AmeriHealth seeks to ensure that our members receive injectable/infusion therapy drugs in a setting that is both safe and cost-effective. Since 2012, AmeriHealth has been reviewing the most appropriate setting for commercial members to receive certain injectable and infusion therapy drugs eligible for coverage under the medical benefit.

Effective October 1, 2020, the following drugs will be added to our Most Cost-Effective Setting Program:

• Nyvepria™ (pegfilgrastim-apgf)
• Phesgo™ (pertuzumab/trastuzumab/hyaluronidase-zzxf)‎
• Uplizna™ (inebilizumab-cdon)

New requests for these drugs will require review for setting, as well as medical necessity, during the precertification process. Members who have precertification approval to receive these drugs in a hospital outpatient facility may continue treatment in this setting until their current precertification approval expires. At the next precertification review, AmeriHealth will evaluate the requested setting and make a coverage determination.

Resources

Visit our Most Cost-Effective Setting Program webpages for AmeriHealth New Jersey and AmeriHealth Pennsylvania for more information, including a downloadable list of all 74 drugs on the program.