Effective September 1, 2026: Pharmacy and Biopharmacy Policies

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Infusion Therapy Site of Care Optimization (TX.PHAR.493)

Ambetter

Policy includes:

• Initial Approval Criteria: In-network outpatient hospital or non-hospital outpatient office or facility for intravenous or injectable therapy*
  • There is (i) no home infusion provider, (ii) lower cost site of care to provide administration, and/or (iii) specialty pharmacy cannot provide drug with one of the following:
    • FDA approved indications require the administration at an outpatient hospital, office or clinic;
    • It is the administration of the initial dose of the treatment or restart of treatment after a 6-month disruption for a short duration of therapy (e.g. 4 weeks);
      • Provider must submit request for initial visit with continued administration at home infusion or ambulatory infusion suite (AIS).
    • Submitted documentation that home based therapy, ambulatory surgical/infusion center is a health risk for the member due to physical or behavioral impairment;
      • Examples of physical or behavioral health impairment: severe venous access issues and vein finder is not available, member does not have access to a caregiver, cardiopulmonary disorder, unable to tolerate intravenous fluid loads, cognitive concerns that impact patient safety*
  • Submitted medical records or infusion records that document severe or lifethreatening adverse events that were non- responsive to pre-medications, analgesics, steroids, antihistamines (e.g. diphenhydramine), fluids or infusion rate reductions.
    • Examples severe or life-threatening adverse events: seizures, anaphylaxis with no other therapy options, myocardial infarction, renal failure*
    • Non-qualifying examples of medical necessity: trypanophobia (fear of needles), pediatrics, preference/convenience, frequent laboratory monitoring, continuation of services from previous Plan.
      • *This is not a complete list of examples
  • Approval duration: Up to one year or length of approval for the drug

• Continued Approval
  • Re-authorization is not permitted. Members must meet the initial approval criteria. Provider must submit updated medical records or infusion records to reassess the member’s site of care and documentation for the need to continue monitoring and advanced treatment capabilities beyond what routinely be needed for the infusion therapy.
  • Approval duration: Up to one year or length of approval for the drug