​Changes to the Most Cost-Effective Setting Program

July 19, 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 July 1, 2022, the following drugs will be reviewed for setting, as well as medical necessity, as part of the precertification process:

  • Amvuttra™ (vutrisiran)
  • Enjaymo™ (sutimlimab-jome)
  • Fylnetra™ (pegfilgrastim-pbbk)
  • Releuko™ (filgrastim-ayow)

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 84 drugs in the program, visit our Most Cost-Effective Setting Program webpages: