CurrentPriority Health MedicarePolicy 092

Reimbursement Requirements for Outpatient Medical Drugs

Customize your policy alerts

Sign up for priority_health_medicare Policy 092 alerts

Get alerted when Policy 092 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs site-of-service, specialty-pharmacy, prior-authorization, billing, coding, and documentation requirements for selected outpatient infusions, injections, and specialty drugs across commercial, Medicaid/Healthy Michigan, and Medicare products.

Policy Summary

PayerPriority Health Medicare

PolicyReimbursement Requirements for Outpatient Medical Drugs

Policy CodePolicy N/A

Change TypeExpanded applicability and clarified requirements

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionVerify the current Medical Drug List and determine whether the requested infusion or injection has a site-of-service restriction.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2026, the policy was expanded to apply to in-network providers in addition to out-of-network providers.

Effective January 1, 2026, the policy name changed to Reimbursement Requirements for Outpatient Medical Drugs.

J9271 was removed from the example portion because the code was removed from the edit.

The policy definition and applicability language were clarified through updates made in October 2025, February 2026, June 2026, and September 2026.

Home, office, or approved siteRequired alternative site of care for applicable selected drugs

877-974-4411Fax for medical drug prior-authorization and exception requests

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.

CurrentPriority Health MedicarePolicy 092

Reimbursement Requirements for Outpatient Medical Drugs

Customize your policy alerts

Sign up for priority_health_medicare Policy 092 alerts

Get alerted when Policy 092 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerPriority Health Medicare

PolicyReimbursement Requirements for Outpatient Medical Drugs

Policy CodePolicy N/A

Change TypeExpanded applicability and clarified requirements

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionVerify the current Medical Drug List and determine whether the requested infusion or injection has a site-of-service restriction.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2026, the policy was expanded to apply to in-network providers in addition to out-of-network providers.

Effective January 1, 2026, the policy name changed to Reimbursement Requirements for Outpatient Medical Drugs.

J9271 was removed from the example portion because the code was removed from the edit.

The policy definition and applicability language were clarified through updates made in October 2025, February 2026, June 2026, and September 2026.

Home, office, or approved siteRequired alternative site of care for applicable selected drugs

877-974-4411Fax for medical drug prior-authorization and exception requests

Support telephone number for exception requests

2In-network specialty pharmacies listed

J1299Example drug code for Soliris

Jan. 1, 2026Policy expansion and name change effective

Coverage and Site-of-Service Criteria

Commercial Product Site-of-Service Criteria

For fully funded and self-funded commercial products, Priority Health requires selected infusions and injections to be administered in the member’s home, physician office, or another Priority Health-approved site of care when all applicable criteria are met.

ALL of the following

The requested therapy is included on Priority Health’s current Medical Drug List with a Site of Service (SOS) restriction denoted. Examples include, but are not limited to, Soliris (J1299; injection, eculizumab, 2 mg).
Providers are responsible for verifying the current Medical Drug List at the time of service.
A medical injectable drug is administered in an outpatient hospital setting and is not on Priority Health’s Standard Fee Schedule.
The member receives the therapy at an alternative Priority Health-approved site of care, including the home or physician office, as required by Priority Health.

Exception Criteria

Exceptions may be considered when the provider submits a member-specific medical-necessity rationale through the applicable prior authorization process. The specialty-pharmacy exception permits administration at a non-covered site only under the conditions stated below.

An exception may be considered when ANY of the following applies

The member continues therapy at a non-covered site of service because the drug is obtained from an in-network specialty pharmacy.
The drug must be dispensed by a specialty pharmacy. The provider may submit a claim for administration of the medication only.
The medication is not available through an in-network specialty pharmacy and the provider submits a prior authorization request to Priority Health’s Pharmacy Department with a member-specific medical-necessity rationale.
Fax the completed medical drug prior authorization form to 877.974.4411 or call 800.942.0954 for support.
Only the starting dose or doses are administered at the non-approved site when multiple administrations are required and the medication is not subject to limited distribution.
All subsequent doses remain subject to the site-of-service policy.
The complexity of the infusion requires administration by, or under the supervision of, specialty-skilled nursing personnel to be performed safely and effectively.

Medicaid and Healthy Michigan Site-of-Service Criteria

For Medicaid and Healthy Michigan Plan members receiving select provider-administered drugs, the drug must be administered at a Priority Health-approved site of service unless an applicable exception is granted.

ALL of the following

The member is receiving a select provider-administered drug subject to Priority Health site-of-service requirements.
The drug is administered at a Priority Health-approved site of service.

Coverage Authorization and Medicare Criteria

Site-of-service compliance does not replace medical-necessity or coverage authorization requirements. The provider or member must satisfy the applicable coverage policy and obtain a favorable decision before treatment, specialty-pharmacy dispensing, or billing when prior authorization is required.

Applicable coverage authorization requirements

The provider verifies the drug’s current status and any site-of-service or specialty-pharmacy requirement on Priority Health’s Medical Drug List, Provider Manual, Drug Information page, or Medical Drug List–Search tool.
Priority Health may add or remove requirements as therapies, pharmacy distribution, and cost-effectiveness strategies change. Site-of-service requirements also apply to non-formulary medications approved through the exception process.
When the requested drug or treatment has prior authorization requirements, the member or provider submits the required request and receives a favorable coverage decision in addition to meeting the place-of-service requirements.
When a covered drug requires specialty-pharmacy dispensing, the prior authorization request identifies ‘Specialty Pharmacy’ in the Billing section before the specialty pharmacy bills and dispenses the drug.

