Most Cost-Effective Setting Program

AmeriHealth Administrators is committed to ensuring that our members receive care that meets the coverage criteria in our medical policies and is delivered in safe, cost-effective settings. Through the Most Cost-Effective Setting (MCES) Program, AmeriHealth Administrators reviews the requested site-of-care treatment settings for certain specialty drugs that are eligible for coverage under the medical benefit. These reviews occur as part of the precertification process for members enrolled in AmeriHealth Administrators medical plans.

AIn 2026, AmeriHealth Administrators has added immunotherapy drugs to the MCES program.

View the complete list of drugs in the Most Cost-Effective Setting Program.

Cost-Effective settings

For the drugs in this program, AmeriHealth Administrators considers the following settings to be safe and cost-effective:

• A physician’s office
• The plan member’s home, where an in-network home-infusion provider administers the drug
• An ambulatory (freestanding), independent infusion suite

Site-of-care review

• Injectable medications are covered when they meet the applicable medical necessity criteria. Once the medical necessity criteria for prescribing these medications are met, the MCES program coverage guideline is used to determine whether the requested site of care is medically necessary.
• The initial dose(s) of medications covered under these guidelines may be administered at the physician’s chosen facility.

Exception criteria (ALL MCES drugs)

• A documented history of an adverse event warranting a more intensive level of care during or following infusion of the prescribed medication unless the adverse event can be appropriately managed by the use of pre-medication(s) or other preventive actions.
• A documented history of a significant comorbidity or concerns regarding fluid overload status that precludes treatment at an alternative less intensive site of care.
• The member is medically unstable (e.g., respiratory, cardiovascular, or renal conditions).

Exception criteria (Immunotherapy drugs)*

• The member is receiving a provider-administered combination chemotherapy at the same visit.
• The member is less than age 18.
• The member is within the initial 3 months of starting therapy.
• The member is experiencing severe toxicity requiring continuous monitoring (e.g., myocarditis, pericarditis, arrhythmia, impaired ventricular function).

*Immunotherapy site of care review is limited to the AmeriHealth Administrators service area.