Administering Injectable/Infusion Therapy Drugs in the Office and Home Settings

We want to ensure that our members receive their medication in the setting that is most appropriate for their needs. Although some injectable/infusion therapy drugs must be given in a high level-of-care setting, such as an outpatient facility, many others can be administered in either the provider’s office or in the member’s home by a home infusion provider.

The most appropriate setting to receive drug therapy is based on factors such as, but not limited to:

• recommendations from the drug manufacturer;
• current standards in medical practice;
• the level of care required by the patient based on his or her medical history and current health status;
• the setting that has been determined to be both cost-effective and safe for the member.

Typically, drugs like infliximab (Remicade^®), alglucerase (Ceredase^®), imiglucerase (Cerezyme^®), velaglucerase alfa (VPRIV^®), eculizumab (Soliris^®), pegfilgrastim (Neulasta^®), and intravenous immunoglobulin (IVIG) require a high level-of-care setting only for patients who are starting a new treatment regimen or who have a history of treatment-related adverse effects that require monitoring. Aside from these exceptions, many patients can receive these drugs in either a provider’s office or in their own home.

Administering drugs in the office or at home

The following options are available for administering injectable/infusion therapy drugs in the office or in the member’s home:

• Buy and bill. Providers can buy the drug and bill the health plan for reimbursement once the drug has been given to the member.
• Direct Ship Injectables Program. Providers can order injectable drugs through the IBC Direct Ship Injectables Program to be shipped to their office or to the member’s home. Note: Infusion therapy drugs are not available through this program.
• Home infusion therapy. Many patients prefer the convenience of receiving infusion therapy drugs in their home through an IBC-participating home infusion provider. Providers should discuss this option with their patients, when appropriate.

For more information about the IBC Direct Ship Injectables Program, visit www.ibx.com/directship or call Customer Service at 1-800-ASK-BLUE. Customer Service can also assist you with home infusion options.

How to request a high level-of-care setting

Providers who request coverage for administration of injectable/infusion therapy drugs in high level-of-care settings for our members may be asked during precertification to provide details about the patient’s medical history to support the request. A team of IBC medical directors and nurses will review the submitted documentation and determine whether coverage in a high level-of-care setting is approved.

Impacts to coverage

IBC will continue to cover injectable/infusion therapy drugs and all services associated with the administration of these drugs so long as the following requirements are met:

• The member meets the medical necessity criteria outlined in the applicable medical policy.
• The drug is given in the setting that has been determined by IBC as most appropriate for the member.

Please call Customer Service if you have any questions about injectable/infusion therapy drug setting options.