precertification section entitled “Myasthemia Gravis Agents" is a new section effective January 1, 2024.)
 
Ophthalmic agents

Eylea® HD - J0178, J3590, and C9161 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)

Tumor Infiltrating Lymphocyte (TIL) Therapy

Lifileucel (pending FDA approval) – J3490, J3590, and C9399

(The Specialty Drugs requiring precertification section entitled “Tumor Infiltrating Lymphocyte (TIL) Therapy" is a new section effective January 1, 2024.)

Miscellaneous therapeutic agents

Lantidra® - J3490, J3590, and C9399

____________________________________________________________________

Deletions

Prosthetics/orthoses
 
Custom limb prosthetics including accessories/components
 
K1014
K1022

Amyotrophic Lateral Sclerosis agents

Radicava™ - J1301
Qalsody™– J3490, J3590, and C9399

Antineoplastic agents
 
Alimta® - J9305
Epkinly™ - C9155
Kanjinti™ - Q5117
Lumoxiti™ - J9313
Mvasi™ - Q5107 (Note: Ophthalmologic use of Mvasi does not require precertification.)
Oportuzumab Monatox (pending FDA approval) - J3490, J3590, and C9399
Pemetrexed - J9322, J9323
Pemfexy™ - J9304, J9314, J9294, J9296, J9297
Ruxience™ - Q5119
SH-111 (pending FDA approval) - J3490, J3590, and C9399
Trazimera™ - Q5116
Truxima™ - Q5115
Zirabev™ - Q5118 (Note: Ophthalmologic use of Zirabev does not require precertification.)
Zynyz™ - J9345

Anti PD-1/PD-L1 human monoclonal antibodies

Balstilimab (pending FDA approval) - J3490, J3590, and C9399
Sintilimab (pending FDA approval) - J3490, J3590, and C9399
Zynyz™ - J3590 and C9399

Chemotherapy-induced nausea and vomiting (CINV) agents

Sustol® - J1627

(The Specialty Drugs requiring precertification section entitled “Chemotherapy induced nausea and vomiting (CINV) agents" is removed effective January 1, 2024.)

Endocrine/metabolic agents

Cosyntropin depot (pending FDA approval) - J3490, J3590, and C9399
Makena® - J1726 and J1729

Enzyme replacement agents

Lamzede® - J3590

Gene Replacement / Gene Editing Therapies

Roctavian™ - J3590 and C9399
Vyjuvek™ - J3590 and C9399

Neutropenia

Neulasta® - J2506 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
Neulasta Onpro™ - J2506
Nivestym™ - Q5110
Nyvepria™ - Q5122
Plinabulin (pending FDA approval) - J3490, J3590, and C9399

Ophthalmic agents

Abicipar (pending FDA approval) - J3490, J3590, and C9399
Eylea® - J0178 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
Eylea® HD – J3590 and C9399

Pulmonary arterial hypertension

Trevyent (pending FDA approval) - J3490 and C9399

Respiratory agents

Tezspire™ - J2356

Miscellaneous therapeutic agents

Donislecel (pending FDA approval) – J3490, J3590, and C9399
Vyvgart™ - J9332
Vyvgart® Hytrulo – J3590 and C9399​




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