CurrentAmeriHealthPolicy N/A

Most Cost-Effective Setting (MCES) Program Drug List

Defines the AmeriHealth Most Cost-Effective Setting Program listing medications for which the treatment setting must be approved as part of precertification; affects providers requesting medical-benefit administration of listed drugs for AmeriHealth members.

Policy Summary

PayerAmeriHealth

PolicyMost Cost-Effective Setting (MCES) Program Drug List

Policy CodePolicy N/A

Change TypeImmunotherapy expansion added (May 1, 2026)

Effective DateJan 1, 2012

Next Review DateTBD

Key ActionObtain AmeriHealth precertification approval of the treatment setting before scheduling medical-benefit administration of listed drugs.

SourceLink

POLICY UPDATE CHANGES

An Immunotherapy MCES Expansion listing oncology immunotherapy agents and criteria for outpatient continuation was launched May 1, 2026.

Multiple new drugs were added to the MCES Program with various 'Date Added' entries through 2026 (e.g., Avtozma, Bildyos, Bosaya, Enoby, Imaavy, Imuldosa, Qivigy, Starjemza).

100+drugs listed under MCES (approx.)

Jan 1, 2012Program established / IVIG inclusion

May 1, 2026Immunotherapy expansion effective

Subject to changeList changeability

Coverage Criteria & Immunotherapy Expansion

MCES Program Coverage and Immunotherapy Expansion Exceptions

Covered when ALL of the following are met

MCES precertification requirement: AmeriHealth approval of the treatment setting has been obtained via precertification and the member meets the medical policy coverage criteria for the requested medication.

Applies to drugs listed in the MCES Program and their generics/biosimilars; review is conducted as part of the precertification process.

Immunotherapy outpatient continuance exceptions

Receiving combination therapy: Receiving a provider-administered combination chemotherapy at the same visit.
Age: Patient is less than 18 years of age.

Policy Summary

PayerAmeriHealth

PolicyMost Cost-Effective Setting (MCES) Program Drug List

Policy CodePolicy N/A

Change TypeImmunotherapy expansion added (May 1, 2026)

Effective DateJan 1, 2012

Next Review DateTBD

Key ActionObtain AmeriHealth precertification approval of the treatment setting before scheduling medical-benefit administration of listed drugs.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

The Immunotherapy MCES Expansion (effective May 1, 2026) allows certain oncology immunotherapy agents to remain administered in the outpatient setting only when specific continuation conditions are met. Members will continue to receive outpatient care if any of the following apply: receiving a provider‑administered combination chemotherapy at the same visit; the patient is less than 18 years of age; the treatment is within the first 3 doses of starting therapy; or the patient is experiencing severe toxicity requiring continuous monitoring (examples include myocarditis, pericarditis, arrhythmias, impaired ventricular function). These exceptions apply specifically to the immunotherapy agents added under the May 1, 2026 expansion.

Provider Requirements and Precertification

Prior Authorization

Treatment setting approval required

AmeriHealth must approve the treatment setting for medications on the Most Cost-Effective Setting (MCES) Program drug list. This review is performed during the precertification process to confirm the member meets applicable medical policy coverage criteria and that the requested treatment setting is safe and cost‑effective.

MCES Program applies to the drugs listed on the MCES Program Drug List (see policy drug list).
All generics and biosimilars to a reference product on the MCES list are subject to precertification review.

Note

Biosimilar/generic precertification

All generics and biosimilars of reference products included in the MCES Program are subject to the same precertification review as brand products to determine appropriate treatment setting and coverage under AmeriHealth medical policy.

Documentation Required

Precertification documentation

Documentation submitted with the precertification request must demonstrate that the member meets the applicable medical policy coverage criteria and include information supporting that the requested treatment setting meets MCES program requirements (for example: clinical rationale for setting, prior treatments and responses, relevant labs/imaging, and any supporting specialty consult notes).

Include sufficient clinical records to show medical necessity and why the chosen setting is required.
Document prior authorization or precertification identifiers and clinician contact information.

Denial Risk

Precertification required

Failure to obtain AmeriHealth approval of the treatment setting prior to administration may result in denial of coverage or payment. Providers should obtain precertification approval that specifically authorizes the treatment setting for the listed medication.

Do not assume site-of-care coverage without prior AmeriHealth approval.
Verify precertification decision includes approved setting before scheduling or administering therapy.

Key Definitions

IVIG/SCIG class

DefinitionIntravenous/subcutaneous immunoglobulin (IVIG/SCIG) class — immunoglobulin therapies included in the Most Cost-Effective Setting (MCES) Program.

MCES inclusion effective dateJanuary 1, 2012 (IVIG/SCIG class added to MCES on this date).

Scope noteSome IVIG/SCIG products approved by the FDA after January 1, 2012 are reflected with the January 1, 2012 date to indicate when program requirements went into effect for the class.

Typical settings impactedOffice, infusion center, hospital outpatient, home — treatment setting approval required via precertification for listed products.

Immunotherapy MCES Expansion

DefinitionImmunotherapy MCES Expansion — addition of specified oncology immunotherapy agents to the MCES Program effective May 1, 2026.

Effective dateMay 1, 2026 (Immunotherapy MCES Expansion launched).

Outpatient continuation exceptionsMembers may continue to receive care in the outpatient setting if ANY of the following apply: receiving a provider‑administered combination chemotherapy at the same visit; patient is less than 18 years of age; within the first 3 doses of starting therapy; experiencing severe toxicity requiring continuous monitoring (e.g., myocarditis, pericarditis, arrhythmias, impaired ventricular function).

Example agents addedDarzalex/Faspro; Imfinzi; Jemperli; Keytruda/Qlex; Libtayo; Loqtorzi; Opdivo/Qvantig; Rybrevant/Faspro; Tecentriq/Hybreza; Zynyz (all Date Added = May 1, 2026).

Program ruleAll generics and biosimilars to a reference product in this expansion are subject to precertification review for the most cost‑effective setting; list is subject to change.

Approved Sites of Care

Note

Site-of-care approval (office | infusion center | hospital outpatient | home)

AmeriHealth must approve the treatment setting (site of care) for listed MCES medications via the precertification process; the Immunotherapy MCES Expansion includes specific conditions under which members may continue care in the outpatient setting.

Approved settings include: office, infusion center, hospital outpatient, or home (approval obtained through precertification).
Immunotherapy outpatient continuation applies if patient is receiving a provider‑administered combo chemotherapy at the same visit; is <18 years old; is within the first 3 doses of therapy; or is experiencing severe toxicity requiring continuous monitoring.

OpenPayer

Most Cost-Effective Setting (MCES) Program Drug List

Coverage Criteria & Immunotherapy Expansion

Provider Requirements and Precertification

Key Definitions

Approved Sites of Care

Step Therapy / Program Application

Biosimilar Handling

Program Background