Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 08.00.78i


Attachment:A

Policy #:08.00.78i

Description:List of self-injectable drugs

Title:Self-Injectable Drugs


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



Self-Injectable Drugs

For most of the Company's commercial products, self-injectable drugs are not covered under the member's medical benefit and, therefore, are not eligible for reimbursement. Self-injectable drugs are only covered under the member's pharmacy benefit, if one exists. Individual benefits must be verified as coverage may vary by product and/or group. Providers should work directly with the member's Pharmacy Benefit Administrator on options to obtain a self-injectable drug through specialty pharmacy distribution under the member's pharmacy benefit.

The self-injectable drugs listed in this Attachment are subject to change as new medications come to market or new determinations are made by the Company. This list contains only those drugs and biologics that are determined by the Company to be self-injectable.

NOTE: Drugs indicated by an asterisk (*) are pending approval from the US Food and Drug Administration (FDA).

Brand NameGeneric Name
USC Class
Code
Narrative
Date Added
Actimmuneinterferon gamma–1b
Interferons
J9216
Injection, interferon, gamma-1b, 3 million units
1/1/2010
Apokynapomorphine
Anti-Parkinson's, Others
J0364
Injection, apomorphine HCl, 1 mg
1/1/2010
Arixtrafondaparinux
Anticoagulants, Injectable, Other
J1652
Injection, fondaparinux sodium, 0.5 mg
1/1/2010
Avonexinterferon beta–1a
Interferons
J1826
Injection, interferon beta-1a, 30mcg
1/1/2011
Avonexinterferon beta–1a
Interferons
Q3025
Injection, interferon beta-1a, 11 mcg for intramuscular use
1/1/2010
Betaseroninterferon beta–1b
Interferons
J1830
Injection interferon beta-1b, 0.25 mg
1/1/2010
Bravelleurofollitropin
Gonadotropins
J3355
Injection, urofollitropin, 75 IU
1/1/2010
Caverjectalprostadil
Peripheral Vasodilators
J0270
Injection, alprostadil, 1.25 mcg
1/1/2010
Cetrotidecetrorelix acetate
Anabolic Hormones
J3490
Unclassified drugs
1/1/2010
Cimziacertolizumab pegol
GI Anti-Inflammatory
J0718
Injection, certolizumab pegol, 1 mg
1/1/2010
Copaxoneglatiramer acetate
Nervous System Disorders, Other
J1595
Injection, glatiramer acetate, 20 mg
1/1/2010
Edexalprostadil
Peripheral Vasodilators
J0270
Injection, alprostadil, 1.25 mcg
1/1/2010
Egrifta tesamorelin
Analog; growth hormone-releasing factor
J3490Unclassified drugs12/8/2010
Enbreletanercept
Antiarthritic, Syst.Bio. Response Modifier
J1438
Injection, etanercept, 25 mg
1/1/2010
Extaviainterferon beta–1b
Interferons
J1830
Injection interferon beta-1b, 0.25 mg
1/1/2010
Firazyr icatibant bradykinin B2 receptor antagonist J1744 Injection, icatibant, 1 mg 9/9/2011
Follistim AQfollitropin beta
Gonadotropins
S0128
Injection, follitropin beta, 75 IU
1/1/2010
Forteoteriparatide
Bone Formation Agents
J3110
Injection, teriparatide, 10 mcg
1/1/2010
Fragmindalteparin
Anticoagulants, Fractionated Heparins
J1645
Injection, dalteparin sodium, per 2500 IU
1/1/2010
Fuzeonenfuvirtide
HIV Entry/Fusion Inhibitor
J1324
Injection, enfuvirtide, 1 mg
1/1/2010
Ganirelix ganirelix acetate
Gonadotropins
S0132
Injection, ganirelix acetate, 250 mcg
1/1/2010
Gattex teduglutide
GLP Agonist
J3490 Unclassified drugs 9/12/2012
Genotropinsomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Genotropin MiniQuicksomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Gonal-ffollitropin alfa
Gonadotropins
S0126
Injection, follitropin alfa, 75 IU
1/1/2010
Gonal-f RFFfollitropin alfa
Gonadotropins
S0126
Injection, follitropin alfa, 75 IU
1/1/2010
Humatropesomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Humiraadalimumab
Antiarthritic, Syst.Bio. Response Modifier
J0135
Injection, adalimumab, 20 mg
1/1/2010
Imitrexsumatriptan
Serotonin 5HT-1 Receptor Agonists
J3030
Injection, sumatriptan succinate, 6 mg
1/1/2010
Increlexmecasermin
Anabolic Hormones
J2170
Injection, mecasermin, 1 mg
1/1/2010
Infergeninterferon alfacon–1
Interferons
J9212
Injection, interferon alfacon-1, recombinant, 1 mcg
1/1/2010
Innoheptinzaparin
Anticoagulants, Fractionated Heparins
J1655
Injection, tinzaparin sodium, 1000 IU
1/1/2010
Kineretanakinra
Antiarthritic, Syst.Bio. Response Modifier
J3490
Unclassified drugs
1/1/2010
Kynamro mipomersen
Antihyperlipidemic Agent
J3490 Unclassified drugs 1/31/2013
Lovenoxenoxaparin
Anticoagulants, Fractionated Heparins
J1650
Injection, enoxaparin sodium, 10 mg
1/1/2010
Lupron
(2-week kit only)
leuprolide
GRH Analogs
J9218
Leuprolide acetate, per 1 mg
1/1/2010
Luverislutropin alfa
Gonadotropins
J3490
Unclassified drugs
1/1/2010
Menopurmenotropins
Gonadotropins
S0122
Injection, menotropins, 75 IU
1/1/2010
Miacalcincalcitonin–salmon
Bone Density Regulators, Calcitonins
J0630
Injection, calcitonin salmon, up to 400 units
1/1/2010
*Mulsevo semuloparin Anticoagulant J3490 Unclassified drugs 9/12/2012
Norditropinsomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Norditropin NordiFlexsomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Novarelchorionic gonadotropin
Gonadotropins
J0725
Injection, chorionic gonadotropin, per 1,000 USP units
1/1/2010
Nutropinsomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Nutropin AQsomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Omnitropesomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Orencia
(for subcutaneous use)