Medicare indications not meeting an applicable coverage policy

Coding and Specialty Pharmacy Reference

Example drug subject to site-of-service requirementsHCPCS

J1299

Injection, eculizumab, 2 mg (Soliris)

ModifiersModifier

No codes listed

Claim coding systemsmixed

No codes listed

Policy Information

PolicyReimbursement Requirements for Outpatient Medical Drugs, Billing Policy No. 092

Date of originJune 19, 2025

Review datesOctober 2025; February 2026; June 2026; September 2026

Accredo Contact

PharmacyAccredo Specialty Pharmacy

Phone877.222.7336

Fax

Provider Requirements and Submission Actions

Prior Authorization

Verify site-of-service restrictions

Verify the current Medical Drug List and determine whether the requested infusion or injection has a Site of Service restriction. If the restriction applies, arrange administration in the home, office, or another Priority Health-approved site of care.

Prior Authorization

Request an exception

If the medication is unavailable through an in-network specialty pharmacy or an exception is needed, submit a completed Medical Drug Prior Authorization form to the Priority Health Pharmacy Department by fax at 877.974.4411. Include a member-specific medical-necessity rationale; support is available at 800.942.0954.

Prior Authorization

Starting-dose exception

An exception may be considered for starting doses only when multiple administrations are required and the medication is not subject to limited distribution. All subsequent doses remain subject to the policy.

Policy Definitions

Fully Funded (Fully Insured) Commercial Products

Plan typeEmployer-offered group health plan

Claims riskTransferred from the employer to the insurance carrier

Premium and claimsThe employer pays a predetermined premium; the insurer administers benefits and pays covered medical claims

Self-Funded Commercial Products

Plan typeEmployer-sponsored benefit arrangement

Claims fundingThe employer funds covered medical claims using its own assets

Financial risk

Policy Summary

PayerPriority Health Medicare

PolicyReimbursement Requirements for Outpatient Medical Drugs

Policy CodePolicy N/A

Change TypeExpanded applicability and clarified requirements

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionVerify the current Medical Drug List and determine whether the requested infusion or injection has a site-of-service restriction.

SourceLink

On This Page

The member has a history of infusion reactions that led to serious adverse events despite premedication and infusion-rate control.

The member has a history of severe adverse events following an infusion, such as anaphylaxis, seizure, thromboembolism, myocardial infarction, or renal failure.

The member is medically unstable, such as having unstable renal function or unstable vascular access.

The distance from the member’s location to the nearest approved site of service is unreasonable.

The member receives an immune checkpoint inhibitor in combination with provider-administered chemotherapy on the same day.

Medicaid and Healthy Michigan exception circumstances

The member has a documented history of infusion reactions or severe adverse events.
The member is medically unstable.
The distance to an approved site of care is unreasonable.

The indication does not meet the criteria of an applicable National Coverage Determination (NCD), Local Coverage Determination (LCD), or specific medical policy.
A Pre-Service Organization Determination (PSOD) is completed before service, consistent with the applicable Provider Manual requirements.

Accredo Contact

PharmacyAccredo Specialty Pharmacy

Fax888.979.8904

Phone877.222.7336

Optimed Contact

PharmacyOptimed Specialty Pharmacy

Phone877.385.0535

Fax877.326.2856

Optimed Contact

PharmacyOptimed Specialty Pharmacy

Fax877.326.2856

Phone877.385.0535

Documentation Required

Support medical-necessity exceptions

Document and submit an exception request when the infusion can only be performed safely and effectively by or under the supervision of specialty skilled nursing personnel, or when the member has qualifying clinical or access circumstances.

Serious infusion reactions despite premedication and infusion-rate control
Severe adverse events following an infusion
Medically unstable situations, such as unstable renal function or unstable vascular access
Unreasonable distance from the nearest approved site of service

Prior Authorization

Request a combination-therapy exception

Members receiving immune checkpoint inhibitors in combination with provider-administered chemotherapy on the same day may be considered for an exception. Submit the request with the applicable medical-necessity rationale.

Denial Risk

Handle gene and cell therapy exceptions individually

Gene and cell therapy exceptions are excluded from the listed exception criteria and will be assessed on a case-by-case basis.

Prior Authorization

Obtain coverage authorization before treatment

Obtain a favorable coverage decision when the requested medication has medical-necessity or other prior-authorization requirements, in addition to meeting site-of-service requirements. A specialty pharmacy may not bill or dispense the requested drug until the favorable decision is received.

Prior Authorization

Complete a Medicare PSOD

For Medicare indications that do not meet applicable NCD, local LCD, or specific medical-policy criteria, complete a Pre-Service Organization Determination (PSOD).

Documentation Required

Identify specialty-pharmacy billing

When submitting a prior-authorization request for a drug requiring specialty-pharmacy billing, include the phrase “Specialty Pharmacy” in the Billing section of the prior-authorization form.

Denial Risk

Authorization is not a payment guarantee

Authorization does not guarantee payment. Providers must still comply with applicable site-of-service, coding, billing, documentation, benefit, and medical-necessity requirements; an authorization on file does not supersede coding, billing, or reimbursement requirements.

The employer retains the underlying financial risk for healthcare costs, even when administrative functions are delegated to a third-party administrator

In-Network Specialty Pharmacy

DefinitionA pharmacy contracted to dispense applicable specialty drugs for Priority Health members

Listed providersAccredo Specialty Pharmacy and Optimed Specialty Pharmacy

Listing dateProviders listed as of October 27, 2025; the list is subject to change based on contractual agreements

Priority Health-Approved Site of Service

Home settingA home setting approved by Priority Health for administration of applicable provider-administered drugs

Office settingAn office setting approved by Priority Health for administration of applicable provider-administered drugs

Other approved locationAnother site of care approved by Priority Health; providers must verify the applicable requirement at the time of service