Specialty Care Medication Site of Care/Infusible Updated Drug List
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Defines McLaren Health Plan's Site of Care requirements for certain specialty injectable and infusible medications for Community and McLaren Health Advantage members, including reimbursement exclusions for hospital outpatient infusion centers and potential preauthorization requirements.
Effective August 1, 2024, McLaren Health Plan updated the list of injectable/infusible medication codes subject to Site of Care requirements.
Infusions for the listed medications are excluded from reimbursement when administered in a hospital outpatient infusion center; they must be administered in a non-facility setting (home or non-hospital affiliated infusion center).
Medications on the list may still require preauthorization regardless of site of care; refer to the Service Codes Requiring Preauthorization list on the MHP website.
Exceptions to the site-of-care requirement may be made when a physician submits an authorization request with supporting documentation indicating contraindications to home or non-hospital infusion.
Site of Care Coverage Criteria
Site of Care coverage criteria
Coverage and reimbursement conditions for listed injectable/infusible medications:
Exception pathway
- A physician may submit an authorization request requesting an exception.
- The request must include supporting clinical documentation indicating contraindications to administration in the home or a non-hospital infusion center; McLaren Health Plan will review for possible approval.
- Prescribers and members will receive advance notification if they are impacted by these Site of Care requirements.
Operational contact
Affected Codes and Reimbursement Notes
Authorization, Exceptions, and Provider Guidance
Preauthorization may still be required; see Service Codes Requiring Preauthorization
Medications on the Site of Care list may require preauthorization regardless of the site where they are administered. Providers must consult the Service Codes Requiring Preauthorization list on the McLaren Health Plan website for preauthorization requirements and instructions.
- Reference: McLarenHealthPlan.org > Providers > Medical Management and Authorization > Referral and Authorization Guidelines (Service Codes Requiring Preauthorization list).
Submit physician authorization request with supporting documentation for exceptions
A physician may submit an authorization request with supporting clinical documentation to request an exception when a member cannot safely receive the medication in the home or a non-hospital infusion center; MHP will review the documentation for possible exception approval.
- Include supporting documentation that indicates the contraindication to home or non-hospital infusion.
- Prescribers and members will receive advance notification if impacted by Site of Care requirements.
- For questions, contact Provider Relations at (888) 327-0761 (TTY: 711).
Key Definitions
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