AmeriHealth will make changes to the specialty medical benefit drugs in the Most Cost-Effective Setting Program, effective January 1, 2022.
AmeriHealth seeks to ensure that our members receive injectable/infusion therapy drugs in settings that are both safe and cost-effective. We continually review the most appropriate setting for commercial members to receive selected injectable and infusion therapy drugs eligible for coverage under the medical benefit.
Additions
Neupogen® (filgrastim) will be added to our Most Cost-Effective Setting Program.
New requests for Neupogen® will require review for setting, as well as medical necessity, during the precertification process. Members who have precertification approval to receive this drug 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.
Removals
Nucala® (mepolizumab) and Trogarzo® (ibalizumab-uiyk) will be removed from the Most Cost-Effective Setting Program.
Resources
For more information, including a list of all 77 drugs in the program, visit our Most Cost-Effective Setting Program webpages: