Coverage Policy Manual
Policy #: 2020005
Category: Administrative
Initiated: March 2020
Last Review: October 2025
Self-Administered Medication
Description:
Self-administered medications are medications an individual typically takes orally, by intramuscular or subcutaneous injection, by nebulizer, by insertion, or by topical application and do not require healthcare provider supervision.
Policy/
Coverage:
Effective May 6, 2026
 
Self-administered medications do not meet Primary Coverage Criteria to be covered under the medical benefit. These medications are covered under the pharmacy benefit unless excluded from formulary and may be subject to Standard Guideline Management.
 
Medications are determined as self-administered primarily when the medication does not require administration or direct supervision by a qualified healthcare provider and the medication does not require continuous or periodic monitoring immediately before, during, or after administration by a qualified healthcare provider.
 
Other factors evaluated when considering self-administration include:
    1. Medication route of administration is oral, inhaled, intranasal, rectal, subcutaneous injection, intramuscular injection, or topical application.
    2. Medication dosage form is a tablet, capsule, oral solution, prefilled syringe, auto-injector, suppository, nasal spray, metered dose inhaler, nebulized solution, or cream/ointment.
    3. Comorbid condition that interferes with medication delivery.
    4. Frequency of administration.
    5. Medication is not allowed by policy under the medical benefit.
 
MEDICATIONS SUBJECT TO THIS POLICY:
 
Any medication that is FDA approved for self-administration is subject to this policy. This policy also applies to individuals that require or opt for healthcare provider administration. Any new injected pharmacologic or biologic agent should be presumed to be subject to this policy unless specifically excluded. Any applicable clinician administered dosage form (e.g., intravenous infusion) of a drug that can also be self-administered may be covered under the medical benefit.
 
Some medications may have both healthcare provider administered and self-administered formulations under the same medical billing code. Unless otherwise specified in a drug specific medical coverage policy, all formulations are excluded from the medical benefit and members should seek coverage through their pharmacy benefit.
 
Below is a list of medications that are considered self-administered by FDA labeling and benefits should be checked under the pharmacy benefit. They are not covered under the medical benefit. This list may be updated periodically.
 
Effective April 01, 2021, the following list of medications will be excluded from the medical benefit and be directed toward the member’s pharmacy benefit.
 
