|
Code
|
Descriptor Generic Name
|
Descriptor Brand Name
|
Exclusion Effective Date
|
Exclusion End Date
|
Comments
|
|
J0135
|
INJECTION,
ADALIMUMAB, 20 MG
|
Humira
|
12/06/2003
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, weekly or every other week.
|
|
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)
|
Caverject, Edex
|
11/14/2002
|
N/A
|
Usually
self-injected by patient on an "as-needed basis".
|
|
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)
|
Muse
|
11/14/2002
|
N/A
|
Suppository
|
|
J0630
|
INJECTION,
CALCITONIN SALMON, UP TO 400 UNITS
|
Calcimar, Miacalcin
|
11/14/2002
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, daily or every other day.
|
|
J1324
|
INJECTION,
ENFUVIRTIDE, 1 MG
|
Fuzeon
|
02/15/2007
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, twice daily.
|
|
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)
|
Enbrel
|
11/14/2002
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, usually twice a week.
|
|
J1595
|
INJECTION,
GLATIRAMER ACETATE, 20 MG
|
Copaxone
|
02/07/2004
|
N/A
|
Self-administration;
subcutaneous 20 mg/day
|
|
J1675
|
INJECTION, HISTRELIN
ACETATE, 10 MICROGRAMS
|
Supprelin
|
05/16/2007
|
N/A
|
Non-acute
subcutaneous administration, usually once daily by patient
|
|
J1815
|
INJECTION, INSULIN,
PER 5 UNITS
|
Humalog, Humulin, Iletin, Insulin Lispo, Novo
Nordisk, NPH, Pork Insulin, Regular Insulin, Ultralente,
Velosulin, Humulin R,
Iletin II Regular Port, Insulin Purified Pork, Relion, Lente Iletin I, Novolin R, Humulin R U-500
|
11/14/2002
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, every day.
|
|
J1817
|
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
|
11/14/2002
|
N/A
|
Non-acute chronic
filling of pump by patient.
|
|
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)
|
Betaseron
|
11/14/2002
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, usually every other day.
|
|
J2170
|
INJECTION,
MECASERMIN, 1 MG
|
Increlex, Iplex
|
02/15/2007
|
N/A
|
Non-acute
subcutaneous injection twice daily by patient.
|
|
J2354
|
INJECTION,
OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25
MCG
|
Sandostatin
|
11/14/2002
|
N/A
|
Usually
self-administered injections two to four times daily, depending on the
indication.
|
|
J2940
|
INJECTION, SOMATREM,
1 MG
|
Protropin
|
11/14/2002
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, several time a week.
|
|
J2941
|
INJECTION,
SOMATROPIN, 1 MG
|
Genotropin
|
11/14/2002
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, several time a week.
|
|
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)
|
Imitrex
|
11/14/2002
|
N/A
|
Subcutaneous (SC)
injection by patient at onset of symptoms (up to two times in a 24-hour
period).
|
|
J3110
|
INJECTION,
TERIPARATIDE, 10 MCG
|
Forteo
|
12/06/2003
|
N/A
|
Non-acute,
subcutaneous (SC) injection into thigh or abdomen (lower stomach area)
once a day by patient using multidose prefilled delivery device (FORTEO pen - contains 28
daily doses).
|
|
J3490
|
UNCLASSIFIED DRUGS
|
Byetta (exenatide)
|
09/01/2006
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, within the 60-minute period
before morning and evening meals.
|
|
J3490
|
UNCLASSIFIED DRUGS
|
Symlin (Pramlintide
acetate)
|
05/16/2007
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, immediately prior to major meals.
|
|
J3590
|
UNCLASSIFIED
BIOLOGICS
|
Kineret
|
05/16/2007
|
N/A
|
Non-acute
subcutaneous (SC) injection by patient, every day.
|
|
J3590
|
UNCLASSIFIED
BIOLOGICS
|
Peg-Intron
|
12/06/2003
|
N/A
|
Subcutaneous weekly
administration for one year by patient.
|
|
J3590
|
UNCLASSIFIED
BIOLOGICS
|
Pegasys
|
12/06/2003
|
N/A
|
Subcutaneous weekly
administration for 48 weeks by patient.
|
|
J3590
|
UNCLASSIFIED
BIOLOGICS
|
Raptiva
|
02/07/2004
|
N/A
|
Non-acute
subcutaneous weekly injection by patient.
|
|
J3590
|
UNCLASSIFIED
BIOLOGICS
|
Somavert
|
05/16/2007
|
N/A
|
Non-acute
subcutaneous injection daily, by patient.
|
|
J9212
|
INJECTION,
INTERFERON ALFACON-1, RECOMBINANT, 1 MCG
|
Infergen
|
12/06/2003
|
N/A
|
Subcutaneous
administration three times per week for 24-48 weeks, by patient.
|
|
J9213
|
INTERFERON, ALFA-2A,
RECOMBINANT, 3 MILLION UNITS
|
Roferon A
|
12/06/2003
|
N/A
|
Hepatitis C:
Subcutaneous administration three times per week for 12 months by
patient.
Hairy cell leukemia: Subcutaneous administration daily for 16 - 24 weeks
and three times per week by patient.
CML: Subcutaneous daily.
|
|
J9216
|
INTERFERON, GAMMA
1-B, 3 MILLION UNITS
|
Actimmune
|
12/06/2003
|
N/A
|
Non-acute
subcutaneous administration usually three times per week by patient.
|
|
J9218
|
LEUPROLIDE ACETATE,
PER 1 MG
|
Lupron
|
11/14/2002
|
N/A
|
Non-acute, usually
daily subcutaneous (SC) injection by patient.
|
|
Q0515
|
INJECTION,
SERMORELIN ACETATE, 1 MICROGRAM
|
Geref
|
03/06/2006
|
N/A
|
Non-acute
subcutaneous daily administration by patient.
|