Effective January 1, 2019, Highmark implemented the Site of Care Drug Management Program designed to improve the experience for members using certain medically billed infusion drugs that are considered safe and effective for administration outside of a hospital setting. The program helps decrease the cost of care for these therapies by ensuring appropriate utilization of the drugs through medical policy and a prior authorization requirement.
With the implementation of this program, the medical policies for these drugs were revised to incorporate a medical necessity review for the requested site of care in addition to the already existing review that takes place for clinical appropriateness of the drug therapy.
Approved sites of care include the following:
- Home Infusion
- Doctor’s Office (not affiliated with a hospital)
- Ambulatory Infusion Center (not affiliated with a hospital)
The list of Site of Care drugs can be found:
- Within the Highmark Site of Care Medical Policy I-151, which is accessible via the MEDICAL POLICY SEARCH tool at the top of this website.
- In the list of Procedure Codes Requiring Authorization, under the “SOC” category.
Submission of authorization requests for drugs should be done through our online provider portal (Availity). This helps ensure that your authorization is processed in a timely manner.
Last updated on 7/9/2024 11:48:47 AM