Generic Name, (brand name), HCPCS Code
Adalimumab, (e.g., Humira), J0139  
Adalimumab-aacf, (e.g., Idacio), Q5144
Adalimumab-aaty, (e.g., Yuflyma), Q5141
Adalimumab-adaz, (e.g., Hyrimoz), J3590
Adalimumab-adbm, (e.g., Cyltezo), Q5143
Adalimumab-afzb, (e.g., Abrilada), Q5145
Adalimumab-aqvh, (e.g., Yusimry), J3590
Adalimumab-atto, (e.g., Amjevita), J3590
Adalimumab-bwwd, (e.g., Hadlima), J3590
Adalimumab-fkjp, (e.g., Hulio), Q5140
Adalimumab-ryvk, (e.g., Simlandi), Q5142
Alirocumab, (e.g., Praluent), J3590    
Anakinra, (e.g., Kineret), J3590
Asfotase alfa, (e.g., Strensiq), J3490
Benralizumab, (e.g., Fasenra), J0517
Beremagene Geperpavec-svdt, (e.g., Vyjuvek), J3401
Bimekizmab, (e.g., Bimzelx), J3590
Birch Triterpenes, (e.g., Filsuvez), J3590
Brodalumab, (e.g., Siliq), J3590
Calcium Acetate, (N/A), J0615
C-1 esterase inhibitor, (e.g., Haegarda), J0599
Dihydroergotamine mesylate, (e.g., Atzumi) nasal powder
Dupilumab, (e.g., Dupixent), J3590
Efgartigimod alfa and Hyaluronidase-qvfc, (e.g., Vyvgart Hytrulo) prefilled pen only
Emtricitabine and tenofovir disoproxil fumarate, (e.g., Truvada), J0750, J0751
Eplontersen, (e.g., Wainua), J3490
Erenumab, (e.g., Aimovig), J3590
Esketamine, (e.g., Spravato), J0013
Etanercept, (e.g., Enbrel), J1438
Evolucumab, (e.g., Repatha), J3590    
Ferric Citrate, (N/A), J0609
Fremanezumab-vfrm, (e.g., Ajovy), J3031
Furosemide, (e.g., Lasix Onyu), J3490
Galcanezumab-gnlm, (e.g., Emgality), J3590
Garadacimab, (e.g., Andembry) injection, J3590  
Glatiramer acetate, (e.g., Copaxone), J1595
Glatiramer acetate, (e.g., Glatopa), J1595
Guselkumab, (e.g., Tremfya) Subcutaneous injection only
Icatibant, (e.g., Firazyr), J1744
Infliximanb-dqqb, (e.g., Zymfentra), J1748
Interferon beta-1a, (e.g., Avonex), J1826
Interferon beta-1a, (e.g., Rebif), Q3028
Interferon beta-1b, (e.g., Betaseron), J1830
Interferon beta-1b, (e.g., Extavia), J1830
Interferon gamma-1b, (e.g., Actimmune), J9216
Ixekizumab, (e.g., Taltz), J3590
Lanadelumab-flyo, (e.g., Takhzyro), J0593
Lanthanum Carbonate, (N/A), J0607, J0608
Lenacapavir, (e.g., Yeztugo), J0752
Mecasermin, (e.g., Increlex), J2170
Mepolizumab, (e.g., Nucala), J2182
Metreleptin, (e.g., Myalept), J3490    
Nemolizumab, (e.g., Nemluvio), J3590
Ofatumumab, (e.g., Kesimpta), J3590
Olezarsen, (e.g., Tryngolza) injection, J3490   
Omalizumab-igec, (e.g., Omyclo) injection, Q5154
Omalizumab, (e.g., Xolair), J2357
Pegcetacoplan, (e.g., Empaveli), C9399, J7799   
Peginterferon beta-1a, (e.g., Plegridy), J3490
Plozasiran, (e.g., Redemplo), J3490
Rilonacept, (e.g., Arcalyst, J2793
Risankizumab-rzaa subcutaneous, (e.g., Skyrizi SC), J3590
Ropeginterferon alfa-2b-nift, (e.g., Besremi), C9399, J9999   
Sarilumab, (e.g., Kevzara), J3590
Satralizumab, (e.g., Ensprying), J3490  
Secukinumab subcutaneous, (e.g., Cosentyx SC), J3590
Sevelamer Carbonate, (N/A), J0601, J0602
Sevelamer Hydrochloride, (N/A), J0603
Siberprenlimab, (e.g., Voyxact), J3590
Somapacitan-beco, (e.g., Sogroya),  J3590
Somatropin, (e.g., Genotropin), J2941
Somatropin, (e.g., Humatrope), J2941
Somatropin, (e.g., Norditropin), J2941
Somatropin, (e.g., Nutropin), J2941
Somatropin, (e.g., Omnitrope), J2941
Somatropin, (e.g., Saizen), J2941
Somatropin, (e.g., Zomacton), J2941
Somatropin, (e.g., Zorbtive), J2941
Sotatercept-crsk, (e.g., Winrevair), J3590
Spesolimab-sbzo, (e.g., Spevigo) Subcutaneous injection only, J1747 JB modifier  
Sucroferric Oxyhydroxide, (e.g., Velphoro), J0605
Tesamorelin acetate, (e.g., Egrifta), J3590    
Tezepelumab ekko, (e.g., Tezspire), J2356
Tocilizumab subcutaneous, (e.g., Actemra SC), J3590
Tocilizumab subcutaneous, (e.g., Tyenne SC), J3590
Tralokinumab, (e.g., Adbry), C9399, J3590   
Vadadustat, (e.g., Vafseo), J0901
Vedolizumab subcutaneous, (e.g., Entyvio SC), J3590
Zilucoplan, (e.g., Zilbrysq), J3490
 
Effective March 30, 2026 to May 5, 2026
 
Self-administered medications do not meet Primary Coverage Criteria to be covered under the medical benefit. These medications are covered under the pharmacy benefit unless excluded from formulary and may be subject to Standard Guideline Management.
 
Medications are determined as self-administered primarily when the medication does not require administration or direct supervision by a qualified healthcare provider and the medication does not require continuous or periodic monitoring immediately before, during, or after administration by a qualified healthcare provider.
 
Other factors evaluated when considering self-administration include:
1. Medication route of administration is oral, inhaled, intranasal, rectal, subcutaneous injection, intramuscular injection, or topical application.
2. Medication dosage form is a tablet, capsule, oral solution, prefilled syringe, auto-injector, suppository, nasal spray, metered dose inhaler, nebulized solution, or cream/ointment.
3. Comorbid condition that interferes with medication delivery.
4. Frequency of administration.
5. Medication is not allowed by policy under the medical benefit.
 
MEDICATIONS SUBJECT TO THIS POLICY:
 
Any medication that is FDA approved for self-administration is subject to this policy. This policy also applies to individuals that require or opt for healthcare provider administration. Any new injected pharmacologic or biologic agent should be presumed to be subject to this policy unless specifically excluded. Any applicable clinician administered dosage form (e.g., intravenous infusion) of a drug that can also be self-administered may be covered under the medical benefit.
 
