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5/22/2025
The Aurora Extravascular Implantable Cardioverter Defibrillator (EV-ICD) System (Medtronic Inc.) for the treatment of life-threatening ventricular arrhythmias (Retroactively Effective To October 20, 2023)
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This communication is being issued to provide advance notice of the updated coverage position for the Aurora Extravascular Implantable Cardioverter Defibrillator (EV-ICD) System (Medtronic Inc.) for the treatment of life-threatening ventricular arrhythmias for Medicare Advantage members.
The Aurora Extravascular Implantable Cardioverter Defibrillator (EV-ICD) System (Medtronic Inc.) for the treatment of life-threatening ventricular arrhythmias (Retroactively Effective To October 20, 2023)e44639e1-dccf-43ee-9c8f-18fd3ebb2dff
4/29/2025
Updated Preventive Coverage for Hepatitis B Vaccine and Colorectal Cancer Screening (Retroactively Effective)
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The purpose of this communication is: 

  • to provide notice of updated preventive coverage for hepatitis B vaccine and colorectal cancer screening for Medicare Advantage members, retroactively effective to January 1, 202​5
  • to provide notice, in accordance with CMS, of updated high-risk diagnosis codes for colorectal cancer screening for Medicare Advantage members, retroactively effective to October 1, 2024 
Updated Preventive Coverage for Hepatitis B Vaccine and Colorectal Cancer Screening (Retroactively Effective)55e33aac-165c-42eb-b582-a0c70f6e4837
4/1/2025
04/01/2025 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products
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The intent of this document is to communicate Medicare Advantage Product coverage determinations for services identified through the Quarterly Code Update process. The procedure codes that represent these services will become effective on 04/01/2025, unless otherwise noted. 

For more information related to these services, please refer to specific policies when applicable.​​​​​​​

04/01/2025 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products02f4a5f6-8e17-4e09-a15f-5df2cd6cf850
12/23/2024
Coverage of Tofersen (Qalsody®) for the Treatment of Amyotrophic Lateral Sclerosis (ALS) for AmeriHealth New Jersey Medicare Advantage Members (Retroactively Effective to January 1, 2024)
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The purpose of this document is to communicate the Company's coverage position for tofersen (Qalsody®) for AmeriHealth New Jersey Medicare Advantage members. Coverage for tofersen (Qalsody) for AmeriHealth New Jersey ​Medicare Advantage members is retroactively effective to January 1, 2024.​
Coverage of Tofersen (Qalsody®) for the Treatment of Amyotrophic Lateral Sclerosis (ALS) for AmeriHealth New Jersey Medicare Advantage Members (Retroactively Effective to January 1, 2024)749f377c-23de-4672-92ec-43c9d0bd0206
12/23/2024
Exon Skipping Drugs for Duchenne Muscular Dystrophy (DMD) (Eteplirsen (Exondys 51), Golodirsen (Vyondys 53), Viltolarsen (Viltepso)), Casimersen (Amondys 45) (Retroactively Effective to January 1, 2024)
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The purpose of this document is to communicate the Company's coverage position for Exon Skipping Drugs for Duchenne Muscular Dystrophy (DMD) (Eteplirsen (Exondys 51), Golodirsen (Vyondys 53), Viltolarsen (Viltepso)), Casimersen (Amondys 45) for AmeriHealth New Jersey Medicare Advantage members. ​Coverage for Exon Skipping Drugs for Duchenne Muscular Dystrophy (DMD)(Eteplirsen (Exondys 51), Golodirsen (Vyondys 53), Viltolarsen (Viltepso)), Casimersen (Amondys 45)) for Medicare Advantage members is retroactively effective for each of these exon skipping drugs for DMD as of the specific FDA approval dates.​


Exon Skipping Drugs for Duchenne Muscular Dystrophy (DMD) (Eteplirsen (Exondys 51), Golodirsen (Vyondys 53), Viltolarsen (Viltepso)), Casimersen (Amondys 45) (Retroactively Effective to January 1, 2024)7001965e-8fac-4683-9d6c-b8cc79ae1968
10/14/2024
Preventive Coverage of Pre-exposure Prophylaxis for the Prevention of HIV Infection (Retroactively Effective September 30, 2024)
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Retroactively effective September 30, 2024, t​he purpose of this communication is to provide notice of the preventive coverage of pre-exposure prophylaxis for the prevention of HIV infection under the Company's medical benefit (Part B)​ for Medicare Advantage members. ​ 
Preventive Coverage of Pre-exposure Prophylaxis for the Prevention of HIV Infection (Retroactively Effective September 30, 2024)faa73e7e-6f7b-4a55-8f13-7b8aecf7780a
10/8/2024
10/01/2024 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products (Updated October 8, 2024)
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The intent of this document is to communicate Medicare Advantage Product coverage determinations for services identified through the Quarterly Code Update process. The procedure codes that represent these services will become effective on 10/01/2024.

For more information related to these services, please refer to specific policies when applicable.​​​​​​

10/01/2024 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products (Updated October 8, 2024)03da2f93-74f8-43fa-9f33-14abfba84cb5
8/28/2024
New Preventive Coverage of 21-valent Pneumococcal Vaccine for Medicare Advantage Members (Retroactively effective to June 17, 2024)
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The purpose of this communication is to provide notice regarding the new preventive coverage criteria for 21-valent pneumococcal vaccine for Medicare Advantage members.  Services covered are retroactively effective to June 17, 2024.​
New Preventive Coverage of 21-valent Pneumococcal Vaccine for Medicare Advantage Members (Retroactively effective to June 17, 2024)a3496d0d-256a-43ea-92b1-9fd121647897
8/12/2024
Pemivibart (Pemgarda) for Pre-Exposure Prophylaxis for Coronavirus Disease 2019 (COVID-19) for Medicare Advantage Members (Retroactively Effective to 03/22/2024)
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The purpose of this document is to communicate the Company's coverage position for pemivibart (Pemgarda) for pre-exposure prophylaxis for Coronavirus disease 2019 (COVID-19) for Medicare Advantage members.  Coverage for pre-exposure prophylaxis for Coronavirus disease 2019 (COVID-19) for Medicare Advantage ​members​ is retroactively effective to March 22, 2024.​
Pemivibart (Pemgarda) for Pre-Exposure Prophylaxis for Coronavirus Disease 2019 (COVID-19) for Medicare Advantage Members (Retroactively Effective to 03/22/2024)24a0284f-a81c-4cba-92e5-7412c466bc24
8/5/2024
Coverage of Cantharidin (Ycanth) Topical Solution Medicare Advantage Products (Retroactively Effective to 04/01/2024)
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The purpose of this document is to communicate that the Company has revised its coverage position for cantharidin (Ycanth)​ topical solution.  

The coverage position for cantharidin (Ycanth)​, represented by HCPCS code J7354, has been revised from non-covered to medically necessary.  This medically necessary coverage position is retroactively effective for dates of service beginning 04/01/2024. ​
​
Coverage of Cantharidin (Ycanth) Topical Solution Medicare Advantage Products (Retroactively Effective to 04/01/2024)28937e82-6884-402c-818b-f68a0440ba3a
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