This page outlines the Site of Care for Specialty Drug Administration policy and the medications to which this policy applies. It provides the criteria used to determine the medical necessity of hospital outpatient administration as the site of service for identified specialty medications.

This policy applies to the following infusions administered by health care professionals:

Exondys 51  
IVIG  
Inflectra (infliximab-dyyb)  
Inflectra - Psoriasis and Psoriatic Arthritis: Targeted Immune Modulators   
Lemtrada  
Luxturna*  
Ocrevus  
Radicava (edaravone)  
Remicade (infliximab)  
Remicade - Psoriasis and Psoriatic Arthritis: Targeted Immune Modulators  
Renflexis (infliximab-abda)  
Renflexis - Psoriasis and Psoriatic Arthritis: Targeted Immune Modulators  
Soliris
Tysabri

*Product is available for administration at facilities identified below:

• Bascom Palmer Eye Institute
• Massachusetts Eye and Ear
• Alkek Eye Center – University of Baylor College of Medicine
• Shiley Eye Institute – University of California San Diego
• Casey Eye Institute – Oregon Health and Science University

Site of Care

The first dose of the medications subject to this policy may be given at the physician’s facility of choice only when multiple administrations are required and provided that the medication is available and not subject to limited distribution.

This includes hospital outpatient facilities, non-hospital outpatient facilities and home care. In the event the therapy is represented by a single administration, the policy applies to the first administration.

All subsequent doses will be subject to the Aetna Site of Care for Drug Administration policy, which requires the use of non-hospital outpatient facilities or home care.

Clinical rationale and documentation must be provided for review of Medical Necessity exceptions.  

Criteria for Medical Necessity

Aetna considers hospital outpatient facility medication infusion medically necessary for members that have been documented as meeting one or more of the six criteria below:

• Member is medically unstable for administration of medication at alternate levels of care as noted by any of the following:
  • Documented clinical history of cardiopulmonary conditions that may cause an increased risk of severe adverse reactions
  • An inability to safely tolerate intravenous volume loads, including from unstable renal function
  • Unstable vascular access
  • Physical or cognitive impairments such that home infusion, where appropriate, would present an unnecessary health risk
• Member is initiating therapy.
• Member is reinitiating therapy after not being on therapy for at least 6 months.
• Member has a previously documented severe or potentially life-threatening adverse event during or following infusion of the prescribed drug, and the adverse event cannot be managed through pre-medication in the home or office setting.
• The drug requested is subject to limited distribution and is not available for administration at non-hospital outpatient facilities or for home infusion.

For IVIG:

• Member is changing to a different immune globulin product.
• Member has immunoglobulin A (IgA) deficiency with anti-IgA antibodies.

If the member does not meet any of the above criteria, and the proposed hospital outpatient facility is considered a least costly site of care, hospital outpatient infusion would be approved.

Applicable codes

• J1300
• J1459
• J1460
• J1557
• J1559
• J1561
• J1566
• J1567
• J1568
• J1569
• J1571
• J1572
• J1573
• J1745 NDC 57894-030-01 (Remicade (infliximab)
• J0202 NDC 58468-0200-01 (Lemtrada)
• J2323 NDC 64406-008-01 (Tysabri)
• J3490 NDC 60923-0284-10 or 60923-0363-02 (Exondys 51 specific J code currently unassigned)
• C9399 NDC 60923-0284-10 or 60923-0363-02 (Exondys 51 specific J code currently unassigned)
• J3490 NDC 50242-0150-01 (Ocrevus specific J code currently unassigned)
• J3590 NDC 50242-0150-01 (Ocrevus specific J code currently unassigned)
• C9399 NDC 50242-0150-01 (Ocrevus specific J code currently unassigned)
• Q5102 NDC 32228-001-01 (Inflectra - infliximab-dyyb)
• J3490, C9399 NDC 70510-2171-1; 70510-2171-2 (Radicava (edaravone))
• Q5102 NDC: 0006-4305-02 Renflexis (infliximab-abda)
• J3490 NDC 71394-0415-01 (Luxturna specific J code currently unassigned)
• J3590 NDC 71394-0415-01 (Luxturna specific J code currently unassigned)
• C9399 NDC 71394-0415-01 (Luxturna specific J code currently unassigned)