ph-9001
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Voluntary Site of Service Management Policy

Policy Number: PH-9001

Provider-Administered Drug Program - Voluntary Site of Service Management Policy

Date of Origin: 4/1/2019    

  1. Background

The Provider-Administered Drug Program includes, effective July 1, 2019, Voluntary Site of Service Management.  Voluntary Site of Service Management manages members receiving infusions of select specialty medications as listed in this policy in a high cost outpatient treatment facility. According to criteria outlined in this policy, members and providers may elect to transition care to a more cost-effective, clinically-appropriate location to receive their infusion(s).

  1. Scope
  1. Applicable to all groups and individual health plans that participate in the Provider-Administered Drug Program and have home healthcare benefits  
    1. New utilizers of these medications on or after July 1, 2019 with sufficient home health benefits, will managed by this service.
    2. Members currently using these medications will be extended the opportunity to participate in Voluntary Site of Service Management upon prior authorization renewal or by identification through paid claims reporting.
  1. Program Requirements
  1. Impacted members will be identified through the existing Provider-Administered Drug prior authorization program or through paid claims reporting for identification of current utilizers.
  2. All drugs in Voluntary Site of Service Management require prior authorization.
  3. Members with approved drug prior authorizations  and identified as receiving the select specialty drugs as listed in section IV in a hospital outpatient setting will be transitioned internally to Magellan Rx’s Infusion Referral Center (IRC).
  4. The IRC will confirm that the following criteria are met in order for the member to be transitioned to an alternate place of treatment, such as a home infusion provider or infusion suite.
    1. The member must have sufficient home health benefits in place.
    2. The member must agree to transition care to alternate setting.
    3. The prescriber must be contacted and agree to transition the member’s infusion to an alternate place of treatment.
    4. The prescriber must approve that the use of the alternate place of treatment is clinically appropriate for the member’s infusion.
  5. When required, the home infusion provider will obtain all necessary nursing precertifications as specified by the member’s benefits.
  1. Drugs in Scope
    1. Select infused specialty medications included in the Voluntary Site of Service Management program are subject to change.
    2. Drugs in Scope

HCPCS

Brand Name

Generic Name

J3262

ACTEMRA

tocilizumab

J1931

ALDURAZYME

laronidase

J0490

BENLYSTA

belimumab

J0597

BERINERT

C1 esterase inhibitor

J1556

BIVIGAM

intravenous immune globulin

J1786

CEREZYME

imiglucerase

J0717

CIMZIA

certolizumab pegol

J0598

CINRYZE

C1 esterase inhibitor

J1743

ELAPRASE

idursulfase

J3060

ELELYSO

taliglucerase alfa

J3380

ENTYVIO

vedolizumab

J0180

FABRAZYME

agalsidase beta

J1572

FLEBOGAMMA

intravenous immune globulin

J1569

GAMMAGARD

intravenous immune globulin

J1566

GAMMAGARD S/D

intravenous immune globulin

J1557

GAMMAPLEX

intravenous immune globulin

J1561

GAMUNEX

intravenous immune globulin

J1599

IMMUNE GLOBULIN

intravenous immune globulin

Q5103

INFLECTRA

infliximab-dyyb

J0221

LUMIZYME

alglucosidase alfa

J1458

NAGLAZYME

galsulfase

J1568

OCTAGAM

intravenous immune globulin

J0129

ORENCIA

abatacept

J1459

PRIVIGEN

intravenous immune globulin

J1745

REMICADE

infliximab

Q5104

RENFLEXIS

Infliximab-abda

J1602

SIMPONI ARIA

golimumab

J1300

SOLIRIS

eculizumab

J3357

STELARA

ustekinumab

J3385

VPRIV

velaglucerase alfa