Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

New policies for Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics

March 28, 2017

Independence has created policies to communicate the medical necessity criteria for therapeutic drug monitoring (TDM) of antidepressants, antipsychotics, and antiepileptic medications. The following policies were posted as Notifications on March 8, 2017, and go into effect April 7, 2017:

  • Commercial: #06.02.55: Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics
  • Medicare Advantage: # MA06.029: Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics

Medically necessary criteria

TDM for antidepressants, antipsychotics, and antiepileptic medications is considered medically necessary, and, therefore, covered for any of the following reasons when a plan is in place to use the test findings clinically:

  • dose optimization after initial prescription or dose change;
  • suspected complete or partial non-adherence or non-compliance to prescribed medication;
  • lack of clinical improvement under recommended dose;
  • clinical improvement under recommended dose but with adverse effects;
  • initiation of combination therapy with a drug known for its interaction potential or suspected drug interaction;
  • relapse prevention under maintenance treatment.

Coverage limits

When the above criteria are met, TDM is considered medically necessary, and, therefore, covered for the following number of units:

  • Antidepressants: A combined maximum of up to 15 units of tests per calendar year.
    • – CPT® codes: 80332, 80333, 80334, 80335, 80336, 80337, 80338
  • Antiepileptics: A combined maximum of up to 15 units of tests per calendar year.
    • – CPT codes: 80339, 80340, 80341, 80355, 80366, 80156, 80157, 80164, 80165, 80168, 80171, 80175, 80177, 80183,
      80184, 80185 , 80186, 80188, 80199, 80201, 80203
  • Antipsychotics: A combined maximum of up to 15 units of tests per calendar year.
    • – CPT codes: 80342, 80343, 80344, 80159, 80173, 80178

Specimen validity/adulteration testing is not eligible for separate reimbursement, as this is considered part of the laboratory quality control practice.

More information

To view the Notifications for these policies, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications.

If you have any questions, please contact your Network Coordinator.

CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.