AmeriHealth wants to ensure that our members receive injectable/infusion
therapy drugs in a setting that is both safe and cost-effective for their
clinical condition. Since 2012, AmeriHealth has been reviewing the most
appropriate setting for commercial members to receive certain injectable and
infusion therapy drugs as part of the precertification review process.
Effective January 1, 2018, the drugs Nucala®,
Ocrevus™, Radicava™, and
Somatuline® Depot will be added to the list of drugs that
require review for setting as part of the precertification process for
commercial members.
Members who have approvals extending into 2018 for Nucala and Ocrevus can
continue to receive treatment in their current setting until their
precertification approval expires. However, during the next precertification
request, AmeriHealth will review the requested setting and make a
determination. Members who are currently receiving Radicava and Somatuline
Depot will be subject to precertification review as of January 1, 2018. This
will ensure that members meet the coverage criteria for the drug and that they
are receiving treatment in a cost-effective setting.
What does this mean for your patients?
These drugs are covered by AmeriHealth for members who meet the clinical
criteria outlined in our medical policy for each drug and receive the drug in
the setting approved by AmeriHealth during precertification review.
During precertification review, each member?s medical needs and clinical
history are evaluated to determine if the drug and setting requested by the
provider are appropriate. Typically, the first administration of the drugs
included in this program will be approved in the hospital outpatient facility.
This allows the member to be monitored for any treatment-related adverse
effects. If the member does not experience any adverse effects during
treatment, subsequent drug administration will be approved in a more
cost-effective setting, such as the member?s home, the provider?s office, or an
ambulatory (freestanding) infusion suite. If there are circumstances that
require a member to continue receiving the drug in the hospital outpatient
facility, the provider must submit documentation to AmeriHealth that
specifically addresses these circumstances when submitting a request for
coverage.
Medical policy information
To review the medical policies for the drugs listed, visit our Medical Policy Portal and type the name of the drug in the
Search box.
Drugs included in the Most Cost-Effective
Setting Program
As of January 1, 2018, the drugs that will require precertification
approval for setting are:*
- Actemra® (tocilizumab)
- Aralast NP® (alpha-1 proteinase inhibitor [human])
- Cerezyme® (imiglucerase)
- Elelyso™ (taliglucerase alfa)
- Entyvio® (vedolizumab)
- Exondys-51™ (eteplirsen)
- Fabrazyme® (agalsidase beta)
- Glassia® (alpha-1 proteinase inhibitor [human])
- Inflectra® (infliximab-dyyb)
- Intravenous/subcutaneous immunoglobulin (IVIG/SCIG)
- Lumizyme® (alglucosidase alfa)
- Neulasta® (pegfilgrastim)
- Neulasta® (pegfilgrastim) Onpro®
(pegfilgrastim)
- Nucala® (mepolizumab) – NEW
FOR 2018!
- Ocrevus™ (ocrelizumab) – NEW FOR 2018!
- Orencia® (abatacept)
- Prolastin® (alpha-1 proteinase inhibitor [human])
- Prolia® (denosumab)
- Radicava™ (edaravone) – NEW FOR 2018!
- Remicade® (infliximab)
- Renflexis® (infliximab-abda)
- Sandostatin® LAR Depot (octreotide aetate)
- Simponi Aria® (golimumab)
- Soliris® (eculizumab)
- Somatuline® Depot (lanreotide) – NEW FOR 2018!
- Stelara® (ustekinumab)
- 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.