AmeriHealth and its affiliates (collectively, AmeriHealth) has made changes to the specialty medical benefit drugs in the Most Cost-Effective Setting Program.
As of December 1, 2022, the following drugs will be reviewed for setting, as well as medical necessity, as part of the precertification process.
- Lanreotide
- Nivestym® (filgrastim-aafi)
- Rolvedon™(eflapegrastim-xnst)
- Skyrizi® IV (risankizumab-rzaa)
- Spevigo® (spesolimab-sbzo)
- Stimufend® (pegfilgrastim-fpgk)
- Tzield™ (teplizumab-mzwv)
- Xenpozyme® (olipudase alfa-rpcp)
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 91 drugs in the program, visit our Most Cost-Effective Setting Program webpages: