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Coverage criteria policies

Minimum/maximum drug dosage

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

This policy provides information about the minimum and maximum dosage and billing units allowed per administration for certain professionally-administered medications.

Claims may not be paid for quantities outside these limits.

Coverage

This policy provides information about the minimum and maximum billing units allowed per administration for select medications administered by healthcare professionals. Quantities were determined using FDA-approved labeling, compendium sources or other peer-reviewed, published clinical evidence.

Per administration doses outside these limits are considered not medically necessary.

Drugs Impacted by this Policy

Medications are approved and used based on clinical trials using pre-specified dosage regimens. These regimens allow for a minimum and maximum dosage range to be established according to labeled indications or as supported by other clinical evidence.

Weight-based regimens are calculated based on the highest 90th percentile of weight across adult age bands observed for US males, 120kg.

Maximum doses of single use products requiring less than a full vial are rounded up to the nearest full vial to account for payment of waste. Minimum doses allow billing of waste separately from the dose administered.

The following drugs and codes are included in this policy.

Drug Name

Procedure Code

Procedure Description

Min Dosage

Min Billing Unit

Max Dosage

Max Billing Unit

Actemra

J3262

Tocilizumab injection, 1 mg

1 mg

1

800 mg

800

Aranesp

J0881, J0882

Darbepoetin alfa, 1 mcg

1 mcg

1

500 mcg

500

Berinert

J0597

C-1 Esterase, 10 units

10 units

1

2400 units

240

Botox

J0585

Onabotulinumtoxin A, 1 unit

1 unit

1

300 units

300

Dysport

J0586

Abobotulinumtoxin A, 5 units

5 units

1

1000 units

200

Euflexxa

J7323

Hyaluronan, per dose (20mg/2mL)

20 mg

1

120 mg

6

Eylea

J0178

Aflibercept, 1 mg

2 mg

2

4 mg

4

Gel-One

J7326

Gel-One, per dose (30 mg/3mL)

30 mg

1

60 mg

2

Gel-Syn

J7328

Gel-Syn, 0.1 mg (16.8 mg/2 mL)

16.8 mg

168

100.8 mg

1008

Gen-Visc 850

Q9980

Genvisc 850, 1 mg (25 mg/2.5 mL)

25 mg

1

250 mg

250

Hyalgan

J7321

Hyaluronan, per dose (20 mg/2mL)

20 mg

1

200 mg

10

Hymovis

C9471

Hymovis, 1mg (24 mg/3 mL)

24 mg

1

96 mg

96

Immune Globulin

J1459, J1556 J1557, , J1561, J1562, J1566, J1568, J1569, J1572

Immune globulin, 500 mg

500 mg

1

120 gm

240

Immune Globulin -

J1559, J1575

Immune globulin, subcutaneous infusion, 100 mg

100 mg

1

120 gm

240

Monovisc

J7327

Monovisc, per dose (88mg/4mL)

80 mg

1

160 mg

2

Myobloc

J0587

RimabotulinumtoxinB, 100 units

100 units

1

10,000 units

100

Neulasta

J2505

Pegfilgrastim, 6 mg

6 mg

1

6 mg

1

Orencia

J0129

Abatacept, 10 mg

10 mg

1

1000 mg

100

Orthovisc

J7324

Hyaluronan, per dose (30 mg/2mL)

30 mg

1

180 mg

6

Prolastin

J0256

Alpha 1 Proteinase Inhibitior, 10mg

10 mg

1

7200 mg

720

Prolia / Xgeva

J0897

Denosumab, 1 mg

60 mg

60

120 mg

120

Remicade

J1745

Infliximab, 10 mg

10 mg

1

1200 mg

120

Soliris

J1300

Eculizumab, 10 mg

300 mg

30

1200 mg

120

Stelara

J3357

Ustekinumab, 1 mg

45 mg

45

90 mg

90

Supartz

J7321

Hyaluronan, per dose (25 mg/2.5mL)

25 mg

1

250 mg

10

Synvisc / Synvisc One

J7325

Hyaluronan, 1 mg

16 mg

16

96 mg

96

Tysabri

J2323

Natalizumab, 1 mg

300 mg

300

300 mg

300

Xeomin

J0588

IncobotulinumtoxinA, 1 unit

1 unit

1

150 units

150

Xgeva / Prolia

J0897

Denosumab, 1 mg

60 mg

60

120 mg

120

Xolair

J2357

Omalizumab, 5 mg

150 mg

30

375 mg

75

Zometa

J3489

Zolendronic acid, 1 mg

1 mg

1

4 mg

4

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. McDowell MA, Fryar CD, et al., Anthropometric reference data for children and adults: United States, 2003-2006. National Health Statistics Reports, #10. Hyattsville, MD: National Center for Health Statistics. October 22, 2008.

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Policy activity

  • 11/19/2012 - Date of origin
  • 08/08/2016 - Effective date
Review date
  • 08/2017
Revision date
  • 08/08/2016

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