On October 1, 2018, AmeriHealth launched new webpages to support its Most Cost-Effective Setting Program for AmeriHealth members. As part of this program, AmeriHealth reviews the requested site of service where members receive certain specialty drugs eligible for coverage under the medical benefit. This review ensures that drugs are being administered in settings that are both safe and cost-effective.
In addition to providing detailed information about the Most Cost-Effective Setting Program, these webpages include comprehensive lists of specialty drugs that require review for site of service. The lists are updated throughout the year, as the program is expanded.
For more information about the Most Cost-Effective Setting Program, visit our new, dedicated webpages for AmeriHealth New Jersey and AmeriHealth Pennsylvania.
Recent additions to the Most Cost-Effective Setting Program
The following drugs require precertification approval for medical necessity and setting as of the date noted:*
AmeriHealth New Jersey
- Adagen? (pegademase bovine) – AS OF OCTOBER 1, 2018
- Crysvita? (burosumab-twza) – NEW FOR JANUARY 1, 2019
- FulphilaTM (pegfilgrastim-jmdb) – NEW FOR JANUARY 1, 2019
- Ilaris? (canakinumab) – NEW FOR JANUARY 1, 2019
- Naglazyme? (galsulfase) – AS OF OCTOBER 1, 2018
- OnpattroTM (patisiran) – NEW FOR JANUARY 1, 2019
AmeriHealth Pennsylvania
- Adagen? (pegademase bovine) – AS OF OCTOBER 1, 2018
- Crysvita? (burosumab-twza) – AS OF OCTOBER 1, 2018
- FulphilaTM (pegfilgrastim-jmdb) – AS OF JUNE 25, 2018
- Ilaris? (canakinumab) – NEW FOR JANUARY 1, 2019
- Naglazyme? (galsulfase) – AS OF OCTOBER 1, 2018
- OnpattroTM (patisiran) – AS OF AUGUST 10, 2018
*This list of drugs is subject to change.
Note: All biosimilars to the originator products in this program are subject to precertification review for most cost-effective setting.