ModifiedBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monoclonal antibody and antiviral treatments for COVID-19

Governs coverage, coding, and reimbursement for FDA-approved or authorized monoclonal antibodies and certain antiviral medications for COVID-19 for BCBSRI commercial and Medicare Advantage members; includes timing and cost-share guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonoclonal antibody and antiviral treatments for COVID-19

Policy CodePolicy N/A

Change TypeCoverage and code-status revisionscost-share policy clarified

Effective Date01-01-2022

Next Review DateN/A

Key ActionObtain prior authorization when required and bill using the exact HCPCS/Q/J code for the product and dose; follow CMS submission guidance where specified.

SourceLink

POLICY UPDATE CHANGES

Cost share waiver for monoclonal antibody services ended for commercial products as of dates of service on or after 12/2023 and for Medicare Advantage as of 07/01/2023 — cost share follows applicable Subscriber Agreement/Evidence of Coverage.

Coverage and reimbursement status for specific monoclonal antibody HCPCS/CPT codes updated with effective and deletion dates (multiple M0/Q0-series codes) indicating periods when covered vs not covered.

01-01-2022Effective

05-09-2025Last reviewed

Multiple M0/Q0Code list

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

Monoclonal antibody coverage criteria

Covered when ALL of the following are met

Initial eligibility: Member has positive COVID-19 test result

Age: Over 12 years of age>12 years

Risk: At high risk for progressing to severe COVID-19 and/or hospitalization

CDC risk-factor guidance applies

Setting: Not hospitalized

Timing: Administration given within 10 to 12 days of symptom onset<=10-12 days

Code- and date-specific reimbursement

Coverage and reimbursement are code-, dose-, and date-specific. Entries indicate Covered and Separately Reimbursed, No reimbursement when product provided at no cost, or Not Covered for DOS on/after specified dates.

Code-specific coverage entries: Each listed HCPCS/Q/J-code entry includes its effective/revision dates and one of: 'Covered and Separately Reimbursed', 'No reimbursement for claims submitted to BCBSRI for products health care providers receive at no cost', or 'Not Covered for DOS on or after [date]'.

Do not bill BCBSRI when CMS guidelines direct submission to Original Medicare; observe DOS cutoff dates provided.

E/M reimbursement during PHE (commercial)

Commercial Products only

E/M code policy: 99211 Evaluation & Management Service reimbursed for commercial products effective 8/31/2022 until PHE ends.

Applies to commercial products only.

The policy lists multiple monoclonal antibody HCPCS/CPT entries that are explicitly Not Covered for dates of service on or after the deletion dates shown in the code table. Examples include M0239 / Q0239 (bamlanivimab) — Not Covered for DOS on or after 4/17/21, and several casirivimab/imdevimab and sotrovimab administration codes (e.g., M0240–M0244 / Q0240–Q0244, M0247/M0248 / Q0247) that transition from being Covered and Separately Reimbursed during early effective ranges to Not Covered for DOS on or after 1/25/22 or 4/6/22 as shown in the reimbursement entries.

If a monoclonal antibody product was supplied to the provider at no cost by the U.S. Government, claims for the drug line item will be denied as provider liability and will have no reimbursement. Providers should append the appropriate modifier (e.g., modifier to indicate the drug was purchased versus supplied) per the claims instructions; when the product was provided at no cost, no reimbursement is available from BCBSRI for that drug line item.

Where CMS billing guidance directs submission to Original Medicare, providers must follow those instructions and do not bill BCBSRI for the affected dates and codes. Several entries (for example, certain bamlanivimab, casirivimab/imdevimab, and related codes) explicitly state Per CMS billing guidelines, submit to Original Medicare — Do Not Bill to BCBSRI for the effective ranges identified and then indicate later deletion dates when the codes become Not Covered for DOS on or after the cutoff.

Bamlanivimab administered alone was authorized under EUA early in the pandemic but the EUA was revoked; the policy lists bamlanivimab entries (e.g., M0239 / Q0239) as Not Covered for dates of service on or after 4/17/21, reflecting the revocation and corresponding coverage change.

Multiple monoclonal antibody and related antiviral product codes are recorded with explicit 'Not Covered for DOS on or after [date]' statements in the claims table. Examples include sotrovimab entries (M0247 / Q0247 — Not Covered for DOS on or after 4/6/22), many casirivimab/imdevimab codes (M0240–M0244 / Q0240–Q0244 — Not Covered for DOS on or after 1/25/22), and tocilizumab/remdesivir entries that include Not Covered for DOS on or after 4/6/22 in their reimbursement notes.