Some medications may have both healthcare provider administered and self-administered formulations under the same medical billing code. Unless otherwise specified in a drug specific medical coverage policy, all formulations are excluded from the medical benefit and members should seek coverage through their pharmacy benefit.
 
Below is a list of medications that are considered self-administered by FDA labeling and benefits should be checked under the pharmacy benefit. They are not covered under the medical benefit. This list may be updated periodically.
 
Effective April 01, 2021, the following list of medications will be excluded from the medical benefit and be directed toward the member’s pharmacy benefit.
 
Generic Name                                           (brand name)                                            HCPCS Code
Adalimumab                                                (e.g., Humira)                                             J0139  
Adalimumab-aacf                                         (e.g., Idacio)                                               Q5144
Adalimumab-aaty                                        (e.g., Yuflyma)                                            Q5141
Adalimumab-adaz                                       (e.g., Hyrimoz)                                            J3590
Adalimumab-adbm                                      (e.g., Cyltezo)                                             Q5143
Adalimumab-afzb                                        (e.g., Abrilada)                                            Q5145
Adalimumab-aqvh                                       (e.g., Yusimry)                                            J3590
Adalimumab-atto                                        (e.g., Amjevita)                                            J3590
Adalimumab-bwwd                                     (e.g., Hadlima)                                             J3590
Adalimumab-fkjp                                        (e.g., Hulio)                                                 Q5140
Adalimumab-ryvk                                       (e.g., Simlandi)                                            Q5142
Alirocumab                                               (e.g., Praluent)                                             J3590    
Anakinra                                                  (e.g., Kineret)                                               J3590
Asfotase alfa                                            (e.g., Strensiq)                                             J3490
Benralizumab                                           (e.g., Fasenra)                                             J0517
Beremagene Geperpavec-svdt                    (e.g., Vyjuvek)                                             J3401
Bimekizmab                                             (e.g., Bimzelx)                                            J3590
Birch Triterpenes                                      (e.g., Filsuvez)                                            J3590
Brodalumab                                             (e.g., Siliq)                                                  J3590
Calcium Acetate                                                                                                        J0615
C-1 esterase inhibitor                               (e.g., Haegarda)                                           J0599
Dihydroergotamine mesylate                     (e.g., Atzumi) nasal powder
Dupilumab                                               (e.g., Dupixent)                                           J3590
Efgartigimod alfa and Hyaluronidase-qvfc    (e.g., Vyvgart Hytrulo) prefilled pen only
Eplontersen                                             (e.g., Wainua)                                             J3490
Erenumab                                               (e.g., Aimovig)                                             J3590
Esketamine                                            (e.g., Spravato)                                             J0013
Etanercept                                              (e.g., Enbrel)                                               J1438
Evolucumab                                            (e.g., Repatha)                                            J3590    
Ferric Citrate                                                                                                            J0609
Fremanezumab-vfrm                                (e.g., Ajovy)                                                J3031
Furosemide                                            (e.g., Lasix Onyu)                                       J3490
Galcanezumab-gnlm                               (e.g., Emgality)                                           J3590
Garadacimab                                         (e.g., Andembry) injection                            J3590  
Glatiramer acetate                                 (e.g., Copaxone)                                          J1595
Glatiramer acetate                                 (e.g., Glatopa)                                             J1595
Guselkumab                                         (e.g., Tremfya) Subcutaneous injection only
Icatibant                                               (e.g., Firazyr)                                               J1744
Infliximanb-dqqb                                    (e.g., Zymfentra)                                           J1748
Interferon beta-1a                                  (e.g., Avonex)                                               J1826
Interferon beta-1a                                  (e.g., Rebif)                                                  Q3028
Interferon beta-1b                                  (e.g., Betaseron)                                          J1830
Interferon beta-1b                                  (e.g., Extavia)                                              J1830
Interferon gamma-1b                             (e.g., Actimmune)                                        J9216
Ixekizumab                                          (e.g., Taltz)                                                 J3590
Lanadelumab-flyo                                 (e.g., Takhzyro)                                           J0593
Lanthanum Carbonate                                                                                            J0607, J0608
Mecasermin                                        (e.g., Increlex)                                             J2170
Mepolizumab                                      (e.g., Nucala)                                               J2182
Metreleptin                                         (e.g., Myalept)                                              J3490    
Nemolizumab                                     (e.g., Nemluvio)                                             J3590
Ofatumumab                                      (e.g., Kesimpta)                                            J3590
Olezarsen                                          (e.g., Tryngolza) injection                              J3490   
Omalizumab-igec                                (e.g., Omyclo) injection                                Q5154
Omalizumab                                       (e.g., Xolair)                                                J2357
Pegcetacoplan                                    (e.g., Empaveli)                                          C9399, J7799   
Peginterferon beta-1a                          (e.g., Plegridy)                                            J3490
Plozasiran                                         (e.g., Redemplo)                                          J3490
Rilonacept                                         (e.g., Arcalyst)                                            J2793
Risankizumab-rzaa subcutaneous        (e.g., Skyrizi SC)                                        J3590
Ropeginterferon alfa-2b-nift                   (e.g., Besremi)                                           C9399, J9999   
Sarilumab                                           (e.g., Kevzara)                                           J3590
Satralizumab                                      (e.g., Ensprying)                                        J3490  
Secukinumab subcutaneous                (e.g., Cosentyx SC)                                   J3590
Sevelamer Carbonate                                                                                          J0601, J0602
Sevelamer Hydrochloride                                                                                     J0603
Siberprenlimab                                    (e.g., Voyxact)                                          J3590
Somapacitan-beco                              (e.g., Sogroya)                                          J3590
Somatropin                                        (e.g., Genotropin)                                       J2941
Somatropin                                        (e.g., Humatrope)                                       J2941
Somatropin                                        (e.g., Norditropin)                                       J2941
Somatropin                                        (e.g., Nutropin)                                          J2941
Somatropin                                        (e.g., Omnitrope)                                       J2941
Somatropin                                        (e.g., Saizen)                                            J2941
Somatropin                                        (e.g., Zomacton)                                        J2941
Somatropin                                        (e.g., Zorbtive)                                           J2941
Sotatercept-crsk                                (e.g., Winrevair)                                         J3590
Spesolimab-sbzo                               (e.g., Spevigo) Subcutaneous injection only J1747 JB modifier  
Sucroferric Oxyhydroxide                   (e.g., Velphoro)                                          J0605
Tesamorelin acetate                          (e.g., Egrifta)                                              J3590    
Tezepelumab ekko                            (e.g., Tezspire)                                           J2356
Tocilizumab subcutaneous                 (e.g., Actemra SC)                                     J3590
Tocilizumab subcutaneous                 (e.g., Tyenne SC)                                       J3590
Tralokinumab                                    (e.g., Adbry)                                               C9399, J3590   
Vadadustat                                       (e.g., Vafseo)                                             J0901
Vedolizumab subcutaneous               (e.g., Entyvio SC)                                       J3590
Zilucoplan                                        (e.g., Zilbrysq)                                            J3490
 
