Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA08.007q


Attachment:B

Policy #:MA08.007q

Description:Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage

Title:Medicare Part B vs. Part D Crossover 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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


DRUGS THAT ARE USUALLY SELF-ADMINISTERED:
CONSIDERED PART D ONLY (WITH J/S/C CODES) – EXCLUDED FROM PART B COVERAGE



The following drugs are usually self-administered (defined as a drug that is self-administered more than 50 percent of the time) and excluded from Medicare medical coverage (Part B). The Incident-to-Provision does not apply to these drugs when administered in the office setting as these drugs are always excluded from Part B coverage:

Generic Drug Name
Brand Drug Name
Code
Description
Abaloparatide
Tymlos
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Abatacept
Orencia *
subcutanous only
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Abatacept
Orencia *
Subcutaneous only
J0129
Injection, abatacept, 10mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
Adalimumab-adbm
Cyltezo
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Adalimumab-atto
Amjevita
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Adalimumab
Humira
J0135
Injection, adalimumab, 20 mg
Albiglutide
Tanzeum
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Alirocumab
Praluent
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Alprostadil
Caverject, Edex, Prostaglandin E1
J0270
Injection, alprostadil, 1.25 mcg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)
Alprostadil
Muse
J0275
Alprostadil urethral suppository (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)
Anakinra
Kineret
C9399 J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Apomorphine hydrochloride injection
Apokyn
J0364
Injection Apomorphine Hydrochloride, 1mg
Asfotase alfa
Strensiq
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Belimumab
Benlysta *
subcutanous only
J0490
Injection, belimumab, 10 MG
Brodalumab
Siliq
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
C1 esterase inhibitor (human)
Haegarda
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Calcitonin
Miacalcin, Fortical
J0630
Injection, calcitonin-salmon, up to 400 units
Corticotropin
H.P. Acthar Gel (subcutaneous)
J0800
Injection Corticotropin, up to 40 Units
Daclizumab
Zinbryta
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Dulaglutide
Trulicity
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Dupilumab
Dupixent
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Enfuvirtide
Fuzeon
J1324
Injection, enfuvirtide, 1 mg
Erenumamab-aooe
Aimovig
C9399, J3490, J3590Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Etanercept
Enbrel
J1438
Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
Etanercept-SZZS
Erelzi
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Evolocumab
Repatha
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Exenatide
Bydureon
(extended release for injectable suspension)
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Exenatide
Byetta
(exenatide injection)
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Fremanezumab-vfrm
Ajovy
J3031
Injection, fremanezumab-vfrm, 1 MG (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
Galcanezmab
Emgality
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Glatiramer acetate
Copaxone, Glatopa
J1595
Injection, glatiramer acetate, 20 mg
Golimumab
Simponi
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Icatibant
Firazyr
J1744
Injection, icatibant, 1mg
Insulin
All Applicable Brand Name Insulins
J1815
Injection, insulin, per 5 units
Insulin
All Applicable Brand Name Insulins
S5550
Insulin, rapid onset, 5 units
Insulin
All Applicable Brand Name Insulins
S5551
Insulin, most rapid onset (Lispro or Aspart); 5 units
Insulin
All Applicable Brand Name Insulins
S5552
Insulin, intermediate acting (NPH or Lente); 5 units
Insulin
All Applicable Brand Name Insulins
S5553
Insulin, long-acting; 5 units
Insulin
All Applicable Brand Name Insulins
S5565
Insulin cartridge for use in insulin delivery device other than pump; 150 units
Insulin
All Applicable Brand Name Insulins
S5566
Insulin cartridge for use in insulin delivery device other than pump; 300 units
Insulin
All Applicable Brand Name Insulins
S5570
Insulin delivery device, disposable pen (including insulin); 1.5 ml size
Insulin
All Applicable Brand Name Insulins
S5571
Insulin delivery device, disposable pen (including insulin); 3 ml size
Insulin
Toujeo
Insulin glargine injection
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Insulin
Lantus Solostar
Insulin glargine
injection
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Interferon alfacon-1, recombinant
J9212
Injection, interferon alfacon-1, recombinant, 1 microgram
Interferon alfa-2a, recombinant
J9213
Injection, interferon, alfa-2a, recombinant, 3 million units
Interferon beta-1a
Rebif
Interferon beta-1a, 11mcg)
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Interferon beta-1b
Betaseron, Extavia
J1830
Injection interferon beta-1b, 0.25 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)
Interferon gamma 1-b
Actimmune
J9216
Injection, interferon, gamma 1-b, 3 million units
Ixekizumab
Taltz
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Lanadelumab-flyo
Takhzyro
J0593
Injection, lanadelumab-flyo, 1 MG (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)
Leuprolide Acetate
Lupron
J9218
Leuprolide acetate, per 1 mg
Liraglutide
Saxenda
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Liraglutide
Victoza
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Mecasermin
Increlex
J2170
Injection, mecasermin, 1 mg
Methotrexate
Otrexup, (methotrexate injection for subcutaneous use)
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Methotrexate
Rasuvo
methotrexate injection for subcutaneous use)
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Methylnaltrexone Bromide
Relistor
J2212
Injection, methylnaltrexone 0.1mg
Metreleptin (injection)
Myalept (Metreleptin for injection 11 mg)
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Mipomersen
Kynamro
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Octreotide
Sandostatin *
subcutaneous only
J2354
Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg
Papaverine, Phentolamine, Alprostadil, Atropine
Quad-Mix
C9399, J3490, J3590Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Parathyroid Hormone
Natpara
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Pasireotide
SIGNIFOR
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Peginterferon alfa-2a
Pegasys,
Pegasys Proclick Pen Injector
C9399, J3490, J3590S0145
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Injection, pegylated interferon alfa-2a, 180 mcg per ml,
Peginterferon alfa-2b
PEG-Intron,
Sylatron
C9399, J3490, J3590S0148
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Injection, pegylated interferon alfa-2b, 10 mcg
Sarilumab
Kevzara
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Semaglutide
Ozempic
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Tocilizumab
Actemra *
subcutaneous only
J3262
Injection, tocilizumab, 1 MG
Peginterferon beta-1a
Plegridy
C9399, J3490, J9390
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Pegvisomant
Somavert
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Pramlintide acetate
Symlin
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Secukinumab
Cosentyx
C9399,J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Sermorelin acetate
Q0515
Injection, sermorelin acetate, 1 mcg
Somatrem
N/A
J2940
Injection, somatrem, 1 mgInjection
Somatropin
Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Serostim, Zomacton, Zorbitive
J2941
Injection, somatropin, 1 mg
Sumatriptin
Dosepro, Imitrex, Sumavel, Zembrace
J3030
Injection, sumatriptan succinate, 6 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
Teriparatide
Forteo
J3110
Injection, teriparatide, 10 mcg
Tesamorelin
Egrifta
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
N/A
Trimix
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics
Urofollitropin
Bravelle
J3355
Injection urofollitropin, 75 IU


Note: Drug codes that must use modifier JB when the subcutaneous form of the drug is administered are listed with an asterisk * in the Coding Table


Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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