CommercialCoverageMedium impact
08.00.78aw, Self-Administered Drugs and Biologics
Independence Blue Cross·NJ · Pharmacy, Rheumatology, Nephrology +4 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.00.78aw to 08.00.78ay, effective 01/01/2026, adding nine FDA-approved self-administered drugs/biologics to Attachment A (including Forzinity, Lasix Onyu, Redemplo, Sandostatin, multiple Ustekinumab brands, and Vyvgart Hytrulo) and four pending FDA-approval drugs. Self-administered drugs remain non-covered under the medical benefit but may be available through pharmacy benefits; billing teams must verify individual member coverage and direct patients to specialty pharmacy.
Action Required
By 12/31/2025: Billing team must update system reference materials to include new self-administered drug list from policy 08.00.78ay Attachment A. When claims are submitted for Forzinity (J3490), Lasix Onyu (J1938 or J3490), Redemplo (J3490), Sandostatin (J2354), Ustekinumab brands (Q5100, J3357, Q9999, Q9998, Q5137, J3590, Q5098, Q5099, Q9996), or Vyvgart Hytrulo (J3590) on or after 01/01/2026: (1) Do NOT bill under medical benefit; (2) Verify member's pharmacy benefit coverage before processing; (3) Direct patients/providers to specialty pharmacy for distribution; (4) Do NOT use S9370 or other injection therapy S-codes for billing administration of these drugs under medical benefit. For New Jersey members only, verify whether self-administered coagulation factors covered under medical vs. pharmacy benefit. Failure to route claims correctly will result in denials.