Effective February 1, 2026 to March 29, 2026
 
Self-administered medications do not meet primary coverage criteria to be covered under the medical benefit. These medications are covered under the pharmacy benefit unless excluded from formulary and may be subject to Standard Guideline Management.
 
Medications are determined as self-administered primarily when the medication does not require administration or direct supervision by a qualified healthcare provider and the medication does not require continuous or periodic monitoring immediately before, during, or after administration by a qualified healthcare provider.
 
Other factors evaluated when considering self-administration include:
1. Medication route of administration is oral, inhaled, intranasal, rectal, subcutaneous injection, intramuscular injection, or topical application.
2. Medication dosage form is a tablet, capsule, oral solution, prefilled syringe, auto-injector, suppository, nasal spray, metered dose inhaler, nebulized solution, or cream/ointment.
3. Comorbid condition that interferes with medication delivery.
4. Frequency of administration.
5. Medication is not allowed by policy under the medical benefit.
 
MEDICATIONS SUBJECT TO THIS POLICY:
 
Any medication that is FDA approved for self-administration is subject to this policy. This policy also applies to individuals that require or opt for healthcare provider administration. Any new injected pharmacologic or biologic agent should be presumed to be subject to this policy unless specifically excluded. Any applicable clinician administered dosage form (e.g., intravenous infusion) of a drug that can also be self-administered may be covered under the medical benefit.
 
Some medications may have both healthcare provider administered and self-administered formulations under the same medical billing code. Unless otherwise specified in a drug specific medical coverage policy, all formulations are excluded from the medical benefit and members should seek coverage through their pharmacy benefit.
 
Below is a list of medications that are considered self-administered by FDA labeling and benefits should be checked under the pharmacy benefit. They are not covered under the medical benefit. This list may be updated periodically.
 
Effective April 01, 2021, the following list of medications will be excluded from the medical benefit and be directed toward the member’s pharmacy benefit.
 
