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Select oncology medications are being added to the Site of Care management program
Aetna supports efforts, where medically appropriate, to treat patients at nonhospital facilities or in the comfort of their home. We appreciate this effort now more than ever to slow transmission of SARS-CoV-2 through methods such as social distancing and reducing contact with patients who potentially have COVID-19. The CDC has provided guidance for health care facilities to 1) provide the appropriate level of necessary medical care, 2) protect health care personnel and non-COVID-19 patients from infection, 3) prepare for a potential surge in patients with respiratory infection and 4) prepare for Personal Protective Equipment (PPE) and staffing shortages. See CDC guidance.
In alignment with these goals, during and after COVID-19, we are adding and will continue to add additional medications to our Site of Care process starting July 1, 2020. The Site of Care policy provides criteria to determine the medical necessity of hospital outpatient administration as the site of service for identified specialty medications.
This change applies to members in commercial plans who receive a renewal authorization for the below specialty medications, to continue maintenance monotherapy. This change does not apply to Medicare or Medicaid members.
Which specialty drugs are affected?
This policy change applies to the following infusions administered by health care professionals when administered as monotherapy for maintenance: nivolumab (Opdivo®), pembrolizumab (Keytruda), ipilimumab (Yervoy®), durvalumab (Imfinzi durvalumab), cemiplimab (LibtayoTM), avelumab (Bavencio®) and atezolizumab (Tecentriq®).
The initial combination therapy regimens for medications subject to this policy may be given at the physician’s facility of choice. All subsequent doses for maintenance monotherapy will be subject to the Aetna Site of Care for Drug Administration policy, which requires the use of nonhospital outpatient facilities for administration. Members that fulfill Aetna’s Site of Care medical necessity criteria will be allowed to continue infusions in the outpatient hospital.
Safety
These medications are commonly administered in outpatient community physician practices, not in hospital-based outpatient facilities. The administration of checkpoint inhibitors is associated with less toxicity compared to other medications that are infused in the same practice setting. The side effects associated with these medications develop over time because of their immune medicated mechanism. Infusion reactions are a common concern when transitioning patients to an alternate site of care. Severe or life-threatening reactions have occurred in less than 2 percent of patients receiving these medications. Infusion reactions (all grades) have been reported in less than 10 percent of patients receiving the approved checkpoint inhibitors, except avelumab, in which reactions are reported in 25 percent of patients.
Costs and coordination
Costs for these medications, when administered in the outpatient hospital, often may exceed $20,000 per infusion. Savings associated with non-hospital-based administration or specialty-pharmacy-provided medication may exceed 50 percent.
Members and providers may choose in-network options, including using independent infusion centers and home infusion, or the medication may be administered in the physician’s office. When this is not possible, Aetna can coordinate with the facility to deliver patient-specific medication from a specialty pharmacy. Aetna’s specialized team of infusion consultants will help identify the best option for members and their health care providers.
We’re here to help
If you have questions about this policy, please contact us.
Thank you in advance for your cooperation.