Medications and Diabetic Supplies Payable on the Pharmacy Benefit (Medicaid Expansion)

Policy ID: ME-I-9015-001-07

Section: Injections

Effective Date: January 01, 2022

Revised Date: June 12, 2024

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Applies To: Medicaid Expansion Only

Description

Medications administered by an individual that do not require professional administration by a healthcare provider are considered self-administered medications and are not covered under the medical benefit.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Self-administered medications do not require professional administration by a healthcare provider. The medications and diabetic supplies found in this policy may be subject to prior approval and are to be processed by pharmacy point of sale systems per the North Dakota Department of Human Services Preferred Drug List and Preferred Diabetic Supplies List. Self-administered medications are excluded from standard medical benefits.

A medication or diabetic supply found in this policy may be considered medically necessary when administered by a healthcare provider if one of the following criteria applies and documentation is provided.

Training and education purposes; or
A medical reason is provided as to why an individual cannot self-administer (i.e., physical disability, anxiety/panic attack, previous severe reaction to the medication); or
Medication access limitations; or
An individual's primary insurance requires medical claim processing; or
An individual is hospitalized.

Procedure Codes

A4238

A4239

A9276

A9277

A9278

E2102

E2103

J0135

J0364

J0593

J0596

J0597

J0598

J0599

J0717

J1000

J1071

J1110

J1290

J1438

J1595

J1628

J1645

J1650

J1652

J1744

J1748

J1826

J1830

J2170

J2212

J2793

J2941

J3110

J3121

J3145

J3262

J3357

J3535

J7170

J7175

J7179

J7180

J7181

J7182

J7183

J7185

J7186

J7187

J7188

J7189

J7190

J7192

J7193

J7194

J7195

J7198

J7200

J7201

J7202

J7203

J7204

J7205

J7207

J7208

J7209

J7210

J7211

J7212

J7527

J7686

Q3027

Q3028

Q4074

Q5131

Q5132

Q5137

S0090

S0117

S0138

S1030

S1031

S1034

S1035

S1036

S1037

S4990

S4991

S4995

Diagnosis Codes

Not Applicable to this policy

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 01, 2022

Adopted Medicaid Expansion specific policy

Internal Medical Policy Committee 1-20-2022

Removed Procedure codes J0517 and J2182 as there are healthcare administered products that may be covered on the medical benefit

Internal Medical Policy Committee 3-23-2022 - Effective April 01, 2022

Added new codes, A4238 and E2102, to the policy

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Removed code J7336 from the policy as this code is part of medical policy, ME-I-9018-001-01 Capsaicin patch (Qutenza)

Internal Medical Policy Committee 11-29-2022 - Effective January 01, 2023

Added new codes, A4239 and E2103, to the policy
Removed codes, K0553 and K0554, from the policy

Internal Medical Policy Committee 11-15-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 - Effective March 01, 2024

Added codes, Q5131 and Q5132, to the policy

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Added new code, J1748, for infliximab-dyyb (Zymfentra) subcutaneous, to the policy
Added new code, Q5137, for ustekinumab-auub (Wezlana) subcutaneous, to the policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: ME-I-9015-001-06

Section: Injections

Effective Date: January 01, 2022

Revised Date: January 15, 2024

Revision Effective Date: March 01, 2024

Last Reviewed: January 16, 2024

Archived Date: June 30, 2024

Applies To: Medicaid Expansion Only

Description

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Training and education purposes; or
A medical reason is provided as to why an individual cannot self-administer (i.e., physical disability, anxiety/panic attack, previous severe reaction to the medication); or
Medication access limitations; or
An individual's primary insurance requires medical claim processing; or
An individual is hospitalized.

Procedure Codes

A4238

A4239

A9276

A9277

A9278

E2102

E2103

J0135

J0364

J0593

J0596

J0597

J0598

J0599

J0717

J1000

J1071

J1110

J1290

J1438

J1595

J1628

J1645

J1650

J1652

J1744

J1826

J1830

J2170

J2212

J2793

J2941

J3110

J3121

J3145

J3262

J3357

J3535

J7170

J7175

J7179

J7180

J7181

J7182

J7183

J7185

J7186

J7187

J7188

J7189

J7190

J7192

J7193

J7194

J7195

J7198

J7200

J7201

J7202

J7203

J7204

J7205

J7207

J7208

J7209

J7210

J7211

J7212

J7527

J7686

Q3027

Q3028

Q4074

Q5131

Q5132

S0090

S0117

S0138

S1030

S1031

S1034

S1035

S1036

S1037

S4990

S4991

S4995

Diagnosis Codes

Not Applicable to this policy

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 01, 2022

Adopted Medicaid Expansion specific policy

Internal Medical Policy Committee 1-20-2022

Removed Procedure codes J0517 and J2182 as there are healthcare administered products that may be covered on the medical benefit

Internal Medical Policy Committee 3-23-2022 - Effective April 01, 2022

Added new codes, A4238 and E2102, to the policy

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Removed code J7336 from the policy as this code is part of medical policy, ME-I-9018-001-01 Capsaicin patch (Qutenza)

Internal Medical Policy Committee 11-29-2022 - Effective January 01, 2023

Added new codes, A4239 and E2103, to the policy
Removed codes, K0553 and K0554, from the policy

Internal Medical Policy Committee 11-15-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 - Effective March 01, 2024

Added codes, Q5131 and Q5132, to the policy

Medical Policies Quick Search

Medications and Diabetic Supplies Payable on the Pharmacy Benefit (Medicaid Expansion)

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer