Medicare Advantage
Advanced Search

Medicare Part B vs. Part D Crossover Drugs
MA08.007au

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

The Company's Medicare Advantage Prescription Drug (MA-PD) and Prescription Drug Plans (PDP) for drugs covered under either the medical benefit (Part B) or the pharmacy benefit (Part D) are identified in the chart below.

PLEASE REFER TO THE FOLLOWING ATTACHMENTS FOR ADDITIONAL INFORMATION

Attachment A: Medicare medical benefit (Part B) drugs that can be accessed at a retail or long-term-care pharmacy setting. Claims from a retail or long-term-care pharmacy process at a medical benefit (Part B) cost share with no pharmacy benefit (Part D) True-Out Of-Pocket (TrOOP) expenses applied

Attachment B: Drugs that are usually self-administered (defined as a drug that is self-administered more than 50% of the time) and excluded from Medicare medical benefit (Part B) coverage

Attachment C: Vaccination and inoculation coverage

Attachment D: Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit (Part B)

Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit (Part B)

Attachment F: Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting

MEDICARE PART B VS. PART D CHART
DRUG CATEGORIES​RULE
Parenteral Nutrition (TPN)
Part B coverage – If the individual has a permanent dysfunction of the digestive tract

Part D coverage – All other indications, including dialysis
Preexposure Prophylaxis (PrEP) (using oral or injectable antiretroviral drugs) for Human Immunodeficiency Virus (HIV) Prevention in individuals at high riskAlways covered under Part B
Intravenous Immune Globulin (IVIG)Part B coverage – If administered at home for primary immunodeficiency (refer to Attachment F for a list of those diagnosis codes that represent primary immunodeficiencies that may be covered under Part B)

Part D coverage – If provided in the home for all other indications

Note: Primary immunodeficiencies not included in Attachment F may be reviewed for coverage through applicable Part D benefits.
Subcutaneous Immune Globulin (SCIG)


Part B coverage – If administered at home on an external infusion pump that is an item of durable medical equipment for primary immunodeficiency OR chronic inflammatory demyelinating polyneuropathy that has responded to IVIg treatment (refer to Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the medical benefit [Part B])

Part D coverage – If it does not meet Part B rules above, may be reviewed for coverage through applicable Part D benefits.
Inhaled Nebulized Solutions:

acetylcysteine (Mucomyst),
albuterol, albuterol and ipratropium (DuoNeb), albuterol sulfate (AccuNeb, Proventil),
arformoterol (Brovana), budesonide inhalation suspension (Pulmicort Respules),
cromolyn (Intal),
dornase alfa (Pulmozyme),
formoterol fumarate (Performist),
iloprost (Ventavis),
ipratropium bromide,
levalbuterol hydrochloride (Xopenex), metaproterenol sulfate (Alupent),
pentamidine isethionate (NebuPent),
revefenacin (Yupelri),
treprostinil (Tyvaso),
tobramycin inhalation solution (TOBI, Bethkis)		Part B coverage – If used with a nebulizer in the home setting (refer to the specific policy on Nebulizers and Inhalation Solutions for inhalation drugs that may be covered under Part B.)

Part D coverage – If used with a metered dose inhaler or other non-nebulized administration or when used in a long-term-care facility



Immunosuppressant:
mycophenolate mofetil (CellCept), azathioprine (Imuran, Azasan), Cyclosporine (Systemic) (Neoral, Gengraf), sirolimus (Rapamune), tacrolimus (Prograf), Mycophenolic Acid (Myfortic) and cyclosporine (Sandimmune); methotrexate,
(Trexall);
basiliximab (Simulect), belatacept (Nulojix); Orthoclone OKT3 (muromomab-CD3); Atgam (lymphocyte Immune globulin)		Part B coverage – For beneficiaries who received a transplant from a Medicare-approved facility and were entitled or qualified for Medicare Part A at the time of the transplant

Part D coverage – All other scenarios
Separately billable ESRD Drugs furnished by the dialysis center:
(e.g., Erythropoietin (EPO) [Aranesp, Epogen, Procrit], Lidocaine, Vancomycin, Levocarnitine, Calcitriol)		Part B coverage – Treatment of anemia for individuals with chronic renal failure (CRF) who are on dialysis

Part D coverage – All other indications
Oral Chemotherapy (Chemo)
Drugs with Intravenous (IV) Equivalent:
e.g., melphalan (Alkeran); methotrexate (Trexall); etoposide (VePesid); and capecitabine (Xeloda); topotecan (Hycamtin); temozolomide (Temodar); Busulfan (Myleran); Cyclophosphamide (Cytoxan)		Part B coverage – Oral chemotherapy agents used in cancer treatment that contain the same active ingredient (or pro-drug) as injectable dosage form that would be covered as: 1) not usually self-administered and 2) provided incident to* a physician's service

Part D coverage – All other oral agents covered
Oral/Rectal Anti-Emetic Drugs:
Included but not limited to:
dolasetron mesylate (Anzemet), granisetron hydrochloride (Kytril), ondansetron hydrochloride (Zofran), oral NK-1 Antagonists** (e.g., aprepitant [Emend], rolapitant [Varubi], netupitant and palonosetron [Akynzeo])


Part B coverage –
If oral anti-emetic is related to IV cancer treatment and is full replacement for IV administration within 2 hours of cancer treatment and continued for up to 48 hours

OR

If oral or rectal anti-emetic is related to oral cancer treatment administered within 2 hours before oral anticancer drug

Part D coverage –
If IV cancer treatment is administered in the home setting, the oral anti-emetic is covered under Part D, since type/dosage of chemotherapy does not require IV antiemetic drugs. 

OR

If it doesn't meet Part B rules above, covered under Part D
Osteoporosis drugs:
(Forteo, Calcitonin)		Part B coverage – For osteoporosis drugs under the following scenario: for women, homebound, with osteoporosis with a bone fracture related to post-menopausal osteoporosis and unable to self-administer the injections and the family is unable or unwilling to administer the injections) and when administered by a home health agency

Part D coverage – for all other indications
Products Generally Administered in a Physician's Office/Clinic (non-self-injectables) (e.g., intramuscular [IM] injections, infusible drugs, or subcutaneous [SQ] injections not usually self-administered)





Part B coverage – If medically necessary and supplied by any of the following: physician, health center/clinic, hospital, critical access hospital (CAH) outpatient department, ambulance, end-stage renal disease (ESRD) facilities, comprehensive outpatient rehabilitation facility (CORF), hospital outpatient department (HOPD), Hospital Outpatient Prospective Payment System (OPPS)
Drugs that are Considered Supplies (e.g., radiopharmaceuticals, contrast media)Always covered under Part B
Antigens

Note: This does not include antibodies (i.e., Xolair)		Always covered under Part B
Blood/Hemophilia Clotting FactorsAlways covered under Part B
Drugs Provided with an External Infusion Pump in the Home Setting

Note: Only available for individuals residing in their home***

Part B coverage – For selected drugs in the home setting furnished through a covered external infusion pump (See Attachment E). This does not apply to those drug categories listed in this policy with special rules.

Part D coverage – When administered in the home
setting with or without an external infusion pump (e.g., including Intravenous drip, intramuscular injections, infusion) and does not meet the special rules in Attachment E or when used in a long-term care facility.
Prophylactic Vaccines Covered Only under Part B (Influenza, Pneumococcal, and Covid-19 Vaccines)

Note: The incident-to provision* does not apply to vaccines.		Part B coverage – Influenza, pneumococcal, and Covid-19 vaccines are always covered under Part B

Part D coverage – Never covered under Part D
Prophylactic Vaccines Covered under Both Benefits (Hepatitis B, Tetanus, Rabies, Botulin antitoxin, Antivenin Sera, and Immune Globulin)

Note: The incident-to provision* does not apply to vaccines.		Part B coverage – Tetanus, botulin antitoxin, antivenin sera, immune globulin and rabies vaccines are covered under Part B to treat an injury or as a result of direct exposure to a disease or condition.

Hepatitis B vaccines are covered for individuals at intermediate to high risk for contracting hepatitis B, which includes individuals who have not previously received a completed hepatitis B vaccine series or whose vaccine history is unknown. ​(See attachment D for definitions and appropriate diagnosis codes.)

