Reviewed Sep 25, 2026 · maintained by Erin Rose · general reference, not legal or coding advice
Read this first: what "Confirmed" and "Named policy" mean
Every row comes from the payer's own policy document, with a link and a date. Confirmed means we re-read that exact page on Sep 25, 2026, and it says both parts: no hospital outpatient, and where care goes instead. Named policy means the linked page confirms the program covers the drug, and the details on where care goes and the exceptions come from the payer's other policy documents we collected.
This covers commercial plans. Several payers below say explicitly their program does not reach Medicare Advantage or Medicaid managed care — check the specific plan before relying on this for a non-commercial patient.
Which payers redirect care, and where
A site-of-care policy names specific infused drugs and says where they may be administered. Miss it, and the claim can be denied for place of service even though the drug and dose were approved.
| Payer | Status | Drugs affected | Where care moves | Exceptions | Source |
|---|---|---|---|---|---|
| Aetna | Named policy | 56 drugs, incl. Orencia, Eylea, Fabrazyme | A non-hospital site — home… | adverse-reaction history +2 more | Orencia, Jul 1, 2026 |
| Arkansas BCBS | Named policy | 34 drugs, incl. Orencia, Dysport, Eylea | Hospital-based outpatient infusion is "non-preferred"… | first 90 days of therapy +3 more | Anifrolumab (Saphnelo), Aug 19, 2026 |
| BCBS Michigan | Confirmed | 54 drugs, incl. Orencia, Fabrazyme, Lemtrada | Prior-authorization requests are asked to identify a lower-cost site of… | a stated clinical reason for hospital outpatient administration, reviewed case by case | Vyepti, Oct 9, 2025 |
| Blue Shield of California | Confirmed | 60 drugs, incl. Orencia, Fabrazyme, Lemtrada | A preferred site of service — home… | new-start first dose +2 more | Vimizim, Aug 1, 2026 |
| CareFirst BCBS | Confirmed | 36 drugs, incl. Orencia, Fabrazyme, Lemtrada | Outpatient hospital administration is time-limited (commonly up to… | adverse reaction +4 more | Cabenuva, Jul 17, 2025 |
| Highmark BCBS | Confirmed | 57 drugs, incl. Orencia, Eylea, Fabrazyme | A physician’s office not affiliated with a hospital… | hospital outpatient administration is allowed only when the member meets medically-unstable exception criteria | Lumizyme, Apr 1, 2024 |
| Horizon BCBS NJ | Confirmed | 22 drugs, incl. Orencia, Fabrazyme, Lumizyme | An office/outpatient setting by a healthcare professional… | policy’s medical-necessity criteria are met +1 more | Fasenra, Sep 11, 2020 |
| Kaiser Permanente WA | Confirmed | 2 drugs, incl. Remicade, Entyvio | A non-hospital setting… | see the payer’s site-of-care policy for new-start and reauthorization exceptions | Remicade, Jun 1, 2026 |
| Premera Blue Cross | Confirmed | 46 drugs, incl. Orencia, Fabrazyme, Lumizyme | Medically necessary sites are a physician’s office… | first 90 days of an initial course, or re-initiation after 6+ months off therapy +3 more | Entyvio, Jun 1, 2026 |
| UnitedHealthcare | Named policy | 26 drugs, incl. Fabrazyme, Lumizyme, Nexviazyme | An alternative site — physician office… | medical instability +2 more | Soliris, Aug 1, 2026 |
"Drugs affected" is the count of drugs in our data carrying a site-of-care rule for that payer — a floor, not the payer's full list. Click a payer name for the full detail and the source quote.
Before you schedule the infusion
The setting changes how the visit is paid. Medicare pays a hospital outpatient department under the Hospital Outpatient Prospective Payment System and a physician office under the Physician Fee Schedule. Commercial payers also contract the two settings separately, which is why their site-of-care programs name the setting, not just the drug.
- Check the payer and the drug against the table. Site-of-care rules are drug-specific, not blanket — a payer can run the program for Orencia and not for Remicade.
- Ask about the exceptions before you fight the denial. Nearly every policy exempts the first dose or two, a documented medical reason (vascular access, prior reaction, medical instability), or being out of range of a network home-infusion or freestanding option.
