Home Infusion Therapy
Home infusion therapy is a limited benefit. Home infusion therapy involves beneficiaries receiving medication (including chemotherapy drugs) in their own home by other than oral means, for example, intramuscularly, subcutaneously, intravenously, or infused through a piece of durable medical equipment. This remains a limited benefit whether the medications are self- or caretaker-administered, or administered by a health care provider.
Prior Authorization Requirement
Prior authorization is required for all beneficiaries except those with other health insurance. The prior authorization must be received before the initiation of the therapy in order to ensure medications are received from the correct TRICARE source and any required nursing visits are pre-approved. Services rendered without prior authorization may be ruled as non-covered benefits or may result in a payment penalty. When the provider initially certifies self or caretaker infusion, or injection is medically appropriate for either homebound or non-homebound beneficiaries, the beneficiary must receive education from a home health agency.
Nursing visits will be authorized by Health Net Federal Services, LLC (HNFS) based on the type of services, homebound status* of the beneficiary and classification of home health nursing provider.
The type of medication and length of administration will determine whether the home infusion/injection medication will be paid under the medical benefit or through the TRICARE pharmacy benefit.
*Homebound status for a beneficiary is determined by the provider.
Submitting a Request
The request must be submitted to HNFS for home infusion/injection services. When requesting authorization, be sure to include the dose, frequency and route of administration for the medication. Health Net Federal Services will generate authorizations as appropriate if the drug is a covered benefit. If covered under the medical benefit, the provider should submit the claim to PGBA. If covered under the TRICARE pharmacy benefit, HNFS will fax an authorization to the TRICARE pharmacy and the provider should submit the claim to the TRICARE pharmacy. There may be separate charges for durable medical equipment, supplies, prosthetics, and specific drugs with applicable copayments and cost shares.