Generic Name                                           (brand name)                                            HCPCS Code
Adalimumab                                                (e.g., Humira)                                             J0139  
Adalimumab-aacf                                         (e.g., Idacio)                                               Q5144
Adalimumab-aaty                                        (e.g., Yuflyma)                                            Q5141
Adalimumab-adaz                                       (e.g., Hyrimoz)                                            J3590
Adalimumab-adbm                                      (e.g., Cyltezo)                                             Q5143
Adalimumab-afzb                                        (e.g., Abrilada)                                            Q5145
Adalimumab-aqvh                                       (e.g., Yusimry)                                            J3590
Adalimumab-atto                                        (e.g., Amjevita)                                            J3590
Adalimumab-bwwd                                     (e.g., Hadlima)                                             J3590
Adalimumab-fkjp                                        (e.g., Hulio)                                                 Q5140
Adalimumab-ryvk                                       (e.g., Simlandi)                                            Q5142
Alirocumab                                               (e.g., Praluent)                                             J3590    
Anakinra                                                  (e.g., Kineret)                                               J3590
Asfotase alfa                                            (e.g., Strensiq)                                             J3490
Benralizumab                                           (e.g., Fasenra)                                             J0517
Beremagene Geperpavec-svdt                    (e.g., Vyjuvek)                                             J3401
Bimekizmab                                             (e.g., Bimzelx)                                            J3590
Birch Triterpenes                                      (e.g., Filsuvez)                                            J3590
Brodalumab                                             (e.g., Siliq)                                                  J3590
Calcium Acetate                                                                                                        J0615
C-1 esterase inhibitor                               (e.g., Haegarda)                                           J0599
Dihydroergotamine mesylate                     (e.g., Atzumi) nasal powder
Dupilumab                                               (e.g., Dupixent)                                           J3590
Efgartigimod alfa and Hyaluronidase-qvfc    (e.g., Vyvgart Hytrulo) prefilled pen only
Eplontersen                                             (e.g., Wainua)                                             J3490
Erenumab                                               (e.g., Aimovig)                                             J3590
Etanercept                                              (e.g., Enbrel)                                               J1438
Evolucumab                                            (e.g., Repatha)                                            J3590    
Ferric Citrate                                                                                                            J0609
Fremanezumab-vfrm                                (e.g., Ajovy)                                                J3031
Galcanezumab-gnlm                               (e.g., Emgality)                                           J3590
Garadacimab                                         (e.g., Andembry) injection                            J3590  
Glatiramer acetate                                 (e.g., Copaxone)                                          J1595
Glatiramer acetate                                 (e.g., Glatopa)                                             J1595
Guselkumab                                         (e.g., Tremfya) Subcutaneous injection only
Icatibant                                               (e.g., Firazyr)                                               J1744
Infliximanb-dqqb                                    (e.g., Zymfentra)                                           J1748
Interferon beta-1a                                  (e.g., Avonex)                                               J1826
Interferon beta-1a                                  (e.g., Rebif)                                                  Q3028
Interferon beta-1b                                  (e.g., Betaseron)                                          J1830
Interferon beta-1b                                  (e.g., Extavia)                                              J1830
Interferon gamma-1b                             (e.g., Actimmune)                                        J9216
Ixekizumab                                          (e.g., Taltz)                                                 J3590
Lanadelumab-flyo                                 (e.g., Takhzyro)                                           J0593
Lanthanum Carbonate                                                                                            J0607, J0608
Mecasermin                                        (e.g., Increlex)                                             J2170
Mepolizumab                                      (e.g., Nucala)                                               J2182
Metreleptin                                         (e.g., Myalept)                                              J3490    
Nemolizumab                                     (e.g., Nemluvio)                                             J3590
Ofatumumab                                      (e.g., Kesimpta)                                            J3590
Olezarsen                                          (e.g., Tryngolza) injection                              J3490   
Omalizumab-igec                                (e.g., Omyclo) injection                                Q5154
Omalizumab                                       (e.g., Xolair)                                                J2357
Pegcetacoplan                                    (e.g., Empaveli)                                          C9399, J7799   
Peginterferon beta-1a                          (e.g., Plegridy)                                            J3490
Rilonacept                                         (e.g., Arcalyst)                                            J2793
Risankizumab-rzaa subcutaneous        (e.g., Skyrizi SC)                                        J3590
Ropeginterferon alfa-2b-nift                   (e.g., Besremi)                                           C9399, J9999   
Sarilumab                                           (e.g., Kevzara)                                           J3590
Satralizumab                                      (e.g., Ensprying)                                        J3490  
Secukinumab subcutaneous                (e.g., Cosentyx SC)                                   J3590
Sevelamer Carbonate                                                                                          J0601, J0602
Sevelamer Hydrochloride                                                                                     J0603
Somapacitan-beco                              (e.g., Sogroya)                                          J3590
Somatropin                                        (e.g., Genotropin)                                       J2941
Somatropin                                        (e.g., Humatrope)                                       J2941
Somatropin                                        (e.g., Norditropin)                                       J2941
Somatropin                                        (e.g., Nutropin)                                          J2941
Somatropin                                        (e.g., Omnitrope)                                       J2941
Somatropin                                        (e.g., Saizen)                                            J2941
Somatropin                                        (e.g., Zomacton)                                        J2941
Somatropin                                        (e.g., Zorbtive)                                           J2941
Sotatercept-crsk                                (e.g., Winrevair)                                         J3590
Spesolimab-sbzo                               (e.g., Spevigo) Subcutaneous injection only J1747 JB modifier  
Sucroferric Oxyhydroxide                   (e.g., Velphoro)                                          J0605
Tesamorelin acetate                          (e.g., Egrifta)                                              J3590    
Tezepelumab ekko                            (e.g., Tezspire)                                           J2356
Tocilizumab subcutaneous                 (e.g., Actemra SC)                                     J3590
Tocilizumab subcutaneous                 (e.g., Tyenne SC)                                       J3590
Tralokinumab                                    (e.g., Adbry)                                               C9399, J3590   
Vadadustat                                       (e.g., Vafseo)                                             J0901
Vedolizumab subcutaneous               (e.g., Entyvio SC)                                       J3590
Zilucoplan                                        (e.g., Zilbrysq)                                            J3490    
 
