NGS IL Self-Administered Drugs and Biologicals Excluded from Coverage

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (R18) (A2311)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00131

Contractor Type

Article Information

Article ID Number

A2311

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (R18)

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

Illinois

Secondary Geographic Jurisdiction

Illinois

Original Article Effective Date

10/01/2002

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, 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	Adalimumab	08/17/2003	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 injection	11/29/2002	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	01/15/2003	N/A
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Calcitonin-salmon	11/29/2002	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)	Etanercept	04/15/2003	N/A
J1815	INJECTION, INSULIN, PER 5 UNITS	Insulin	01/01/2003	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	11/29/2002	N/A
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Octreotide acetate	11/29/2002	N/A
J2440	INJECTION, PAPAVERINE HCL, UP TO 60 MG	Papaverine HCL injection (up to 60 mg)	01/15/2003	N/A
J2760	INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG	Phentolamine mesylate injection, 500 mg	01/15/2003	N/A
J2940	INJECTION, SOMATREM, 1 MG	Somatrem	11/29/2002	N/A
J2941	INJECTION, SOMATROPIN, 1 MG	Somatropin	11/29/2002	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)	Sumatriptan succinate	11/29/2002	N/A
J3110	INJECTION, TERIPARATIDE, 10 MCG	Teriparatide	12/15/2003	N/A
J3490	UNCLASSIFIED DRUGS	Pramlintide acetate injection (Symlin™)	08/15/2005	N/A
J3490	UNCLASSIFIED DRUGS	Nitroglycerin lingual spray	05/16/2003	N/A
J3590	UNCLASSIFIED BIOLOGICS	Peginterferon alfa-2a (Pegasys™)	08/15/2005	N/A
J3590	UNCLASSIFIED BIOLOGICS	Exenatide injection (Byetta™)	08/15/2005	N/A
J3590	UNCLASSIFIED BIOLOGICS	Peginterferon Alfa-2b	12/15/2003	N/A
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Interferon alfacon-1, recombinant	04/15/2003	N/A
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Interferon, gamma 1-B	04/15/2003	N/A
J9218	LEUPROLIDE ACETATE, PER 1 MG	Leuprolide acetate, 1mg	11/29/2002	N/A
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Sermorelin acetate, 1 microgram	02/15/2006	N/A
Q3026	INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE	Interferon beta-1a	04/15/2003	N/A
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Glatiramer	05/16/2006	N/A
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Enfuvirtide, Fuzeon	05/16/2006	N/A
J3590	UNCLASSIFIED BIOLOGICS	Anakinra	05/16/2006	N/A
J3590	UNCLASSIFIED BIOLOGICS	Efalizumab	05/16/2006	N/A
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Histrelin acetate, 10 mg	06/16/2006	N/A
J1562	INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG	Immune Globulin Subcutaeneous (Vivaglobin)	02/15/2007	N/A
J2170	INJECTION, MECASERMIN, 1 MG	Mecasermin rinfabate	02/15/2007	N/A

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published July 2008 (R18): The article text paragraph has been revised to remove information that can be found in: "Process for Determining Self-Administered Drug Exclusions – Medical Policy Article." As part of the on going consolidation process throughout National Government Services the previous title "Medicare Payment for Drugs and Biologicals Furnished Incident to a Physician's Service" has also been revised. Article published January 2008 (R17): Article revised for Annual CPT/HCPCS update. The CPT copyright language was updated. The CPT/HCPCS code table was updated as follows: The description to J1562 under the "Generic Description" has been revised from INJECTION, IMMUNE GLOBULIN, SUBCUTANEOUS to INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN) with no change in effective date. Article published February 2007 (R16): Article revised to replace HCPCS code for Enfuvirtide Fuzeon from J3490 to J1324, due to the annual 2007 HCPCS update, with no change in effective date. As part of our new corporate identity implementation, the contractor name has also been changed to National Government Services (formerly AdminaStar Federal) beginning with this version of the Article. Article published January 2007 (R15): Article revised to include Immune Globulin Subcutaneous (Vivaglobin) (J1562) and Mecasermin rinfabate (J2170) on the self-administered drug list exclusion effective February 15, 2007 to match the carrier. Article published May 2006 (R14): Article revised to include Histrelin acetate (J1675) on self-administered drug list exclusion effective June 16, 2006 to match the carrier. Article published April 2006 (R13): Article revised to include Glatiramer (J1595), Enfuviritide (J3490), Anakinra (J3590) and Efalizumab (J3590) on self-administered drug list exclusion effective May 16, 2006 to match the carrier. Article published January 2006 (R12): Article revised to include Sermorelin acetate (Q0515) on self-administered drug list exclusion effective February 15, 2006 to match the carrier. Leuprolide acetate injection, brand-name drug, 1 mg (C9430) is also deleted from the list due to the 2006 HCPCS changes. Article published July 2005 (R11): Article revised to change code J3490 (unclassified drugs) for Pegasys peginterferon alfa – 2a to J3590 (unclassified biologics). Also nitroglycerin paste (J3490) added in error on revision R9, was removed. No change in the 7/1/2005 effective date of the article. Article published July 2005 (R10): Article revised to include Pegasys (peginterferon alfa – 2a); Byetta (exenatide injection); and Symlin (pramlintide acetate) on self-administered drug list exclusion effective August 15, 2005 to match the carrier. Article published March 2005 (R9): Correction: HCPCS code J3490 for nitroglycerin paste is deleted to match the Illinois carrier coverage. Article published February 2005 (R8): The list of excluded drugs is updated: The code for teriparatide is changed from J3490 to J3110; the code for adalimumab is changed from J3490 to J0135. Both changes are effective 01/01/2005. In addition, code J3490 is added to represent nitroglycerin paste. This drug is excluded from coverage effective 02/15/2005. Article published January 2005 (R7): Self-administered drug (SAD) article (A2310) with links to carrier and Medicare Articles Database Web sites is revised replacing information about linking to the carrier exclusion list with the Indiana carrier list of excluded codes. This list is augmented with OPPS HCPCS code C9430. Article published December 2004 (R6): Annual review. CMS references throughout the text have been updated to reflect the CMS Online Manual System. Carrier Web addresses are updated. Article published December 2003 (R5): Updated Palmetto GBA (Ohio carrier) Web address. Article published November 2003 (R4): Added Medicare Articles Database link and carrier contractor numbers. Added WPS navigating instructions. Article published May 2003 (R3): Updated carrier Web addresses. Article published February 2003 (R2): Updated carrier Web addresses. Article published October 2002 (R1): Added carrier Web instructions Article published October 2002: Original article published on ASF Web site.

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