Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 08.00.78l


Attachment:A

Policy #:08.00.78l

Description:This is a listing of prescription drugs that are considered by the Company to be self-administered.

Title:Self-Administered 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-Administered Drugs

For most of the Company's commercial products, self-administered drugs are not covered under the member's medical benefit and, therefore, are not eligible for reimbursement under the member's medical benefit. Self- administered drugs are only covered under the member's pharmacy benefit, if one exists, unless an exception by product or group exists. Therefore, 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-administered drug through specialty pharmacy distribution under the member's pharmacy benefit.

The Company-determined, self-administered 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-administered.

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


Brand NameGeneric Name
USC Class
Code
Date Added
Actemra SC
(for subcutaneous use)
Note: For Intravenous use of Actemra covered under the medical benefit, please refer to policy 08.00.85c Tocilizumab (Actemra®) for Intravenous Infusion
tocilzumab
Immunomodu-
lators
J3590
10/22/2013
Actimmuneinterferon gamma–1b
Interferons
J9216
1/1/2010
AdvateAntihemophilic Factor VIII
Clotting Factor
J7192
1/1/2014
AlphanateAntihemophilic Factor VIII/von Willebrand Factor Complex (human)
Clotting Factor
J7186
1/1/2014
AlphanineCoagulation Factor IX (human)
Clotting Factor
J7193
1/1/2014
Apokynapomorphine
Anti-Parkinson's, Others
J0364
1/1/2010
Arixtrafondaparinux
Anticoagulants, Injectable, Other
J1652
1/1/2010
Avonexinterferon beta–1a
Interferons
J1826
1/1/2011
Bebulin VHCoagulation Factor IX complex (human)
Clotting Factor
J7194
1/1/2014
BenefixCoagulation Factor IX (recombinant)
Clotting Factor
J7195
1/1/2014
Betaseroninterferon beta–1b
Interferons
J1830
1/1/2010
Bravelleurofollitropin
Gonadotropins
J3355
1/1/2010
Caverjectalprostadil
Peripheral Vasodilators
J0270
1/1/2010
Cetrotidecetrorelix acetate
Anabolic Hormones
J3490
1/1/2010
Cimzia (eligible for self-administion by commercial members only)certolizumab pegol
Gastrointes-
tinal anti-Inflammatory
J0717
1/1/2014
Copaxoneglatiramer acetate
Nervous System Disorders, Other
J1595
1/1/2010
Edexalprostadil
Peripheral Vasodilators
J0270
1/1/2010
Egrifta tesamorelin
Analog; growth hormone-releasing factor
J3490
12/8/2010
Enbreletanercept
Antiarthritic, Syst.Bio. Response Modifier
J1438
1/1/2010
Extaviainterferon beta–1b
Interferons
J1830
1/1/2010
Feiba NFAnti-inhibitor Coagulant Complex
Hemostatic
J7198
1/1/2014
Firazyr icatibant
bradykinin B2 receptor antagonist
J1744
9/9/2011
Follistim AQfollitropin beta
Gonadotropins
S0128
1/1/2010
Forteoteriparatide
Bone Formation Agents
J3110
1/1/2010
Fragmindalteparin
Anticoagulants, Fractionated Heparins
J1645
1/1/2010
Fuzeonenfuvirtide
HIV Entry/Fusion Inhibitor
J1324
1/1/2010
Ganirelix ganirelix acetate
Gonadotropins
S0132
1/1/2010
Gattex teduglutide
GLP Agonist
J3490
9/12/2012
Genotropinsomatropin
Anabolic Hormones
J2941
1/1/2010
Genotropin MiniQuicksomatropin
Anabolic Hormones
J2941
1/1/2010
Gonal-ffollitropin alfa
Gonadotropins
S0126
1/1/2010
Gonal-f RFFfollitropin alfa
Gonadotropins
S0126
1/1/2010
Helixate FSAntihemophilic Factor VIII
Clotting Factor
J7192
1/1/2014
Hemofil-MAntihemophilic Factor VIII
Clotting Factor
J7190
1/1/2014
Humate-PAntihemophilic Factor VIII/Von Willebrand Factor Complex (human)
Clotting Factor
J7187
1/1/2014
Humatropesomatropin
Anabolic Hormones
J2941
1/1/2010
Humiraadalimumab
Antiarthritic, Syst.Bio. Response Modifier
J0135
1/1/2010
Imitrexsumatriptan
Serotonin 5HT-1 Receptor Agonists
J3030
1/1/2010
Increlexmecasermin
Anabolic Hormones
J2170
1/1/2010
Infergeninterferon alfacon–1
Interferons
J9212
1/1/2010
Innoheptinzaparin
Anticoagulants, Fractionated Heparins
J1655
1/1/2010
Kineretanakinra
Antiarthritic, Syst.Bio. Response Modifier
J3490
1/1/2010
Koate-DVIAntihemophilic Factor VIII
Clotting Factor
J7190
1/1/2014
Kogenate
Kogenate FS
Antihemophilic Factor VIII
Clotting Factor
J7192
1/1/2014
Kynamro mipomersen
Antihyperlipidemic Agent
J3490
1/31/2013
Lovenoxenoxaparin
Anticoagulants, Fractionated Heparins
J1650
1/1/2010
Lupron
(2-week kit only)
leuprolide
GRH Analogs
J9218
1/1/2010
Luverislutropin alfa
Gonadotropins
J3490
1/1/2010
Menopurmenotropins
Gonadotropins
S0122
1/1/2010
Miacalcincalcitonin–salmon
Bone Density Regulators, Calcitonins
J0630
1/1/2010
MonoclateAntihemophilic Factor VIII
Clotting Factor
J7190
1/1/2014
MononineCoagulation Factor IX (human)
Clotting Factor
J7193
1/1/2014

