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AmeriHealth wants to ensure that our members receive injectable/infusion
therapy drugs in a setting that is both safe and cost-effective. Since 2012, as
part of our Most Cost-Effective Setting Program, AmeriHealth has been
reviewing the settings where members receive certain drugs that are eligible
for coverage under the medical benefit. Requests for these drugs are evaluated
during precertification review to determine if the member meets the medical
necessity criteria in our medical policy for coverage and if
the requested treatment setting is safe and cost-effective.
Effective September 1, 2017, the following drugs will be
added to this program:
- Actemra® (tocilizumab)
- Entyvio® (vedolizumab)
- Inflectra® (infliximab-dyyb)
- Orencia® (abatacept)
- Remicade® (infliximab)
- Renflexis® (infliximab-abda)
- Simponi Aria® (golimumab)
Members who are receiving these drugs in a hospital outpatient facility will
be mailed letters notifying them of this change, based on when their current
AmeriHealth precertification approval expires.
Note: Members ages 17 and younger are currently eligible to receive
treatment with these seven drugs in any setting when the member meets the
medical necessity criteria for coverage in our medical policy.
Appropriate settings
The hospital outpatient facility is typically the most costly setting in
which to administer drugs. The settings that AmeriHealth considers to be
cost-effective are:
- a physician?s office;
- the member?s home, where the drug is administered by an in-network home
infusion provider;
- an ambulatory (freestanding) infusion suite, not owned by a hospital or
health system in our network.
Requests for drugs in the Most Cost-Effective Setting Program to be
administered in a hospital outpatient facility will be considered for members
who are receiving their initial therapeutic dose or for members whose condition
requires the intensive monitoring and care uniquely available in a hospital
outpatient facility. AmeriHealth requires providers to submit relevant medical
records to support requests for ongoing administration of these drugs in a
hospital outpatient facility. This information will be reviewed, and a coverage
determination on setting will be made.
What does this mean for your patients?
Adult members who have current precertification approvals for these seven
drugs to be administered in a provider?s office, ambulatory (freestanding)
infusion suite, or their home are not affected by these changes. These
members can continue to receive treatment in these settings, if they continue
to meet the medical necessity criteria in the AmeriHealth medical policy.
Drugs included in the Most Cost-Effective
Setting Program
The following is a complete list of drugs that will be part of the Most
Cost-Effective Setting Program as of September 1,
2017:*
- Actemra® (tocilizumab) – NEW!
- Aralast NP® (alpha-1 proteinase inhibitor [human])
- Berinert® (C1 esterase inhibitor [human])
- Cerezyme® (imiglucerase)
- Cinryze® (C1 esterase inhibitor [human])
- ElelysoTM (taliglucerase alfa)
- Entyvio® (vedolizumab) – NEW!
- Exondys-51TM (eteplirsen)
- Fabrazyme® (agalsidase beta)
- Glassia® (alpha-1 proteinase inhibitor [human])
- Inflectra® (infliximab-dyyb) – NEW!
- Intravenous/subcutaneous immunoglobulin (IVIG/SCIG)
- Kalbitor® (ecallantide)
- Lumizyme® (alglucosidase alfa)
- Myozyme® (alglucosidase alfa)
- Neulasta® (pegfilgrastim)
- Neulasta® (pegfilgrastim) Onpro®
- Orencia® (abatacept) – NEW!
- Prolastin® (alpha-1 proteinase inhibitor [human])
- Prolia® (denosumab)
- Remicade® (infliximab) – NEW!
- Renflexis® (infliximab-abda) – NEW!
- Sandostatin® LAR Depot (octreotide acetate)
- Simponi Aria® (golimumab) – NEW!
- Soliris® (eculizumab)
- Stelara® (ustekinumab)
- SynriboTM (omacetaxine mepesuccinate)
- Vimizim® (elosulfase alfa)
- VPRIV® (velaglucerase alfa)
- Xolair® (omalizumab)
- Zemaira® (alpha-1 proteinase inhibitor [human])
*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.
Adult members who have current precertification
approvals for these seven drugs to be administered in a hospital outpatient
facility can continue to receive treatment in that setting until their
precertification approval expires. At the next precertification review,
AmeriHealth will evaluate the requested setting and make a coverage
determination.
Requests for adult members who are new to treatment with any of these seven
drugs will undergo precertification review for both indication and setting, and
AmeriHealth will make a coverage determination.
Medical policy information
You can find additional information about these drugs in the following
AmeriHealth commercial medical policies:
- #08.00.34: Infliximab and Related Biosimilars
- #08.00.62: Abatacept (Orencia®) for Injection for
Intravenous Use
- #08.00.85: Tocilizumab (Actemra®) for Intravenous
Infusion
- #08.01.15: Golimumab (Simponi Aria®) Intravenous (IV)
Injection
- #08.01.18: Vedolizumab (Entyvio®)
To review the medical policies for the drugs listed, visit our Medical Policy Portal. Select Accept and Go to Medical
Policy Online, then select Commercial and type the name of the
drug in the Search field.
If you have questions about these changes, please contact your Provider
Partnership Associate or Network Coordinator.
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