Part D coverage – If it does not meet the rule above, covered under Part D
All Other Prophylactic Vaccines

Note: The incident-to provision* does not apply to vaccines.		Part B coverage – Vaccines other than influenza, pneumococcal, Covid-19, hepatitis B, tetanus or rabies are never covered under Part B

Part D coverage – All other prophylactic vaccines for the prevention of illness

​ 

*THE INCIDENT-TO PROVISION
In order to meet all of the general requirements for coverage under the incident-to provision, a US Food and Drug Administration (FDA)-approved drug or biologic must be all of the following:
  • A formulation that is not usually self-administered
  • Furnished by a physician​
  • Administered by the physician or by auxiliary personnel employed by the physician and under the physician's personal supervision
The charge, if any, for the drug or biologic must be included in the physician’s bill, and the cost of the drug or biologic must represent an expense to the physician. If the MA organization supplies the drug to the provider, the MA organization will account for the drug under its A/B benefits. If a network pharmacy supplies the drug directly to the beneficiary, the drug will be accounted for under its Part D benefits.


**ORAL NK-1 ANTAGONISTS (e.g., aprepitant [Emend], rolapitant [Varubi], netupitant and palonosetron [Akynzeo])

Oral anti-emetic drugs aprepitant (Emend) and rolapitant (Varubi) are approved under Part B when used in combination with a 5-HT3 antagonist and dexamethasone, as a replacement for IV antiemetic administration. Netupitant and palonosetron (Akynzeo) is approved under Part B when used in combination with dexamethasone, as a replacement for IV antiemetic administration; a separate 5-HT3 antagonist is not needed.


***CLARIFICATION ON THE HOME SETTING
In addition to a hospital, a Skilled Nursing Facility (SNF), or a distinct part of a SNF, the following facility or distinct parts of facilities cannot be considered a home for purposes of receiving the Medicare Part B DME benefit:
  • A nursing home that is dually certified as both a Medicare SNF and a Medicaid Nursing Facility (NF)
  • A Medicaid-only NF that primarily furnishes skilled care
  • A nonparticipating nursing home (i.e., neither Medicare nor Medicaid) that provides primarily skilled care
  • A distinct part of a facility that primarily furnishes skilled care

Guidelines

At the time of this update, this policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

For members enrolled in a Medicare Advantage medical plan who do not have a Part D prescription benefit with the Company, benefits are covered only for drugs eligible under the Part B benefit.

This policy provides an overview of drugs covered under either the Medicare medical benefit (Part B) or the Medicare pharmacy benefit (Part D) and does not address member cost-share (i.e., copayment, deductible, coinsurance).  

Description

Outpatient prescription drugs are covered for Medicare Advantage members who enroll in a Part D plan. Certain drugs are covered under the medical benefit (Part B) for Medicare Advantage members in accordance with Centers for Medicare & Medicaid Services (CMS) regulations. However, there are prescription drugs that could potentially be covered under either the Part B or the Part D benefit. CMS has provided guidance to resolve potential crossover drug coverage scenarios. This policy provides an overview of the crossover drug scenarios and the procedures for outpatient prescription drug coverage under the Company's Medicare Advantage and stand-alone prescription drug plan (PDP).

MEDICARE MEDICAL BENEFIT (PART B)

Medicare regulations require coverage for outpatient drugs under Part B. Medicare law specifically authorizes coverage for the following Part B drugs when administered on an outpatient basis (see the Medicare Part B vs. Part D Coverage Chart in the Policy section): 
  • ​Antigens (serum)
  • Certain drugs for dialysis, including heparin, erythropoietin (Epogen), epoetin alfa, darbepoetin alfa (Aranesp)
  • Drugs usually not self-administered by the individual (such as intravenous [IV] drugs)
  • Hemophilia clotting factor
  • Immunosuppressive drugs, for individuals who received a transplant from a Medicare-approved facility and were entitled or qualified for Medicare Part A at the time of the transplant
  • Injectable osteoporosis drugs when administered by a home health agency, for women who are homebound, with a bone fracture related to postmenopausal osteoporosis, who are unable to self-administer the injections, and the family is unable or unwilling to administer the injections
  • Intravenous immune globulin when given in the home setting for the indication of primary immunodeficiency (PID) (please refer to Attachment F for a list of those diagnosis codes that represent primary immunodeficiencies that may be covered under Part B)
  • Oral anti-cancer drugs for which there is an IV equivalent (provided the IV equivalent is not a self-administered drug and could be administered incident to a physician's professional service)
  • Oral antiemetic drugs used as part of IV anti-cancer chemotherapeutic regimen as a full therapeutic replacement for an IV antiemetic drug administered within 2 hours of chemotherapy administration and may be continued for up to 48 hours 
  • Oral or rectal antiemetic drugs used as part of an oral anti-cancer chemotherapeutic regimen administered within 2 hours before oral chemotherapy administration​
  • Select drugs taken using durable medical equipment (DME) (such as nebulizers)
  • Select drugs provided in the home setting with an external infusion pump (excludes drugs that do not require an external infusion pump, such as antibiotics) (see Attachment E)
  • The following prophylactic vaccines:
    • ​​Pneumococcal vaccine
    • Influenza vaccine
    • Coronavirus disease (Covid-19) vaccine
    • Hepatitis B vaccine for intermediate- to high-risk individuals, which includes individuals who have not previously completed a hepatitis B vaccine series or whose vaccine history is unknown. ​ (see Attachment D for a definition of high risk)
MEDICARE PHARMACY BENEFIT (PART D)

In general, the definition of a Part D–​covered drug is contingent upon the following:
  • ​The drug being available only by prescription
  • The drug being approved by the US Food and Drug Administration (FDA) (unless granted special approval)
  • The drug being used and sold in the United States
  • The drug being used for a medically accepted indication
A drug that is covered under the Medicare hospital benefit (Part A) or medical benefit (Part B), as it is being prescribed and dispensed or administered to an individual, is excluded from the definition of a Part D drug and, therefore, cannot be included in Part D basic coverage.

Examples of drugs that are covered under the Part D benefit include:
  • ​Biological products not covered under Part B
  • Drugs that are not usually self-administered and provided in the home setting without DME (e.g., intramuscular injection)
  • Self-injected insulin and the supplies necessary for the injection, for those individuals with diabetes at home. This includes syringes, needles, alcohol swabs, and gauze.
  • Prescription drugs not covered under Part B
  • Prescription smoking cessation agents
  • Vaccines not covered under Part B
  • Barbiturates (used in the treatment of epilepsy, cancer, or a chronic mental health disorder)
  • Benzodiazepines
Examples of drugs excluded from the Part D benefit include:
  • ​Agents used for anorexia, weight loss/gain, fertility, cosmetic/hair growth, prescription cough, and cold products for symptomatic relief
  • Agents used for the treatment of sexual or erectile dysfunction (ED)
  • Less Than Effective (LTE) Drug Efficacy Study Implementation (DESI) drugs
  • Nonprescription/over-the-counter (OTC) drugs
  • Prescription vitamins and minerals (except prenatal, fluoride, and vitamin D analogues)
Benefits may vary based on product line, group, or contract. Individual member benefits must be verified.

References

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024–25 Influenza Season. [CDC Web site]. 08/29/2024. Available at: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024–25 Influenza Season | MMWR (cdc.gov)​​​. Accessed January 28, 2026. 

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 11693. Pub 100-02: Medicare Benefit Policy. International Classification of Disease (ICD-10) Code Update for Coverage of Intravenous Immune Globulin (IVIG) Treatment of Primary Immune Deficiency Diseases in the Home [CMS Web site]. 11/09/2022. Available at: r1169​3bp.pdf (cms.gov). Accessed January 28, 2026. ​

Centers for Medicare & Medicaid Services (CMS). Seasonal Influenza Vaccines Pricing. Available at: Vaccine Pricing | CMS​​​. Accessed January 28, 2026. ​​

Centers for Medicare & Medicaid Services (CMS). Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home. Effective 08/13/2019. Available at: https://www.cms.gov/training-education/medicare-learning-networkr-mln/compliance/medicare-provider-compliance-tips/intravenous-immune-globulin. Accessed January 28, 2026. ​​

Centers for Medicare & Medicaid Services (CMS). MLN Matters. Effective January 1, 2021. MM11880 – ​Billing for Home Infusion Therapy Services on or After January 1, 2021. Available at: https://www.cms.gov/files/document/mm11880.pdf. Accessed January 28, 2026. ​​

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15, Section 50.4.4.2: Immunizations. [CMS Website]. Effective 10/19/2022. Available at:
http://www.cms.gov/Regulations-and-Guidance/Guidance/​Manuals/dow​nloa​ds/bp102c15.pdf. Accessed January 28, 2026. 

Centers for Medicare & Medicaid Services (CMS). Decision Memo for Aprepitant for Chemotherapy-Induced Emesis (CAG-00248R). 5/29/2013. Available at:
http://www.cms.gov/medicare-coverage-database/details/nca-decisi​on-memo.aspx?NCAId=264. Accessed January 28, 2026. 

