Policy requirements for a trial of an injectable drug therapy may be waived for persons who meet diagnostic criteria for needle phobia (see appendix for DSM 5 criteria), if there is documentation of preexisting excessive fear (outside of the particular request being considered) of injections and blood draws with documented attempts at management and psychological counseling, especially if there are associated symptoms (vasovagal syncope, panic attack).
Notes: Aetna covers injectable medications when an appropriate oral alternative drug does not exist. This coverage includes those medications intended to be self-administered. The medication must be medically necessary and appropriate to the member's needs or condition.
Experimental or investigational drugs or drugs that have not been proven safe and effective for a specific disease or approved for a mode of treatment by the Food and Drug Administration (FDA) and/or the National Institutes of Health are not covered. This provision does not exclude coverage of established “off label” uses of otherwise FDA-approved prescribed medications.
Drugs related to the treatment of non-covered services are not covered. Infertility injectable medications are covered only when required by regulation or covered by a specific benefit design. Steroids are not covered for the enhancement of performance, as this is not considered treatment of disease.
Note: Some state-to-state and plan type variations exist.
Certain classes of injectable medications are excluded from coverage under some benefit plans. Please check benefit plan descriptions for details:
* Exception: Infertility injectable medications are covered only when required by regulation or covered by a specific benefit design.
**Contraceptive injectable medications are covered under plans with the contraceptives rider or under plans with a contraceptives benefit.
Note: Medical necessity criteria for oral and certain self-administered injectable medications are addressed in Pharmacy Clinical Policy Bulletins (PCPBs).
Specific Phobia: DSM 5 Diagnostic Criteria:
Source: APA, 2013.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|90281 - 90399||Immune globulins [intramuscular, intravenous, subcutaneous]|
|90465 - 90466, 90468 - 90472, 90474||Immunization administration for vaccines/toxoids [intradermal, intramuscular, percutaneous, subcutaneous]|
|90581 - 90658, 90666 - 90676, 90691 - 90710, 90713 - 90749||Vaccines, toxoids [intradermal, intramuscular, intravesicular, percutaneous, subcutaneous]|
|96365-96379||Therapeutic, prophylactic, and diagnostic injections and infusions|
|Other HCPCS codes related to the CPB:|
|A4737, A9543, A9545, A9563, A9564, A9600 - A9605, A9699, C8957 - C9235, G0008 - G0010, G0260, G0332, G3001, J0120 - J0270, J0278 - J2543, J2550 - J3520, J3570 - J3590, J7187 - J7199, J7319, J9000 - J9999, Q0081 - Q0085, Q0515, Q2009 - Q2017, Q3027, Q4079, Q4081 - Q4086, S0017 -S0081, S0091 - S0093, S0122 - S0132, S0145 - S0156, S0162 - S0167, S0171, S0195, S5550 - S5553||Injectable medications and administration [intramuscular, intrathecal, intravenous, subcutaneous]|
|ICD-10 codes covered if selection criteria are met:|
|F40.231||Fear of injections and transfusions|
|F40.298||Other specified phobia [needle phobia]|