- Get the site-of-care authorization in writing before the infusion, not after — most payers deny the claim rather than just the site, and an after-the-fact appeal is a weaker position than a pre-service exception request.
- Self-funded (ERISA) employer plan? These are the payer's fully-insured commercial policies. A self-funded plan can adopt the same insurer's network and utilization rules, or write its own — check the plan document, not just the insurer's public policy.
Payer by payer
The full redirect target, every exception, and the source quote for each confirmed payer.
Aetna · 56 drugs in our data · Named policy
Where care moves: A non-hospital site — home, a physician’s office, or an infusion center — for follow-up doses, under Aetna’s Site of Care Utilization Management Policy.
Exceptions:
- adverse-reaction history
- medical instability
- vascular access issues
Drugs in our data (56 total): Orencia, Eylea, Fabrazyme, Lemtrada, Lumizyme and others.
Note : For commercial plans, Site of Care Utilization Management Policy applies. For information on site of service for intravenous Orencia, see Utilization Management Policy on Site of Care for Specialty Drug Infusions .
From Aetna's own Orencia bulletin, dated Jul 1, 2026. We re-checked this exact page on Sep 25, 2026; it confirms Aetna runs this named program for this drug, but the redirect-target and exceptions above are drawn from CareCost's collection of payer policy documents rather than being verbatim on this one page.
Arkansas BCBS · 34 drugs in our data · Named policy
Where care moves: Hospital-based outpatient infusion is "non-preferred"; care is steered to an in-network stand-alone infusion center or home infusion, under Coverage Policy #2018030 (Site of Care or Site of Service Review).
Exceptions:
- first 90 days of therapy
- no in-network infusion center within 30 miles and no in-network home infusion available
- listed clinical-risk grounds
- applies only to plans with a Medical Pharmacy Mandatory Site of Care requirement
Drugs in our data (34 total): Orencia, Dysport, Eylea, Fabrazyme, Anifrolumab (Saphnelo) and others.
Saphnelo Anifrolumab-fnia J0491
From Arkansas BCBS's own Anifrolumab (Saphnelo) bulletin, dated Aug 19, 2026. We re-checked this exact page on Sep 25, 2026; it confirms Arkansas BCBS runs this named program for this drug, but the redirect-target and exceptions above are drawn from CareCost's collection of payer policy documents rather than being verbatim on this one page.
BCBS Michigan · 54 drugs in our data · Confirmed
Where care moves: Prior-authorization requests are asked to identify a lower-cost site of care — provider office or home infusion — rather than a hospital outpatient facility; a request for hospital outpatient must state a reason.
Exceptions:
- a stated clinical reason for hospital outpatient administration, reviewed case by case
Drugs in our data (54 total): Orencia, Fabrazyme, Lemtrada, Lumizyme, Anifrolumab (Saphnelo) and others.
Site of administration? Provider office/Home infusion Other: _____________________________ Hospital outpatient facility (go to #3) Reason for Hospital Outpatient: _________________________
From BCBS Michigan's own Vyepti bulletin, dated Oct 9, 2025. We re-checked this exact page on Sep 25, 2026 and its own text supports the redirect and exceptions above.
Blue Shield of California · 60 drugs in our data · Confirmed
Where care moves: A preferred site of service — home, a physician’s office, or an independent infusion center not associated with a hospital — is required on PPO, Direct Contract HMO and ASO/Shared Advantage plans.
Exceptions:
- new-start first dose
- re-initiation after 6+ months off therapy
- documented need for additional clinical monitoring
Drugs in our data (60 total): Orencia, Fabrazyme, Lemtrada, Lumizyme, Anifrolumab (Saphnelo) and others.
Members with the following plans: PPO, Direct Contract HMO, and when applicable, ASO, Shared Advantage, HMO (non-direct) may be required to have their medication administered at a preferred site of service, including the home, a physician’s office, or an independent infusion center not associated with a hospital.
From Blue Shield of California's own Vimizim bulletin, dated Aug 1, 2026. We re-checked this exact page on Sep 25, 2026 and its own text supports the redirect and exceptions above.
CareFirst BCBS · 36 drugs in our data · Confirmed
Where care moves: Outpatient hospital administration is time-limited (commonly up to 45–65 days for a new start or re-initiation); beyond that window, or absent a qualifying reason, care moves to a physician’s office, home infusion, or ambulatory care.
Exceptions:
- adverse reaction
- medical instability
- behavioral/cognitive impairment without an available caregiver
- alternative site more than 30 miles from home
- age under 14 (drug-specific)
Drugs in our data (36 total): Orencia, Fabrazyme, Lemtrada, Lumizyme, Alpha1-Proteinase Inhibitor (Human) and others.
This policy provides coverage for administration of Cabenuva in an outpatient hospital setting for up to 65 days when a member is new to therapy or is reinitiating therapy after not being on therapy for at least 6 months.
From CareFirst BCBS's own Cabenuva bulletin, dated Jul 17, 2025. We re-checked this exact page on Sep 25, 2026 and its own text supports the redirect and exceptions above.
Highmark BCBS · 57 drugs in our data · Confirmed
Where care moves: A physician’s office not affiliated with a hospital, a non-hospital-affiliated specialized infusion center, or the home.
Exceptions:
- hospital outpatient administration is allowed only when the member meets medically-unstable exception criteria
Drugs in our data (57 total): Orencia, Eylea, Fabrazyme, Lemtrada, Lumizyme and others.
Ezyme replacement therapies in this policy may be considered medically necessary for individuals 18 years of age and older when applicable clinical criteria for individual medication policies are met and when administered in a physician’s office not affiliated with a hospital, specialized infusion centers not affiliated with a hospital or in the home.
From Highmark BCBS's own Lumizyme bulletin, dated Apr 1, 2024. We re-checked this exact page on Sep 25, 2026 and its own text supports the redirect and exceptions above.
Horizon BCBS NJ · 22 drugs in our data · Confirmed
Where care moves: An office/outpatient setting by a healthcare professional, or home infusion by a home-health nurse, under Policy #142 (Site of Administration for Infusion and Injectable Prescription Medications); hospital outpatient is not considered medically necessary unless the policy’s criteria are met. Precertification runs through MagellanRx Management.
Exceptions:
- policy’s medical-necessity criteria are met
- does not apply to Medicare Advantage products
Drugs in our data (22 total): Orencia, Fabrazyme, Lumizyme, Benlysta, Fasenra and others.
Benralizumab (Fasenra)
From Horizon BCBS NJ's own Fasenra bulletin, dated Sep 11, 2020. We re-checked this exact page on Sep 25, 2026 and its own text supports the redirect and exceptions above.
Kaiser Permanente WA · 2 drugs in our data · Confirmed
Where care moves: A non-hospital setting; home infusion is covered only through Kaiser Permanente Specialty Home Infusion (no out-of-network home-infusion benefit).
Exceptions:
- see the payer’s site-of-care policy for new-start and reauthorization exceptions
Drugs in our data (2 total): Remicade, Entyvio.
Must be administered in a non-hospital setting. See site of care policy for criteria, reauthorization, and exceptions for new starts.
From Kaiser Permanente WA's own Remicade bulletin, dated Jun 1, 2026. We re-checked this exact page on Sep 25, 2026 and its own text supports the redirect and exceptions above.
Premera Blue Cross · 46 drugs in our data · Confirmed
Where care moves: Medically necessary sites are a physician’s office, an infusion center, or home infusion; a hospital-based outpatient setting is not medically necessary unless the policy’s site-of-service criteria are met.
Exceptions:
- first 90 days of an initial course, or re-initiation after 6+ months off therapy
- no infusion center within 50 miles and no contracted home-infusion agency
- defined clinical risk factors
- does not apply to Alaska fully-insured members
Drugs in our data (46 total): Orencia, Fabrazyme, Lumizyme, Anifrolumab (Saphnelo), Nexviazyme and others.
Entyvio (vedolizumab) IV is subject to review for site of service administration.
From Premera Blue Cross's own Entyvio bulletin, dated Jun 1, 2026. We re-checked this exact page on Sep 25, 2026 and its own text supports the redirect and exceptions above.
UnitedHealthcare · 26 drugs in our data · Named policy
Where care moves: An alternative site — physician office, ambulatory infusion suite, or home infusion — under UnitedHealthcare’s ‘Provider Administered Drugs – Site of Care’ policy.
Exceptions:
- medical instability
- vascular access issues
- adverse-event history
Drugs in our data (26 total): Fabrazyme, Lumizyme, Nexviazyme, Prolia/Xgeva, Soliris and others.
Soliris® (eculizumab) J1299
From UnitedHealthcare's own Soliris bulletin, dated Aug 1, 2026. We re-checked this exact page on Sep 25, 2026; it confirms UnitedHealthcare runs this named program for this drug, but the redirect-target and exceptions above are drawn from CareCost's collection of payer policy documents rather than being verbatim on this one page.
Payers we checked and could not confirm
These payers have at least one site-of-care rule in our data, but we left them off the table above — either the cited language never named a specific alternative site, or a live re-check of the citation on Sep 25, 2026 no longer supported it. Listed here instead of silently dropped, so "why isn't my payer above" has an answer.
- Anthem / Elevance (1 drug with a site-of-care rule in our data) — Only one cited rule, requiring administration by a healthcare professional — no hospital exclusion.
- BCBS Federal Employee Program (5 drugs with a site-of-care rule in our data) — Cited language requires a "healthcare setting" for anaphylaxis monitoring — a safety requirement, not a hospital-to-non-hospital redirect.
- BCBS Kansas (25 drugs with a site-of-care rule in our data) — Our corpus names a "Medication Administration Site of Care" CAM policy, and BCBS Kansas does run one (confirmed by independent search), but a live re-check of the cited drug bulletin on 2026-09-25 did not find the redirect language on the page itself.
- BCBS Massachusetts (13 drugs with a site-of-care rule in our data) — Cited language is about medical-benefit vs. pharmacy-benefit billing, not where the infusion happens.
- BCBS Minnesota (1 drug with a site-of-care rule in our data) — Only one cited rule, about a self-administration step for Xolair, not a hospital-outpatient redirect.
- BCBS Mississippi (4 drugs with a site-of-care rule in our data) — Cited language covers prior-authorization and self-administration failure, not site of care.
- BCBS Nebraska (3 drugs with a site-of-care rule in our data) — Cited language covers inpatient/outpatient and self-administration, not a hospital-to-non-hospital redirect.
- BCBS South Carolina (47 drugs with a site-of-care rule in our data) — Our corpus names a Site of Care Specialty Drugs list; the cited page is a JavaScript-rendered document we could not re-verify by static fetch on 2026-09-25.
- BCBS Tennessee (1 drug with a site-of-care rule in our data) — Only one cited rule, about COVID-19 inpatient vs. outpatient management, not site of care generally.
- Centene / Ambetter (2 drugs with a site-of-care rule in our data) — Cited language is mixed (one rule requires a hospital setting, the other requires self-administration first) and does not describe a consistent redirect.
- Cigna (45 drugs with a site-of-care rule in our data) — Our corpus names Cigna’s Coverage Policy 1605 (Medication Administration Site of Care), and Cigna does run one (confirmed by independent search), but a live re-check of three different cited drug bulletins on 2026-09-25 found none of them mention it on the page itself.
- Excellus BCBS (38 drugs with a site-of-care rule in our data) — Our corpus names a "Site of Care Redirection" policy (PHARMACY-118); a live re-check of two cited drug bulletins on 2026-09-25 found only a generic "site of care may affect approval timeframe" note, not the redirect language.
- Florida Blue (25 drugs with a site-of-care rule in our data) — Cited language says "additional requirements may apply" for hospital-affiliated administration but never names an alternative site or a redirect outcome in our data.
- HCSC (IL/TX/OK/NM/MT) (36 drugs with a site-of-care rule in our data) — Our corpus names a "Specialty Medication Administration Site of Care" program (ADM1001.034), but a live re-check of the cited drug bulletins on 2026-09-25 did not find that language on the page itself, so we could not re-confirm this row’s citation.
- HMSA (BCBS Hawaii) (1 drug with a site-of-care rule in our data) — Only one cited rule, about COVID-19 outpatient criteria, not site of care generally.
- Independence Blue Cross (30 drugs with a site-of-care rule in our data) — Cited language reserves reimbursement to "the most appropriate, cost-effective setting" without naming hospital outpatient or a specific alternative site.
- Regence BCBS (44 drugs with a site-of-care rule in our data) — Cited language says site-of-care "requirements must be met" and cross-references a separate policy (dru408) whose full text is not in our corpus, so we cannot confirm what it requires.
