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Reminder: Seven drugs to be added to Most Cost-Effective Setting Program

August 17, 2017

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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.

As previously communicated, 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. The first wave of letters was mailed at the end of July for members whose precertification expires in September.

Note: Members ages 17 and younger are currently eligible to receive treatment with these seven drugs in any setting. Requests for these drugs will continue to require precertification review for indication, to ensure that the member meets the coverage criteria 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 applicable 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 these medical policies, 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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