Most Cost-Effective Setting Program

AmeriHealth Administrators wants plan 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 Administrators 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 plan members enrolled in AmeriHealth Administrators 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 Administrators considers the following settings to be safe and cost-effective:

  • A physician's office
  • The plan member's home, where an in-network home-infusion provider administers the drug
  • 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 plan members who meet one of the following criteria:

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