Centers for Medicare & Medicaid Services (CMS). Decision Memo for Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N). 09/30/2024. Available at:
NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Decision Memo (cms.gov)​. Accessed January 28, 2026.  ​

​Centers for Medicare & Medicaid Services (CMS). National Coverage Decision (NCD). 110.18: Aprepitant for Chemotherapy-Induced Emesis. 5/29/2013. Available at:
NCD - Aprepitant for Chemotherapy-Induced Emesis (110.18) (cms.gov)​. Accessed January 28, 2026. 

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. [CMS Website]. revised 10/12/2023. Available at:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/do​wnlo​ads/bp102c15.pdf. Accessed https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33794

Centers for Medicare & Medicaid Services (CMS). Medicare Part D Manual. Chapter 6: Part D Drugs and Formulary Requirements. [CMS Website]. 01/15/16. Available at:
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Part-D-Benefi​t​s-Manual-Chapter-6.pdf. Accessed January 28, 2026. ​​

Centers for Medicare & Medicaid Services (CMS). National Coverage Decision (NCD).110.21: Erythropoiesis stimulating agents (ESAs) in cancer and related neoplastic conditions. [CMS Web site]. 07/30/07. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=322&ncdver=1&bc=BAABAAAA​AAAA&. Accessed January 28, 2026.  

Noridian. Local Coverage Determination (LCD): External Infusion Pumps (L33794). Original:10/01/2015, Revised: 07/01/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33794. January 28, 2026.    

Noridian. Local Coverage Article for External Infusion Pumps - Policy Article (A52507). Original:10/01/2015, Revised: 01/12/2024. Available at:https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52507&DocID=A52507. Accessed January 28, 2026. 

Noridian. Local Coverage Determination (LCD): Immunosuppressive Drugs (L33824). Original:10/01/2015. Revised: 04/01/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33824. Accessed January 28, 2026.    
Noridian. Local Coverage Determination (LCD): Intravenous Immune Globulin (L33610). Original: 10/01/2015, Revised: 01/01/2024. Available at: 
LCD - Intravenous Immune Globulin (L336​10) (cms.gov). Accessed January 28, 2026.​​

Noridian. Local Coverage Article (LCA): Intravenous Immune Globulin (A52509). Original:10/01/2015. Revised: 01/01/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52509&ver=61. Accessed January 28, 2026. 

Noridian Heal​thcare Solutions, LLC., Local Coverage Determination (LCD). L33370: Nebulizers. Original: 10/01/15. Revised: 01/01/2024. Available at: LCD - Nebulizers (L33370) (cms.gov). Accessed January 28, 2026.

Noridian Healthcare Solutions, LLC. Local Coverage Article: Nebulizers - Policy Article (A52466). Original:10/01/15. Revised: 02/01/2026. Available at: Article - Nebulizers - Policy Article (A52466) (cms.gov)​. Accessed January 28, 2026.

Noridian. Local Coverage Determination (LCD): Oral anticancer Drugs (L33826). Original:10/01/2015. Revised: 01/01/2026. Available at:https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33826&ver=22&=. Accessed January 28, 2026.

 Noridian. Local Coverage Article (LCA): Oral anticancer Drugs (A52479). Original:10/01/2015. Revised: 10/01/2024. Available at: Article - Oral Anticancer Drugs - Policy Arti​cle (A52479) (cms.gov). Accessed January 28, 2026.

Noridian. Local Coverage Determination (LCD): Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) (L33827). Original:10/01/2015. Revised: 01/01/2024. Available at: LCD - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) (L33827) (cms.gov)​. Accessed January 28, 2026.​

Noridian. Local Coverage Article (LCA): Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) (A52480). Original:10/01/2015. Revised: 01/01/2026. Available at:https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52480&ver=90&bc=0. Accessed January 28, 2026. 

Novitas Solutions, Inc. Local Coverage Determination (LCD) L35093 - Immune Globulin. [Novitas Solutions Web site]. Original:10/01/2015, Revised: 02/05/2023. Available at: LCD - Immune Globulin (L35093) (cms.gov). Accessed January 28, 2026. ​​​

Novitas Solutions, Inc. Article (A56786) Billing and Coding: Immune Globulin (IVIG). [Novitas Medicare Services Web site]. Original: 08/08/2019, Revised: 01/11/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56786&ver=62&bc=0​. Accessed January 28, 2026. 

Noridian. Local Coverage Determination (LCD). Parenteral Nutrition (L38953). Original: 09/05/2021, Revised: 01/01/2024. Available at: LCD - Parenteral Nutrition (L38953) (cms.gov)​. Accessed January 28, 2026. 

Novitas Solutions, Inc. Article (A53127) For Self-Administered Drug Exclusion List. [Novitas Medicare Services Web site]. Original:10/01/2015, Revised: 08/31/2025. Available at: Article - Self-Administered Drug Exclusion List: (A53127)​​. Accessed January 28, 2026. 

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Influenza Virus Vaccine Safety and Availability [FDA Web site]. 09/18/2018. Available at: https://www.fda.gov/vacc​ines-blood-biologics/safety-availability-biologics/influenza-virus-vaccine-safety-av​ailability​. Accessed January 28, 2026. 

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. FDA Approves First Respiratory Syncytial Virus (RSV) Vaccine [FDA Web site].​ 05/04/2023. Available at: FDA Approves First Respiratory Syncytial Virus (RSV) Vaccine | FDA. Accessed January 28, 2026. ​

Coding

CPT Procedure Code Number(s)
See Attachments.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
​See Attachments.
HCPCS Level II Code Number(s)
See Attachments.
Revenue Code Number(s)
N/A

MODIFIERS

TO REPORT SUBCUTANEOUS ROUTE OF ADMINISTRATION, APPEND THE FOLLOWING MODIFIER:

JB Administered Subcutaneously​

Coding and Billing Requirements

Policy History

Revisions From MA08.007au:​
03/30/2026

This version of the policy will become effective  03/30/2026.


The Company's coverage position has been updated to reflect that coverage may be available through the part D benefit for CPT code 90624 in Attachment C of this policy.


Revisions From MA08.007at:​
​01/01/2026
​​Inlcusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for a code update effective 01/01/2026.

The following HCPCS codes have been terminated and deleted from Attachment B: Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage:
  • J9212  Injection, interferon alfacon-1, recombinant, 1 microgram
  • J3355  Injection, urofollitropin, 75 iu
  • J2940  Injection, somatrem, 1 mg
The following HCPCS codes have been terminated and deleted from Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B:
  • J1457  Injection, gallium nitrate, 1 mg
  • J0288  Injection, amphotericin b cholesteryl sulfate complex, 10 mg​​
​The following CPT code in attachment C of this policy was revised: 91323

Revisions From MA08.007as:​
​09/22/2025
​This version of the policy will become effective 09/22/2025.


The following HCPCS code was added to Attachment B (DRUGS THAT ARE USUALLY SELF-ADMINISTERED:  CONSIDERED PART D ONLY – EXCLUDED FROM PART B COVERAGE) with a retro-effective date of 07/01/2025:

  • Q5099 Injection, Ustekinumab-stba (Steqeyma), biosimilar, 1mg

The following HCPCS codes were added to Attachment B (DRUGS THAT ARE USUALLY SELF-ADMINISTERED:  CONSIDERED PART D ONLY – EXCLUDED FROM PART B COVERAGE) with a retro-effective date of 08/31/2025:

  • Q5098 Injection, Ustekinumab-srlf (Imuldosa), biosimilar, 1mg​
  • Q5100 Injection, Ustekinumab-kfce (Yesintek), biosimilar, 1 mg​

The following HCPCS​ codes were deleted for Steqeyma (ustekinumab-stba) from Attachment B (DRUGS THAT ARE USUALLY SELF-ADMINISTERED:  CONSIDERED PART D ONLY – EXCLUDED FROM PART B COVERAGE) of this policy:

  • C9399 Unclassified drugs or biologics
  • J3490 Unclassified drugs​
  • J3590 Unclassified biologics

The intent of this policy has not changed; however, Attachment C (Vaccine Coverage) has been revised to include vaccines that are controlled by the United States government through the Strategic National Stockpile (SNS).

 

The following CPT code was added to Attachment C (Vaccine Coverage) with a retro-effective date of 07/01/2025: 90635​


Revisions From MA08.007ar:
​07/01/2​025​
Inlcusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for a code update effective 07/01/2025.

