NGS AS, GU, HI, NV,NMI Self-Administered Drugs and Biologicals Excluded from Coverage

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (A47529)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00454

Contractor Type

Article Information

Article ID Number

A47529

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

American Samoa
Guam
Hawaii
Nevada
Northern Mariana Islands

Secondary Geographic Jurisdiction

American Samoa
Guam
Hawaii
Nevada
Northern Mariana Islands

Original Article Effective Date

07/01/2008

Article Revision Effective Date

07/01/2008

Article Text

The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see "Process for Determining Self-Administered Drug Exclusions – Medical Policy Article"). The column, "Brand Names," provides one or more examples but not all. Information about drugs not separately reimbursed or not covered for reasons other than "usually self-administered," is found in other carrier and fiscal intermediary publications and sites.

In the interest of consistent Medicare coverage, the National Government Services fiscal intermediary will follow the coverage decision for self-administered drugs as determined by the carrier in each respective state. HCPCS codes for the same drugs that apply only to providers that bill the fiscal intermediary (e.g., HCPCS codes used for drugs billable under the Outpatient Prospective Payment System [OPPS]) are included when applicable.

Coverage Topic

Outpatient Hospital Services
Prescription Drugs

Coding Information

No Coding Information has been entered in this section of the article.

Coding Table Information

CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Comments
J0135	INJECTION, ADALIMUMAB, 20 MG	Injection, Adalimumab, 20 mg, Humira, Injection, alprostadil	11/01/2003	N/A
J0270	INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Alprostadil, Caverjet, Edex®, Prostin VR®, 1.25 mcg	01/15/2003	N/A
J0275	ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Alprostadil urethral suppository (Muse®), variable	01/15/2003	N/A
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Injection Calcitonin-salmon up to 400 unites, Calcimar®, Miacalcin®, up to 400 units	01/15/2003	N/A
J1438	INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Injection etanercept (Enbrel®), 25 mg	01/15/2003	N/A
J1562	INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG	Injection, immune globulin, subcutaneous, 100mg (Vivaglobulin®)	04/15/2007	N/A
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Injection, glatiramer acetate (Copaxone®), 20 mg	05/01/2004	N/A
J1650	INJECTION, ENOXAPARIN SODIUM, 10 MG	Injection, enoxaparin sodium, 10 mg (Lovenox®)	11/01/2006	N/A
J1652	INJECTION, FONDAPARINUX SODIUM, 0.5 MG	Injection, Fondaparinux sodium, 0.5 mg (Arixtra®)	04/15/2006	N/A
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Injection, histrelin acetate, 10 micrograms	08/15/2006	N/A
J1815	INJECTION, INSULIN, PER 5 UNITS	Injection, insulin, per 5 units (Humalog® Humulin®, Iletin®, Insulin Lispro®, Novo Nordisk®, NPH®, Pork insulin, Regular insulin, Ultralente®, Velosulin®, Humulin R®, Iletin II Regular Pork®, Insulin Purified Pork, Relion®, Lente Iletin I®, Novolin R®, Humulin R U-500®)	11/01/2003	N/A
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Insulin for administration through DME (i.e. insulin pump) per 50 units (Humalog®, Humulin®, Vesolin BR®, Iletin II NPH Pork, Lantus®, Lispro-PFC®, Novolin®, Novolog®, Novolog Flexpen®, Novolog Mix, Relion ®,Novolin®)	01/15/2003	N/A
J1830	INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Interferon beta-1b (Betaseron®), 0.25 mg	01/15/2003	N/A
J2170	INJECTION, MECASERMIN, 1 MG	Injection, mecasermin (Increlex®, Iplex®), 1 mg	04/15/2007	N/A
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg (Sandostatin®)	10/15/2005	N/A
J2440	INJECTION, PAPAVERINE HCL, UP TO 60 MG	Injection, papaverine HCI, up to 60 mg	11/01/2003	N/A
J2940	INJECTION, SOMATREM, 1 MG	Injection, somatrem (Protropin®), 1 mg	01/15/2003	N/A
J2941	INJECTION, SOMATROPIN, 1 MG	Injection somatropin 1 mg (Humatrope®, Genotropin®, Nutropin®), Biotropin®, Genotropin®, Genotropin Miniquick®, Norditropin®, Nutropin AQ®, Saizen®, Saizen Somatropin®, RDNA Origin®, Serostim®, B, C Serostim RDNA Origin®, Zorbtive®)	01/15/2003	N/A
J3030	INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Injection, sumatriptan succinate (Imitrex®), 6 mg	01/15/2003	N/A
J3110	INJECTION, TERIPARATIDE, 10 MCG	Injection, teriparatide (Forteo®), 10 mcg	11/01/2003	N/A
J3140	INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG	Injection, testosterone suspension, up to 50 mg	10/15/2005	N/A
J3150	INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG	Injection, testosterone propionate, up to 100 mg	10/15/2005	N/A
J3355	INJECTION, UROFOLLITROPIN, 75 IU	Injection, Urofollitropin (Bravelle®, Fertinex®, Follistim®, Gonal-F®), 75 IU	04/15/2007	N/A
J3490	UNCLASSIFIED DRUGS	Exanatide (Byetta®), variable	04/15/2006	N/A
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Enfuvirtide (Fuzeon®), 1 mg	05/01/2004	N/A
J3490	UNCLASSIFIED DRUGS	Pramlintide acetate (Symlin®)	04/15/2006	N/A
J3590	UNCLASSIFIED BIOLOGICS	Anakinra (Kineret®), variable	10/15/2005	N/A
J3590	UNCLASSIFIED BIOLOGICS	Efalizumab (Raptiva®), variable	05/01/2004	N/A
J3590	UNCLASSIFIED BIOLOGICS	Peginterferon, alfa-2a (Pegasys®), variable	05/01/2005	N/A
J3590	UNCLASSIFIED BIOLOGICS	Peginterferon, alfa-2b (Peg-Intron®), variable	11/01/2003	N/A
J3590	UNCLASSIFIED BIOLOGICS	Pegvisomant (Somavert®), variable	05/01/2004	N/A
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Injection, interferon alfacon-1 (Infergen®), recombinant, 1 mcg	11/01/2003	N/A
J9213	INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS	Interferon, alfa-2A (Roferon-A®), recombinant, 3 million units	11/01/2003	N/A
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Interferon gamma-1b (Actimmune®), 3 million units	01/15/2003	N/A
J9218	LEUPROLIDE ACETATE, PER 1 MG	Leuprolide acetate, (Lupron®, Eligard®), 1 mg	01/15/2003	N/A
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Injection, sermorelin acetate (Geref®), 1 microgram	04/15/2007	N/A

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published June 2008: This article replaces - A2372 - Self-Administered Drug Exclusion - Medical Policy Article.

Related Documents
Article(s) A47521 - Process for Determining Self-Administered Drug Exclusions – Medical Policy Article