CurrentUnitedHealthcarePolicy N/A

Provider Administered Drugs - Site of Care Policy (expanded oncology injectable list)

Know when UnitedHealthcare releases new policies or updates existing guidance.

Defines site-of-care medical necessity review and coverage rules for certain provider-administered oncology drugs and who this affects (providers, members, and participating UnitedHealthcare commercial plans). Applies to prior authorization requests for listed injectable oncology medications beginning Aug 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyProvider Administered Drugs - Site of Care Policy (expanded oncology injectable list)

Policy CodePolicy N/A

Change TypeExpanded drug list added

Effective DateAug. 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization including site-of-care selection and clinical records so the Optum Cancer Guidance Program can perform medical necessity site-of-care review.

SourceLink

POLICY UPDATE CHANGES

Several oncology drugs (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 expanded drug list

30mi / 10migeographic distance allowance

Optum Cancer Guidancemedical necessity review program

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Coverage Criteria

Outpatient hospital infusion coverage criteria

Covered in outpatient hospital setting when ALL of the following are met:

Geographic access: The closest in-network ambulatory infusion suite or community oncology practice is greater than 30 miles one way from the member's residence (or greater than 10 miles if the member lives in an urban population area), or state-required mileage if less than 30 miles; and there are no oncology home infusion services available in the member's residential area.>30 miles or >10 miles urban or state-specified

Member residence will be mapped by the Cancer Guidance Program team to confirm distance and local availability.

Medical necessity indications: Documentation of medical diagnoses or conditions and the member's treatment plan indicate that administration in the outpatient hospital setting is medically necessary as determined by review of submitted clinical records.N/A

Determination made by the Optum Cancer Guidance Program during prior authorization.

The Provider Administered Drug Program for medical injectable medications does not apply to Indemnity/Options PPO plans. These plan types are explicitly excluded from the program and are therefore not subject to the site-of-care requirements described in this policy.

When the Optum Cancer Guidance Program determines that a member does not meet medical necessity criteria for continued administration in the outpatient hospital setting, coverage for the hospital outpatient site may not be approved and an alternate eligible site of care will be required (for example, home infusion, ambulatory infusion center, or community oncology office).

The ordering provider will be notified through the Cancer Guidance Program workflow and must select an alternate site (home infusion, community oncology office, or ambulatory infusion suite) in the prior authorization tool for a specified number of infusions. If continued outpatient hospital treatment is not justified, the Cancer Guidance Program Nurse will contact the provider and request that the provider add the alternate site to the prior authorization.

Coding and Distance Rules

inv-04: Distance to nearest non-hospital provider — Greater than 30 miles one-way (or greater than 10 miles for urban population areas; state-required mileage if less than 30 miles).

Distance threshold (rural/default)Greater than 30 miles one-way from member's residence to nearest in‑network ambulatory infusion suite or community oncology practice.

Distance threshold (urban)Greater than 10 miles one-way if the member lives in an urban population area.

State-specific mileageUse state-required mileage if that requirement is less than 30 miles.

Home infusion availability requirementCoverage continuation in outpatient hospital also requires that no oncology home infusion services are available in the member's residential area.

Most actionable criterionIf the closest in‑network ambulatory infusion suite or community oncology practice is >30 miles one way (>10 miles in urban areas) and no home infusion is available, outpatient hospital administration may continue.—highlighted

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Site-of-Care Review

Prior authorization is required for medications in scope and must include site-of-care selection. The Optum Cancer Guidance Program will evaluate medical necessity for the selected site of care as part of the prior authorization review.

Prior authorization already required for in-scope medications
Site-of-care selection must be included in the prior authorization submission
Optum Cancer Guidance Program conducts the site-of-care medical necessity review

Note

Alternate Site Update Requirement

If medical necessity for continued outpatient hospital infusion is not met, the Cancer Guidance Program Nurse will contact the treating provider and request that an alternate site of care be added to the prior authorization for a specified number of infusions (e.g., home infusion, ambulatory infusion suite, or community oncology office).

