Precertification required for listed specialty drugs

As of January 1, 2026, all listed specialty brands and their generic equivalents or biosimilars require precertification for AmeriHealth Medicare Advantage members; the list is subject to change.

• Applies to all brands listed in the document and any generics or biosimilars.

Prior authorization details not specified in this list

This segment lists drug names by therapeutic category and does not provide detailed prior authorization criteria or clinical triggers.

• Providers must follow general precertification process but no PA rules are specified here.

List subject to change; biosimilars and class members require precertification

The list is subject to change; precertification requirements also apply to FDA‑approved biosimilars and to any unlisted brands, generics, or new drugs approved in a listed class during the benefit year.

• Reference-product biosimilars marked with ‡ are included under the biosimilar applicability note.

Drug list only — no extra provider actions in this segment

This excerpt contains only drug listings by category (see respiratory and miscellaneous sections); no additional provider-action instructions are included in chunk 19 beyond the drug names.

• Providers should not infer authorization criteria from the drug list alone.

Precertification review vendor and documentation notes

Drugs marked with † are subject to precertification review by CareCore National, LLC d/b/a eviCore healthcare; benefits, copayments, and restrictions may apply and may change annually.

• Contact the external review vendor for precertification requirements where noted.
• Benefits and cost‑sharing provisions may change on January 1 of each year.

Agent listing only — no additional provider instructions in this section

The miscellaneous therapeutic agents section lists many brands but does not specify additional provider-action steps or documentation requirements in chunk 22 itself.

• Providers must submit precertification requests when applicable, but chunk 22 contains only the agent names.

Denial risk if precertification is not obtained

Failure to obtain precertification for any listed specialty drug, including its generic equivalents or biosimilars, may result in denial or coverage limitation.

• Obtain precertification before initiating therapy to avoid claim denials or coverage actions.

No authorization/denial triggers provided in this list

This segment provides only drug names grouped by category and does not include explicit authorization or denial triggers.

• Do not rely on this list for clinical authorization criteria; seek the full policy or vendor guidance for triggers.

Site-of-care rules not specified for listed IV agents

Site-of-care requirements (e.g., infusion center rules) are not specified in this portion of the document despite inclusion of intravenous agents.

• If site-of-care rules are needed, consult the full policy or payer/vendor guidance.

Biosimilar applicability for products marked with ‡

Precertification requirements apply to all FDA‑approved biosimilars to the reference products noted with ‡ in the list (e.g., Soliris ® is marked with ‡).

• When a reference product is marked with ‡, any FDA‑approved biosimilar to that product also requires precertification.