CurrentAmeriHealthPolicy N/A

Most Cost-Effective Setting (MCES) Program Drug List — Treatment Setting Precertification

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.

Policy Summary

PayerAmeriHealth

PolicyMost Cost-Effective Setting (MCES) Program Drug List — Treatment Setting Precertification

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2012

Next Review DateN/A

Key ActionObtain precertification of the treatment setting for medications on the MCES list before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2012Program established

>=100Drugs listed

IVIG/SCIGClass added

2012-01-01Effective metadata

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

Prior Authorization

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.

Policy Summary

PayerAmeriHealth

PolicyMost Cost-Effective Setting (MCES) Program Drug List — Treatment Setting Precertification

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2012

Next Review DateN/A

Key ActionObtain precertification of the treatment setting for medications on the MCES list before providing services.

SourceLink

On This Page

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Documentation Required

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.

Note

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.

Denial Risk

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

Most Cost-Effective Setting (MCES) Program — definition and purpose

Program nameMost Cost-Effective Setting (MCES) Program

PurposeRequires AmeriHealth approval of the treatment setting for certain medications covered under the AmeriHealth medical benefit to ensure the setting is safe and cost‑effective and to manage total cost of care.

When review occursThe review is conducted as part of the precertification process.

ScopeApplies to medications listed on the MCES Drug List and includes entire drug classes where specified.

Program established2012

IVIG/SCIG — class addition and inclusion in MCES

Class addedIntravenous/subcutaneous immunoglobulin (IVIG/SCIG)

Effective date for classJanuary 1, 2012

Applicability noteProgram requirements apply to all drugs in the IVIG/SCIG class regardless of individual FDA approval dates — the January 1, 2012 date indicates when requirements went into effect for the class.

Related operational impactAll generics and biosimilars to a reference product in this program (including IVIG/SCIG) are subject to precertification review for most cost‑effective setting.

Site of Care Requirements

Prior Authorization

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

Billing Rule

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.