The following CPT Codes have been added to attachment C of this policy: 90612*, 90613*, ​91323*. An asterisk was added to the codes to denote that at the time of this policy being published, there is no US Food and Drug Administration (FDA) approval for these vaccines, therefore, these vaccines are considered experimental/investigational, and are not covered under any benefit.
​
The following CPT Code in attachment C of this policy was revised: 90620
The following HCPS code in attachment B of the policy was revised: 
  • Q9998 Injection, ustekinumab-aekn (selarsdi), biosimilar, 1 mg​
The following HCPCS codes were added to attachment B of this policy with a retro-effective date of 06/01/2025:
  • ​Q9999 Injection​​, ustekinumab-aauz (otulfi*)​, biosimilar, 1 mg
  • C9399 Unclassified drugs or biologicals, ustekinumab-stba (stegeyma*)
  • J3490 Unclassified drugs, ustekinumab-stba (stegeyma*)​
  • J3590 Unclassified biologics, u​stekinumab-stba (stegeyma*)
​An asterisk was added to the above codes to denote that a​ JB modifier must be used.

Revisions From MA08.007aq:
01/01/2​025​
This version of the policy will be issued on 06/16/2025 with a retroactively effective date of 01/01/2025.

The intent of this policy has not changed; however, the Medicare Part B vs. Part D Chart and Attachment D were revised to expand the hepatitis B criteria to include individuals who have not previously received a completed hepatitis B vaccine series or whose vaccine history is unknown. 

The following HCPS codes were added to this policy with a retroactive effective date of 01/01/2025:

  • ​Q5140​​ ​Injection, adalimumab-fkjp, biosimilar, 1 mg

  • Q5141 Injection, Adalimumab-aaty, Biosimilar, 1mg​

  • Q5142 Injection, adalimumab-ryvk, biosimilar, 1 mg

  • Q5143 Injection, adalimumab-adbm, biosimilar, 1 mg

  • Q9996 Injection, Ustekinumab-ttwe (Pychiva), subcutaneous, 1mg

  • Q9998 Injection, Ustekinumab-aekn (Selarsdi), 1 mg​​​​​​


Revisions From MA08.007ap:
01/01/2025

This version of the policy will become effective on 01/01/2025. 

The intent of this policy has not changed; however, the Medicare Part B VS. Part D Chart was revised to include a section for HIV PrEP as always covered under Part B.

  • Preexposure Prophylaxis (PrEP) (u​sing oral or injectable antiretroviral drugs) for Human Immunodeficiency Virus (HIV) Prevention in individuals at high risk
In addition, the Adjudication columns were removed from the Medicare Part B VS. Part D Chart​. 

​An asterisk has been added to J1628 Tremfya® (guselkumab)* in attachment B (Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage) ​to indicate use of the modifier JB when the subcutaneous form of the drug is administered.​

The following HCPCS codes were termed and removed from attachment B (Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage):
  • ​J0135 Injection, adalimumab, 20 mg
  • Q5131 Injection, adalimumab-aacf (idacio), biosimilar, 20 mg
  • Q5132 Injection, adalimumab-afzb (abrilada), biosimilar, 10 mg
The following HCPCS codes were added to attachment B (Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage):
  • J0139 Injection, adalimumab, 1 mg​
  • Q5144 Injection, adalimumab-aacf (idacio), biosimilar, 1 mg
  • Q5145 Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg​​​
The experimental/investigational designation was removed from the following CPT code in Attachment C (Vaccination and inoculation coverage) of this policy since there is US Food and Drug Administration (FDA) approval for this vaccine at this time:
  • 90683​​

​The following CPT codes were termed and removed from Attachment C (Vaccination and inoculation coverage):

  • ​90630
  • 90654​
The following CPT code was added to Attachment C (Vaccination and inoculation coverage) as experimental/investigational since there is no US Food and Drug Administration (FDA) approval for the vaccine at this time:
  • ​90593
The following CPT code narrative was revised in Attachment C Vaccination and inoculation coverage):
  • 90661​

Revisions From MA08.007ao:
10/01/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.


This policy has been identified for the HCPCS code update, effective 10/01/2024.


The following HCPCS code has been termed and removed from Attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B): 

J1170 Injection, hydromorphone, up to 4 mg


The following HCPCS Code has been added to attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B​) : 

J1171 Injection, hydromorphone, 0.1 mg


On 10/7/2024, the following CPT code was added to Att C (Vaccination and inoculation coverage) as Experimental/Investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:

  • ​90624​

Revisions From MA08.007an:
09/01/2024

This version of the policy was published on 09/09/2024 and is retroactively effective to 09/01/2024.  ​


The following drug was added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):​ 

  • ​ZymfentraTM (infliximab-dyyb) 

​In addition, the asterisk has been removed from Cosentyx (secukinumab), listed with HCPCS codes C9399, J3490 and J3590, because it no longer requires JA or JB modifiers. ​


The following  HCPCS codes C9399, J3490, and J3590 for Wezlana™​ (ustekinumab-auub) and Omvoh™ (mirikizumab-mrkz) were removed because these drugs are represented by specific HCPCS codes.


Revisions From MA08.007am:
08/12/2024

This version of the policy will be effective on 08/12/2024. ​​


The following drugs were added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):​ 

  • Wegovy (semaglutide) effective 06/30/2024
  • Zepbound (tirzepatide) effective 06/30/2024​​

Revisions From MA08.007al:
07/01/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

 

This policy has been identified for the CPT & HCPCS code update, effective 07/01/2024.


The following HCPCS code narrative has been revised in Attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B)​:

Changed from:

J1574 ​Injection, ganciclovir sodium (Exela) not therapeutically equivalent to J1570, 500 mg

Changed to: 

J1574 Injection, ganciclovir sodium (exela), not therapeutically equivalent to j1570, 500 mg


The following HCPCS code has been termed and removed from attachment B (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage)::

C9168 Injection, mirikizumab-mrkz, 1 mg


The following HCPCS Codes have been added to attachment B (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):

J2267 Injection, mirikizumab-mrkz, 1 mg

Q5137 Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg


The following CPT code has been added to attachment C of this policy (Vaccination and inoculation coverage)​ as eligible. 

90684 Pneumococcal conjugate vaccine, 21 valent (PCV21), for intramuscular use


The following CPT codes have been added to attachment C of this policy (Vaccination and inoculation coverage)​ as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:

90637 Influenza virus vaccine, quadrivalent (qIRV), mRNA; 30 mcg/0.5 mL dosage, for intramuscular use

90638 Influenza virus vaccine, quadrivalent (qIRV), mRNA; 60 mcg/0.5 mL dosage, for intramuscular use​


Revisions From MA08.007ak:
03/17/2024​This version of the policy was published on 04/08/2024 and is retroactively effective to  03/17/2024.  ​

The following drug was added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):​ ​

Wezlana (ustekinumab) (C9399, J3490, J3590) subcutaneous route 


​The following HCPCS code was added to Attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B​) for the treatment of documented chronic inflammatory demyelinating polyneuropathy (CIDP):

  • J1575 Injection, immune globulin/hyaluronidase, 100 mg immuneglobulin​ 

In addition, this policy has been identified for the 04/01/2024 HCPCS code update. The HCPCS coding changes listed below became effective 04/01/2024. 

The following HCPCS code has been added to Attachment B of this policy:
  • C9168 Injection, mirikizumab-mrkz, 1 mg​
​The following HCPCS code has been deleted from Attachment B of this policy:
  • J3380 Injection, vedolizumab, intravenous, 1 mg​

Revisions From MA08.007aj:
01/14/2024​This version of the policy published on 02/26/2024 with a retro-effective date of 01/14/2024. ​

The following drugs were added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):​ 

  • YUFLYMA (adalimumab-aaty​) (C9399, J3490, J3590)
  • Omvoh (mirikizumab-mrkz) subcutaneous route (C9399, J3490, J3590)
  • Entyvio (vedolizumab) subcutaneous route (C9399, J3490, J3590) and J3380
  • Haegarda (injection, C-1 esterase inhibitor (human), (Haegarda), 10 units​ (J0599)​​


The following HCPCS code was added to Attachment B:
Q3028 Injection, interferon beta-1a, 1 mcg for subcutaneous use.​

An * was added to Cosentyx®​ (secukinumab) and Entyvio (vedolizumab) ​to indicate use of the modifier JB when the subcutaneous form of the drug is administered.


The following HCPCS codes were removed from Attachment B for Haegarda since a specific code exi

s:

C9399, J3490, J3590

The following CPT codes were added to Attachment C (Vaccination and inoculation coverage):

​91304, 91318, 91319, 91320, 91321, 91322

In addition, the Covid-19 vaccine was added to the Medicare Part B Vs. Part D Chart for Prophylactic Vaccines Covered Only under Part B. ​

Revisions From MA08.007ai:
01/02/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

 

This policy has been identified for the CPT & HCPCS code update, effective 01/02/2024.


