Site of Care Drug Management

Last Updated: Thursday, September 12, 2024

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)

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*FOR NEW YORK ONLY: All in-network hospital-based facilities will be considered approved sites of care during the authorization review process for members to receive their infusion medication for at least 2022, until further notice. All out-of-network and out-of-area hospital facilities will still be considered non-approved sites and subject to the terms of the Site of Care Policy I-151.

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 on the Medical Policies landing page under Policies & Programs.

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In the list of Procedure Codes Requiring Authorization, under the “SOC” category
- Procedure Codes Requiring Authorization

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In the list of Procedure Codes Requiring Authorization, under the “SOC” category
- Procedure Codes Requiring Authorization

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Our online provider portal 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, using the number(s) below, if the provider portal is unavailable.

The Site of Care request fax form can be found on the Medical Injectable Drug Forms page under Resources & Education and then Forms in the top website menu.

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833-581-1861

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833-619-5745

Forms Removed

Effective July 1, 2024, West Virginia Law (Senate Bill 267) mandates the electronic submission of prior authorization requests. For this reason, Highmark removed West Virginia prior authorization forms from the Provider Resource Center (PRC). All prior authorization requests must now be submitted to Highmark via our provider portal (Availity).