Medication Administration Site of Care - CAM 173

Under many benefit plans, medically necessary services must be rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. Where applicable, the plan may compare the cost-effectiveness of alternative services, settings or supplies when determining least intensive setting.

  • An injectable medication must meet applicable medical necessity criteria for coverage. When coverage criteria are met for the injectable medication, this coverage policy is used to determine the medical necessity of the requested site of care.

Alternative less-intensive site of care facilities include:

  • Non-hospital affiliated outpatient infusion (e.g., ambulatory infusion center or physician office)
  • Home infusion

Injectable medication treatment in a hospital outpatient setting or at a hospital-affiliated infusion suite* as medically necessary for an individual with ANY of the following:

  • The prescribed medication has a site-of-care restriction for administration per the FDA-approved label
  • A documented history of an adverse event warranting a more intense level of care during or following infusion of the prescribed medication, unless the adverse event can be appropriately managed by the use of pre-medication(s) or other preventive actions
  • A documented history of a significant comorbidity (e.g., cardiopulmonary disorder) or concerns regarding fluid overload status that precludes treatment at an alternative less-intensive site of care

*Note: A hospital outpatient setting or a hospital-affiliated infusion suite is expected to have immediate access to specific services of a medical center/hospital setting, including having emergency resuscitation equipment and personnel (ACLS protocol), emergency services, and inpatient admission or intensive care, if necessary.

When the above medical necessity criteria for administration of an injectable medication in a hospital outpatient setting or hospital-affiliated infusion suite are not met, an alternative less-intensive site of care should be utilized.

Impacted Drugs 
The Site of Care drug program identifies members who are receiving certain specialty drugs at a higher cost site of service (i.e., hospital outpatient setting) and encourages them to move to an equally appropriate, alternative site of service (infusion center or home). Drugs included in this program include but are not limited to:

Actemra (IV)



Simponi Aria


Epoprostenol Sodium






Stelara (IV)

Aralast NP




Amondys 45 (*)

Exondys 51



Aralast NP


Nucala vial



Fasenra prefilled syringe




Flebogamma DIF


Uptravi IV










Gammagard liquid IV

Orencia (IV)


Carimune NF

Gammagard S/D







Cimzia Lyophilized powder



Vyondys 53


Gamunex-C IV




















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This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2017 Forward     

09/14/2022 Annual review, no change to policy intent, but updating list of impacted medications. 


Annual review, no change to policy intent. 


Annual review, no change to policy intent. 


Interim review to update medication list. No other changes made. 


Annual review, no change to policy intent. 


Annual review, no change to policy intent. 


Amending language immediately prior to the list of impacted drugs to state: Drugs included in this program include, but, are not limited to the following list: No other changes made. 


New Policy

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