*Mulsevo

semuloparin
Anticoagulant

J3490
9/12/2012
Norditropinsomatropin
Anabolic Hormones
J2941
1/1/2010
Norditropin NordiFlexsomatropin
Anabolic Hormones
J2941
1/1/2010
Novarelchorionic gonadotropin
Gonadotropins
J0725
1/1/2010
Novoeightturotocog alfaClotting FactorJ719210/16/2013
Novoseven
NovosevenRT
Recombinant Coagulation Factor VIIa (rFVIIa)
Clotting Factor
J7189
1/1/2014
Nutropinsomatropin
Anabolic Hormones
J2941
1/1/2010
Nutropin AQsomatropin
Anabolic Hormones
J2941
1/1/2010
Omnitropesomatropin
Anabolic Hormones
J2941
1/1/2010
Orencia
(for subcutaneous use)
Note:
For Intravenous use of Orencia covered under the medical benefit, please refer to policy 08.00.62d Abatacept (Orencia®).
abatacept
Immuno-
modulator
J3590
9/9/2011
Otrexupmethotrexatefolic acid antagonistJ349010/11/2013
Ovidrelchorionic gonadotropin
Gonadotropins
J0725
1/1/2010
Pegasyspeginterferon alfa–2a
Interferons
S0145
1/1/2010
PEG-Intronpeginterferon alfa–2b
Interferons
S0148
10/1/2010
PEG-Intron Redi-Penpeginterferon alfa–2b
Interferons
S0148
10/1/2010
Pregnylchorionic gonadotropin
Gonadotropins
J0725
1/1/2010
*Preosparathyroid hormone
Hormone
J3490
1/1/2011
Profilnine SDCoagulation Factor IX complex (human)
Clotting Factor
J7194
1/1/2014
Proplex T Coagulation Factor IX complex (human)
Clotting Factor
J7194
1/1/2014
*Protropinsomatrem
Anabolic Hormones
J2940
4/30/2010
RecombinateAntihemophilic Factor VIII
Clotting Factor
J7192
1/1/2014
Rebifinterferon beta–1a
Interferons
J1826
1/1/2011
Rebifinterferon beta–1a
Interferons
Q3027
1/1/2014
Rebifinterferon beta–1a
Interferons
Q3028
1/1/2014
RefactoAntihemophilic Factor VIII
Clotting Factor
J7192
1/1/2014
Relistormethylnaltrexone bromide acetate
MU-Opioid Receptor Antagonists
J2212
1/1/2010
Repronexmenotropins
Gonadotropins
S0122
1/1/2010
RixubisCoagulation Factor IX (recombinant)
Clotting Factor
J7195
1/1/2014
Roferon-Ainterferon alfa-2a
Interferons
J9213
4/30/2010
Saizensomatropin
Anabolic Hormones
J2941
1/1/2010
Serostimsomatropin
Anabolic Hormones
J2941
1/1/2010
Signifor pasireotide
somatostatin analog
J3490
1/31/2013
Simponigolimumab
Antiarthritic, Syst.Bio. Response Modifier
J3490
1/1/2010
Somavertpegvisomant
Anabolic Hormones
J3490
1/1/2010
Sumavel DoseProsumatriptan
Serotonin 5HT-1 Receptor Agonists
J3030
1/1/2010
Supprelinhistrelin
Sex Hormones, Other
J1675
1/1/2010
Sylatronpeginterferon alfa–2b
Interferons
S0148
5/10/2011
Tev-Tropinsomatropin
Anabolic Hormones
J2941
1/1/2010
Tretton Coagulation Factor XIII-A-subunit (recombinant)Coagulation FactorJ719912/23/2013
WilateVon Willebrand Factor/Factor VIII Complex (human)
Coagulation Factor Complex
J7183
1/1/2014
XynthaAntihemophilic Factor (recombinant)
Clotting Factor
J7185
1/1/2014
Zorbtivesomatropin
Anabolic Hormones
J2941
1/1/2010



Version Effective Date: 02/26/2014

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