The following HCPCS Code has been added to attachment B (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):


Q5132 Injection, adalimumab-afzb (abrilada), biosimilar, 10 mg​


The following CPT codes have been added to attachment C of this policy (Vaccination and inoculation coverage):

  • 90589
  • 90623
The following CPT code has been added to attachment C of this policy (Vaccination and inoculation coverage)​ as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:
  • 90683​

Revisions From MA08.007ah:
​01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
10/01/2023

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

 

This policy has been identified for the HCPCS code update, effective 10/01/2023.


The following HCPCS code has been termed and removed from attachment B (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):


J0800 Injection, corticotropin, up to 40 units ​


On 10/19/2023, the following HCPCS Code has been added to attachment B (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage) retro-effective to 10/1/2023 in accordance with Novitas Solutions, Inc. Local Coverage Article A53127 Self-Administered Drug Exclusion List:


J0801 Injection, corticotropin (acthar gel), up to 40 units ​


Revisions From MA08.007ag​:
09/03/2023​

​This version of the policy will be published on 09/25/2023 with a retro-effective date of 09/03/2023.


The following drugs were added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B cove

rage):​ 

J1812 INSULIN (FIASP), PER 5 UNITS 

J1814 INSULIN (LYUMJEV), PER 5 UNITS 

J1941 INJECTION, FUROSEMIDE (FUROSCIX), 20 MG

In addition, the following drugs were added to Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit (Part B): ​

J1811 Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units

J1813 Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units


Revisions From MA08.007af:
06/25/2023

​This version of the policy will be effective on 06/25/2023.


The following drugs were added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):​ 

  • IDACIO® (adalimumab-aacf) (C9399, J3490, J3590)
  • IDACIO® (adalimumab-aacf) (Q5131)​ effective 07/01/2023
  • ABRILADA (adalimumab-afzb) (C9399, J3490, J3590)
  • HADLIMA (adalimumab-bwwd) (C9399, J3490, J3590)
  • HULIO® (adalimumab-fkjp) (C9399, J3490, J3590)
  • HYRIMOZ (adalimumab-adaz) (C9399, J3490, J3590)
  • YUSIMRY (adalimumab-aqvh) (C9399, J3490, J3590)​

The following CPT codes were added to Attachment C of this policy (Vaccination and inoculation coverage) for the Respiratory syncytial virus vaccine​:

  • 90678​
  • 90679

Revisions From MA08.007ae:
03/27/2023

​This version of the policy will be effective on  03/27/2023.

​

  • ​Mounjaro™ (terzepatide) (C9399, J3490, J3590)

The following HCPCS code was added to Attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B​):

  • J1574 INJECTION, GANCICLOVIR SODIUM (EXELA) NOT THERAPEUTICALLY EQUIVALENT TO J1570, 500


Revisions From MA08.007ad:
11/14/2022

​This version of the policy will be issued on 12/05/2022 with a retro-effective date of 11/14/2022. 


The following revisions have been made to the MEDICARE PART B VS. PART D CHART:


  • Subcutaneous Immune Globulin (SCIG) to communicate when Part B vs Part D Coverage applies:

Part B coverage – If administered at home on an external infusion pump that is an item of durable medical equipment for primary immunodeficiency OR chronic inflammatory demyelinating polyneuropathy that has responded to IVIg treatment​ (please refer to Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the medical benefit (Part B))​

Part D coverage – If it doesn’t meet Part B rules above, ​may be reviewed for coverage through applicable Part D benefits.​​


Attachment B

The following drug was​ added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):

  • ​Adbry™ (tralokinumab-Idrm) (C9399, J3490, J3590) subcutaneous route

​In addition, an * was added to Skyrizi to indicate use of the modifier JB when the subcutaneous form of the drug is administered.


Attachment E

The following HCPCS codes were added to the language of Attachment E for the administration of pooled plasma derivative, subcutaneous immune globulin:

  • J1555 injection, immune globulin (Cuvitru), 100mg
  • J1558 Injection, immune globulin (xembify), 100 mg
Attachment F
The following ICD-10 code was added to Attachment F of this policy (Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting):

  • ​D80.1 Nonfamilial hypogammaglobulinemia​
The following header was added to Attachment F for the following ICD-10 codes:

The following diagnosis codes when used to represent primary immunodeficiencies are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting:

a
D80.7 Transient hypogammaglobulinemia of infancy

NOTE: 

On 01/04/2023 this policy was amended to add the following ICD-10 code to Attachment F (Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting) which became effective 10/01/2022 :

  • D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS] ​

Revisions From ​MA08.007ac:
09/19/2022

​This version of the policy will be issued on 10/07/2022 with a retro-effective dat

e of 09/19/2022.​


ge):

  • ofatumumab (Kesimpta) ((C9399, J3490, J3590) subcutaneous route

​Effective 10/01/2022, the following ICD-10 code has been termed and removed from Attachment D this policy:


D68.0 Von Willebrand's disease


In addition, the following ICD-10 codes have been added to Attachment D of this policy: 


D68.00  Von Willebrand disease, unspecified

D68.01 Von Willebrand disease, type 1

D68.020  Von Willebrand disease, type 2A

D68.021  Von Willebrand disease, type 2B

D68.022  Von Willebrand disease, type 2M

D68.023  Von Willebrand disease, type 2N

D68.029  Von Willebrand disease, type 2, unspecified

D68.03  Von Willebrand disease, type 3

D68.04   Acquired von Willebrand disease

D68.09  Other von Willebrand disease


Revisions From ​MA08.007ab:
07/01/2022

​This version of the policy will become effective 07/01/2022.


The following drugs were​ added to Attachment B of this policy (Drugs that are usually self-administered: considered Part D only-excluded from Part B coverage):

  • guselkumab (Tremfya®) ​(J1628)
  • interferon beta-1a (Avonex®​) (J1826)
  • ustekinumab subcutaneous (Stelara®) (J3357)
  • ropeginterferon alfa-2b (Besremi®) (C9399, J3490, J3590)
  • risankizumab-rzaa (Skyrizi®) (C9399, J3490, J3590​)
  • Somapacitan-beco (Sogroya®) (C9399, J3490, J3590)
The following CPT code was added to Attachment C of this policy (Vaccination and inoculation coverage) as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:
  • ​90584
​The following CPT code narrative has been revised in Attachment C of this policy: 
  • ​90739​
The policy criteria for Blinatumomab was revised in Attachment E of this policy (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B):

  • Blinatumomab (J9039) for the treatment of pediatric and adult individuals with acute lymphoblastic leukemia (ALL). ​(please refer to the specific policies, Implantable and External Infusion Pumps and Blinatumomab [Blincyto®])​
The following HCPCS code was added to Attachment E of this policy:
  • J1551 ​Injection, immune globulin (cutaquig), 100 mg
The following HCPCS code was deleted from  Attachment E for the administration of pooled plasma derivative, subcutaneous immune globulin for the treatment of documented primary immune deficiency disease:
  • ​​​J7799 NOC drugs, other than inhalation drugs, administered through DME [Cutaquig®]​​

Revisions From MA08.007aa:
05/23/2022

​This version of the policy will become effective 05/23/2022​.


The policy was updated to communicate the coverage criteria for oral and rectal anti-emetics, consistent with Noridian Medicare Local Coverage Determinations and Articles. 


The coverage criteria for Oral​ and Rectal Anti-Emetic Drugs was added/revised:

  • Part B: NK-1 Antagonist anti-emetics was revised.
  • Part B: Oral anti-emetics administered with IV cancer treatments was revised.
  • Part B: Oral/rectal anti-emetics administered with oral cancer treatments was added.​
  • Part D: Home setting for IV cancer treatments and IV anti-emetics drugs was added.

​Attachment A: "Part B drugs that can be accessed through the Part D pharmacy benefit: pharmacy claims process at Medicare Part B cost share with no true out-of-pocket (TrOOP) expenses applied" was updated with four oral anti-emetics: Dolisetron, Rolapitant, Nabilone, Netupitant-palonosetron.


Revisions From MA08.007z:
01/01/2022

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

 

This policy has been identified for the CPT code update, effective 01/01/2022.


The following CPT codes have been added to the policy in attachment C:​ 90759


Revisions From MA08.007y:
07/18/2021
This version of the policy will be issued on 08/13/2021 with a retro-effective date of 07/18/2021. 

The following CPT code has been changed from experimental/investigational to eligible under Medicare Part B in attachment C of this policy:
  • ​90671​
The following policy criteria were revised in attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B) ​of this policy to expand Subcutaneous immune globulin (SCIg)​ (Hizentra) for the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) that has responded to IVIg treatment in accordance with Noridian local coverage determation L33794 External Infusion Pumps.  

