Self-administered drugs should be billed through the member pharmacy benefit.
In some instances, key clinical programs and monitoring of these drugs are bypassed when the medication is incorrectly billed under the medical benefit.
How to submit the claim
When a self-administered drug is billed under the medical benefit, and member plan language does not support coverage under the medical benefit, the self-administered drug code and related administration charge will be denied with the notation that the claim should be submitted through the pharmacy benefit for consideration.
You may submit a pre-determination request if the member needs assisted administration of the drug and the provider would like to process the claim through the medical benefit.
Exception – when member requires assisted administration
Claims with approved authorizations on file indicating that the member requires assisted administration will be eligible for consideration under the medical benefit.