NGS WI Self-Administered Drugs and Biologicals Excluded from Coverage

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (A47525)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00450

Contractor Type

Article Information

Article ID Number

A47525

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

Wisconsin

Secondary Geographic Jurisdiction

Wisconsin

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
J1562	INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG	Immune Globulin Subcutaneous (Vivaglobin)	01/01/2007	N/A
J2170	INJECTION, MECASERMIN, 1 MG	Mecasermin rinfabate	01/01/2007	N/A
J3590	UNCLASSIFIED BIOLOGICS	Efalizumab	04/01/2006	N/A
J3590	UNCLASSIFIED BIOLOGICS	Anakinra	04/01/2006	N/A
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Enfuvirtide	04/01/2006	N/A
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Glatiramer	04/01/2006	N/A
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Histrelin acetate 10mg	02/01/2006	N/A
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Sermorelin acetate, 1 microgram	01/01/2006	N/A
J3590	UNCLASSIFIED BIOLOGICS	Peginterferon alfa-2a	07/01/2005	N/A
J3490	UNCLASSIFIED DRUGS	Pramlintide acetate	07/01/2005	N/A
J3590	UNCLASSIFIED BIOLOGICS	Exenatide	07/01/2005	N/A
J3110	INJECTION, TERIPARATIDE, 10 MCG	Teriparatide	11/01/2003	N/A
J3590	UNCLASSIFIED BIOLOGICS	Peginterferon Alfa-2B	11/01/2003	N/A
J0135	INJECTION, ADALIMUMAB, 20 MG	Adalimumab	07/03/2003	N/A
J3490	UNCLASSIFIED DRUGS	Nitroglycerin lingual spray	04/01/2003	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)	Etanercept	03/01/2003	N/A
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Interferon alfacon-1, recombinant	03/01/2003	N/A
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Interferon, gamma 1-B	03/01/2003	N/A
Q3026	INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE	Interferon beta-1a	03/01/2003	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	12/01/2002	N/A
J2760	INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG	Phentolamine mesylate injection, up to 5mg	12/01/2002	N/A
J2440	INJECTION, PAPAVERINE HCL, UP TO 60 MG	Papaverine HCL injection (up to 60 mg)	12/01/2002	N/A
J1815	INJECTION, INSULIN, PER 5 UNITS	Insulin	10/15/2002	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	10/15/2002	N/A
J2940	INJECTION, SOMATREM, 1 MG	Somatrem	10/15/2002	N/A
J2941	INJECTION, SOMATROPIN, 1 MG	Somatropin	10/15/2002	N/A
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Calcitonin-salmon	10/15/2002	N/A
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Octreotide acetate	10/15/2002	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	10/15/2002	N/A
J9218	LEUPROLIDE ACETATE, PER 1 MG	Leuprolide acetate, 1mg	10/15/2002	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	10/15/2002	N/A

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published July 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