Most Cost-Effective Setting (MCES) Program Drug List
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Defines the AmeriHealth Most Cost-Effective Setting program and lists medications whose treatment setting must be approved through the precertification process; applies to providers requesting medical-benefit administration settings for listed drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria
This document does not enumerate specific coverage criteria for individual drugs. The MCES drug list provided here is subject to change, and providers should confirm current program membership before requesting a treatment setting. Note that all generics and biosimilars to reference products on the MCES list are also included and are subject to the program’s precertification review for treatment setting.
Provider Actions and Requirements
MCES program — precertification of treatment setting
The AmeriHealth Most Cost-Effective Setting (MCES) Program requires precertification of the treatment setting for certain medical-benefit medications. As part of the precertification review, AmeriHealth will evaluate whether the requested setting is safe, clinically appropriate, and the most cost-effective option for the member. This review is conducted in addition to verification that the member meets the medical policy coverage criteria.
- MCES program applies to the listed drugs and to all generics and biosimilars of a reference product in the program (see drug list).
- Setting approval is determined during the precertification/medical-benefit review — indicate anticipated site of service (e.g., outpatient infusion center, physician office, home infusion, inpatient) on the request.
Step therapy not defined
This policy does not define a formal step therapy pathway. However, members and providers should note that generics and biosimilars to a reference product included in the MCES program are subject to precertification review; formulary or medical-management edits may apply.
- No defined step-therapy sequence is specified in this policy.
- Coverage and prior-authorization requirements (including setting review) still apply to generics and biosimilars in the program.
Documentation for setting approval
Documentation submitted with the precertification request must demonstrate that the requested treatment setting is safe for the member and represents a cost-effective option compared with alternative settings. Provide clinical records, rationale for site selection, relevant lab or monitoring data, prior treatments, and any factors that affect safety or feasibility of alternate settings. Failure to provide sufficient documentation may delay processing or result in denial.
- Include clinical justification for the selected site of service and why a lower-cost setting is not appropriate if applicable.
- Attach pertinent medical records, prior authorization history, and any required monitoring parameters.
- If precertification is not obtained or documentation is incomplete, the request may be denied or payment adjusted.
Precertification required
Precertification approval is required for medications and requested treatment settings subject to the MCES program. Requests submitted without prior precertification may be denied or subject to retroactive review. Providers should obtain precertification before scheduling treatment to avoid claim denials or member liability.
- Obtain precertification for both the medication and the treatment setting when the drug is on the MCES list.
- Confirm approval prior to delivering services; keep approval documentation on file.
- Denials may occur if precertification is not obtained or the requested setting is not approved.
Background
The Most Cost-Effective Setting (MCES) Program was established to manage total cost of care by ensuring that members receiving certain medications meet applicable medical policy coverage criteria and receive therapy in an appropriate, cost-effective setting. As part of the medical-benefit review, medications on the MCES list require precertification of the requested treatment setting so AmeriHealth can verify that the setting is safe and aligns with cost-effectiveness goals.
Definitions
Step Therapy
| Step | Requirement | Notes |
|---|---|---|
| 1 | ||
| Step therapy not specified in this document | ||
| All generics and biosimilars to a reference product on the MCES list are subject to precertification review for most cost-effective setting; the program drug list is subject to change. |
Site of Care Approval
Approve site of care via MCES precertification
The treatment setting (infusion center, hospital outpatient, office, or home) for medications on the MCES list must be approved through the MCES precertification review to ensure safety and cost‑effectiveness.
- Infusion center
- Hospital outpatient
- Office
- Home
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