AmeriHealth and its affiliates (collectively, AmeriHealth) have made changes to the specialty medical benefit drugs in the Most Cost-Effective Setting Program.
As of June 1, 2023, the following drug will be reviewed for setting, as well as medical necessity, as part of the precertification process for members enrolled in Commercial plans:
- Briumvi™ (ublituximab-xiiy)
Based upon clinical review, AmeriHealth has elected to remove the following products from the Most Cost-Effective Setting Program:
- Phesgo™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- 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, we 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 84 drugs in the program, visit our Most Cost-Effective Setting Program webpages: