Highmark's Site of Care Oncology Drug Management

This email is intended for producers with ACA, CHIP, and group business (fully insured and self-funded) in Delaware, New York, Pennsylvania, and West Virginia.

Lower Healthcare Costs with Highmark's Site of Care Oncology Drug Management Program

Why am I receiving this?

Highmark is committed to providing innovative solutions that help you manage healthcare costs while maintaining optimal care for all members. We are introducing our Site of Care Oncology Drug Management Program, designed to significantly lower the cost of medications by strategically aligning members to clinically appropriate and cost-effective settings.

What do I need to know?

The Site of Care (SOC) Oncology Drug Management program focuses on select oncology immunotherapy medications that can safely be administered at each care setting within the program. Highmark’s authorization review process is guided by our SOC Oncology policy. We consider multiple factors, including the member's individual medical needs and the clinical appropriateness of the drug, to align care with the least intensive setting that meets those needs. This can include dedicated infusion suites, physician offices, the member's home, or the hospital outpatient setting.

Key Benefits:

Cost Savings: By strategically aligning care to the least intensive setting that meets clinical needs, employers and members can realize significant savings on drug therapy costs.
Medical Appropriateness: Our clinical team carefully reviews each case to ensure the recommended site of care aligns with the member's specific clinical situation. This ensures quality care is never compromised.
Safe and Effective Administration: Drugs included in the program have been clinically evaluated to confirm safe and effective administration at various care settings within the program.
Convenient Access: Several locations are available within a network of low-cost infusion providers, offering members access to the appropriate level of care needed.

Self-Funded Client Program Cost:
Building on site of care program successes, the new oncology focused program offers potentially significant savings, in some cases thousands of dollars per infusion. For members receiving oncology infusions in a hospital setting when a less intensive setting is equally safe and effective, a care coordination fee of $1,750 per claim may apply. This fee only applies when the actual realized savings are $1,750 or greater.

Should a client choose to opt out of the program, a $0.50 PCPM (per contract per month) fee is available to cover administrative work to turn off the program and manage a non-standard policy exception.

What do I need to do?

Inform your clients of this new program.

Fully insured clients, including ACA and CHIP members, will receive this program as a standard offering beginning 9/1/2025. No action is required.
Self-Funded clients will begin making the choice to offer this program beginning with renewals on 1/1/2026.

Questions?

Please contact your Highmark Client Manager or Sales Executive.

Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association:
Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company.
Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.
PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418.
Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.
West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Visit https://www.highmarkbcbswv.com/networkaccessplan to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card.
Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield.
Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
Highmark Blue Cross Blue Shield and Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

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