Medical policy: Self Administered Medications

Policy number: MP 2.176

Effective date: 11/1/2026

Policy

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.

Cross-references

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

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

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.

Description/Background

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.

Rationale

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.

Definitions

N/A

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These polices are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

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

References

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.