Site of Care Medical Pharmacy
Customize your policy alerts
Sign up for AmeriHealth Caritas Policy CCPD ID: CCP.8004 alerts
Get alerted when Policy CCPD ID: CCP.8004 changes without checking for updates manually.
Monitor payer policy activity
Defines site-of-care prior authorization requirements for a long list of specialty/infusible drugs when administered in outpatient hospital settings instead of home, in-network infusion centers, or in-network offices; applies to AmeriHealth Caritas Medicaid members. Providers must obtain distinct site-of-care authorization in addition to any clinical prior authorization.
Added language to clarify that a site-of-care (SOC) authorization is distinct from a clinical authorization.
Added anaphylaxis as a site-of-care exemption criterion.
Added FDA-approved biosimilars for drugs already in the policy and statement that newly approved generics/biosimilars/505(b)(2) drugs will automatically be included.
Added Code list and Code Description and updated related HCPCS/J-codes.
Coverage Criteria and Exemptions
Site-of-Care Exemption Criteria
Outpatient hospital administration is covered only when ONE of the following site-of-care exemption criteria is met:
Added explicitly as SOC exemption
Multiple sub-conditions grouped under medical instability
Specific immunoglobulin exemption
All three required for this alternative IVIG/SCIG exemption
This policy does not apply to certain medications when used in the pediatric population. Specifically, medications used in patients younger than 21 years (< 21) are excluded from the site-of-care authorization requirement and are not subject to the outpatient-hospital SOC restriction described in this document.
Reimbursement for outpatient hospital administration of the listed drugs is limited when a safe alternative site exists. If a drug can be safely administered in the member’s home, an in‑network infusion center, or an in‑network office, outpatient hospital administration will not be authorized for reimbursement unless one of the policy’s exemption criteria is met. The policy further clarifies that a separate site-of-care (SOC) authorization is required in addition to any clinical prior authorization that may apply.
Related Codes and Pediatric Coding Notes
What Providers Must Do
Site-of-care prior authorization required for outpatient hospital administration
Site-of-care prior authorization is required for the listed specialty/infusion drugs when administered in an outpatient hospital setting and is distinct from any clinical prior authorization that may also be required.
No step therapy specified — focus on SOC authorization
No step therapy requirements are specified in this policy; the primary authorization requirement is site-of-care authorization and the listed SOC exemptions.
Required documentation to justify outpatient hospital administration
Clinical documentation must demonstrate that at least one SOC exemption criterion is met (for example: documented anaphylaxis or severe infusion reaction; medical instability with significant comorbidity or fluid-status concerns; clinically significant physical or cognitive impairment; difficulty with vascular access; or IVIG/SCIG–specific evidence such as IgA deficiency with anti‑IgA antibodies or the alternative IVIG/SCIG environment/access conditions).
- Documented history of anaphylaxis or severe adverse reaction during or immediately following an infusion.
- Evidence member is medically unstable for safe outpatient/home administration (complex condition/status/therapy, significant comorbidity, fluid‑status concerns).
- Documentation of physical or cognitive impairment precluding outpatient/home treatment or difficulty establishing/maintaining vascular access.
- For IVIG/SCIG: documentation of IgA deficiency with anti‑IgA antibodies OR all three: home environment unsuitable; prescriber unable to administer in office; no ambulatory infusion suite options.
Denial risk if SOC authorization not obtained
Reimbursement for outpatient hospital administration will not be authorized unless site-of-care authorization is obtained when the listed drugs can be safely administered in the home, an in‑network infusion center, or an in‑network office.
Policy Background
This policy lists numerous specialty injectable and infusion drugs (including immune globulins, monoclonal antibodies, and other specialty infusible agents) for which outpatient hospital reimbursement requires a distinct site-of-care (SOC) authorization when administration could safely occur in less intensive settings such as the home, an in‑network infusion center, or an in‑network office. The policy also defines specific exemption criteria (for example, documented anaphylaxis or medical instability and IVIG/SCIG–specific criteria) that permit outpatient hospital administration without an SOC denial when met.
Key Definitions
Care Setting Definitions and Ordering Rules
SOC authorization required when outpatient hospital used instead of home/office/infusion center
Outpatient hospital administration requires SOC authorization when the drug can be safely administered in home, an in‑network infusion center, or an in‑network office; exceptions in the SOC exemption criteria permit hospital administration without denial.
- Settings considered: home, in‑network office, in‑network infusion center, hospital outpatient.
- Authorization for hospital outpatient reimbursement is contingent on meeting an SOC exemption or obtaining SOC authorization.
Biosimilars and Automatic Inclusion
Automated inclusion of newly approved biosimilars/generics/505(b)(2)
Newly approved generics, biosimilars, or 505(b)(2) versions of drugs already listed in this policy will automatically be included under this SOC policy.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.