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^®
• 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 acetate)
• 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.