Effective January 1, 2026 to January 31, 2026
 
Self-administered medications do not meet primary coverage criteria to be covered under the medical benefit. These medications are covered under the pharmacy benefit unless excluded from formulary and may be subject to Standard Guideline Management.
 
Medications are determined as self-administered primarily when the medication does not require administration or direct supervision by a qualified healthcare provider and the medication does not require continuous or periodic monitoring immediately before, during, or after administration by a qualified healthcare provider.
 
Other factors evaluated when considering self-administration include:
    1. Medication route of administration is oral, inhaled, intranasal, rectal, subcutaneous injection, intramuscular injection, or topical application.
    2. Medication dosage form is a tablet, capsule, oral solution, prefilled syringe, auto-injector, suppository, nasal spray, metered dose inhaler, nebulized solution, or cream/ointment.
    3. Comorbid condition that interferes with medication delivery.
    4. Frequency of administration.
    5. Medication is not allowed by policy under the medical benefit.
 
MEDICATIONS SUBJECT TO THIS POLICY:
 
Any medication that is FDA approved for self-administration is subject to this policy. This policy also applies to individuals that require or opt for healthcare provider administration. Any new injected pharmacologic or biologic agent should be presumed to be subject to this policy unless specifically excluded. Any applicable clinician administered dosage form (e.g., intravenous infusion) of a drug that can also be self-administered may be covered under the medical benefit.
 
Some medications may have both healthcare provider administered and self-administered formulations under the same medical billing code. Unless otherwise specified in a drug specific medical coverage policy, all formulations are excluded from the medical benefit and members should seek coverage through their pharmacy benefit.
 
Below is a list of medications that are considered self-administered by FDA labeling and benefits should be checked under the pharmacy benefit. They are not covered under the medical benefit. This list may be updated periodically.
 
Effective April 01, 2021, the following list of medications will be excluded from the medical benefit and be directed toward the member’s pharmacy benefit.
 
