Specialty Medication Administration Site of Care

This policy defines site‑of‑care for specialty medication administration of infused pharmacologic and biologic agents, permitting the provider’s choice of hospital outpatient, non‑hospital outpatient, or home care for the first 45 days but favoring non‑hospital outpatient or home infusion for subsequent doses when clinically appropriate. Hospital outpatient infusion is considered medically necessary only with documented medical instability (e.g., significant cardiopulmonary risk, inability to tolerate IV volume, unstable renal function), prior severe infusion reactions, pediatric safety/practicality concerns, reinitiation after ≥6 months, documented drug shortages, or other specific clinical barriers to home/office infusion; therapies and dosing must be supported by authoritative references and coverage is subject to the member’s benefit plan and does not replace medical‑necessity review of the drug itself.

"Requested therapy is covered when supported by peer‑reviewed scientific literature and proven effective for the relevant diagnosis or procedure."