Revisions From MA08.007x:
07/01/2021This policy has been identified for the CPT code update, effective 07/01/2021.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

The following CPT codes have been added to Attachment C (Vaccination and inoculation coverage)​ of this policy as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for these vaccines:

  • ​90626
  • 90627
  • 9
  • 0671
 added to Attachment C (Vaccination and inoculation coverage)​ of this policy:

  • 90677​
  • 90758

Revisions From MA08.007w:
06/07/2021The version of this policy will become effective 06/07/2021.

The following policy criteria was revised in attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B) ​of this policy to expand Blinatumomab to pediatric individuals:

Blinatumomab (J9039) for the treatment of pediatric​ and adult individuals with the following:

  •  or
  • Minimal residual disease positive CD19-positive  (MRD+) B-cell precursor acute lymphoblastic leukemia (B-ALL)
    (please refer to the specific policies, Implantable and External Infusion Pumps and Blinatumomab [Blincyto®])​

Revisions From MA08.007v:
01/02/2021The version of this policy was published on 04/26/2021 with a retroactive  effective date of 01/02/2021.
​
The following HCPCS codes have been removed from Attach​m​ent B (Drugs that are usually self-administered: considered Part D only – excluded from  Part B coverage​) of this policy:
    ​
    Actemra J3262 
    ​​Zinbryta (C9399, J3490, J3590)
The following statement was added to the Guidelines section of the policy: 

This policy provides an overview of drugs covered under either the Medicare medical benefit    (Part B) or the Medicare pharmacy benefit (Part D) and does not address member cost-share (i.e., copayment, deductible, coinsurance).  

Revisions From MA08.007u:
01/01/2021This policy has been identified for the CPT code update, effective 01/01/2021.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

The following CPT code has been added to Attachment C (Vaccination and inoculation coverage)​ of this policy as eligible under Part B when given to an individual who is at high risk for rabies following an encounter with an animal:


Revisions From MA08.007t:
10/01/2020The version of this policy will become effective 10/01/2020. 

The following HCPCS code was added to Attachment E for the administration of pooled plasma derivative, subcutaneous immune globulin for the treatment of documented primary immune deficiency disease (Please refer to the specific policy on Immune Globulin: Intravenous (IVIG).):
  • ​​​J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME [Cutaquig®]​

The following ICD-10 codes has been added to this policy to Attachment D:

F13.130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated

F13.131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium

F13.132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance

F13.139 Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified

F14.13  Cocaine abuse, unspecified with withdrawal

F14.93  Cocaine use, unspecified with withdrawal

F15.13  Other stimulant abuse with withd

rawal

F19.130 Other psychoactive substance abuse with withdrawal, uncomplicated

F19.131 Other psychoactive substance abuse with withdrawal delirium

F19.132 Other psychoactive substance abuse with withdrawal with perceptual disturbance

F19.139 Other psychoactive substance abuse with withdrawal, unspecified       

N18.30  Chronic kidney disease, stage 3 unspecified

N18.31  Chronic kidney disease, stage 3a

N18.32  Chronic kidney disease, stage 3b​


The following ICD-10 code has been deleted from Attachment D of this policy:​


N18.3 Chronic kidney disease, stage 3 (moderate)​


​Revisions From MA08.007s:
07/01/2020This policy has been identified for the HCPCS code update, effective 07/01/2020.

The following HCPCS code has been added to Attachment E of this policy
  • J1558

Revisions From MA08.007r:
06/08/2020This version of the policy will become effective 06/08/2020.

The following revisions have been made to the MEDICARE PART B VS. PART D CHART regarding Nebulized Inhalation Solutions to communicate when Part B coverage applies.
  • The following inhalation solutions may be covered under Part B coverage if used with a nebulizer in the home setting. (Please refer to the specific policy on Nebulizers and Inhalation Solutions for inhalation drugs that may be covered under Part B.):
  • pentamidine isethionate (NebuPent®)
  • aformoterol (Brovana®)
  • formoterol fumarate (Performist®)
  • treprostinil (Tyvaso®)
  • iloprost (Ventavis®
  • )
  • revefenacin (Yupelri®)
The following inhalation solution was added to Attachment A of this policy (Medicare medical benefit (Part B) drugs that can be accessed at a retail or long-term care pharmacy setting. Claims from a retail or long-term care pharmacy process at a medical benefit (Part B) cost share with no pharmacy benefit (Part D) True-Out Of-Pocket (TrOOP) expenses applied:
  • revefenacin (Yupelri®)
The following HCPCS codes were added to Attachment E for the administration of pooled plasma derivative, subcutaneous immune globulin for the treatment of documented primary immune deficiency disease (Please refer to the specific policy on Immune Globulin: Intravenous (IVIG).):

J1555 INJECTION, IMMUNE GLOBULIN (CUVITRU), 100 MG
J1575 INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN
J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME [Xembify®]

Revisions From MA08.007q:
01/01/2020This policy has been identified for the annual CPT code update effective 01/01/2020.

The following CPT code has been added to attachment C of this policy:

90694

Revisions From MA08.007p:
12/02/2019This version of the policy will become effective 12/02/2019.

The following criterion for Intravenous Immune Globulin (IVIG) has been revised to communicate when Part B coverage applies:
  • Part B coverage- If administered at home for primary immunodeficiency, (please refer to Attachment F for a list of those diagnosis codes that represent primary immunodeficiencies that may be covered under Part B)
The following criterion for IVIG has been revised to communicate when Part D coverage applies:
  • Part D coverage – If provided in the home for all other indications.
Note: Primary immunodeficiencies not included in attachment F may be reviewed for coverage through applicable Part D benefits.

Attachment F added to the policy to convey Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting.

The following ICD-10 diagnosis codes were added to Attachment F of this policy:

D80.0, D80.2, D80.3, D80.4, D80.5
D80.6, D80.7, D81.0, D81.1, D81.2
D81.5, D81.6, D81.7, D81.89, D81.9
D82.0, D82.1, D82.4, D83.0, D83.1
D83.2, D83.8, D83.9, G11.2

The following drugs that are usually self- administered were added to Attachment B of this policy:

Actemra J3262 subcutaneous route
Aimovig C9399, J3490, J3590
Ajovy J3031
Benlysta J0490 subcutaneous route
Cyltezo C9399, J3490, J3590
Emgality C9399, J3490, J3590
Kevzara C9399, J3490, J3590
Lantus Solostart C9399, J3490, J3590
Orencia J0129 subcutaneous route
Ozempic C9399, J3490, J3590
Takhzyro J0593
Tymlos J3590

For drugs that have more than one method of administration, application of the JA or JB modifier is required to indicate the route of administration.
  • To report the intravenous route of administration, append the following modifier:
JA Administered Intravenously
  • To report the subcutaneous route of administration, append the following modifier:
JB Administered Subcutaneously

Drug codes that must use HCPCS modifier JB when the subcutaneous form of the drug is administered are listed with an asterisk * in the Coding Table of Attachment B if this policy.

Revisions From MA08.007o:
07/01/2019This policy has been identified for the CPT code update, effective 07/01/2019.

The following CPT code has been added to Attachment C, of this policy as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:
  • 90619
The following CPT code narrative has been revised in Attachment C of this policy: 90734

Revisions From MA08.007n:
02/25/2019This version of the policy will become effective 02/25/2019.

The following changes have been made to Attachment C of this policy (Vaccination and inoculation coverage).
  • The Company’s coverage position has changed from Experimental/Investigational to covered for the following CPT code 90660.
  • The Company’s coverage position for CPT code 90697 has changed from covered under Part B, regardless of whether the vaccine is ordered by a doctor of medicine or osteopathy, to never covered under Part B and are only covered under Part D.
The following changes have been made to Attachment D of this policy (Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit [Part B]).
  • The following ICD-10 codes have been added:
    D68.0, F11.10, F11.11, F11.120, F11.121F11.122, F11.129, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F13.10, F13.11, F13.120, F13.121, F13.129, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F14.10, F14.11, F14.120, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F15.10, F15.11, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F16.10, F16.11, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.90, F19.920, F19.921, F19.922, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, I12.0, I13.11, I13.2, Z20.5, Z72.52
  • The following ICD-10 codes have been deleted:
    F12.20, F12.21, F12.220, F12.221, F12.222, F12.229, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F18.10, F18.11, F18.121, F18.129, F18.14, F18.150, F18.120, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.21, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.90, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F55.0, F55.1, F55.2, F55.4, F55.8, F66, F72, F73, F78, F79, Q90.0, Q90.1, Q90.2, Q90.9

Revisions From MA08.007m:
01/01/2019This policy has been identified for the CPT code update, effective 01/01/2019.