Generic Name                                         (brand name)                                               HCPCS Code
Adalimumab                                              (e.g., Humira)                                                J0139  
Adalimumab-aacf                                       (e.g., Idacio)                                                  Q5144
Adalimumab-aaty                                       (e.g., Yuflyma)                                              Q5141
Adalimumab-adaz                                      (e.g., Hyrimoz)                                              J3590
Adalimumab-adbm                                     (e.g., Cyltezo)                                               Q5143
Adalimumab-afzb                                       (e.g., Abrilada)                                              Q5145
Adalimumab-aqvh                                       (e.g., Yusimry)                                             J3590
Adalimumab-atto                                        (e.g., Amjevita)                                             J3590
Adalimumab-bwwd                                     (e.g., Hadlima)                                              J3590
Adalimumab-fkjp                                        (e.g., Hulio)                                                  Q5140
Adalimumab-ryvk                                       (e.g., Simlandi)                                             Q5142
Alirocumab                                               (e.g., Praluent)                                              J3590    
Anakinra                                                   (e.g., Kineret)                                               J3590
Asfotase alfa                                             (e.g., Strensiq)                                             J3490
Benralizumab                                            (e.g., Fasenra)                                             J0517
Bimekizmab                                              (e.g., Bimzelx)                                             J3590
Birch Triterpenes                                       (e.g., Filsuvez)                                             J3590
Brodalumab                                              (e.g., Siliq)                                                   J3590
Calcium Acetate                                                                                                          J0615
C-1 esterase inhibitor                                 (e.g., Haegarda)                                           J0599
Dihydroergotamine mesylate                      (e.g., Atzumi) nasal powder
Dupilumab                                                (e.g., Dupixent)                                            J3590
Efgartigimod alfa and Hyaluronidase-qvfc     (e.g., Vyvgart Hytrulo) prefilled pen only
Eplontersen                                              (e.g., Wainua)                                             J3490
Erenumab                                                (e.g., Aimovig)                                             J3590
Etanercept                                               (e.g., Enbrel)                                               J1438
Evolucumab                                             (e.g., Repatha)                                            J3590    
Ferric Citrate                                                                                                             J0609
Fremanezumab-vfrm                                 (e.g., Ajovy)                                                J3031
Galcanezumab-gnlm                                (e.g., Emgality)                                           J3590
Garadacimab                                           (e.g., Andembry) injection                            J3590  
Glatiramer acetate                                   (e.g., Copaxone)                                          J1595
Glatiramer acetate                                   (e.g., Glatopa)                                             J1595
Guselkumab                                           (e.g., Tremfya) Subcutaneous injection only
Icatibant                                                 (e.g., Firazyr)                                               J1744
Infliximanb-dqqb                                      (e.g., Zymfentra)                                           J1748
Interferon beta-1a                                    (e.g., Avonex)                                               J1826
Interferon beta-1a                                    (e.g., Rebif)                                                  Q3028
Interferon beta-1b                                    (e.g., Betaseron)                                           J1830
Interferon beta-1b                                    (e.g., Extavia)                                               J1830
Interferon gamma-1b                                (e.g., Actimmune)                                         J9216
Ixekizumab                                             (e.g., Taltz)                                                  J3590
Lanadelumab-flyo                                    (e.g., Takhzyro)                                            J0593
Lanthanum Carbonate                                                                                                J0607, J0608
Mecasermin                                           (e.g., Increlex)                                              J2170
Mepolizumab                                          (e.g., Nucala)                                               J2182
Metreleptin                                             (e.g., Myalept)                                              J3490    
Nemolizumab                                         (e.g., Nemluvio)                                             J3590
Ofatumumab                                          (e.g., Kesimpta)                                             J3590
Olezarsen                                              (e.g., Tryngolza) injection                                J3490   
Omalizumab-igec                                    (e.g., Omyclo) injection                                  Q5154
Omalizumab                                           (e.g., Xolair)                                                   J2357
Pegcetacoplan                                        (e.g., Empaveli)                                             C9399, J7799   
Peginterferon beta-1a                               (e.g., Plegridy)                                              J3490
Rilonacept                                              (e.g., Arcalyst)                                              J2793
Risankizumab-rzaa subcutaneous            (e.g., Skyrizi SC)                                           J3590
Ropeginterferon alfa-2b-nift                       (e.g., Besremi)                                              C9399, J9999   
Sarilumab                                               (e.g., Kevzara)                                               J3590
Satralizumab                                           (e.g., Ensprying)                                            J3490  
Secukinumab subcutaneous                     (e.g., Cosentyx SC)                                       J3590
Sevelamer Carbonate                                                                                                   J0601, J0602
Sevelamer Hydrochloride                                                                                              J0603
Somapacitan-beco                                   (e.g., Sogroya)                                              J3590
Somatropin                                              (e.g., Genotropin)                                          J2941
Somatropin                                              (e.g., Humatrope)                                          J2941
Somatropin                                              (e.g., Norditropin)                                          J2941
Somatropin                                              (e.g., Nutropin)                                              J2941
Somatropin                                              (e.g., Omnitrope)                                           J2941
Somatropin                                              (e.g., Saizen)                                                J2941
Somatropin                                              (e.g., Zomacton)                                            J2941
Somatropin                                              (e.g., Zorbtive)                                               J2941
Sotatercept-crsk                                       (e.g., Winrevair)                                            J3590
Spesolimab-sbzo                                      (e.g., Spevigo) Subcutaneous injection only    J1747 JB modifier  
Sucroferric Oxyhydroxide                           (e.g., Velphoro)                                            J0605
Tesamorelin acetate                                  (e.g., Egrifta)                                                J3590    
Tezepelumab ekko                                    (e.g., Tezspire)                                             J2356
Tocilizumab subcutaneous                         (e.g., Actemra SC)                                       J3590
Tocilizumab subcutaneous                         (e.g., Tyenne SC)                                         J3590
Tralokinumab                                            (e.g., Adbry)                                                 C9399, J3590   
Vadadustat                                               (e.g., Vafseo)                                                J0901
Vedolizumab subcutaneous                        (e.g., Entyvio SC)                                         J3590
Zilucoplan                                                  (e.g., Zilbrysq)                                              J3490    
 
Due to the detail of the policy statement, the document containing the coverage statements for dates prior to January 1, 2026 is not online. If you would like a hardcopy print, please email: codespecificinquiry@arkbluecross.com
CPT/HCPCS:
C9399Unclassified drugs or biologicals
J0013Esketamine, nasal spray, 1 mg
J0135Injection, adalimumab, 20 mg
J0139Injection, adalimumab, 1 mg
J0517Injection, benralizumab, 1 mg
J0593Injection, lanadelumab flyo, 1 mg (code may be used for medicare when drug administered under direct supervision of a physician, not for use when drug is self administered)
J0599Injection, c 1 esterase inhibitor (human), (haegarda), 10 units
J0601Sevelamer carbonate (renvela or therapeutically equivalent), oral, 20 mg (for esrd on dialysis)
J0602Sevelamer carbonate (renvela or therapeutically equivalent), oral, powder, 20 mg (for esrd on dialysis)
J0603Sevelamer hydrochloride (renagel or therapeutically equivalent), oral, 20 mg (for esrd on dialysis)
J0605Sucroferric oxyhydroxide, oral, 5 mg (for esrd on dialysis)
J0607Lanthanum carbonate, oral, 5 mg (for esrd on dialysis)
J0608Lanthanum carbonate, oral, powder, 5 mg, not therapeutically equivalent to j0607 (for esrd on dialysis)
J0609Ferric citrate, oral, 3 mg ferric iron, (for esrd on dialysis)
J0615Calcium acetate, oral, 23 mg (for esrd on dialysis)
J0750Emtricitabine 200mg and tenofovir disoproxil fumarate 300mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv)
J0751Emtricitabine 200mg and tenofovir alafenamide 25mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv)
J0752Oral, lenacapavir, 300 mg, fda approved prescription, only for use as hiv pre exposure prophylaxis (not for use as treatment for hiv)
J0901Vadadustat, oral, 1 mg (for esrd on dialysis)
J1438Injection, etanercept, 25 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
J1595Injection, glatiramer acetate, 20 mg
J1744Injection, icatibant, 1 mg
J1747Injection, spesolimab-sbzo, 1 mg
J1748Injection, infliximab-dyyb (zymfentra), 10 mg
J1826Injection, interferon beta 1a, 30 mcg
J1830Injection, interferon beta 1b, 0.25 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
J2170Injection, mecasermin, 1 mg
J2182Injection, mepolizumab, 1 mg
J2356Injection, tezepelumab-ekko, 1 mg
J2357Injection, omalizumab, 5 mg
J2793Injection, rilonacept, 1 mg
J2941Injection, somatropin, 1 mg
J3031Injection, fremanezumab vfrm, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
J3401Beremagene geperpavec svdt for topical administration, containing nominal 5 x 10 9 pfu/ml vector genomes, per 0.1 ml
J3490Unclassified drugs
J3590Unclassified biologics
J7799Noc drugs, other than inhalation drugs, administered through dme
J9216Injection, interferon, gamma 1 b, 3 million units
J9999Not otherwise classified, antineoplastic drugs
Q3028Injection, interferon beta 1a, 1 mcg for subcutaneous use
Q5131Injection, adalimumab-aacf (idacio), biosimilar, 20 mg
Q5132Injection, adalimumab afzb (abrilada), biosimilar, 10 mg
Q5140Injection, adalimumab-fkjp, biosimilar, 1 mg
Q5141Injection, adalimumab-aaty, biosimilar, 1 mg
Q5142Injection, adalimumab-ryvk biosimilar, 1 mg
Q5143Injection, adalimumab-adbm, biosimilar, 1 mg
Q5144Injection, adalimumab-aacf (idacio), biosimilar, 1 mg
Q5145Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg
Q5154Injection, omalizumab igec (omlyclo), biosimilar, 5 mg
References:
Clinical Pharmacology [database online]. URL: http://www.clinicalpharmacology.com

FDA Approved Medication Package Insert https://www.fda.gov/

Medicare Benefit Policy Manual. (2019, July 12) Retrieved March 13, 2020, from https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/downloads/bp102c15.PDF

Self-Administration Drug Exclusion Report List. (n.d.) Retrieved March 13, 2020, from https://www.cms.gov/medicare-coverage-database/reports/sad-exclusion-list-report.aspx?Cntrctr=All&AllHCPCS=yes&DateFrom=01/01/2019&DateTo=03/01/2020&bc=AIAAAEAAAAAA&#ResultsAnchor

Lexicomp Online(2020) Lexicomp Online Lexi-Drugs Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.

The benefits and risks of self-medication. Retrieved March 13, 2020, from http://apps.who.int/medicinedocs/en/p/about/
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants.
CPT Codes Copyright © 2026 American Medical Association.