Provider may be asked to add an alternate site during the prior authorization process

Background

This policy expands the Provider Administered Drugs - Site of Care Program effective Aug. 1, 2026 by adding several oncology injectable drugs (for example, Darzalex Faspro, Imfinzi, Jemperli, Keytruda and variants, Libtayo, Opdivo and variants, Phesgo, Tecentriq and variants, Yervoy). For prior authorizations that include these drugs, the Optum Cancer Guidance Program will perform a separate site-of-care medical necessity review to determine whether outpatient hospital administration is appropriate or whether administration should occur at an alternate eligible site of care.

Definitions

inv-10: Closest in-network non-hospital infusion provider within 30 miles one-way (or within 10 miles for urban areas), unless state regulations specify a lesser distance.

Primary geographic ruleClosest in‑network non‑hospital infusion provider (ambulatory infusion suite or community oncology practice) must be within 30 miles one‑way for outpatient hospital site NOT to be continued.

Urban exceptionWithin 10 miles one‑way for members in urban population areas.

State regulation overrideIf a state requires a lesser mileage than 30 miles, that state‑specific distance applies.

Action for providersCancer Guidance Program will map the member's residence to determine in‑network non‑hospital provider availability within the specified distances.

Most actionable itemClosest in‑network non‑hospital infusion provider must be within 30 miles one‑way (10 miles for urban areas) unless state law specifies a smaller distance — if not, outpatient hospital administration may be permitted when no home infusion exists.

Initial Therapy Site-of-Care Authorization

Initial therapy site-of-care authorization

Initial prior authorization must include site-of-care selection; the Cancer Guidance Program will evaluate medical necessity for outpatient hospital administration.

Initial PA requirements: Submit prior authorization for the in-scope medication and select site-of-care(s) (hospital outpatient and one or more alternate sites such as home infusion, ambulatory infusion center, or community oncology office) in the authorization tool.N/A

Optum Cancer Guidance Program will perform the site-of-care medical necessity review during the prior authorization process and may request alternate site selections if hospital outpatient site is not justified.

Documentation to include: Provide clinical records and the member's treatment plan to support medical necessity for the requested site of care.N/A

Documentation is reviewed by the Cancer Guidance Program as part of the PA review.

Continuation Therapy Site Rules

Continuation therapy site rules

Continuation at hospital outpatient setting allowed only if medical necessity for that site is met; otherwise continuation must occur at an eligible alternate site.

Continuation at hospital: Member meets site-of-care medical necessity for continued outpatient hospital infusions as determined by the Optum Cancer Guidance Program review.N/A

If site-of-care medical necessity for continued outpatient hospital treatment is not met, the Cancer Guidance Program Nurse will request the provider add an alternate site of care to the prior authorization for a specified number of infusions.

Step Therapy / Alternate Site Requirements

Requirement	Action for provider
When the Cancer Guidance Program requests an alternate site-of-care selection for continued outpatient therapy
Provider must add an alternate site of care to the prior authorization for the specific number of infusions requested in the Cancer Guidance Program tool

Site of Care Determination

Note

Cancer Guidance Program determines hospital outpatient medical necessity

Medical necessity for administration in the hospital outpatient setting will be determined by the Optum Cancer Guidance Program during the PA review; if criteria are not met, coverage for the outpatient hospital site may not be approved and an alternate eligible site will be required.

Note

Alternate covered settings when hospital outpatient not required

When hospital outpatient administration is not medically necessary, covered alternate settings include home health infusion, ambulatory infusion agencies/suites, or community oncology offices if they meet eligibility and geographic access requirements.

Providers may select home infusion, a community oncology office, or an ambulatory infusion suite as alternate sites during the prior authorization process.
Member residence will be mapped to confirm alternate providers are within the required geographic distance (30 miles one-way, or 10 miles in urban areas; state-required mileage may apply).

Catch payer policy changes before they impact reimbursement

Catch payer policy changes before they impact reimbursement

OpenPayer

Provider Administered Drugs - Site of Care Policy (expanded oncology injectable list)

Coverage Criteria

Coding and Distance Rules

Provider Actions and Requirements

Background

Definitions

Initial Therapy Site-of-Care Authorization

Continuation Therapy Site Rules

Step Therapy / Alternate Site Requirements

Site of Care Determination