- Wellmark BCBS (1 drug with a site-of-care rule in our data) — Only one cited rule, about choosing the SC pen over the IV form, not where the IV is given.
Frequently asked
- What is a site-of-care policy?
- A rule a health plan puts on an infused drug that says where the infusion can happen. It is separate from prior authorization — the drug can be approved and still get denied if it is given in the wrong place. The usual target is the hospital outpatient department, because it is the most expensive place to get the same drug.
- Which drugs does this apply to?
- Infused specialty drugs billed under the medical benefit — biologics for autoimmune disease, enzyme-replacement therapies, complement inhibitors, IVIG, and similar. Self-administered injectables and oral drugs are not affected. Oncology drugs are commonly carved out even at payers with a broad site-of-care program (see the exceptions column).
- Does this apply to Medicare or Medicaid?
- Mostly no. Every payer in this table runs the program on commercial plans; several rows say explicitly that it does not apply to Medicare Advantage or Medicaid managed care. Confirm the specific plan type before relying on this table for a Medicare Advantage patient.
- What does "Named policy" mean if it is not "Confirmed"?
- Both mean the payer's own policy document, cited on this page, confirms the drug is subject to a specific, named site-of-care program. "Confirmed" means we re-checked that exact page on the verified date and its own text also states the redirect target and exceptions. "Named policy" means the redirect-target and exceptions details come from CareCost's wider collection of payer policy documents rather than being verbatim on that one linked page — the program is real and named, we just could not re-quote every detail from the single cited URL.
- Why are payers like Cigna and Regence missing?
- We found evidence in our data that they run a similar program, but when we re-checked the specific citation live on 2026-09-25, the cited page no longer showed the redirect language (documents get reorganized). Rather than publish a citation we could not stand behind today, we left them out — see the full list of payers we checked and could not confirm, below the table.
- Can the practice appeal a site-of-care denial?
- Yes, through the payer's standard appeal process, and most policies list specific exceptions — most commonly the first dose or two while a patient is monitored for a reaction, no in-network home-infusion or freestanding infusion option within a set distance, or a documented medical reason the hospital setting is required (vascular access issues, prior adverse reactions, medical instability). Cite the exception in the payer's own policy, not a general hardship argument.
- How current is this table?
- Row counts and example drugs come from CareCost's collection of payer policy documents, fetched Aug 3–13, 2026. Every "Confirmed" row was independently re-checked against the live payer document on Sep 25, 2026. Payer policy changes without notice; verify against the linked source before you rely on it for a specific claim.
Related references
Check the site-of-care rule before you schedule
CareCost Estimate flags a patient's site-of-care exposure alongside the copay estimate, so the front desk sees it before the visit, not after the denial.
Try CareCost FreeSources & how this is maintained
- What this table is
- Which commercial payers run a site-of-care utilization-management program on infused specialty drugs, which drugs it names, where it moves the infusion, and the exceptions — each row cited to the payer's own policy document.
- Where the data comes from
- CareCost's collection of payer policy documents: 762 site-of-care rule records across 28 payers and 97 drugs, fetched directly from payer policy documents Aug 3–13, 2026. Generated by
scripts/build-site-of-care-by-payer.mjs, re-run against the live corpus any time it refreshes. - How each row was verified
- Every row's citation is asserted to exist in the corpus at build time (payer + drug + source URL + date must match exactly, or the build fails). Rows marked Confirmed were also independently re-fetched from the live internet on Sep 25, 2026 and their own text checked against the redirect-target and exceptions claims. Rows marked Named policy passed the first check but not full live re-verification of every detail; see the "Read this first" note above.
- Coverage
- 10 payers confirmed (7 fully re-verified live, 3 named-policy); 18 more payers had at least one site-of-care rule in our data but did not meet the bar for this table — see "Payers we checked and could not confirm" above.
- What can be wrong
- Payer policy changes without notice, and our corpus's fetch window is Aug 3–13, 2026. A specific drug's rule can also differ by plan type (PPO vs. HMO), state, or whether the plan is self-funded. This is a reference for a billing office, not legal or coding advice — confirm the current policy with the payer before relying on it for a specific claim.
- Corrections
- Send one with the payer and drug and we will re-verify against the primary document.