The following CPT code has been added to Attachment C of this policy as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:
  • 90689

Revisions From MA08.007l:
10/08/2018This version of the policy will become effective 10/08/2018.

The Company’s coverage position has changed from Not Medically Necessary to Medically Necessary on the use of the nasal spray influenza vaccine (LAIV4) during the 2018–19 influenza season based on the Advisory Committee on Immunization Practices (ACIP) recommendation.

The following diagnoses for primary immune deficiency (PID) were removed from the description section and from Attachment E of this policy with reference made to: (Please refer to the specific policy on Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
  • Congenital hypogammaglobulinemia
  • Immunodeficiency with increased IGM
  • Common variable immunodeficiency
  • Wiskott-Aldrich syndrome
  • Combined immunity deficiency

Revisions From MA08.007k:
07/30/2018This version of the policy will become effective 07/30/2018.

The following drug was added to Attachment B of this policy:

C1 esterase inhibitor (human)
Haegarda
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics

The following CPT code has been deleted from attachment C of this policy:
90703.

The following HCPCS code has been deleted from attachment B of this policy:
J1817 Insulin for administration through DME (ie, insulin pump) per 50 units

The following HCPCS code has been added to attachment E of this policy:
J9039 Injection, blinatumomab, 1 microgram

The following indication has been added to attachment E of this policy for Blinatumomab (J9039):
  • Minimal residual disease positive (MRD+) B-cell acute lymphoblastic leukemia (B-ALL)

Revisions From MA08.007j:
01/01/2018 This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT code has been added to Attachment C, of this policy: 90756
    The following changes were made through a newsflash:
    • The following codes were moved from E/I to MN in Attachment C: 90750, 90739 and will follow the policy benefit coverage criteria

Revisions From MA08.007i:
11/17/2017Added to Attachment A: PART B DRUGS ACCESSED AT A RETAIL OR LONG-TERM CARE PHARMACY SETTING. CLAIMS PROCESS AT A MEDICAL BENEFIT (PART B) COST SHARE WITH NO PHARMACY BENEFIT (PART D) TRUE-OUT-OF-POCKET (TROOP) EXPENSES APPLIED.
  • Heparin and saline flushes
The following drugs were added to Attachment B (Drugs self administered and excluded under part B:

J0800: H.P. Acthar® Gel; J0364: Apokyn; C9399, J3490, J3590, Amjevita™; C9399, J3490, J3590: Dupixent®; C9399, J3490, J3590: Erelzi™; C9399, J3490, J3590: Kynamro®; C9399, J3490, J3590: Orencia®; C9399, J3490, J3590: Quad-Mix; C9399, J3490, J3590: Rasuvo®; C9399, J3490, J3590: Siliq™.

The following brand name drugs were added for the following CPT/HCPCS codes: J1595: Glatopa; J1830: Extavia; J2941: Omnitrope, Zomacton™, Zorbtive; J3030: Sumavel® Dosepro®, Zembrace; C9399, J3490, J3590: Pegasys® Proclick™.

Attachment D the following codes were added:

F18.11 Inhalant abuse, in remission
F19.11 Other psychoactive substance abuse, in remission

Revisions From MA08.007h:
10/01/2017This policy has been identified for the ICD-10 code update, effective 10/01/2017.

The following ICD-10 codes has been added to this policy to Attachment D.
    E11.10 Type 2 diabetes mellitus with ketoacidosis without coma
    E11.11 Type 2 diabetes mellitus with ketoacidosis with coma

Revisions From MA08.007g:
07/01/2017This policy has been identified for the CPT code update, effective 07/01/2017.

The following CPT codes have revised narratives: 90620, 90621, 90651

The following CPT code has been added to this policy; in Attachment C: 90587

Revisions From ​ MA08.007f:
01/01/2017The following policy requirements have been revised:

Attachment B: Drugs that are usually self-administered (defined as a drug that is self-administered more than 50 percent of the time) and excluded from Medicare medical benefit (Part B).Attachment B

The following drugs were added in accordance with Medicare.

J3355 Bravelle
C9399, J3590 Byetta
C9399, J3490, J3590 Bydureon
C9399: Cosentyx®;
C9399, J3490, J3590: Egrifta®;
J1744 Firazyr
C9399, J3490, J3590 Myalept™ 
C9399, J3490, J3590: Natpara®
C9399, J3590: Otrexup™
C9399, J3490, J3590: Plegridy®;
C9399, J3490, J3590: Praluent®;
C9399, J3490, J3590: Repatha™
C9399, J3490, J3590: Rebif®
J2212, Relistor;
C9399, J3490: Saxenda
C9399, J3490, J3590 SIGNIFOR®;
C9399, J3490, J3590: Simponi®;
C9399, J3490, J3590: Strensiq®;
C9399, J3490, J3590 Sylatron
C9399, J3490, J3590: Taltz ®
C9399, J3490, J3590 Tanzeum
C9399, J3490 Toujeo®;
J3590: TriMix;
C9399, J3490: Trulicity®;
C9399, J3490, J3590: Victoza
C9399, J3490, J3590: Zinbryta™

Attachment C:

The following CPT codes have been added to this policy: 90674, 90682, 90750

The following CPT codes have revised narratives: 90655, 90656, 90657, 90658, 90661, 90685, 90686, 90687, 90688, 90698 and 90734.

Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit (Part B).
  • The following criteria were revised;
      For the administration of parenteral inotropic therapy using the drugs; dobutamine (J1250), milrinone (J2260) or dopamine (J1265) for individuals with American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Stage D heart failure (HF) or New York Heart Association (NYHA) Class IV HF.
  • The following codes are deleted codes J9110, J9375, J9380 and have been removed from Attachment E
  • J1562 Injection, immune globulin (Vivaglobin), 100 mg is no longer on the market and is being removed from the policy

Revisions From MA08.007e:
10/01/2016 This policy has been identified for the ICD-10 CM code update, effective 10/01/2016
The following ICD-10 CM codes have been revised in this policy:

FROM: O24.011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
TO: O24.011 Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester

FROM: O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
TO: O24.012 Pre-existing type 1 diabetes mellitus, in pregnancy, second trimester

FROM; 24.013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
TO; O24.013 Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester

TO; O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester
FROM; O24.019 Pre-existing type 1 diabetes mellitus, in pregnancy, unspecified trimester

FROM; 24.02 Pre-existing diabetes mellitus, type 1, in childbirth
TO; O24.02 Pre-existing type 1 diabetes mellitus, in childbirth

FROM; O24.03 Pre-existing diabetes mellitus, type 1, in the puerperium
TO; O24.03 Pre-existing type 1 diabetes mellitus, in the puerperium

FROM; O24.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
TO; O24.111 Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester

FROM; O24.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
TO; O24.112 Pre-existing type 2 diabetes mellitus, in pregnancy, second trimester

FROM; O24.113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
TO; O24.113 Pre-existing type 2 diabetes mellitus, in pregnancy, third trimester

FROM; O24.119 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester
TO; O24.119 Pre-existing type 2 diabetes mellitus, in pregnancy, unspecified trimester

FROM: O24.12 Pre-existing diabetes mellitus, type 2, in childbirth
TO: O24.12 Pre-existing type 2 diabetes mellitus, in childbirth

FROM: O24.13 Pre-existing diabetes mellitus, type 2, in the puerperium
TO: O24.13 Pre-existing type 2 diabetes mellitus, in the puerperium
  • The following ICD-10 CM codes have been deleted from this policy:
    E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359,E09.321, E09.329, E09.331, E09.339 E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331 E10.339, E10.341, E10.349 E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359
  • The following ICD-10 CM codes have been added to this policy:
    E08.3211, E08.3212, E08.3213, E08.3219, E08.3291, E08.3292, E08.3293, E08.3299, E08.3311, E08.3312, E08.3313, E08.3319, E08.3391, E08.3392, E08.3393, E08.3399, E08.3411, E08.3412, E08.3413, E08.3419, E08.3491, E08.3492, E08.3493, E08.3499, E08.3511, E08.3512, E08.3513 E08.3519, E08.3521, E08.3522, E08.3523, E08.3529, E08.3531, E08.3532, E08.3533, E08.3539 E08.3541, E08.3542, E08.3543, E08.3549, E08.3551, E08.3552, E08.3553, E08.3559, E08.3591, E08.3592, E08.3593, E08.3599, E08.37X1, E08.37X2, E08.37X3, E08.37X9, E09.3211, E09.3212, E09.3213, E09.3219, E09.3291, E09.3292, E09.3293, E09.3299, E09.3311, E09.3312, E09.3313, E09.3319, E09.3391, E09.3392, E09.3393, E09.3399, E09.3411, E09.3412, E09.3413, E09.3419, E09.3491, E09.3492, E09.3493, E09.3499, E09.3511, E09.3512, E09.3513, E09.3519, E09.3521, E09.3522, E09.3523, E09.3529, E09.3531, E09.3532, E09.3533, E09.3539, E09.3541, E09.3542, E09.3543, E09.3549, E09.3551, E09.3552, E09.3553, E09.3559, E09.3591, E09.3592, E09.3593, E09.3599, E09.37X1, E09.37X2, E09.37X3, E09.37X9, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.37X1 E10.37X2, E10.37X3, E10.37X9, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531 E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, 13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.37X1, E13.37X2, E13.37X3, E13.37X9, O24.415, O24.425, O24.435.

