Most Cost-Effective Setting (MCES) Program Drug List
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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.
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).
Coverage Criteria & Immunotherapy Expansion
MCES Program Coverage and Immunotherapy Expansion Exceptions
Covered when ALL of the following are met
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.
- Early dosing period: Within the first 3 doses of starting therapy.
- Severe toxicity monitoring: Experiencing severe toxicity requiring continuous monitoring (e.g., myocarditis, pericarditis, arrhythmias, impaired ventricular function).
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.
Coverage for medications listed in the MCES Program requires that AmeriHealth approval of the treatment setting be obtained through the precertification process and that the member meet the underlying medical policy coverage criteria for the requested drug. For the Immunotherapy MCES Expansion, precertification and documentation that medical‑policy criteria are met remain required; the expansion only permits outpatient continuation when the specified exceptions are present.
Provider Requirements and Precertification
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.
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.
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.
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
Approved Sites of Care
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.
Step Therapy / Program Application
| Policy item | Details |
|---|---|
| Generics and biosimilars | All generics and biosimilars to a reference product included in the MCES Program are subject to precertification review for the most cost‑effective setting. |
Biosimilar Handling
Biosimilars and generics require precertification
Reiterate: all generics and biosimilars to reference products in the MCES Program require precertification review to establish the most cost‑effective setting.
Program Background
The Most Cost‑Effective Setting (MCES) Program was established to manage the total cost of care by ensuring members meet medical policy coverage criteria and that the treatment setting for certain medical‑benefit drugs is safe and cost‑effective. AmeriHealth conducts this review as part of the precertification process and requires approval of the treatment setting for listed drugs (examples: office, infusion center, hospital outpatient, or home). The program originally included the IVIG/SCIG class beginning January 1, 2012 and was expanded on May 1, 2026 to include select oncology immunotherapy agents with defined outpatient continuation rules.
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