Drug infusion/injection site-of-care policy

These drugs need to be given at approved treatment facilities in the GCIT network:

• Amtagvi
• Casgevy
• Elevidys
• Encelto
• Hemgenix
• Itvisma
• Kebilidi
• Kresladi
• Lenmeldy
• Lyfgenia
• Luxturna
• Otarmeni
• Qalsody
• Redemplo
• Roctavian
• Skysona
• Spinraza
• Tecelra
• Waskyra
• Zevaskyn
• Zolgensma
• Zynteglo

To learn more, go to our Aetna Institutes page. You can also find a GCIT network facility.

• GCIT network facility list - English (PDF)
• GCIT network facility list - Spanish (PDF)

This policy covers therapy in a hospital outpatient setting (up to 45 days) when any of the following apply:

1. The patient is new to therapy or restarting after not being on therapy for at least 6 months (3 months for Xolair).
2. The patient is switching to a therapy they haven’t had before.*
3. The patient’s had a gap in therapy.*

This policy covers provider-administered therapy in a hospital outpatient setting when any of the following apply:

Adverse reactions or medical risk

• The patient has a serious reaction that doesn’t get better with standard treatments (e.g., acetaminophen, steroids, antihistamines, fluids).
• The patient has a severe adverse event such as anaphylaxis, heart attack, blood clots or seizures during or right after administration.
• The patient has an IgA deficiency with anti-IgA antibodies* or has developed anti-drug antibodies* that raise the risk of a reaction.
• The patient’s health is unstable due to respiratory, heart or kidney conditions.

Access and safety challenges

• The patient has vein access issues that require special procedures.*
• The patient has serious behavioral, physical or cognitive challenges and doesn’t have a caregiver to help during treatment.

Specific drug scenarios

• The patient is receiving Perjeta, bevacizumab (Avastin, Alymsys, Avzivi, Mvasi, Vegzelma, Zirabev) or trastuzumab (Herceptin, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) and provider-administered combination chemotherapy.
• The patient is receiving Adcetris or rituximab (Riabni, Rituxan, Ruxience, Truxima) and provider-administered chemotherapy or other drug therapies in the same visit.
• The patient is under 14 years old and receiving Perjeta, trastuzumab or rituximab.

Immune checkpoint inhibitors

For patients receiving immune checkpoint inhibitors (e.g., Bavencio, Imfinzi, Jemperli, Keytruda, Keytruda Qlex, Libtayo, Loqtorzi, penpulimab-kcqx , Opdivo, Opdivo Qvantig, Opdualag, Tecentriq, Tecentriq Hybryza, Tevimbra, Unloxcyt, Yervoy, Zynyz), we may approve hospital outpatient therapy if any of the following apply:

• The patient is in the first 3 months of starting treatment.
• The patient is continuing a maintenance regimen with chemotherapy (e.g., Tecentriq bevacizumab for non-small lung cancer, Tecentriq + paclitaxel protein-bound for breast cancer or Keytruda + pemetrexed for non-small cell lung cancer).
• The patient has severe toxicity that requires close monitoring, which may include:

Skin reactions: grade 2 to 4 bullous dermatitis, Stevens-Johnson syndrome

Liver issues: transaminitis

Lung issues: pneumonitis

Pancreatic issues: acute pancreatitis

Hormonal issues: primary adrenal insufficiency

Neurological issues: aseptic meningitis, encephalitis, transverse myelitis

Heart conditions: myocarditis, pericarditis, arrhythmias and impaired ventricle or conduction function

To request prior authorization for hospital outpatient care (when required), you’ll need to include medical records that show one or more of the following:

1. The patient had a serious reaction that didn’t improve with standard treatments. Or the patient had a severe reaction during or right after the drug was given (e.g., anaphylaxis, heart attack, seizures).
2. The patient has IgA antibodies or has developed anti-drug antibodies.
3. The patient’s health is unstable due to issues with breathing, heart function or kidney health.
4. The patient has vein access issues that require special procedures only available in a hospital outpatient setting.
5. The patient has behavioral, physical or cognitive challenges and doesn’t have a caregiver to support safe treatment.
6. The patient is receiving combination chemotherapy that must be given by a provider.

If the patient doesn’t meet the criteria for hospital outpatient care, the drug is still covered when given in another setting — like a doctor’s office, at home or at an ambulatory care center.