Effective January 1, 2019, Highmark implemented the Site of Care Drug Management Program designed to improve the experience for members using certain medically billed infusion drugs that are considered safe and effective for administration outside of a hospital setting. The program helps decrease the cost of care for these therapies by ensuring appropriate utilization of the drugs through medical policy and a prior authorization requirement.
With the implementation of this program, the medical policies for these drugs were revised to incorporate a medical necessity review for the requested site of care in addition to the already existing review that takes place for clinical appropriateness of the drug therapy.
Approved sites of care include the following:
- Home Infusion
- Doctor’s Office (not affiliated with a hospital)
- Ambulatory Infusion Center (not affiliated with a hospital)
The list of Site of Care drugs can be found:
- Within the Highmark Site of Care Medical Policy I-151, which is accessible via the MEDICAL POLICY SEARCH tool at the top of this website.
- In the list of Procedure Codes Requiring Authorization, under the “SOC” category.
Our online provider portal(s) is the preferred channel for submitting authorization requests for drugs and helps ensure that your authorization is processed in a timely manner. Authorization requests should only be faxed if the provider portal(s) is unavailable. If necessary, the designated fax number for medical injectable authorization requests (including Site of Care drug authorization requests) is 833-581-1861. The Site of Care request fax form can be found here on the Provider Resource Center in the left-hand menu under FORMS then Medical Injectable Drugs.
Last updated on 10/26/2023 2:15:18 PM