Medical policy: Self Administered Medications

Número de política: MP 2.176

Fecha de entrada en vigor: 11/1/2026

Política

Note: This policy only applies to Commercial Products

For the purposes of this policy, "Self-administered" medications are medications which have been identified as being medically appropriate for administration by a patient or caregiver, safely and effectively, without medical supervision. In identifying medications considered to be appropriate for self-administration the medication must be:

• Prescribed by an eligible healthcare provider and,
• Identified in published literature as safe and effective for self-administration with or without proper instruction or initial observation (e.g. Medicare guidelines, FDA recommendations)

The route of administration is irrelevant to the appropriateness of self-administration. Self-administered medications may be administered orally (by mouth), subcutaneously (under the skin), topically, by inhalation, or occasionally by intramuscular injection.

The inability of a caregiver or member to self-administer a medication does not constitute an exception from the designation of a medication as self-administered.

In general, those medications determined to be “self-administered medications” are not eligible for reimbursement consideration under the member’s medical benefit. Self-administered drugs are only eligible for reimbursement consideration under the member’s pharmacy benefit, whether provided through Capital Blue Cross or another Insurer.

In the event it is necessary for an eligible provider to administer a “self-administered medication”, for any reason, only the administration service will be eligible for reimbursement consideration under the medical benefit.

Attachment A represent medications Capital Blue Cross considers to be “self-administered”, as defined herein, and therefore are not eligible for reimbursement consideration under the Medical Benefit unless otherwise mandated by law (e.g. insulin and/or medications required for the treatment of diabetes or for emergent treatment). These listings are subject to change as new medications come to market or additional medications are identified as safe, effective, and appropriate for self-administration.

Referencias cruzadas

• MP 2.103 Off-Label Use of Medications and Other Interventions
• MP 2.001 Allergy Testing and Immunotherapy

Variaciones del producto

Esta política solo se aplica a ciertos programas y productos administrados por Capital Blue Cross y está sujeta a variaciones en los beneficios. Consulte la información adicional a continuación.

FEP PPO - Refer to Section VI of the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Indemnity: Groups that have an embedded prescription medication in the major medical component of their Traditional plan are excluded from this medical policy.

Descripción/Antecedentes

Medications that are administered orally, via inhalation, subcutaneously (SQ), or sometimes intramuscularly (IM), are drugs that can be safely given by a patient or caregiver without medical supervision. These drugs are considered "self-administered". Professional providers should educate patients and caregivers on techniques to safely administer injectable medications and medications administered by oral inhalation via nebulization.

Fundamento

The intent of this policy is to document and define the benefit under which self-administered prescription medications are eligible for reimbursement consideration. For those medications that are self-administered, Capital Blue Cross members are required to use their pharmacy benefit if one exists and acquire the medication through a pharmacy provider or preferred vendor.

Definiciones

N/D

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas pólizas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios de los miembros, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: esta lista de códigos puede no ser exhaustiva y los códigos están sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

Specific coding for this medical policy is found in the attachments to the policy listed below.

Referencias

1. NCCN Drug and Biologics Compendium. Fort Washington, PA: National Comprehensive Cancer Network (NCCN); Updated periodically.
2. Physicians' Desk Reference (PDR). Montvale, NJ: Thomson PDR; Updated periodically.

Attachment A: Self-administered medications excluded from coverage under the Medical Benefit for Commercial

Note: All oral medications are excluded from the medical benefit and are not listed specifically in this table.