Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 08.00.78z


Attachment:A

Policy #:08.00.78z

Description: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.

Brand Name
Generic Name
USC Class
Code
Date Added
N/Agalcanezumab Monoclonal Antibodies
J3590
05/28/2018
Actemra SC
(for subcutaneous use)
Note: For Intravenous use of Actemra covered under the medical benefit, please refer to policy 08.00.85 Tocilizumab (Actemra®) for Intravenous Infusion
tocilizumabMonoclonal Antibodies
J3590
10/22/2013
Actimmuneinterferon gamma–1bInterferons
J9216
1/1/2010
Advateantihemophilic factor VIII Clotting Factor
J7192
1/1/2014
Adynovateantihemophilic factor VIIIClotting Factor
J7207
1/01/2016
Afstyla antihemophilic factor VIIIFactor VIII
J7210
12/12/2016
Aimovigerenumab-aooe Monoclonal Antibodies
J3590
05/28/2018
Alphanateantihemophilic factor VIII/von Willebrand factor complex (human) Clotting Factor
J7186
1/1/2014
Alphanine SDcoagulation factor IX (human) Clotting Factor
J7193
1/1/2014
Alprolixcoagulation factor IX (recombinant)Clotting Factor
J7201
7/30/2014
Amjevitaadalimumab-atto Antiarthritic, Syst. Bio. Response Modifier
J3590
12/12/2016
Apokynapomorphine Anti-Parkinson's, Others
J0364
1/1/2010
Arixtrafondaparinux Anticoagulants, Injectable, Other
J1652
1/1/2010
Avonexinterferon beta–1aInterferons
J1826
1/1/2011
Bebulincoagulation factor IX complex (human) Clotting Factor
J7194
1/1/2014
Benefixcoagulation factor IX (recombinant) Clotting Factor
J7195
1/1/2014
Benlysta (for subcutaneous use)
Note: For Intravenous use of Benlysta covered under the medical benefit, please refer to policy 08.00.99 Belimumab (Benlysta®)
belimumab Monoclonal Antibodies
J3590
09/28/2017
BerinertC1 Esterase Inhibitor Subcutaneous (Human)Biologicals, Other
J0597
01/01/2018
Betaseroninterferon beta–1bInterferons
J1830
1/1/2010
BravelleurofollitropinGonadotropins
J3355
1/1/2010
CaverjectalprostadilPeripheral Vasodilators
J0270
1/1/2010
Cetrotidecetrorelix acetate Anabolic Hormones
J3490
1/1/2010
Cimziacertolizumab pegolGastrointes-
tinal anti-Inflammatory
J0717
1/1/2014
CinryzeC1 Esterase Inhibitor Subcutaneous (Human)Biologicals, Other
J0598
01/01/2018
Coagadexcoagulation factor X, (human)Clotting Factor
J7175
1/01/2016
Copaxoneglatiramer acetate Nervous System Disorders, Other
J1595
1/1/2010
CorifactFactor XIIIf concentrate (Human)Clotting Factor
J7180
12/01/2014
CosentyxsecukinumabMonoclonal Antibodies
J3590
3/25/2015
Cyltezoadalimumab-adbmAntiarthritic, Syst. Bio. Response Modifier
J3590
05/28/2018
DupixentdupilumabMonoclonal Antibodies
J3590
05/31/2017
EdexalprostadilPeripheral Vasodilators
J0270
1/1/2010
Egrifta tesamorelinAnalog; growth hormone-releasing factor
J3490
12/8/2010
Eloctaterecombinant factor VIII Fc fusion proteinClotting Factor
J7205
7/30/2014
Elonva corifollitropin alfaModified follicule stimulating hormone
J3490
7/30/2014
EnbreletanerceptAntiarthritic, Syst. Bio. Response Modifier
J1438

