CurrentColorado Rocky Mountain Health PlansPolicy N/A

Provider Administered Drugs - Site of Care Policy

Know when Colorado Rocky Mountain Health Plans releases new policies or updates existing guidance.

Defines site-of-care medical necessity review and coverage rules for certain provider-administered injectable oncology and related drugs, and explains how prior authorization and care coordination affect where members receive infusions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProvider Administered Drugs - Site of Care Policy

Policy CodePolicy N/A

Change TypeAdded drugs to site-of-care policy

Effective DateAug. 1, 2026

Next Review DateN/A

Key ActionDuring prior authorization the ordering provider must select an alternate site (home infusion, community oncology office, or ambulatory infusion suite) for the specified number of infusions in the Cancer Guidance Program tool when applicable.

SourceLink

POLICY UPDATE CHANGES

Several oncology medications (e.g., Darzalex Faspro, Imfinzi, Jemperli, Keytruda and variants, Libtayo, Opdivo and variants, Phesgo, Tecentriq and variants, Yervoy) are added to the Provider Administered Drugs - Site of Care Policy effective Aug. 1, 2026.

Aug. 1, 2026effective date for added drugs

30 midistance threshold (non-urban)

10 midistance threshold (urban)

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Site-of-Care Coverage Criteria

Medical necessity site-of-care criteria

Site-of-care determination performed by the Optum Cancer Guidance Program as part of prior authorization; coverage depends on meeting medical necessity for outpatient hospital infusion or availability of alternate in‑network sites within specified distances.

Site-of-care coverage determination: 1) Medication is in‑scope for the Provider Administered Drugs - Site of Care Policy; AND 2) Prior authorization request is submitted and includes clinical records and the member's treatment plan for review by the Cancer Guidance Program; AND 3) The Cancer Guidance Program maps the member's residence to identify available in‑network alternate providers (home infusion, ambulatory infusion centers, or community oncology offices) within applicable travel distance; AND 4) Medical necessity criteria for outpatient hospital infusion are documented (diagnoses/conditions indicating outpatient hospital administration is required).Alternate site available if distance >? — continued hospital coverage allowed when alternate sites are NOT available within 30 miles one‑way (10 miles in urban population areas) or state‑required mileage if less than 30 miles

If ALL are met, the member may continue receiving the drug in the outpatient hospital setting; otherwise coverage is provided for administration at an eligible alternate site of care (with care coordination as appropriate).

The Provider Administered Drug Program for medical injectable medications does not apply to all commercial products. Specifically, Indemnity/Options PPO plans are excluded from the program; other UnitedHealthcare commercial plans listed in the source remain in scope. Providers should confirm plan type before initiating site-of-care processes or prior authorization workflows.

If medical necessity for treatment in the outpatient hospital setting is not met following review by the Optum Cancer Guidance Program, continued administration in that setting will not be supported. In those cases coverage will be provided for administration at an eligible alternate site of care (for example, home infusion, ambulatory infusion suite, or community oncology office), and members will be notified by letter and outreach call to allow discussion of options with their treating provider.

Providers should submit required clinical records and the member’s treatment plan as part of the prior authorization so the Cancer Guidance Program can complete the medical necessity and site-of-care determination; when a transition is required, care coordination assistance (home health, ambulatory infusion agencies, or community oncology offices) may be offered to support continuity of care.

Codes, Distance Thresholds, and Related Coding Rules

Prior authorization affected codesmixed

affected codes

Medications in scope continue to require prior authorization (specific HCPCS/CPT/NDC codes not listed in this document).

Maximum travel distance for alternate-site requirement

Maximum travel distance (non-urban)>30 miles one-way — member may continue outpatient hospital coverage only if no in-network alternate site is within 30 miles

Maximum travel distance (urban)>10 miles one-way in urban population areas — alternate-site requirement uses 10-mile threshold for urban members

State-required mileageState regulatory requirements may set a maximum distance less than 30 miles; where applicable the state-required mileage applies

Provider Requirements and Actions

Prior Authorization

Prior authorization — select alternate site during PA

For prior authorization requests that require a site-of-care medical necessity review, the ordering provider must select an alternate site of care (home infusion, community oncology office, or ambulatory infusion suite) for a specified number of infusions in the Cancer Guidance Program tool during the PA process.

Alternate site options: home infusion, community oncology office, ambulatory infusion suite.
Selection is made in the Cancer Guidance Program tool during prior authorization.

Step Therapy

Step therapy — site-of-care applied alongside existing UM

Site-of-care requirements will be applied in addition to existing utilization management; the document does not impose any new step sequencing or additional step therapy requirements beyond current UM processes.

Site-of-care medical necessity review is performed through the Optum Cancer Guidance Program in addition to evaluating the PA and drug regimen.

Background and Scope

Certain injectable oncology and related agents may be medically appropriate to administer outside the hospital outpatient setting. Starting Aug. 1, 2026, specified oncology drugs will be added to the Provider Administered Drugs - Site of Care Policy and will be subject to a site-of-care medical necessity review performed through the Optum Cancer Guidance Program as part of prior authorization. This review considers clinical records and geographic access to determine whether members may continue receiving treatment in the outpatient hospital setting or should be transitioned to an alternate in-network site that meets eligibility requirements. The program aims to enable safe, effective administration at the most suitable location while supporting continuity of care when maintenance treatments are moved to home or ambulatory infusion settings.

Definitions and In-Scope Criteria

In-scope medications

Included oncology and related agents (sample)Darzalex Faspro; Imfinzi; Jemperli; Keytruda (and variants); Libtayo; Opdivo (and variants); Phesgo; Tecentriq (and variants); Yervoy

Scope referencePolicy applies to the Provider Administered Drugs - Site of Care list; refer to the maintained resource for the up-to-date drug list

Prior authorization noteMedications in scope continue to require prior authorization and undergo site-of-care medical necessity review by the Optum Cancer Guidance Program

Geographic eligibility

Primary geographic ruleIf nearest in-network ambulatory infusion suite or community oncology practice is >30 miles one-way from member residence, member may continue hospital outpatient coverage if no eligible alternate site exists

Urban area threshold

Maintenance and Continuation Treatment Criteria

Maintenance treatment site-of-care

Maintenance treatments may be administered at home or ambulatory infusion settings when clinically appropriate; efforts should be made to preserve continuity with the original treating provider.

Continuation guidance: When maintenance treatments are administered at home or in ambulatory infusion settings, care coordination will be provided to support continuity with the original treating provider as appropriate.

No drug‑specific refill or duration limits are described in this policy; preserve site continuity when clinically indicated.

Site-of-Care Operational Rules

Note

Distance thresholds for alternate site eligibility

An alternate in‑network ambulatory infusion suite or community oncology provider must be within 30 miles one‑way of the member's residence (or within 10 miles in urban population areas) for the member to be transitioned away from hospital outpatient coverage; if no eligible alternate site or home infusion services are available within those distances, the member may continue hospital outpatient coverage.

State-required mileage may be less than 30 miles where applicable.
The Cancer Guidance Program maps the member's residence to determine availability of in‑network alternate providers.

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