Most Cost-Effective Setting (MCES) Program Drug List — Treatment Setting Precertification
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Defines the AmeriHealth MCES program that requires precertification of the treatment setting for certain medical-benefit medications to ensure safety and cost-effectiveness; affects providers requesting coverage for listed drugs under the AmeriHealth medical benefit in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria
The list identifies medications included in AmeriHealth’s Most Cost-Effective Setting (MCES) Program and is subject to change. Providers should confirm the current MCES Drug List at the time of precertification because additions or removals may occur.
All generics and biosimilars to a reference product on this list are included in the program and are subject to precertification review to determine the most cost‑effective and clinically appropriate treatment setting.
Provider Actions & Requirements
Precertification for treatment setting
Medications listed on the Most Cost-Effective Setting (MCES) Drug List require pre-certification of the treatment setting before services are provided. AmeriHealth must approve the treatment setting as part of the precertification process to confirm the requested setting is medically appropriate and cost-effective.
- Applies to all drugs on the MCES Drug List.
- Requests must be submitted prior to the planned service date to avoid potential denials or retroprocessing.
Precertification documentation
Providers must submit complete precertification documentation that supports the requested treatment setting. Documentation should allow AmeriHealth to determine that the member meets applicable medical policy criteria and that the setting requested is the most appropriate and cost-effective.
- Include clinical notes, diagnosis, prior treatments, rationale for the requested setting, and any relevant lab or imaging results.
- Incomplete or missing documentation may result in delays, denial, or retroactive processing of the claim.
Biosimilars/generics review
All generics and biosimilars to a reference product included in the MCES Program are subject to the same precertification review for treatment setting as their reference biologic or branded product. Providers must request precertification for these agents as well.
- Biosimilars and generics will be reviewed to ensure the same clinical and setting criteria are met.
- Addition of a product to the MCES list (including within a drug class added on a prior date) makes the precertification requirement effective for that product.
Precertification required
Requests for treatment settings for medications on the MCES list that do not obtain required precertification may be denied or subject to retroprocessing. Providers should verify precertification approval before delivering services.
- Failure to precertify may result in claim denial or payment adjustments.
- Check the current MCES Drug List for products and effective dates before submitting a request.
Definitions
Site of Care Requirements
Infusion center setting requires approval
The requested treatment setting (for example, an infusion center) for MCES‑listed medications must be approved by AmeriHealth as part of the precertification process to ensure cost‑effectiveness and safety.
- Do not schedule administration in the setting until precertification approval is obtained.
Biosimilar & Generic Guidance
Biosimilars/generics require precertification review
All generics and biosimilars to a reference product in this program are subject to precertification review to determine the most cost‑effective setting before coverage is authorized.
Step Therapy / Review Rules
| Drug / Product | Coverage note |
|---|---|
| All generics and biosimilars to a reference product in the MCES Program | Subject to precertification review for most cost‑effective setting |
| IVIG/SCIG drug class (intravenous/subcutaneous immunoglobulin) | Included in MCES Program effective January 1, 2012; all products in this class are subject to precertification review for most cost‑effective setting |
| Individual listed products (examples include Veopozt, Vimizim, VPRIV, Vyepti, Vyvgart, Wezlana, Xbryk, Xembify, Xolaire, Yesintek, Yimmugo, Zemaira) | Listed products are included on the MCES Drug List and are subject to treatment‑setting precertification; the list is subject to change |
Background
The MCES Program evaluates and approves the treatment setting in which certain medical‑benefit drugs are administered to manage total cost of care while ensuring safety and adherence to AmeriHealth policy. Program review is performed as part of the precertification process.
The intravenous/subcutaneous immunoglobulin class (IVIG/SCIG) was added to the MCES Program effective January 1, 2012; program requirements therefore apply to all drugs in that class regardless of individual FDA approval dates.
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