1/1/2010
eptacog beta, activatedrecombinant activated human Coagulation Factor VIIaClotting Factor
J7189
05/28/2018
Erelzi etanercept-szzs Antiarthritic, Syst. Bio. Response Modifier
J3590
12/12/2016
Evzio naloxone HClOpioid antagonist
J3490 or J2310
7/30/2014
Extaviainterferon beta–1bInterferons
J1830
1/1/2010
Feibaanti-inhibitor coagulant complex Hemostatic
J7198
1/1/2014
Fibrynafibrinogen concentrate (human)Clotting Factor
J7178
09/28/2017
FirazyricatibantBradykinin B2 receptor antagonist
J1744
9/9/2011
Follistim AQfollitropin betaGonadotropins
S0128
1/1/2010
ForteoteriparatideBone Formation Agents
J3110
1/1/2010
FragmindalteparinAnticoagulants, Fractionated Heparins
J1645
1/1/2010
FuzeonenfuvirtideHIV Entry/Fusion Inhibitor
J1324
1/1/2010
Ganirelix ganirelix acetateGonadotropins
S0132
1/1/2010
GattexteduglutideGLP Agonist
J3490
9/12/2012
GenotropinsomatropinAnabolic Hormones
J2941
1/1/2010
Genotropin MiniQuicksomatropinAnabolic Hormones
J2941
1/1/2010
Glatopaglatiramer acetateNervous System Disorders, Other
J1595
1/01/2016
Gonal-ffollitropin alfaGonadotropins
S0126
1/1/2010
Gonal-f RFFfollitropin alfaGonadotropins
S0126
1/1/2010
HaegardaC1 Esterase Inhibitor Subcutaneous (Human)Biologicals, Other
J3590
09/28/2017
Helixate FSantihemophilic factor VIII Clotting Factor
J7192
1/1/2014
Hemlibraemicizumab-kxwhClotting Factor; Monoclonal Antibodies
Q9995
05/28/2018
Hemofil-Mantihemophilic factor VIIIClotting Factor
J7190
1/1/2014
Humate-Pantihemophilic factor VIII/Von Willebrand factor complex (human)Clotting Factor
J7187
1/1/2014
HumatropesomatropinAnabolic Hormones
J2941
1/1/2010
HumiraadalimumabAntiarthritic, Syst. Bio. Response Modifier
J0135
1/1/2010
Idelvioncoagulation Factor IX (recombinant)Factor IX
J7202
3/09/2016
ImitrexsumatriptanSerotonin 5HT-1 Receptor Agonists
J3030
1/1/2010
IncrelexmecaserminAnabolic Hormones
J2170
1/1/2010
Infergeninterferon alfacon–1Interferons
J9212
1/1/2010
InnoheptinzaparinAnticoagulants, Fractionated Heparins
J1655
1/1/2010
Ixinitycoagulation Factor IX (recombinant)Factor IX
J7195
7/15/2015
Kevzarasarilumab Monoclonal Antibodies
J3590
12/12/2016
KineretanakinraAntiarthritic, Syst.Bio. Response Modifier
J3490
1/1/2010
Koate-DVIantihemophilic Factor VIIIClotting Factor
J7190
1/1/2014
Kogenate FSantihemophilic Factor VIII Clotting Factor
J7192
1/1/2014
Kovaltryantihemophilic Factor VIIIClotting Factor
J7211
3/09/2016
Kynamro mipomersenAntihyperlipidemic Agent
J3490
1/31/2013
LovenoxenoxaparinAnticoagulants, Fractionated Heparins
J1650
1/1/2010
Lupron (2-week kit only)leuprolideGRH Analogs
J9218
1/1/2010
Luverislutropin alfaGonadotropins
J3490
1/1/2010
MenopurmenotropinsGonadotropins
S0122
1/1/2010
Miacalcincalcitonin–salmonBone Density Regulators, Calcitonins
J0630
1/1/2010
Monoclate-Pantihemophilic Factor VIIIClotting Factor
J7190
1/1/2014
MononineCoagulation Factor IX (human) Clotting Factor
J7193
1/1/2014
MyaleptmetreleptinLeptin Analog
J3590
7/30/2014
MulsevosemuloparinAnticoagulant
J3490
9/12/2012
Natpara recombinant human parathyroid hormone (rhPTH 1-84)Hormone
J3590
12/01/2014
NorditropinsomatropinAnabolic Hormones
J2941
1/1/2010
Norditropin NordiFlexsomatropinAnabolic Hormones
J2941
1/1/2010
Novarelchorionic gonadotropinGonadotropins
J0725
1/1/2010
Novoeightturotocog alfaClotting Factor
J7182
10/16/2013
Novoseven
NovosevenRT
recombinant Coagulation Factor VIIa (rFVIIa) Clotting Factor
J7189
1/1/2014
NutropinsomatropinAnabolic Hormones
J2941
1/1/2010
Nutropin AQsomatropinAnabolic Hormones
J2941
1/1/2010
NuwiqAntihemophilic Factor VIIIClotting Factor
J7209
