AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth) and AmeriHealth Administrators have made changes to the specialty medical benefit drugs in the Most Cost-Effective Setting Program.
As of January 28, 2024, the setting in which the following drugs are administered will be reviewed for medical necessity, as part of the precertification process for members enrolled in Commercial plans:
- Ryzneuta® (afbemalenograstim alpha)
- Elfabrio® (pegunigalsidase alfa)
- Omvoh™ (mirikizumab)
- Pombiliti™ (cipaglucosidase alfa)
- Lamzede® (velmanase alfa)
- Rystiggo® (rozanolixizumab)
- Tyruko® (natalizumab-sztn)
- Wezlana (ustekinumab-auub)
- Tofidence™ (tocilizumab-bavi)
Additionally, we have elected to remove the following products from the Most Cost-Effective Setting Program:
- Neulasta® / Onpro (pegfilgrastim)
- Nyvepria™ (pegfilgrastim-apgf)
- Tezspire® (tezepelumab-ekko)
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, we will evaluate the requested setting and make a coverage determination.
With our Most Cost-Effective Setting Program, we seek 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 90 drugs in the program, visit our Most Cost-Effective Setting Program webpages: