Self-Administered Drugs and Biologicals Excluded from Coverage (formerly Self-Administered Drug Exclusion Directive-Medical Policy Article) - R2 (A46073)

Contractor Information

Contractor Name 

National Government Services, Inc.  

Contractor Number 

Number	Type	State(s)
00180	FI	ME
00181	FI	MA
00270	FI	NH, VT

Contractor Type 

FI 

Article Information

Article ID Number 

A46073 

Article Type 

SAD Exclusion Article

Key Article 

Yes

Article Title 

Self-Administered Drugs and Biologicals Excluded from Coverage (formerly Self-Administered Drug Exclusion Directive-Medical Policy Article) - R2 

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 

Number	Type	State(s)
00180	FI	ME
00181	FI	MA
00270	FI	NH, VT

Original Article Effective Date 

05/23/2006

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	Humira	09/06/2003	N/A	Subcutaneous injection once every other week for more than two weeks. Can be administered every week. Prior to 01/01/2005 - J3490
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	03/15/2003	N/A	Apparent on its face.
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Miacalcin	03/15/2003	N/A	Subcutaneous injection daily for more than two weeks.
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	03/15/2003	N/A	Subcutaneous injection twice per week for more than two weeks.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Copaxone	11/10/2003	N/A	Subcutaneous injection daily.
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Supprelin	12/28/2007	N/A	Subcutaneous injection daily
J1815	INJECTION, INSULIN, PER 5 UNITS	Humalog, Regular, NPH, Lente, Ultralente	03/15/2003	N/A	Subcutaneous injection daily for more than two weeks.
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Humalog	11/12/2004	N/A	J1817 replaced code K0548
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	03/15/2003	N/A	Subcutaneous injection every other day for more than two weeks.
J2440	INJECTION, PAPAVERINE HCL, UP TO 60 MG	Papaverine	03/15/2003	N/A	Apparent on its face.
J2940	INJECTION, SOMATREM, 1 MG	Somatrem	03/15/2003	N/A	Subcutaneous injection several times per week for more than two weeks.
J2941	INJECTION, SOMATROPIN, 1 MG	Somatropin, Nutropin	03/15/2003	N/A	Subcutaneous injection several times per week for more than two weeks.
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	03/15/2003	N/A	Apparent on its face.
J3110	INJECTION, TERIPARATIDE, 10 MCG	Forteo	03/15/2003	N/A	Subcutaneous injection daily for more than two weeks.
J3355	INJECTION, UROFOLLITROPIN, 75 IU	Bravelle, Fertinex, Follistim, Gonal-F, Metrodin	12/28/2007	N/A	Subcutaneous injection or Intramuscular injection once a day for seven or more days.
J3490	UNCLASSIFIED DRUGS	Peginterferon	03/15/2003	N/A	Subcutaneous injection once per week for more than two weeks.
J0135	INJECTION, ADALIMUMAB, 20 MG	Humira	01/01/2005	N/A	Subcutaneous injection once every other week for more than two weeks. Can be administered every week.
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Infergen	03/15/2003	N/A	Subcutaneous injection thrice weekly for more than two weeks.
J9213	INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS	Roferon-A	11/12/2004	N/A	Subcutaneous injection thrice weekly for more than two weeks.
J9215	INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU	Alferon-N	03/15/2003	N/A	Subcutaneous injection twice a week for more than two weeks.
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Actimmune	03/15/2003	N/A	Subcutaneous injection thrice a week for more than two weeks.
J9218	LEUPROLIDE ACETATE, PER 1 MG	Lupron	03/15/2003	N/A	Non-acute, usually daily subcutaneous (SC) injection administration by patient.
J3490	UNCLASSIFIED DRUGS	Byetta	12/28/2007	N/A	Subcutaneous injection.
J3490	UNCLASSIFIED DRUGS	Fuzeon	12/28/2007	N/A	Twice-daily subcutaneous injection.
J3490	UNCLASSIFIED DRUGS	Pegasys	12/28/2007	N/A	Subcutaneous injection prolonged use.
J3490	UNCLASSIFIED DRUGS	Symlin	12/28/2007	N/A	Subcutaneous injection
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Sandostation	12/28/2007	N/A	Subcutaneous injection.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Geref	12/28/2007	N/A	Subcutaneous injection once daily for greater than three weeks.

Other Information

Other Comments 

Not applicable.

Revision History Explanation 

Article published June 2008 (R2): The article text paragraph has been revised to remove information found in the article titled "Self-Administered Drug Exclusion Directive - Medical Policy Article". As part of the National Government Services consolidation process, the title has also been revised.

Article published November 14, 2007 (R1): This article revision is published 11/14/2007 and replaces the following articles:

A40897 Contractor 00270 NH/VT
A40897 Contractor 00180 ME
A40409 Contractor 00181 MA.

HCPCS Revisions Notes:

HCPCS J0135, Humira, was previously listed as unclassified drug (J3490) for this contractor. The following HCPCS are additions to the prior list for this contractor and are effective 12/28/2007:

J1675 Supprelin
J3355 Bravelle, Fertinex, Follistim, Gonal-F, Metrodin
Q0515 Geref
J3490 Byetta
J3490 Fuzeon
J3490 Pegasys
J3490 Symlin
J2354 Sandostatin

Related Documents 

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