1/01/2016
Obizurrecombinant antihemophilic porcine sequence factor VIIIClotting Factor
J7188
12/01/2014
OmnitropesomatropinAnabolic Hormones
J2941
1/1/2010
Orencia (for subcutaneous use)
Note: for Intravenous use of Orencia covered under the medical benefit, please refer to policy 08.00.62 Abatacept (Orencia®)
abataceptImmunomodulators
J3590
9/9/2011
OtrexupmethotrexateFolic Acid Antagonist
J3490
10/11/2013
Ovidrelchorionic gonadotropinGonadotropins
J0725
1/1/2010
Palynziqpegvaliase-pqpzEnzymes, Systemic
J3590
05/28/2018
Pegasyspeginterferon alfa–2aInterferons
S0145
1/1/2010
PEG-Intronpeginterferon alfa–2bInterferons
S0148
10/1/2010
PEG-Intron
Redi-Pen
peginterferon alfa–2bInterferons
S0148
10/1/2010
Plegridy PEG interferon beta-1A Interferons
J3490
7/30/2014
Praluent alriocumabMonoclonal Antibodies
J3590
7/15/2015
Pregnylchorionic gonadotropinGonadotropins
J0725
1/1/2010
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
ProtropinsomatremAnabolic Hormones
J2940
4/30/2010
Rasuvomethotrexatefolic acid antagonist
J3490
7/30/2014
Rebifinterferon beta–1aInterferons
J1826
1/1/2011
Rebifinterferon beta–1aInterferons
Q3027
1/1/2014
Rebifinterferon beta–1aInterferons
Q3028
1/1/2014
Rebinyn coagulation Factor IX (recombinant) Clotting Factor
J7195
09/28/2017
Recombinateantihemophilic Factor VIII Clotting Factor
J7192
1/1/2014
Refactoantihemophilic Factor VIII Clotting Factor
J7192
1/1/2014
Relistormethylnaltrexone bromide acetateMU-Opioid Receptor Antagonists
J2212
1/1/2010
RepathaevolocumabMonoclonal Antibodies
J3590
7/15/2015
RepronexmenotropinsGonadotropins
S0122
1/1/2010
RiaSTAPfibrinogen concentrate (human)Clotting Factor
J7178
3/09/2016
Rixubiscoagulation Factor IX (recombinant) Clotting Factor
J7200
1/1/2014
Roferon-Ainterferon alfa-2aInterferons
J9213
4/30/2010
RuconestC1 Esterase Inhibitor Subcutaneous (Recombinant)Biologicals, Other
J0596
01/01/2018
SaizensomatropinAnabolic Hormones
J2941
1/1/2010
Saxendaliraglutide Human GLP-1 Analogs
J3490
1/01/2016
SerostimsomatropinAnabolic Hormones
J2941
1/1/2010
Signifor pasireotidesomatostatin analog
J3490
1/31/2013
Siliqbrodalumab Monoclonal Antibodies
J3590
12/12/2016
SimponigolimumabAntiarthritic, Syst.Bio. Response Modifier
J3490
1/1/2010
SomavertpegvisomantAnabolic Hormones
J3490
1/1/2010
Strensiq asfotase alfaEnzymes, Systemic
J3490
3/25/2015
Sumavel DoseProsumatriptanSerotonin 5HT-1 Receptor Agonists
J3030
1/1/2010
SupprelinhistrelinSex Hormones, Other
J1675
1/1/2010
Sylatronpeginterferon alfa–2bInterferons
S0148
5/10/2011
Taltzixekizumab Monoclonal Antibodies
J3590
12/12/2016
Tev-TropinsomatropinAnabolic Hormones
J2941
1/1/2010
Tremfya guselkumabMonoclonal Antibodies
J3590
09/28/2017
Tretten coagulation Factor XIII-A-subunit (recombinant)Coagulation Factor
J7181
12/23/2013
TymlosabaloparatideBone Formation Agents
J3490
05/31/2017
Vonvendi Von Willebrand Factor (recombinant)Coagulation Factor
J7179
3/09/2016
WilateVon Willebrand Factor/Factor VIII Complex (human)Coagulation Factor Complex
J7183
1/1/2014
Xynthaantihemophilic Factor (recombinant)Clotting Factor
J7185
1/1/2014
Xyostedtestosterone enanthate Sex Hormones, Other
J3121
05/28/2018
Zembrace SymTouchsumatriptan succinateSerotonin 5HT-1 Receptor Agonists
J3490
3/09/2016
Zinbrytadaclizumab (high-yield process)Monoclonal Antibodies
J3590
1/01/2016
ZomactonsomatropinAnabolic Hormones
J2941
09/28/2017
ZorbtivesomatropinAnabolic Hormones
J2941
1/1/2010


Version Effective Date: 07/01/2018
Version Issued Date: 06/29/2018
Version Reissued Date: N/A

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