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Most Cost-Effective Setting Program

AmeriHealth wants our members to receive treatment in accordance with the coverage criteria in our medical policies and in settings that are both safe and cost-effective. Through the Most Cost-Effective Setting Program, AmeriHealth reviews the requested treatment settings for certain specialty drugs that are eligible for coverage under the medical benefit. This review is conducted as part of the precertification process for members enrolled in AmeriHealth medical plans.

View the complete list of drugs in the Most Cost-Effective Setting Program.

Cost-Effective Settings

For the drugs in this program, AmeriHealth considers the following settings to be safe and cost-effective:

  • A physician’s office
  • The member’s home, where the drug is administered by an in-network home infusion provider
  • An ambulatory (freestanding), independent infusion suite

Hospital Outpatient Facility Request

Requests to receive treatment in the hospital outpatient facility with any of the drugs in the Most Cost-Effective Setting Program will only be considered for members who meet one of the following criteria:

  • The member is receiving an initial dose of the drug.
  • The member requires intensive monitoring in a hospital outpatient facility, typically due to a history of adverse reaction to treatment.

Pediatric Exceptions

Members under age 18 who meet the coverage criteria in our medical policies for the following drugs in the Most Cost-Effective Setting Program may be approved to receive treatment in the hospital outpatient facility:

  • Actemra®
  • Entyvio®
  • Inflectra®
  • Ixifi®
  • Orencia®
  • Remicade®
  • Renflexis®
  • Simponi Aria®

When these members turn 18, AmeriHealth may approve treatment in a setting other than the hospital outpatient facility, in accordance with the requirements of the Most Cost-Effective Setting Program.