Skip to main content

Drug Infusion Site of Care Policy

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:

Crysvita - effective 7/13/2018   
Exondys 51 - effective 1/11/2017  
IVIG - effective 1/1/2017  
Inflectra (infliximab-dyyb) - effective 7/1/2017  
Inflectra - Psoriasis and Psoriatic Arthritis: Targeted Immune Modulators - effective 7/1/2017  
Lemtrada - effective 7/1/2017  
Luxturna* - effective 3/9/2018  
Ocrevus - effective 05/23/2017  
Radicava (edaravone) - effective 7/20/2017  
Remicade (infliximab) - effective 7/1/2017  
Remicade - Psoriasis and Psoriatic Arthritis: Targeted Immune Modulators - effective 7/1/2017  
Renflexis (infliximab-abda) - effective 9/1/2017  
Renflexis - Psoriasis and Psoriatic Arthritis: Targeted Immune Modulators - effective 9/1/2017  
Soliris - effective 1/1/2017
Tysabri - effective 7/1/2017

*Product is available for administration at Aetna Gene Therapy Designated Centers identified below:

  • Bascom Palmer Eye Institute – Miami, FL
  • Baylor Eye Center – Houston, TX
  • Massachusetts Eye and Ear – Boston, MA
  • Penn Medicine, Scheie Eye Institute – Philadelphia, PA
  • The Vision Center at Children's Hospital – Los Angeles, CA

 

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. For Luxturna gene therapy, Aetna Gene Therapy Designated Centers listed in the policy apply.

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)
  • J3490 NDC 69794010201 or 69794020301 or 69794030401 (Crysvita specific J Code is currently unassigned)
  • J3590 NDC 69794010201 or 69794020301 or 69794030401 (Crysvita specific J Code is currently unassigned)
  • C9399 NDC 69794010201 or 69794020301 or 69794030401 (Crysvita specific J Code is currently unassigned)

References

American Academy of Allergy, Asthma and Immunology.  Guidelines for the Site of Care for Administration of IGIV Therapy.  December 2011. 

Inflectra [prescribing information]. Lake Forest, IL: Celltrion, Inc.; Nov. 2016.

Lemtrada [prescribing information]. Cambridge, MA: Genzyme Corp.; Nov. 2014.

Luxturna [prescribing information]. Philadelphia, PA: Spark Therapeutics, Inc.; December 2017.

MCG Care Guidelines, 19th Edition, 2015, Home Infusion Therapy:  CMT:  CMT-0009

Ocrevus (ocrelizumab) [prescribing information]. Genentech, Inc.  South San Francisco, CA.  March 2017.  Available online at:https://www.gene.com/download/pdf/ocrevus_prescribing.pdf. Accessed on May 16, 2017.

Katzberg H, Rasutis V, Bril V  Home iVIG for CIDP:  A Focus on Patient Centred Care  Can J Neurol Sci.  2013; 40: 384-388.

Kelly R, Hill A, Arnold L, et. al.  Long-term treatment with eculizumab in paryoxysmal nocturnal hemoglobinuria:  sustained efficacy and improved survival.  Blood 2011; 117(25):6786-6792.

Radicava [prescribing information]. Jersey City, NJ: MT Pharma America, Inc.; May 2017.

Remicade [prescribing information]. Horsham, PA: Janssen Biotech, Inc.; Oct. 2015.

Renflexis [prescribing information]. Kenilworth, NJ: Merck & Co., Inc.; April 2017.

Rigas M, Tandan R, Sterling R.  Safety of Liquid Intravenous Immunoglobulin for Neuroimmunologic Disorders in the Home Setting:  A Retrospective Analysis of 1085 Infusions.  J Clin Neuromusc Dis 2008; 10:52-55

Sarepta Therapeutics, Inc. Exondys 51 (eteplirsen) injection, for intravenous use. Prescribing Information. Reference ID: 3987286. Cambridge, MA: Sarepta; revised September 2016.

Scheinman SJ and Drezner MK. Hereditary hypophosphatemic rickets and tumor-induced osteomalacia. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed September 2017.

Souayah N, Hasan A, Khan H, et. al.  The Safety Profile of Home Infusion of Intravenous Immunoglobulin in Patients with Neuroimmunologic Disorders.  J Clin Neuromusc Dis 2011; 12:S1-S10

Tysabri [prescribing information]. Cambridge, MA: Biogen Idec Inc.; May 2016.

Ultragenyx Pharmaceutical Inc. CRYSVITA (burosumab-twza) injection, for subcutaneous use. Prescribing Information. Novato, CA: Ultragenyx Pharmaceutical Inc; revised April 2018.

U.S. Food and Drug Administration (FDA). FDA approves first therapy for rare inherited form of rickets, x-linked hypophosphatemia. Silver Spring, MD: FDA; April 21, 2018. Available at: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm604810.htm. Accessed April 24, 2018.

JavaScript is required

In order to have the best experience on Aetna.com, Javascript needs to be enabled.
Learn how to change your browser settings to enable Javascript.

You are now leaving the Aetna website

Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.

Continue