Effective September 15, 2021, the following specialty medical benefit drugs were added to our Most Cost-Effective Setting Program:
- Nexviazyme™ (avalglucosidase-alfa-ngpt)
- Saphnelo™ (anifrolumab-fnia)
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.
AmeriHealth seeks to ensure that our members receive injectable/infusion therapy drugs in a setting that is 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.
For more information, including a downloadable list of all 78 drugs in the program, visit our Most Cost-Effective Setting Program webpages: