AmeriHealth wants to ensure that our members receive injectable/infusion therapy drugs in a setting that is both safe and cost-effective for their clinical condition. Therefore, AmeriHealth reviews the most appropriate setting for commercial members to receive certain injectable and infusion therapy drugs as part of the precertification review process.
Effective August 1, 2014, VimizimTM (elosulfase alfa) has been added to the list of medical benefit drugs that require review for setting as part of the precertification process.
The 21 drugs that currently require precertification approval for setting are:
These drugs are covered by AmeriHealth for members who (1) meet the clinical criteria outlined in our medical policy for each drug and (2) receive the drug in the setting approved by AmeriHealth during precertification review.
During precertification review, each member?s unique medical needs and clinical history are evaluated to determine which setting is most appropriate to receive the requested drug. If there are circumstances that require a member to receive a drug in an outpatient facility, the provider must submit documentation to AmeriHealth that specifically addresses these circumstances when submitting a request for coverage.
To review the medical policies for the drugs listed, visit our Medical Policy Portal, select Accept and Go to Medical Policy Online, and type the policy name or number in the Search box.