Billing Codes and Code Tables

Monoclonal antibody administration and drug codesCPT/HCPCS

M0220	administration of Tixagevimab and cilgavimab injection
M0221	administration of Tixagevimab and cilgavimab injection (alternate)
M0222	Intravenous injection, bebtelovimab, includes injection and post administration monitoring
M0223	Intravenous injection, bebtelovimab in the home or residence, includes injection and post monitoring
M0224	Intravenous injection, pemivibart (PEMGARDA), includes injection and post administration monitoring
M0239	intravenous infusion; bamlanivimab - includes infusion and post administration monitoring
M0240	intravenous infusion or subcutaneous injection, casirivimab and imdevimab, includes infusion/injection and monitoring, subsequent repeat doses
M0241	intravenous infusion or subcutaneous injection, casirivimab and imdevimab, includes infusion/injection and monitoring in the home or residence
M0243	intravenous infusion; casirivimab and imdevimab, includes infusion and monitoring
M0244	intravenous infusion or subcutaneous injection, casirivimab and imdevimab, in the home or residence

1–10 of 23

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Monoclonal antibody Q-codes (selected)HCPCS

Q0220	Tixagevimab and cilgavimab, 300 mg
Q0221	Tixagevimab co-packaged with cilgavimab, administered as 2 separate consecutive intramuscular injections
Q0222	Injection, bebtelovimab, 175 mg

Additional monoclonal antibody Q-codesHCPCS

Q0224	Injection, pemivibart (PEMGARDA) 4500 mg
Q0239	Injection, bamlanivimab-xxxx; 700 mg
Q0240	Injection, casirivimab and imdevimab, 600 mg
Q0243	Injection, casirivimab and imdevimab, 2400 mg
Q0244	Injection, casirivimab and imdevimab, 1200 mg
Q0245	Injection, bamlanivimab and etesevimab, 2100 mg
Q0247	Injection, sotrovimab, 500 mg

Tocilizumab and antiviralHCPCS | J-code

Q0249	Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO
J0248	Injection, remdesivir, 1 mg

E/M codes (Commercial Products ONLY)CPT

99211

Evaluation & Management Service

Age

Age requirementOver 12 years of age

PopulationMedicare Advantage and Commercial members

Associated requirementMember must have a positive COVID-19 test result

Timing from symptom onset

Timing windowAdministration within 10 to 12 days of symptom onset

Setting requirementMember must not be hospitalized at time of administration

Provider Billing, Documentation, and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain monoclonal antibody / Q-code and HCPCS drug services for Commercial and Medicare Advantage members. Providers must check benefit-specific rules and obtain prior authorization when indicated before administration.

Codes requiring prior authorization include (but may not be limited to): M0224 / Q0224 (pemivibart/PEMGARDA) — Prior authorization required for Commercial products; M0224 / Q0224 — Requires prior authorization for Medicare Advantage (effective 3/22/2024).
Follow plan-specific prior authorization processes; failure to obtain prior authorization may result in claim denial or member liability.

Billing Rule

Code-specific Billing Requirements and CMS Billing Guidance

Bill using the exact HCPCS/Q-code and date-of-service rules shown. When CMS billing guidance is specified for a code, submit those claims to Original Medicare (do not bill BCBSRI). Include required modifiers and attachments per CMS/BCBSRI instruction.

Background and Rationale

Monoclonal antibodies are laboratory-made proteins designed to mimic components of the immune system and target SARS‑CoV‑2. EUA authorizations for specific monoclonal antibodies changed during the pandemic (for example, bamlanivimab received an EUA in November 2020 and later had its EUA revoked in April 2021), and this policy aligns coverage to FDA EUA status, CMS billing guidance, and CDC risk-factor guidance for administration settings and eligibility.

Definitions

Monoclonal antibody

DefinitionMonoclonal antibodies are laboratory-made proteins that mimic the immune system's ability to fight harmful antigens.

Regulatory noteCoverage aligned with FDA EUA limitations and CDC risk-factor guidance.

CMS coding noteMonoclonal antibody products are considered COVID-19 vaccines per CMS system notes; follow CMS claims guidelines where specified (e.g., submit to Original Medicare when directed).

J0248

CodeJ0248 — Injection, remdesivir, 1 mg

Coverage statusEffective 12/23/21 Covered and Separately Reimbursed when purchased by a healthcare provider