AmeriHealth wants to ensure that our members receive injectable/infusion therapy drugs in safe, cost-effective settings. Since 2012, as part of our Most Cost-Effective Setting Program, AmeriHealth has been reviewing the settings where members enrolled in our commercial products receive certain drugs that are eligible for coverage under the medical benefit.

As a result of the recent expansion of ambulatory (freestanding) infusion suites in our network, effective December 1, 2019, AmeriHealth will remove the setting review exception for pediatric members under 18 years of age who receive the following drugs:

• Actemra^® (tocilizumab)
• Entyvio^® (vedolizumab)
• Inflectra^® (infliximab-dyyb)
• Orencia^® (abatacept)
• Remicade^® (infliximab)
• Renflexis^® (infliximab-abda)
• Simponi Aria^® (golimumab)

Our expanded network of ambulatory infusion suites gives our members increased access to cost-effective, convenient treatment sites.

How this affects your patients

In September 2019, AmeriHealth will send letters to adult subscribers whose dependents are under 18 years of age and currently receiving any of these drugs in a hospital outpatient facility. Subscribers will be notified about the change in the pediatric exception and informed that their dependent can continue to receive treatment in the hospital outpatient facility until their current precertification approval expires. Decisions about future treatment settings will be made at the next precertification review. Settings that AmeriHealth considers to be cost-effective are:

• a physician’s office;
• the member’s home, where the drug is administered by an in-network home infusion provider;
• an ambulatory (freestanding) infusion suite, not owned by a hospital or health system in our network.

Effective December 1, 2019, all requests for these drugs will require precertification review for both medical necessity and setting, regardless of the age of the member.

In accordance with our current program guidelines, requests to receive any drug in the Most Cost-Effective Setting Program in a hospital outpatient facility will be considered for certain members, including those who are receiving their initial therapeutic dose or for members whose condition requires the intensive monitoring and care uniquely available in a hospital outpatient facility. AmeriHealth requires providers to submit relevant medical records to support requests for ongoing administration of these drugs in a hospital outpatient facility. This information will be reviewed, and a coverage determination on setting will be made.

Medical policy information

Providers can find additional information about these drugs in the following AmeriHealth commercial medical policies:

• #08.00.34: Infliximab and Related Biosimilars
• #08.00.62: Abatacept (Orencia^®) for Injection for Intravenous Use
• #08.00.85: Tocilizumab (Actemra^®) for Intravenous Infusion
• #08.01.15: Golimumab (Simponi Aria^®) Intravenous (IV) Injection
• #08.01.18: Vedolizumab (Entyvio^®)

To review these medical policies, visit our Medical Policy Portal.

Learn more

For more information, including a downloadable list of all drugs in the program, visit our Most Cost-Effective Setting Program webpages for AmeriHealth New Jersey or AmeriHealth Pennsylvania.