Revisions From MA08.007d:
01/01/2016Inclusion of a policy in a Code Update does not imply that a full review of the policy was completed at this time.

Medical Policy # MA08.007d; Medicare Part B vs. Part D Crossover Drugs
This policy has been identified for the CPT / HCPCS code update, effective 01/01/2016.

The following HCPCS code has been added to this policy:

J7340: Carbidopa 5 mg/levodopa 20 mg enteral suspension

The following CPT code has been added to this policy:

90625: Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use

The following CPT narratives have been revised in this policy:

90620
FROM: Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, 2 dose schedule, for intramuscular
TO: Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B (memb), 2 dose schedule, for intramuscular

90621
FROM: Meningococcal recombinant lipoprotein vaccine, Serogroup B, 2 or 3 dose schedule, for intramuscular use
TO: Meningococcal recombinant lipoprotein vaccine, Serogroup B (memb), 3 dose schedule, for intramuscular use

90644
FROM: Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use

TO: Meningococcal conjugate vaccine, serogroups c & y and hamophilus influenza type b vaccine (hib-mency), 4 dose schedule, when administered to children 2-18 months of age, for intramuscular use
90647
FROM: Haemophilus influenzae b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule, for intramuscular use
TO: Hamophilus influenza type b vaccine (hib), prp-omp conjugate, 3 dose schedule, for intramuscular use

90648
FROM: Haemophilus influenzae b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for intramuscular use
TO: Hamophilus influenza type b vaccine (hib), prp-t conjugate, 4 dose schedule, for intramuscular use

90649
FROM: Human Papilloma virus vaccine, types 6, 11, 16, 18, quadrivalent (HPV4), 3 dose schedule, for intramuscular use
TO: Human papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vhpv), 3 dose schedule, for intramuscular use

90650
FROM: Human Papilloma virus vaccine, types 16, 18, bivalent (HPV2), 3 dose schedule, for intramuscular use
TO: Human papillomavirus vaccine, types 16, 18, bivalent (2vhpv), 3 dose schedule, for intramuscular use

90651
FROM: Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use
TO: Human papillomavirus vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vhpv), 3 dose schedule, for intramuscular use

90698
FROM: Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenzae Type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use
TO: Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenzae type b, and inactivated poliovirus vaccine, (dtap -ipv/hib), for intramuscular use

90739
FROM: Hepatitis B vaccine (HepB), adult dosage (2 dose schedule), for intramuscular use
TO: Hepatitis b vaccine (hepb), adult dosage 2 dose schedule, for intramuscular use

90748
FROM: Hepatitis B and Haemophilus influenzae b vaccine (Hib-HepB), for intramuscular use
TO: Hepatitis b and hamophilus influenza type b vaccine (hib-hepb), for intramuscular use

The following CPT codes have been deleted from this policy: These vaccines are no longer available.

90645 Hemophilus influenza b vaccine (HIB), HBOC conjugate (4 dose schedule), for intramuscular use
90646 Hemophilus influenza b vaccine (HIB), PRP-D conjugate, for booster use only, intramuscular use
90669 Pneumococcal conjugate vaccine, 7 valent (pcv7), for intramuscular use
90692 Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use
90693 Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. Military)
90703 Tetanus toxoid adsorbed, for intramuscular use
90704 Mumps virus vaccine, live, for subcutaneous use
90705 Measles virus vaccine, live, for subcutaneous use
90706 Rubella virus vaccine, live, for subcutaneous use
90708 Measles and rubella virus vaccine, live, for subcutaneous use
90712 Poliovirus vaccine, (any type[s]) (OPV), live, for oral use
90719 Diphtheria toxoid, for intramuscular use
90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and haemophilus influenzae b vaccine (dtwp-hib), for intramuscular use
90721 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and haemophilus influenzae b vaccine (dtap/hib), for intramuscular use
90725 Cholera vaccine for injectable use
90727 Plague vaccine, for intramuscular use
90735 Japanese encephalitis virus vaccine, for subcutaneous use
S0195 Pneumococcal conjugate vaccine, polyvalent, intramuscular, for children from five years to nine years of age who have not previously received the vaccine

Revisions From MA08.007c:
10/01/2015 ICD-10-CM codes, that were added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

Revisions From MA08.007b:
07/01/2015 This policy has been identified for the CPT code update, effective 07/01/2015.

The following CPT code narratives have been revised in this policy:

90632, 90633, 90634, 90644, 90647, 90648, 90649, 90650, 90653, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90666, 90667, 90668, 90669, 90670, 90672, 90673, 90680, 90681, 90685, 90686, 90687, 90688, 90696, 90698, 90702, 90714, 90716, 90720, 90721, 90732, 90733, 90734, 90736, 90739, 90740, 90743, 90744, 90746, 90747, 90748.

Revisions From MA08.007a:
4/22/2015This version of the policy will become effective 04/22/2015.

The following revisions occurred with this update:

Attachment A
  • The list of Drugs found in Attachment A has been revised.
Attachment C
  • The following policy requirements have been revised:
    • 90630 (to eligible)
  • The following CPT codes have been added to this policy:
    • 90620, 90621
Attachment D:
  • The following criterion has been added to this policy:
    • Diabetes mellitus added; as an indication for high risk groups for the Hepatitis B vaccine:
      • Added diagnosis codes to support the newly added indication
Attachment G
  • The following criterion has been added to this policy:
    • 2 additional drugs covered on an external infusion pump with criteria: Levodopa-Carbidopa enteral suspension and Blinatumomab
Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

Revisions From MA08.007:
01/01/2015This is a new policy.

Note: On 12/18/2014, this policy was identified for the CPT code update, effective 01/01/2015.

The following CPT code has been added to this policy (Part D).
  • 90651
The following CPT codes has been added to this policy as experimental/investigational.
  • 90630
  • 90697
The following CPT codes have been revised in this policy:
  • 90654
  • 90721
  • 90723
  • 90734
The following HCPCS codes have been deleted from this policy:
  • J2271
  • J2275
3/30/2026
3/30/2026
MA08.007
Medical Policy Bulletin
Medicare Advantage
{"7254": {"Id":7254,"MPAttachmentLetter":"A","Title":"Part B drugs that can be accessed through the Part D pharmacy benefit: pharmacy claims process at Medicare Part B cost share with no true out-of-pocket (TrOOP) expenses applied","MPPolicyAttachmentInternalSourceId":10466,"PolicyAttachmentPageName":"e8925e6b-1d9b-4d64-87c3-6b0566a0954e"},"7255": {"Id":7255,"MPAttachmentLetter":"F","Title":"Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting","MPPolicyAttachmentInternalSourceId":10467,"PolicyAttachmentPageName":"2dd78664-f303-4a1f-ab9b-cd7677c70a65"},"7256": {"Id":7256,"MPAttachmentLetter":"E","Title":"Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B","MPPolicyAttachmentInternalSourceId":10468,"PolicyAttachmentPageName":"970fe794-4ebb-4aa0-9da6-28bb6d7202b3"},"7257": {"Id":7257,"MPAttachmentLetter":"C","Title":"Vaccination and inoculation coverage.","MPPolicyAttachmentInternalSourceId":10469,"PolicyAttachmentPageName":"9a291c3f-1f57-4189-afd6-5d00e790b775"},"7258": {"Id":7258,"MPAttachmentLetter":"B","Title":"Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage","MPPolicyAttachmentInternalSourceId":10470,"PolicyAttachmentPageName":"92403d21-b160-46bd-b1dc-790ca1edf0de"},"7259": {"Id":7259,"MPAttachmentLetter":"D","Title":"Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit (Part B).","MPPolicyAttachmentInternalSourceId":10471,"PolicyAttachmentPageName":"09c837cc-ee89-488f-873f-4597d8896f2b"},}
No
Connect with Us

2026 Independence Blue Cross

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.