Note:
For Intravenous use of Orencia, please refer to policy 08.00.62d Abatacept (Orencia®)regarding coverage under the medical benefit.
abatacept Immunomodulator J3590 Unclassified biologics 9/9/2011
Ovidrelchorionic gonadotropin
Gonadotropins
J0725
Injection, chorionic gonadotropin, per 1,000 USP units
1/1/2010
Pegasyspeginterferon alfa–2a
Interferons
S0145
Injection, pegylated interferon alfa-2a, 180 mcg per ml
1/1/2010
PEG-Intronpeginterferon alfa–2b
Interferons
S0148
Injection, pegylated interferon alfa-2b, 10 mcg per 0.5 ml
10/1/2010
PEG-Intron Redi-Penpeginterferon alfa–2b
Interferons
S0148
Injection, pegylated interferon alfa-2b, 10 mcg per 0.5 ml
10/1/2010
Pregnylchorionic gonadotropin
Gonadotropins
J0725
Injection, chorionic gonadotropin, per 1,000 USP units
1/1/2010
*Preosparathyroid hormone Hormone
J3490
Unclassified drugs 1/1/2011
*Protropinsomatrem
Anabolic Hormones
J2940
Injection, somatrem, 1mg 4/30/2010
Rebifinterferon beta–1a
Interferons
J1826
Injection, interferon beta-1a, 30mcg
1/1/2011
Rebifinterferon beta–1a
Interferons
Q3025
Injection, interferon beta-1a, 11 mcg for intramuscular use
1/1/2010
Rebifinterferon beta–1a
Interferons
Q3026
Injection, interferon beta-1a, 11 mcg for subcutaneous use
1/1/2010
Relistormethylnaltrexone bromide acetate
MU-Opioid Receptor Antagonists
J2212
Injection, methylnaltrexone, 0.1 mg
1/1/2010
Repronexmenotropins
Gonadotropins
S0122
Injection, menotropins, 75 IU
1/1/2010
Roferon-Ainterferon alfa-2a
Interferons
J9213
Injection, interferon, alfa-2a, recombinant, 3 million units4/30/2010
Saizensomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Serostimsomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Signifor pasireotide
somatostatin analog
J3490 Unclassified drugs1/31/2013
Simponigolimumab
Antiarthritic, Syst.Bio. Response Modifier
J3490
Unclassified drugs
1/1/2010
Somavertpegvisomant
Anabolic Hormones
J3490
Unclassified drugs
1/1/2010
Sumavel DoseProsumatriptan
Serotonin 5HT-1 Receptor Agonists
J3030
Injection, sumatriptan succinate, 6 mg
1/1/2010
Supprelinhistrelin
Sex Hormones, Other
J1675
Injection, histrelin acetate, 10 mcg
1/1/2010
Sylatronpeginterferon alfa–2b
Interferons
S0148
Injection, pegylated interferon alfa-2b, 10 mcg per 0.5 ml
5/10/2011
Tev-Tropinsomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010
Zorbtivesomatropin
Anabolic Hormones
J2941
Injection, somatropin, 1 mg
1/1/2010

Version Effective Date: 03/27/2013

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