Effective September 1, 2019, AmeriHealth will add the multiple sclerosis drug Tysabri^® (natalizumab) to our Most Cost-Effective Setting Program. This program ensures that requests for certain high-cost specialty drugs are clinically appropriate and are being administered in settings that are safe and cost-effective. Recent expansions to our network of ambulatory (freestanding) infusion suite providers now give our members increased access to these cost-effective, convenient treatment sites.

AmeriHealth considers the following settings to be cost-effective for Tysabri:*

• a physician's office;
• an ambulatory (freestanding) infusion suite, not owned by a hospital or health system in our network.

*These settings must comply with a Risk Evaluation and Mitigation Strategies (REMS) program in order to be approved by AmeriHealth to administer Tysabri.

The hospital outpatient facility will still be considered for members who are receiving an initial dose of Tysabri or if there is a clinical rationale that requires the member to receive Tysabri in the hospital outpatient facility.

Member and provider impact

In June 2019, AmeriHealth will send letters to notify members and prescribing providers affected by this change.

Members who have precertification approval from AmeriHealth to receive Tysabri in a hospital outpatient facility may continue treatment in this setting until their current precertification approval for Tysabri expires. At the next precertification review, AmeriHealth will evaluate the requested setting and make a coverage determination.

New requests for Tysabri received on or after September 1, 2019, will be subject to AmeriHealth review for both setting and medical necessity during the precertification process.

The AmeriHealth precertification team will help providers identify treatment locations that are convenient for our members.

Learn more

Providers can find additional information about Tysabri in the AmeriHealth Medical Policy #08.00.64f: Natalizumab (Tysabri^®). To access this medical policy, visit our Medical Policy Portal.

Visit our Most Cost-Effective Setting Program webpage for AmeriHealth New Jersey or AmeriHealth Pennsylvania for more information, including a downloadable list of all drugs in the program.