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​​Changes to the Most Cost-Effective Setting Program​

December 14, 2022

​AmeriHealth and its affiliates (collectively, AmeriHealth) has made changes to the specialty medical benefit drugs in the Most Cost-Effective Setting Program.

As of December 1, 2022, the following drugs will be reviewed for setting, as well as medical necessity, as part of the precertification process.

  • Lanreotide
  • Nivestym® (filgrastim-aafi)
  • Rolvedon™(eflapegrastim-xnst)
  • Skyrizi® IV (risankizumab-rzaa)
  • Spevigo® (spesolimab-sbzo)
  • Stimufend® (pegfilgrastim-fpgk)
  • Tzield™ (teplizumab-mzwv)
  • Xenpozyme® (olipudase alfa-rpcp)

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

With our Most Cost-Effective Setting Program, AmeriHealth seeks to ensure that members receive treatment with specialty medical benefit drugs in settings that are safe and cost-effective.

Resources

For more information, including a list of all 91 drugs in the program, visit our Most Cost-Effective Setting Program webpages:


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