AmeriHealth will make changes to the specialty medical benefit drugs in the Most Cost-Effective Setting Program.
Effective February 15, 2022, these drugs will be reviewed for setting, as well as medical necessity, as part of the precertification process:
- infliximab (unbranded Johnson & Johnson/Janssen)
- Leqvio® (inclisiran)
- Vyvgart™ (efgartigimod alfa-fcab)
Effective July 1, 2022, this drug will be reviewed for setting, as well as medical necessity, as part of the precertification process:
- Tezspire™ (tezepelumab-ekko)
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.
AmeriHealth seeks to ensure that our members receive specialty drugs in settings that are both safe and cost-effective. With our Most Cost-Effective Setting Program, we review the most appropriate setting for members to receive select injectable and infusion therapy drugs eligible for coverage under the medical benefit.
Resources
For more information, including a list of all 80 drugs in the program, visit our Most Cost-Effective Setting Program webpages: