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Injectable Medications

Number: 0020

Policy

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:

  1. Anabolic steroids when used for performance enhancement (also see CPB 0528 - Androgens and Anabolic Steroids)
  2. Contraceptive injectable medications.** (also see CPB 0510 - Progestins)
  3. Immunizations for travel (also see CPB 0473 - Vaccines for Travel)
  4. Infertility injectable medications* (also see CPB 0327 - Infertility)

* 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.

CPT Codes / HCPCS Codes / ICD-9 Codes
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 - 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]


The above policy is based on the following references:
    1. AHFS Drug Information. Bethesda, MD: American Society of Health-System Pharmacists; Updated periodically.
    2. Physicians' Desk Reference (PDR). Montvale, NJ: Thomson PDR; Updated periodically.
    3. NCCN Drug and Biologics Compendium. Fort Washington, PA: National Comprehensive Cancer Network (NCCN); Updated periodically.
    4. DRUGDEX System [Internet database]. Greenwood Village, CO: Thomson Micromedex. Updated periodically.
    5. Clinical Pharmacology. Tampa,, FL: Gold Standard/Elsevier; Updated periodically.


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