AmeriHealth seeks to ensure that our members receive injectable/infusion therapy drugs in settings that are both safe and cost-effective. Since 2012, our Most Cost-Effective Setting Program applies to select drugs that are eligible for coverage under the medical benefit. These select drugs can be safely given in a physician's office, a freestanding infusion suite, or the member's home by a home infusion provider.

Effective April 1, 2021, the following drugs will be added to our Most Cost-Effective Setting Program:

• Evkeeza^® (evinacumab-dgnb)
• Tepezza^® (teprotumumab-trbw)  

Requests for these drugs 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.

Resources

Visit our Most Cost-Effective Setting Program webpages for AmeriHealth New​ Jersey and AmeriHealth Pennsylvania for more information, including a downloadable list of all drugs on the program.