Provider-Administered Drug Program - Voluntary Site of Service Management Policy

Last Review Date: 08/13//2024

Date of Origin: 4/1/2019

1. Background

The Provider-Administered Drug Program includes, effective July 1, 2019, Voluntary Site of Service Management. Voluntary Site of Service Management manages members receiving infusions of select specialty medications as listed in this policy in a high cost outpatient treatment facility. According to criteria outlined in this policy, members and providers may elect to transition care to a more cost- effective, clinically-appropriate location to receive their infusion(s).

2. Scope

1. 1. Applicable to all groups and individual health plans that participate in the Provider-Administered Drug Program and have home healthcare benefits
      1. New utilizers of these medications on or after July 1, 2019 with sufficient home health benefits, will managed by this service.
      2. Members currently using these medications will be extended the opportunity to participate in Voluntary Site of Service Management upon prior authorization renewal or by identification through paid claims reporting.

3. Program Requirements

1. 1. Impacted members will be identified through the existing Provider-Administered Drug prior authorization program or through paid claims reporting for identification of current utilizers.

1. 2. All drugs in Voluntary Site of Service Management require prior authorization.

1. 3. Members with approved drug prior authorizations and identified as receiving the select specialty drugs as listed in section IV in a hospital outpatient setting will be transitioned internally to Magellan Rx’s Infusion Referral Center (IRC).
   4. The IRC will confirm that the following criteria are met in order for the member to be transitioned to an alternate place of treatment, such as a home infusion provider or infusion suite.
      1. The member must have sufficient home health benefits in place.
      2. The member must agree to transition care to alternate setting.
      3. The prescriber must be contacted and agree to transition the member’s infusion to an alternate place of treatment.
      4. The prescriber must approve that the use of the alternate place of treatment is clinically appropriate for the member’s infusion.

1. 5. When required, the home infusion provider will obtain all necessary nursing precertifications as specified by the member’s benefits.

4. Drugs in Scope

1. 1. Select infused specialty medications included in the Voluntary Site of Service Management program are subject to change.

1. 2. Drugs in Scope